Pediatric Anesthesia ISSN 1155-5645
ORIGINAL ARTICLE
Does obesity prolong anesthesia in children undergoing common ENT surgery? Jennifer J. Lee1, Lena S. Sun2,3, Brian Gu2, Minjae Kim2, Shuang Wang4 & Sena Han2 1 2 3 4
Department of Anesthesiology, Harvard Medical School, Boston, MA, USA Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA Department of Pediatrics, Columbia University Medical Center, New York, NY, USA Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
Keywords obesity; child; anesthesia; otolaryngology; outcomes; complications Correspondence Lena S. Sun, E.M. Papper Professor of Pediatric Anesthesiology and Professor of Anesthesiology and Pediatrics, Columbia University Medical Center, CH 4-440 North, 622 West 168th Street, New York, NY 10032, USA Email: [email protected] Section Editor: Jerrold Lerman Accepted 18 April 2014 doi:10.1111/pan.12442
Summary Objectives: To report the epidemiology of obesity in a pediatric surgical population and determine whether obesity is a risk factor for longer anesthesia duration. Background: Childhood obesity is a significant public health problem in the United States. Epidemiologic studies on pediatric surgical populations have been limited to states with very high prevalence of adult obesity (Michigan, Texas). Data from other states and more recent data since 2006 are unavailable. Methods: We examined anesthesia records for surgical patients age 2– 18 years at Columbia University Medical Center from January 2009 to December 2010. Patients undergoing bariatric surgery or those with records missing preoperative height or weight data were excluded. Body mass index (BMI) was calculated as weight (kg)/height (m2). BMI ≥95th percentile according to national growth charts were considered obese. Results: We reviewed 9522 patients of which 1639 were obese (17.2%). The sex–age category interaction on obesity was not significant using logistic regression (P = 0.11). Among surgical groups, the otolaryngology (ENT) cohort had the highest obesity rate (21.7%, 360/1656). Obese children who had tonsillectomy, adenoidectomy, or both did not have a prolonged anesthetic (P = 0.33) or surgical duration (P = 0.61) compared with nonobese children, adjusting for surgeon, season, surgical procedure code, and ASA status. Conclusion: Children presenting for surgery, particularly the ENT cohort, have a high prevalence of obesity. Obese and nonobese children who had tonsillectomy, adenoidectomy, or both had comparable durations of anesthesia. Therefore, obesity did not lead to longer anesthetic duration.
Introduction Childhood obesity is a significant public health problem in the United States. According to the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2012, 16.9% of children age 2–19 years are estimated to be obese in the United States. (1,2). Importantly, it has been shown that obese children are likely to become obese adults (3), perpetuating the national obesity crisis. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 1037–1043
Obesity in children has been linked to an increased risk of a range of medical comorbidities, including but not limited to pulmonary (4), cardiovascular (5), metabolic (5), and orthopedic disorders (6). Caring for children with obesity poses clinical challenges for all clinicians, including anesthesiologists. Although the care of obese adults during the perioperative period has been studied extensively, relatively fewer studies have been conducted in obese children. Several reports have found that obese children are at an increased perioperative risk 1037
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of adverse respiratory events such as oxygen desaturation, difficult mask ventilation, difficult airway and laryngoscopy, laryngospasm, and airway obstruction compared with their nonobese counterparts (7–10). Additionally, obesity as a secondary diagnosis in children has been linked to increased hospital charges, lengths of stay, and rates of unexpected postoperative admission (11–13). Several recent studies have examined the prevalence of obesity in the US pediatric surgical population, one series from Michigan and another from Texas (14,15). The Michigan study examined all children age 2–18 years presenting for surgery from 2000 to 2004 (14). They found 17.2% of their study population to be obese, with orthopedic and otolaryngology (ENT) procedures being the most commonly performed surgeries in obese children (14). Olutoye et al. (15) conducted a similar epidemiologic analysis at Texas Children’s Hospital, but limited their study to day-surgery patients over a 3-month period in 2006. The prevalence of obesity was 20%, and ENT procedures were the most commonly performed day surgery in their obese cohort (15). In this study, we sought to determine the epidemiology of childhood obesity in pediatric surgical patients of a major metropolitan hospital in New York from 2009 to 2010. Obese children have been reported to have more difficult venous access (16) and a higher rate of adverse respiratory events (6–10). In addition, drug responses may be altered when dosing is based on actual weight rather than ideal body weight (17). We therefore hypothesized that the duration of anesthesia, but not surgery, would be longer in obese children compared with nonobese children. Because the ENT cohort had the highest prevalence of obesity, we focused additional analysis in these patients. The most commonly performed ENT procedures were tonsillectomy, adenoidectomy, and combined tonsillectomy and adenoidectomy. We analyzed anesthetic and surgical durations in patients undergoing these specific ENT procedures. Methods The study was approved by the Columbia University Institutional Review Board. We reviewed electronic anesthesia records from the CompuRecord database at the Columbia University Medical Center of all pediatric patients age 2–18 years presenting for surgery from January 1, 2009 to December 31, 2010. Data entries were reviewed by three co-investigators. All patients with data entries that were missing preoperative height or weight information or judged to be in error by the reviewers were excluded from this study. Patients undergoing bariatric surgery were also excluded. Hence, of 1038
