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In the perioperative arena, it's becoming increasingly common to encounter pediatric patients who are obese, posing a challenge for the nurses who care for them. Healthcare team members educated about special considerations for the obese pediatric patient will be better prepared to provide safe, sensitive, and knowledgeable care for these patients and their families.
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This article outlines basic knowledge about the obesity trend in the pediatric population, associated comorbidities that impact perioperative care, related surgeries, and nursing interventions specific to caring for the obese pediatric patient across the perioperative continuum. The goal is to minimize complications and achieve optimal outcomes.
Pediatric obesity
The incidence of obesity in children and adolescents has been steadily on the rise over the past 3 decades. Estimates of obesity rates in this population in the United States now exceed 15%.1,2 Obesity due to medical causes is responsible for approximately 5% to 10% of cases, and some evidence suggests a possible genetic predisposition in certain families and ethnic groups. The current consensus, however, indicates that the majority of cases are related to societal changes that promote a more sedentary lifestyle and increased caloric intake.2-4
In growing children, the body mass index (BMI) varies with age, decreasing until age 6 and then rising as the child grows older. This is known as the "adiposity rebound." However, the BMI measurement typically used in adults (kg/m2) to determine overweight and obesity doesn't account for sex and age differences, body shape, bone density, or distribution of fat and muscle.5 In 2000, the CDC created a BMI chart specific for children in the United States that correlates weight with height, age, and sex.6 On the chart, a child at the 85th percentile is considered overweight, at the 95th percentile is classified as obese, and at the 99th percentile is categorized as severe obese. The BMI calculation used for adults may be applied to adolescents. In this age group, a BMI higher than 25 indicates overweight; a BMI higher than 30 indicates obesity.3,4
Preoperative and preanesthesia screening
For the obese pediatric patient scheduled for surgery, a thorough preanesthesia evaluation is particularly important because these patients may present with diagnosed and/or undiagnosed comorbidities that could affect care.7 A thorough preanesthesia evaluation fosters development of an individualized plan, provides an opportunity to address unresolved issues before surgery, and may reduce cancellations of OR cases by enhancing preplanning.
At the authors' institution, several days before surgery, a nurse performs an extensive review of the patient's chart and examines the medical history, including previous surgeries and anesthetics used when applicable. The review of anesthesia records includes noting intubation difficulties and any history of intraoperative or postoperative complications. If a patient is referred from another facility, the nurse also reviews the associated medical records. The nurse consults with an attending anesthesiologist to collaboratively problem-solve any potential concerns.
If a patient is scheduled for an ambulatory procedure, the nurse will call the patient/family and conduct a phone interview to assess current health status and ensure that the patient's medical information is complete. At some facilities, it may be important to establish the presence of obesity in patients over the phone before admission to ensure that the surgery will be performed in the most appropriate setting. A standard yet tactful and safe way to determine the presence of obesity during the preoperative phone call could be scripted, and avoiding asking for an estimated weights due to the potential for error. Asking the parent whether the child's size is smaller, average, or larger relative to other children his or her age may indicate whether further questioning and/or a preoperative visit is necessary.
During the preoperative phone call, the nurse may encourage the family to bring in items that will comfort or entertain the child/adolescent while waiting for surgery to lessen anxiety and provide distraction, thus lessening the need for sedating medication. However, families need to be aware that the environment can be fast-paced and they will need to take responsibility for personal items to ensure that they're not lost or broken.
Preoperative physical exam
Children scheduled for an overnight admission visit the preoperative clinic within 30 days of their procedure for an interview, a physical exam, and a review of any pertinent medical tests and evaluations. Each patient is seen by a preoperative clinc nurse and an anesthesiologist. Service-specific exams are completed at this time and may include X-rays or other diagnostic tests. Child life services and social services are available as needed to all patients for consultation. It's important that team members be cognizant of potential emotional issues such as poor body image and low self-esteem.2,3 It's a priority to ensure privacy when weighing the patient or discussing weight-related issues. For older children and adolescents, it's important to be aware that there may be tension between family members regarding the child's weight and it may be helpful to the child to measure the weight in a more private area while the accompanying family member waits nearby.
