ANAESTHESIA FOR CHILDREN

LIVING WITH OBESITY

PRE-ASSESSMENT DEFINING OBESITY P R E - M E D I C AT I O N
Screen for co-morbidities WEIGHT (kg) / HEIGHT (m)2 = BMI Drug (dose adjustment) Time before GA
CVS Hypertension (QR1), cardiac ⇒ Determine BMI centile Dexmedetomidine (AdjBW)
P R E - O P E R AT I V E

dysfunction ⇒ Establish weight category 30-60 minutes QR1

• IN 2-3mcg/kg (max 150mcg)
Respiratory OSA, asthma, smoke exposure
BMI Weight ASA Ketamine (IBW)
GI Fatty liver disease (NAFLD), GORD

QR CODES
centile category grade • PO 5-10mg/kg 10-20 minutes
Endocrine Insulin resistance, Type II DM
Other 2° causes of obesity, metabolic > 91st Overweight 2 • IM 5mg/kg 3-5 minutes
syndrome, psychological > 98th Obese 2 Midazolam (TBW)* QR2
Investigations to consider: > 99.6th Severely obese 3 • PO 0.5mg/kg (max 20mg) 15-30 minutes
⇒ Fasting blood tests: Glucose + insulin, Royal College of Paediatrics and Child Health (QR2) • Buccal 0.3mg/kg (max 10mg) 10-15 minutes
HbA1c, LFTs, TFTs, lipids, Vitamin D
⇒ Sleep study, ECG, echocardiogram, spirometry CONSENT IMPORTANT: ↓ dose if combining pre-medications
QR3
• Refer to paediatric specialists if necessary • ↑ likelihood of cri cal events * Midazolam: risk of of upper airway obstruction
• Perform full airway assessment • Encourage shared decision making in OSA. Consider risks / benefits. Severe OSA ↓
• Safeguarding concerns? • Avoid negative language (QR3) dose to 0.25mg/kg

P R E V E N TAT I V E M E D I C I N E : Offer lifestyle advice and refer to Tier 2 community weight management programme / dietician

INDUCTION DRUG DOSING

Intravenous Gas Ideal body weight (IBW) Adjusted body weight (AdjBW)
Preferable BUT may be difficult • May take longer due to Ideal BMIbody weight (IBW)
50 x height (m)
2
Consider: airway obstruction 2 IBW + 0.35 x (TBW – IBW)
• Topical analgesia (hands, volar aspect wrist) • Use O2 and volatile
BMI = agex
BMI 50
50 height
+ sex (m)
specific BMI at 50 centile
th QR4
th
• USS guidance / IO availability • Avoid N20 BMI50 = age + sex specific BMI at 50 centile
Total body Ideal body Adjusted body
• Priority is to secure the airway in a rapid but controlled manner weight (TBW) weight (IBW) weight (AdjBW)
Atropine Propofol [induction bolus] Propofol [TCI infusion] QR5
A I R WAY Glycopyrrolate Ketamine Alfentanil
• Consider pre-oxygenation where tolerated (FM / HFNO / nasal cannulae) Dexamethasone Morphine Fentanyl
• Airway obstruction under GA IS more common Ondansetron Non-depolarising Remifentanil
I N T R A - O P E R AT I V E

• Difficult facemask ventilation IS more common in children living with Suxamethonium muscle relaxants [Minto infusion] QR6
obesity (3.7%) vs healthy weight children (0.6%) (QR4) Penicillins Dexmedetomidine [IV] Paracetamol
• Use oropharyngeal airway +/- two-person technique

QR CODES
Cephalosporins Local anaesthetics Ibuprofen
• Difficult intubation is NOT more common Sugammadex
Sugammadex Adrenaline Gentamicin
• Obesity in isolation is NOT an indication for rapid sequence induction Neostigmine
Neostigmine Phenylephrine
• Low threshold for endotracheal intubation with videolaryngoscopy Enoxaparin
• Consider decompressing the stomach with a nasogastric / orogastric tube * Do not exceed maximum adult doses
• If a supraglottic airway is appropriate, use 2nd generation (TBW) ANALGESIA
• Use a multimodal approach
V E N T I L AT I O N • Avoid long-acting opiates in severe OSA. Titrate to effect
• Pressure control ventilation 6-8ml/kg (IBW) to limit barotrauma • Use opioid sparing techniques: US guided regional anaesthesia,
• Optimise PEEP to compensate for reduced FRC analgesic adjuncts (dexamethasone, dexmedetomidine)
• Pressure support if spontaneously ventilating with supraglottic airway • An opioid PCA is safe to use – refer to drug dose adjustments above

POSITIONING + EQUIPMENT Nose-chin plane

⇒ TIVA
“Ramp” the patient with pillows / Oxford HELP® pillow at induction Anterior neck space • Titrate to effect
Discuss any additional equipment at team brief: Tragus level • Use depth of anaesthesia
• Table extenders • Wide straps with sternum monitoring
• Transfer board and slide sheet • Anti-embolism stockings if >40kg • Follow AAGBI / SIVA good
practice guidance (QR6)
• Hover mattress >90kg • Intermittent pneumatic
• Gel padding compression (IPC) devices if
• Correctly sized / forearm BP cuff >13 years old + >40kg + surgery Ramped position
• Arterial line >60 minutes (QR5) ↓ risk of difficult laryngoscopy + improves ven la on

EMERGENCE VTE OTHER

P O S T - O P E R AT I V E

• ↑ FiO2 and more upright positioning • Perform risk assessment + follow guidance • Prioritise early mobilisation where possible
• Full reversal with neuromuscular monitoring Total body Subcutaneous enoxaparin • Ensure good hydration
QR CODES

• Awake extubation recommended weight (TBW) dose • BM monitoring if insulin resistance / T2DM QR7
• Insert soft bite block e.g. rolled gauze (QR7) <45kg 0.5mg/kg BD (max 40mg/day) Day case versus inpatient care
• No evidence that obesity increases PONV risk
45-100kg 40mg OD
• NIV should be readily available • Surgery and comorbidity dependent
100-150kg 40mg BD • Consider need for higher level care e.g. HDU
• Usual PACU discharge criteria should be met
>150kg 60mg BD • Obesity as a sole co-morbidity does not preclude
• SpO2 should be maintained at pre-operative
levels with minimal O2 • Limited literature available. Low threshold day case surgery, but does allow a prolonged
for consulting haematologist period of post-operative observation (AM list)
For guidance ONLY, not a substitute for experienced clinical judgment. Always consult local policy where available.
Created by Katherine Russell | Francesca Saddington | Mohammed AbouDaya | Zoë Burton @drzoeburton. With many thanks to the SOBA Team. © Copyright 2022 KR | FS | MA | ZB. All rights reserved.