13 224 patients, 3702 patients were excluded, and a total 9522 patients were studied. We extracted the following demographic data from the CompuRecord database: age, sex, surgical procedure code, surgical group, ASA status, preoperative height and weight, anesthesia duration (calculated by time of induction until time of extubation in intubated patients or end of anesthesia in all other patients), and surgery duration (calculated by time of start until end of procedure). Body mass index (BMI) was calculated as weight (kg)/height (m2). Children were classified as nonobese or obese according to Centers for Disease Control and Prevention (CDC) growth charts from 2000 (18). BMI ≥95th percentile was considered obese (18). Surgical procedure codes were used to classify patients into surgical groups. Within the ENT surgical group, only patients with surgical procedure codes for tonsillectomy, adenoidectomy, or both were used to analyze anesthetic and surgical durations in obese and nonobese children. Descriptive statistics were conducted for all variables. Data are expressed as mean SD or proportions where appropriate. Multiple logistic regression was conducted to test for sex–age group interaction on obesity. The Pearson chi-square test was used to test the association between categorical variables and the binary obesity variable. Multiple linear regressions were used to test for main effects of sex, obesity, and age on anesthesia and surgery durations, where we adjusted for these covariates: surgeon, season, surgical procedure code for tonsillectomy, adenoidectomy, and combined tonsillectomy and adenoidectomy, and ASA status. P < 0.05 was deemed statistically significant. Results A total of 9522 patients were included in this study. There were 5359 males (56.3%) and 4163 females (43.7%) with the age ranging from 2.0 to 18.9 years (mean SD = 9.0 5.0 years). Approximately twothirds of our patients (67.6%) were classified as ASA 1 or 2. Overall, the prevalence of obesity was 17.2% (1639/9522). A summary of the demographics in our total population is presented in Table 1. We examined the prevalence of obesity in age subgroups 2–5 years, 6–9 years, and ≥10 years and examined whether the obesity prevalence in each age category is different according to sex using logistic regression with a sex by age category interaction. This sex–age category interaction was not significant (P = 0.11, Table 2). We then analyzed the distribution of obesity prevalence by surgical groups. These results are shown in © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 1037–1043
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Pediatric obesity and anesthesia duration
Total n = 9522 Sex Male (%) Female (%) Obese (%) Age (years, mean SD) BMI (kgm 2, mean SD) 2–5 years 6–9 years ≥10 years Height (cm, mean SD) 2–5 years 6–9 years ≥10 years Weight (kg, mean SD) 2–5 years 6–9 years ≥10 years ASA (%) 1 2 ≥3 Surgical group (%) General ENT Orthopedic Cardiac Urologic Oncologic Neurosurgery Dental and Oral Ophthalmology Plastic Thoracic Ob/Gyn Vascular Transplant Other Anesthesia duration (min, mean SD) Surgery duration (min, mean SD)
5359 (56.3) 4163 (43.7) 1639 (17.2) 9.0 5.0
Surgical group
Table 1 Demographic and clinical characteristics of overall pediatric surgical population
Other Thoracic Transplant Dental and Oral Vascular Ophthalmologic Plastic Urologic Cardiac General Oncologic Neurosurgery Orthopedic Ob/Gyn ENT
16.6 4.0 17.7 4.6 22.0 6.1 119.0 28.3 134.8 27.1 133.7 28.7 29.1 20.9 38.8 24.1 38.0 22.4 2861 (30.0) 3579 (37.6) 3082 (32.4) 2326 (24.4) 1656 (17.4) 1410 (14.8) 1200 (12.6) 988 (10.4) 481 (5.1) 398 (4.2) 274 (2.9) 248 (2.6) 198 (2.1) 130 (1.4) 83 (0.9) 69 (0.7) 39 (0.4) 22 (0.2) 127 103 76 83
Figure 1. The ENT group had the highest obesity prevalence at 21.7% (360/1656). Compared with the overall surgical population, ENT patients were younger (mean
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
% Obese
Figure 1 Obesity prevalence by surgical groups. The prevalence of obesity was 21.7% in ENT patients (360/1656), 20.5% in obstetrics and gynecology patients (17/83), 20% in orthopedic surgery patients (282/1410), 18.8% in neurosurgery patients (75/398), 17.7% in oncologic surgery patients (85/481), 16.2% in general surgery patients (376/2326), 14.9% in cardiac surgery patients (179/1200), 14.1% in urologic surgery patients (139/988), 13.6% in plastic surgery patients (27/198), 13.3% in ophthalmologic surgery patients (33/248), 13% in vascular surgery patients (9/69), 12.8% in dental and oral surgery patients (35/274) and transplant surgery patients (5/39), 12.3% in thoracic surgery patients (16/130), and 4.5% in all other patients (1/22).