The preoperative physical exam includes an airway assessment, neck evaluation, lung and heart exam, vital signs, weight, and height.7 A thorough airway exam is essential because anatomic changes such as fleshy cheeks, large tongue, abundant flaps of palatal, pharyngeal, and supralaryngeal tissues related to obesity can make tracheal intubation challenging.8 Mallampati scoring, a method used to predict the ease of intubation and mask ventilation, is included in the airway evaluation. Based on the visibility of the base of the uvula, faucial pillars, and soft palate, a high Mallampati score increases the likelihood of a difficult intubation. Grades I and II are considered adequate exposure for intubation. Grades III and IV are considered inadequate exposure.9 In adults, obese patients are more likely to have higher scores than patients of normal weight, and an increased Mallampati score and a neck circumference of more than 40 cm can be predictors of potential intubation problems.10 However, studies to date haven't clearly associated obesity in children with significant rates of difficult intubation.1,3
Common health problems
During the preoperative clinic visit, the practitioner should be alert to the possibility of sleep apnea, which may be undiagnosed in obese children. True sleep apnea is present in 7% of obese children and 26% to 37% of obese children have abnormal sleep studies.11 Families may report patients snoring, gasping for breath at night, and daytime somnolence. In some cases, airway obstruction is so severe that an adenotonsillectomy is needed before the originally scheduled surgery to improve symptoms.2 Patients with previously known sleep apnea may need to be on continuous positive airway pressure. Determination in advance of the anticipated postoperative level of nursing care and monitoring needs will foster a smoother perioperative course.
Obesity is associated with altered pulmonary function, increased work of breathing, chronic hypoxemia, and chronic hypercapnia. Excess adipose tissue can alter pulmonary function because chest wall compliance is reduced and anterior chest wall excursion is limited. The pattern of pulmonary function tests is typically restrictive.3,5 Nearly 30% of obese children suffer from asthma, usually more severe in nature than in children of normal weight. It's likely that an obese child who was overweight as an infant suffered from higher incidences of respiratory infections, and this tendency often continues into childhood.3,8 Optimizing respiratory function before surgery may reduce perioperative complications. Evidence to date fails to demonstrate a higher incidence of aspiration related to obesity in children, therefore there are currently no recommendations to change fasting guidelines for obese children based on obesity alone.3
During the preanesthesia evaluation, the practitioner may discover the need for further follow-up for the obese pediatric patient as information is synthesized. Additional health problems common for this population include hypertension, hyperlipidemia, hyperinsulinemia, type 2 diabetes, fatty liver disease, gastroesophageal reflux, polycystic ovary disease, menstrual irregularities, and depression. 6,8,12-14 Nearly 80% of overweight adolescents have one risk factor for cardiac disease and 20% have two. A higher resting heart rate may be noted in obese adolescents.3 Glucose metabolism is abnormal in 25% of obese children. Steatohepatitis can be present with 15% of these children having evidence of liver involvement.11
Conditions related to obesity include cholelithiasis, gynecomastia, adenotonsillar hypertrophy, and a multitude of orthopedic problems, including slipped capital femoral epiphysis and tibia vara (Blount disease). Consults with other disciplines may be necessary to identify and manage any disease or disorder that could affect anesthesia care and provide an opportunity to initiate appropriate medical care for the child for the future. Potential consults for an obese child can include endocrine, gastrointestinal, cardiology, pulmonary, orthopedics, behavioral medicine, nutrition, and sports medicine.12
The anesthesia care provider will be taking the child's overall medical condition, including I.V. access, into account when determining the anesthetic plan and may elect to order additional tests preoperatively such as a fasting blood glucose, arterial blood gas, chest X-ray, and/or ECG.3,8
Preparing for surgery
Clear communication with the perioperative team about the identified needs of the patient enables subsequent caregivers to promote a safer and smoother surgical experience. For example, accurate communication regarding the patient's airway, significant past medical history, anxiety level, reflux history, and I.V. access makes it possible for the team to be better prepared for the patient on the day of surgery. If I.V. access is anticipated to be a challenge, ensure that a transilluminator or other assistive device will be available to enhance organization and facilitate insertion of the I.V. Communication regarding the need for special equipment such as larger scales and stretchers or extra staffing for safe handling of the patient allows time to plan for resources to be in place. Making arrangements in advance to discretely provide safe seating for family members who may also be overweight or obese fosters an environment of family-centered care.