age SD = 7.1 4.3 years vs 9.0 5.0 years) and ‘healthier’, according to ASA status (% ASA 1 or 2 = 87.6% vs 67.6%). Detailed demographics of the ENT obese and nonobese patients are summarized in Table 3. Anesthesia and surgery durations in obese vs nonobese ENT patients having tonsillectomy, adenoidectomy, or both We reviewed anesthetic and surgical durations in obese vs nonobese children across all surgical groups (Figure 2). To specifically examine whether obesity increased anesthesia duration, we analyzed the surgery and anesthesia durations in a subgroup of ENT patients who had tonsillectomy, adenoidectomy, or both as identified by surgical procedure codes in their records (n = 1174). The prevalence of obesity in this subgroup was 22.1% (obese = 259, nonobese = 915). The demographics of this subgroup are further
Table 2 Age- and sex-specific obesity prevalence in overall pediatric surgical populationa Age-groups (years)
Total n = 9522
BMI (kgm 2, mean SD)
Obese (%)
Obese males (%)
Obese females (%)
2–5 6–9 ≥10
2849 2317 4356
16.6 4.0 17.7 4.6 22.0 6.1
425 (14.9) 444 (19.2) 770 (17.7)
253/1639 (15.4) 274/1312 (20.9) 423/2408 (17.6)
172/1210 (14.2) 170/1005 (16.9) 347/1948 (17.8)
Sex–age group interaction on obesity was not significant (P = 0.11) using logistic regression.
a
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Table 3 Demographic and clinical characteristics of ENT population All ENT Obese, n = 360 Sex Male (%) Female (%) Age (years, mean SD) BMI (kgm 2, mean SD) 2–5 years 6–9 years ≥10 years Height (cm, mean SD) 2–5 years 6–9 years ≥10 years Weight (kg, mean SD) 2–5 years 6–9 years ≥10 years ASA (%) 1 2 ≥3 Anesthesia duration (min, mean SD) Surgery Duration (min, mean SD)
Tonsillectomy, adenoidectomy, or both Nonobese, n = 1296
Total, n = 1656
Obese, n = 259
Nonobese, n = 915
Total, n = 1174
P-value
209 (58.1) 151 (41.9) 7.3 4.0
720 (55.6) 576 (44.4) 7.0 4.4
929 (56.1) 727 (43.9) 7.1 4.3
134 (51.7) 125 (48.3) 7.0 3.8
502 (54.9) 413 (45.1) 6.0 3.7
636 (54.2) 538 (45.8) 6.2 3.8
0.37*
21.9 6.4 24.0 3.2 31.2 5.8
15.6 1.5 16.1 2.0 20.0 3.6
16.8 3.9 18.3 4.3 22.4 6.2
21.3 4.6 23.5 7.2 30.1 3.5
15.6 1.6 16.1 1.9 20.0 3.5
16.6 3.2 18.3 4.1 22.8 5.8
100.3 15.3 128.3 13.0 156.7 16.1
101.0 10.1 125.2 9.6 157.3 14.4
100.9 11.2 126.1 10.7 157.2 14.8
103.9 13.6 128.5 10.6 157.3 12.9
101.4 10.3 124.4 8.8 155.9 13.1
101.8 11.0 125.6 9.5 156.3 13.0
21.7 6.2 40.1 10.7 78.1 24.7
16.0 3.3 25.4 5.5 50.6 15.1
17.1 4.6 29.6 9.9 56.6 21.0
23.0 6.5 39.1 8.5 75.9 18.9
16.1 3.3 25.1 5.1 49.4 13.7
17.3 4.9 29.3 9.0 56.7 19.3
104 (28.9) 211 (58.6) 45 (12.5) 91 63
503 (38.8) 633 (48.9) 160 (12.3) 88 65
607 (36.7) 844 (50.9) 205 (12.4) 89 64
80 (30.9) 164 (63.3) 15 (5.8) 76 24
354 (38.7) 502 (54.9) 59 (6.4) 70 21
434 (37.0) 666 (56.7) 74 (6.3) 72 22
0.33**
53 54
52 57
52 57
37 17
35 18
35 18
0.61**
0.08*
*P-values were generated with the Pearson chi-square statistic. **P-values were derived from the multiple linear regression model, adjusting for surgeon, season, surgical procedure code, and ASA status.
depicted in Table 3. We specifically chose the subgroup of patients who had tonsillectomy, adenoidectomy, or both for two reasons: (1) These were the most common procedures performed in the ENT cohort, which had the highest obesity prevalence of all surgical groups. (2) While the surgical approach in these patients was unlikely to be affected by obesity, we would expect the anesthetic implications of obesity to still be present, making this an ideal group to analyze whether obesity prolongs anesthesia duration specifically. We confirmed that in this ENT subgroup, obesity was not associated with a longer surgery duration (obese 37 17 min vs nonobese 35 18 min, P = 0.61) after adjusting for surgeon, season, surgical procedure code, and ASA status in the multiple linear regression model. In these patients, obesity was also not associated with a prolongation of the anesthesia duration (obese 76 24 min vs nonobese 70 21 min, P = 0.33). The only independent predictor of both longer anesthesia and surgery durations was older age (P < 0.01, Table 4). 1040
Discussion Epidemiology of obesity in the pediatric surgical population This study showed that the pediatric surgical population of a major metropolitan hospital in New York had an obesity prevalence from 2009 to 2010 (17.2%), paralleling the concurrent prevalence for obesity nationwide [16.9% from (1) and (2)]. There were no significant differences in age- or sex-specific prevalence of obesity (P = 0.11). These results are in contrast to NHANES 2009–2010 data, in which male sex and older age were associated with higher rates of childhood obesity in the United States (2). The pediatric obesity rate in our New York surgical cohort (17.2%) was comparable to those reported in previous epidemiologic studies from Michigan [17.2% in (14)] and Texas [20% in (15)], which are both states with significantly higher adult obesity rates [>30% from (19)] than New York [23.9% from (19)]. Our study suggests that obesity prevalence may be distinct between adults and pediatric patients. That is, © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 1037–1043
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Anesthesia duration - Obese
Oncologic
Anesthesia duration - Non-Obese
Other
Surgery duration - Obese Surgery duration - Non-Obese
Thoracic ENT
Urologic
Surgical group
General Ob/Gyn Ophthalmologic Plastic Dental and Oral Vascular Orthopedic Cardiac Neurosurgery Transplant 0
50
100
150
200
250
300
350
400
450
500
Time (min) Figure 2 Anesthesia and surgery durations by surgical groups and obesity status. Anesthesia and surgery durations (mean SD) are reported for each of the surgical groups by obesity status. Standard deviations are not shown to simplify the graphic presentation. Details are as below (anesthesia duration in obese vs nonobese patients, surgery duration in obese vs nonobese patients): transplant surgery (455 95 vs 429 184 min, 340 81 vs 271 154 min), neurosurgery (267 161 vs 250 151 min, 166 131 vs 152 125 min), cardiac surgery (173 96 vs 166 94 min, 106 80 vs 104 77 min), orthopedic surgery (169 119 vs 181 131 min, 105 96 vs 113 107 min), vascular surgery (167 91 vs 162 81 min, 79 49 vs 94 70 min), dental and
oral surgery (162 69 vs 182 85 min, 107 59 vs 123 77 min), plastic surgery (150 91 vs 136 75 min, 95 80 vs 84 74 min), ophthalmologic surgery (125 44 vs 118 53 min, 76 44 vs 71 47 min), obstetrics and gynecology (106 73 vs 108 84 min, 63 58 vs 67 74 min), general surgery (103 60 vs 94 79 min, 60 53 vs 53 71 min), urologic surgery (92 57 vs 105 76 min, 49 48 vs 61 67 min), ENT surgery (91 63 vs 88 65 min, 53 54 vs 52 57 min), thoracic surgery (85 48 vs 121 95 min, 38 32 vs 68 75 min), all other surgery (58 0 vs 43 10 min, 30 0 vs 19 7 min), and oncologic surgery (56 44 vs 49 34 min, 26 32 vs 22 25 min).