On the day of surgery, the team makes additional preparations for the patient. The bedside is readied with an assortment of larger BP cuffs to ensure proper fit, along with standard monitoring equipment and supplies. The appropriate size scale for weighing the patient is available in a comfortable and convenient location. The patient is provided privacy to change into adequately sized hospital attire and to complete additional preoperative requirements necessary, such as providing a urine sample. The patient is weighed and returns to the bedside. Once ready to be on the stretcher, the patient is positioned in a semirecumbent position to maximize respiratory excursion. The team continues providing privacy and includes supportive family at the bedside.
Personal items brought in by the family for the patient's comfort may be used during this time. Providing the patient with warm blankets and socks in the preoperative area help the patient maintain body temperature as they wait for surgery. Actively employing measures to minimize anxiety reduces the need for medications for anxiolysis that may impact respiratory effort. Child life specialists or other staff available may help to relax the patient. If sedation is deemed necessary, the minimal dose is administered and the patient's oxygen saturation is monitored. If an I.V. line will be started during the preoperative phase, assess the need for topical analgesia and/or active distraction and plan accordingly. If topical analgesia is contraindicated or declined, applying a warmed blanket or towel to the potential I.V. site will help to dilate the veins and may provide comfort. Using an inflated BP cuff as a tourniquet may be more effective for dilating veins than using a standard tourniquet.13 Education at this time will benefit the patient (See Patient education).
While the patient is in the preoperative area, the OR team is ensuring that the room and appropriately sized equipment are ready. The OR table must be able to support the weight and girth of obese patients and safety straps must be adequately sized to accommodate larger patients as the potential instability of obese patients places them at higher risk for falls from the OR table. The team ensures that larger sizes of equipment such as retractors, staplers, and instruments are available (See Future planning). Settings for electrocautery will be higher for obese patients due to excess adipose tissue.13
Intraoperative care
Upon arrival to the OR, the patient may be asked to transfer from the stretcher to the OR table for induction to minimize risk of injury to the patient and staff. Alternatively, if transferred to the OR table by staff, availability of lifting devices and use of proper body mechanics by sufficient number of staff is essential.9,13,15 Positioning of obese patients is focused on prevention of injury, safety, and optimization of cardiopulmonary status. Maintaining the patient's position with the head above the horizontal plane of the upper body improves pulmonary mechanics. The OR nurse is prepared as per facility practice to assist with positioning the head and neck for intubation for maximal exposure of the larynx. Preoxygenation before induction helps to offset the lower functional residual capacity of the obese child.8 In some cases, it may be necessary to accommodate for large breasts by first inserting the laryngoscope blade into the mouth and then separately attaching the handle to proceed with intubation.10,13
A study done in Cambridge, England between 1995 and 1999 (n>105,000) showed that 9.56% of obese children between the ages of 1 to 12 had critical incidents during anesthesia. This was compared with 5.89% of obese patients in all age groups, indicating that an obese child in their sample was nearly twice as likely to have an event as compared with obese adults.8 Results of a study conducted during 2004 and 2005 (n>2,000) suggested that obese children undergoing elective noncardiac surgery had a greater incidence of difficult mask ventilation, airway obstruction, bronchospasm, major oxygen desaturation, and other critical respiratory events.1 These studies underscore the need for caregivers to be familiar with the implications of childhood obesity to be able to provide care to minimize potential issues. The obese pediatric patient poses a particular challenge to the anesthesia care provider charged with safely and efficiently implementing a plan that achieves tracheal intubation and I.V. access.