Table 4 Analysis of sex, obesity, and age on anesthesia and surgery durationsa Anesthesia duration
Variable Female Sex Obesity Age
Regression coefficient estimate (95% confidence interval) 0.94 ( 3.11 to 1.22) 1.30 ( 1.33 to 3.94) 0.05 (0.02–0.07)
Surgery duration
Wald v2
P-value
0.73 0.94 14.55
0.39 0.33
ORIGINAL ARTICLE
Does obesity prolong anesthesia in children undergoing common ENT surgery? Jennifer J. Lee1, Lena S. Sun2,3, Brian Gu2, Minjae Kim2, Shuang Wang4 & Sena Han2 1 2 3 4
Department of Anesthesiology, Harvard Medical School, Boston, MA, USA Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA Department of Pediatrics, Columbia University Medical Center, New York, NY, USA Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
Keywords obesity; child; anesthesia; otolaryngology; outcomes; complications Correspondence Lena S. Sun, E.M. Papper Professor of Pediatric Anesthesiology and Professor of Anesthesiology and Pediatrics, Columbia University Medical Center, CH 4-440 North, 622 West 168th Street, New York, NY 10032, USA Email: [email protected] Section Editor: Jerrold Lerman Accepted 18 April 2014 doi:10.1111/pan.12442
Summary Objectives: To report the epidemiology of obesity in a pediatric surgical population and determine whether obesity is a risk factor for longer anesthesia duration. Background: Childhood obesity is a significant public health problem in the United States. Epidemiologic studies on pediatric surgical populations have been limited to states with very high prevalence of adult obesity (Michigan, Texas). Data from other states and more recent data since 2006 are unavailable. Methods: We examined anesthesia records for surgical patients age 2– 18 years at Columbia University Medical Center from January 2009 to December 2010. Patients undergoing bariatric surgery or those with records missing preoperative height or weight data were excluded. Body mass index (BMI) was calculated as weight (kg)/height (m2). BMI ≥95th percentile according to national growth charts were considered obese. Results: We reviewed 9522 patients of which 1639 were obese (17.2%). The sex–age category interaction on obesity was not significant using logistic regression (P = 0.11). Among surgical groups, the otolaryngology (ENT) cohort had the highest obesity rate (21.7%, 360/1656). Obese children who had tonsillectomy, adenoidectomy, or both did not have a prolonged anesthetic (P = 0.33) or surgical duration (P = 0.61) compared with nonobese children, adjusting for surgeon, season, surgical procedure code, and ASA status. Conclusion: Children presenting for surgery, particularly the ENT cohort, have a high prevalence of obesity. Obese and nonobese children who had tonsillectomy, adenoidectomy, or both had comparable durations of anesthesia. Therefore, obesity did not lead to longer anesthetic duration.
Introduction Childhood obesity is a significant public health problem in the United States. According to the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2012, 16.9% of children age 2–19 years are estimated to be obese in the United States. (1,2). Importantly, it has been shown that obese children are likely to become obese adults (3), perpetuating the national obesity crisis. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 1037–1043
Obesity in children has been linked to an increased risk of a range of medical comorbidities, including but not limited to pulmonary (4), cardiovascular (5), metabolic (5), and orthopedic disorders (6). Caring for children with obesity poses clinical challenges for all clinicians, including anesthesiologists. Although the care of obese adults during the perioperative period has been studied extensively, relatively fewer studies have been conducted in obese children. Several reports have found that obese children are at an increased perioperative risk 1037
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Pediatric obesity and anesthesia duration
of adverse respiratory events such as oxygen desaturation, difficult mask ventilation, difficult airway and laryngoscopy, laryngospasm, and airway obstruction compared with their nonobese counterparts (7–10). Additionally, obesity as a secondary diagnosis in children has been linked to increased hospital charges, lengths of stay, and rates of unexpected postoperative admission (11–13). Several recent studies have examined the prevalence of obesity in the US pediatric surgical population, one series from Michigan and another from Texas (14,15). The Michigan study examined all children age 2–18 years presenting for surgery from 2000 to 2004 (14). They found 17.2% of their study population to be obese, with orthopedic and otolaryngology (ENT) procedures being the most commonly performed surgeries in obese children (14). Olutoye et al. (15) conducted a similar epidemiologic analysis at Texas Children’s Hospital, but limited their study to day-surgery patients over a 3-month period in 2006. The prevalence of obesity was 20%, and ENT procedures were the most commonly performed day surgery in their obese cohort (15). In this study, we sought to determine the epidemiology of childhood obesity in pediatric surgical patients of a major metropolitan hospital in New York from 2009 to 2010. Obese children have been reported to have more difficult venous access (16) and a higher rate of adverse respiratory events (6–10). In addition, drug responses may be altered when dosing is based on actual weight rather than ideal body weight (17). We therefore hypothesized that the duration of anesthesia, but not surgery, would be longer in obese children compared with nonobese children. Because the ENT cohort had the highest prevalence of obesity, we focused additional analysis in these patients. The most commonly performed ENT procedures were tonsillectomy, adenoidectomy, and combined tonsillectomy and adenoidectomy. We analyzed anesthetic and surgical durations in patients undergoing these specific ENT procedures. Methods The study was approved by the Columbia University Institutional Review Board. We reviewed electronic anesthesia records from the CompuRecord database at the Columbia University Medical Center of all pediatric patients age 2–18 years presenting for surgery from January 1, 2009 to December 31, 2010. Data entries were reviewed by three co-investigators. All patients with data entries that were missing preoperative height or weight information or judged to be in error by the reviewers were excluded from this study. Patients undergoing bariatric surgery were also excluded. Hence, of 1038
13 224 patients, 3702 patients were excluded, and a total 9522 patients were studied. We extracted the following demographic data from the CompuRecord database: age, sex, surgical procedure code, surgical group, ASA status, preoperative height and weight, anesthesia duration (calculated by time of induction until time of extubation in intubated patients or end of anesthesia in all other patients), and surgery duration (calculated by time of start until end of procedure). Body mass index (BMI) was calculated as weight (kg)/height (m2). Children were classified as nonobese or obese according to Centers for Disease Control and Prevention (CDC) growth charts from 2000 (18). BMI ≥95th percentile was considered obese (18). Surgical procedure codes were used to classify patients into surgical groups. Within the ENT surgical group, only patients with surgical procedure codes for tonsillectomy, adenoidectomy, or both were used to analyze anesthetic and surgical durations in obese and nonobese children. Descriptive statistics were conducted for all variables. Data are expressed as mean SD or proportions where appropriate. Multiple logistic regression was conducted to test for sex–age group interaction on obesity. The Pearson chi-square test was used to test the association between categorical variables and the binary obesity variable. Multiple linear regressions were used to test for main effects of sex, obesity, and age on anesthesia and surgery durations, where we adjusted for these covariates: surgeon, season, surgical procedure code for tonsillectomy, adenoidectomy, and combined tonsillectomy and adenoidectomy, and ASA status. P < 0.05 was deemed statistically significant. Results A total of 9522 patients were included in this study. There were 5359 males (56.3%) and 4163 females (43.7%) with the age ranging from 2.0 to 18.9 years (mean SD = 9.0 5.0 years). Approximately twothirds of our patients (67.6%) were classified as ASA 1 or 2. Overall, the prevalence of obesity was 17.2% (1639/9522). A summary of the demographics in our total population is presented in Table 1. We examined the prevalence of obesity in age subgroups 2–5 years, 6–9 years, and ≥10 years and examined whether the obesity prevalence in each age category is different according to sex using logistic regression with a sex by age category interaction. This sex–age category interaction was not significant (P = 0.11, Table 2). We then analyzed the distribution of obesity prevalence by surgical groups. These results are shown in © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 1037–1043
J.J. Lee et al.