Insertion of a bladder catheter in the larger patient may require additional assistance to hold the abdomen away from the field of view. Insertion of the catheter into an obese female may be facilitated by placing the patient in a lateral position with the upper leg lifted or flexed. The patient may be fitted to graduated compression stockings or sequential compression devices to prevent deep vein thrombosis.13,15
It's important to pay particular attention to the padding and positioning of the patient's body, especially bony prominences and areas in contact with the OR table because adipose tissue isn't as vascular and predisposes obese patients to pressure ulcers.8,15 In general, the lateral and semirecumbent positions, or the prone position with the abdomen free, are tolerated better than the supine or Trendelenburg positions. If the patient is placed in the lateral position, provide adequate axillary support. Carefully select and place noncompressible positioning equipment to ensure that the patient's body is in proper alignment, is securely and safely strapped, and all body parts are confined to the OR table. Follow standard facility OR guidelines for intermittent skin assessments and repositioning.10,13 During surgery, it's important to maintain thermoregulation to prevent increased metabolic demands. Monitor the patient's temperature and implement interventions to promote and/or maintain normothermia such as the use of a forced-air warming device as per manufacturer's guidelines. At the end of surgery, it's recommended that the patient staying overnight is moved directly from the OR table to the hospital bed.13
Postoperative care
Postoperatively, the main priority for the postanesthesia care unit (PACU) nurse providing care for the obese pediatric patient is to maximize oxygenation and ventilation. In one study of adults that compared vital capacity (VC) between patients with a BMI over 30 to those with a BMI under 25 (all with a normal VC preoperatively), comparisons following extubation at 20 minutes and then again at 3 hours demonstrated that those with the higher BMI had reductions in VC of 41% and 28%, respectively compared with decreases of 11% and 6% in patients with a lower BMI.16
Ideally, the patient is extubated when completely awake.8 The PACU nurse should position the patient in a semirecumbent position to alleviate abdominal pressure on the diaphragm and facilitate deeper breathing while monitoring the oxygen saturation closely. Supplemental oxygen should be provided to increase tissue oxygenation. Coughing and deep breathing exercises are encouraged to enhance oxygenation, facilitate removal of anesthetic gases, and prevent pneumonia. Chest physical therapy should be started early, especially in patients who have had abdominal and/or thoracic surgery.8
The anesthesia care team may opt to utilize a multimodal approach to manage pain and may maximize the use of I.V. anesthesia, regional techniques, short-acting opioids, and nonopioid analgesics. Discuss with the patient the goal of pain relief and maximize nonopioid and nonpharmacologic techniques such as comfort measures and distraction while judiciously titrating opioids to effect as ordered. Assess the patient's level of pain using the appropriate pain scale according to the facility's protocol. Perform a skin assessment paying particular attention to bony prominences. Assess comfort and proper sizing for patients wearing sequential compression devices. Reposition the patient with care, ensuring proper body alignment, and adequate support.
Prior to discharge home or to a hospital room, provide education relevant to postoperative care to the patient and family. In addition to information related to the surgical procedure, review the importance of continued coughing and deep-breathing exercises, early ambulation, and strategies for comfort. Verify that the patient and/or family members understand the importance of follow-through with the postoperative instructions. Discharge the patient home as appropriate once discharge criteria are met. For patients transferred to a hospital bed, the clinical handoff provides an opportunity to facilitate continuity of care beyond the initial postoperative period.
Providing family-centered care
Careful coordination and ongoing communication across the continuum is a true collaborative process focused on minimizing complications and promoting optimal individualized patient care. Nursing care along the perioperative course employs measures that address special considerations for the obese pediatric patient to optimize outcomes.
As treatment options evolve, potentially including bariatric surgery, perioperative nurses caring for the pediatric population need to be educated and prepared to provide evidence-based nursing care to the obese pediatric patient and their family. Bariatric surgery is becoming increasingly common as an option for treatment in cases of severe adult obesity when certain criteria are met including lack of success in weight loss programs, significant comorbidities, and passing of psychologic testing. Approximately 100,000 adult patients per year in the United States and Canada undergo bariatric surgery. Currently, however, adolescents represent less than 1% of this population.3
In addition to the multifaceted physiologic and emotional needs directly impacting medical and nursing care, it's important that institutions be prepared to safely provide family-centered care for this increasingly common segment of the population.
Education guide for the obese pediatric patient
Future planning
Considerations for future equipment include planning to accommodate larger patients when purchasing OR tables, stretchers, hospital beds, mattresses, wheelchairs, bed extensions, lifting devices, scales, longer safety straps for relevant equipment, and larger sizes of hospital attire and BP cuffs. Future purchases of reclining chairs for patients or chairs to accommodate families in waiting rooms and patient bedsides should include larger chairs for those who are obese.
When undergoing new construction, it's important to plan to accommodate obese patients and families in new patient rooms, bathroom facilities, and waiting areas. Some items to consider include adequate space, seating, beds, overhead lifting aids, storage needs for larger equipment, doorways, toilets, showers with easy access, and safety bars in bathrooms.
REFERENCES
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