Pediatric obesity and anesthesia duration
Total n = 9522 Sex Male (%) Female (%) Obese (%) Age (years, mean SD) BMI (kgm 2, mean SD) 2–5 years 6–9 years ≥10 years Height (cm, mean SD) 2–5 years 6–9 years ≥10 years Weight (kg, mean SD) 2–5 years 6–9 years ≥10 years ASA (%) 1 2 ≥3 Surgical group (%) General ENT Orthopedic Cardiac Urologic Oncologic Neurosurgery Dental and Oral Ophthalmology Plastic Thoracic Ob/Gyn Vascular Transplant Other Anesthesia duration (min, mean SD) Surgery duration (min, mean SD)
5359 (56.3) 4163 (43.7) 1639 (17.2) 9.0 5.0
Surgical group
Table 1 Demographic and clinical characteristics of overall pediatric surgical population
Other Thoracic Transplant Dental and Oral Vascular Ophthalmologic Plastic Urologic Cardiac General Oncologic Neurosurgery Orthopedic Ob/Gyn ENT
16.6 4.0 17.7 4.6 22.0 6.1 119.0 28.3 134.8 27.1 133.7 28.7 29.1 20.9 38.8 24.1 38.0 22.4 2861 (30.0) 3579 (37.6) 3082 (32.4) 2326 (24.4) 1656 (17.4) 1410 (14.8) 1200 (12.6) 988 (10.4) 481 (5.1) 398 (4.2) 274 (2.9) 248 (2.6) 198 (2.1) 130 (1.4) 83 (0.9) 69 (0.7) 39 (0.4) 22 (0.2) 127 103 76 83
Figure 1. The ENT group had the highest obesity prevalence at 21.7% (360/1656). Compared with the overall surgical population, ENT patients were younger (mean
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
% Obese
Figure 1 Obesity prevalence by surgical groups. The prevalence of obesity was 21.7% in ENT patients (360/1656), 20.5% in obstetrics and gynecology patients (17/83), 20% in orthopedic surgery patients (282/1410), 18.8% in neurosurgery patients (75/398), 17.7% in oncologic surgery patients (85/481), 16.2% in general surgery patients (376/2326), 14.9% in cardiac surgery patients (179/1200), 14.1% in urologic surgery patients (139/988), 13.6% in plastic surgery patients (27/198), 13.3% in ophthalmologic surgery patients (33/248), 13% in vascular surgery patients (9/69), 12.8% in dental and oral surgery patients (35/274) and transplant surgery patients (5/39), 12.3% in thoracic surgery patients (16/130), and 4.5% in all other patients (1/22).
age SD = 7.1 4.3 years vs 9.0 5.0 years) and ‘healthier’, according to ASA status (% ASA 1 or 2 = 87.6% vs 67.6%). Detailed demographics of the ENT obese and nonobese patients are summarized in Table 3. Anesthesia and surgery durations in obese vs nonobese ENT patients having tonsillectomy, adenoidectomy, or both We reviewed anesthetic and surgical durations in obese vs nonobese children across all surgical groups (Figure 2). To specifically examine whether obesity increased anesthesia duration, we analyzed the surgery and anesthesia durations in a subgroup of ENT patients who had tonsillectomy, adenoidectomy, or both as identified by surgical procedure codes in their records (n = 1174). The prevalence of obesity in this subgroup was 22.1% (obese = 259, nonobese = 915). The demographics of this subgroup are further
Table 2 Age- and sex-specific obesity prevalence in overall pediatric surgical populationa Age-groups (years)
Total n = 9522
BMI (kgm 2, mean SD)
Obese (%)
Obese males (%)
Obese females (%)
2–5 6–9 ≥10
2849 2317 4356
16.6 4.0 17.7 4.6 22.0 6.1
425 (14.9) 444 (19.2) 770 (17.7)
253/1639 (15.4) 274/1312 (20.9) 423/2408 (17.6)
172/1210 (14.2) 170/1005 (16.9) 347/1948 (17.8)
Sex–age group interaction on obesity was not significant (P = 0.11) using logistic regression.
a
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Table 3 Demographic and clinical characteristics of ENT population All ENT Obese, n = 360 Sex Male (%) Female (%) Age (years, mean SD) BMI (kgm 2, mean SD) 2–5 years 6–9 years ≥10 years Height (cm, mean SD) 2–5 years 6–9 years ≥10 years Weight (kg, mean SD) 2–5 years 6–9 years ≥10 years ASA (%) 1 2 ≥3 Anesthesia duration (min, mean SD) Surgery Duration (min, mean SD)
Tonsillectomy, adenoidectomy, or both Nonobese, n = 1296
Total, n = 1656
Obese, n = 259
Nonobese, n = 915
Total, n = 1174
P-value
209 (58.1) 151 (41.9) 7.3 4.0
720 (55.6) 576 (44.4) 7.0 4.4
929 (56.1) 727 (43.9) 7.1 4.3
134 (51.7) 125 (48.3) 7.0 3.8
502 (54.9) 413 (45.1) 6.0 3.7
636 (54.2) 538 (45.8) 6.2 3.8
0.37*
21.9 6.4 24.0 3.2 31.2 5.8
15.6 1.5 16.1 2.0 20.0 3.6
16.8 3.9 18.3 4.3 22.4 6.2
21.3 4.6 23.5 7.2 30.1 3.5
15.6 1.6 16.1 1.9 20.0 3.5
16.6 3.2 18.3 4.1 22.8 5.8
100.3 15.3 128.3 13.0 156.7 16.1
101.0 10.1 125.2 9.6 157.3 14.4
100.9 11.2 126.1 10.7 157.2 14.8
103.9 13.6 128.5 10.6 157.3 12.9
101.4 10.3 124.4 8.8 155.9 13.1
101.8 11.0 125.6 9.5 156.3 13.0
21.7 6.2 40.1 10.7 78.1 24.7
16.0 3.3 25.4 5.5 50.6 15.1
17.1 4.6 29.6 9.9 56.6 21.0
23.0 6.5 39.1 8.5 75.9 18.9
16.1 3.3 25.1 5.1 49.4 13.7
17.3 4.9 29.3 9.0 56.7 19.3
104 (28.9) 211 (58.6) 45 (12.5) 91 63
503 (38.8) 633 (48.9) 160 (12.3) 88 65
607 (36.7) 844 (50.9) 205 (12.4) 89 64
80 (30.9) 164 (63.3) 15 (5.8) 76 24
354 (38.7) 502 (54.9) 59 (6.4) 70 21
434 (37.0) 666 (56.7) 74 (6.3) 72 22
0.33**
53 54
52 57
52 57
37 17
35 18
35 18
0.61**
0.08*
*P-values were generated with the Pearson chi-square statistic. **P-values were derived from the multiple linear regression model, adjusting for surgeon, season, surgical procedure code, and ASA status.
depicted in Table 3. We specifically chose the subgroup of patients who had tonsillectomy, adenoidectomy, or both for two reasons: (1) These were the most common procedures performed in the ENT cohort, which had the highest obesity prevalence of all surgical groups. (2) While the surgical approach in these patients was unlikely to be affected by obesity, we would expect the anesthetic implications of obesity to still be present, making this an ideal group to analyze whether obesity prolongs anesthesia duration specifically. We confirmed that in this ENT subgroup, obesity was not associated with a longer surgery duration (obese 37 17 min vs nonobese 35 18 min, P = 0.61) after adjusting for surgeon, season, surgical procedure code, and ASA status in the multiple linear regression model. In these patients, obesity was also not associated with a prolongation of the anesthesia duration (obese 76 24 min vs nonobese 70 21 min, P = 0.33). The only independent predictor of both longer anesthesia and surgery durations was older age (P < 0.01, Table 4). 1040
Discussion Epidemiology of obesity in the pediatric surgical population This study showed that the pediatric surgical population of a major metropolitan hospital in New York had an obesity prevalence from 2009 to 2010 (17.2%), paralleling the concurrent prevalence for obesity nationwide [16.9% from (1) and (2)]. There were no significant differences in age- or sex-specific prevalence of obesity (P = 0.11). These results are in contrast to NHANES 2009–2010 data, in which male sex and older age were associated with higher rates of childhood obesity in the United States (2). The pediatric obesity rate in our New York surgical cohort (17.2%) was comparable to those reported in previous epidemiologic studies from Michigan [17.2% in (14)] and Texas [20% in (15)], which are both states with significantly higher adult obesity rates [>30% from (19)] than New York [23.9% from (19)]. Our study suggests that obesity prevalence may be distinct between adults and pediatric patients. That is, © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 1037–1043
J.J. Lee et al.
Pediatric obesity and anesthesia duration
Anesthesia duration - Obese
Oncologic
Anesthesia duration - Non-Obese
Other
Surgery duration - Obese Surgery duration - Non-Obese
Thoracic ENT
Urologic
Surgical group
General Ob/Gyn Ophthalmologic Plastic Dental and Oral Vascular Orthopedic Cardiac Neurosurgery Transplant 0
50
100
150
200
250
300
350
400
450
500
Time (min) Figure 2 Anesthesia and surgery durations by surgical groups and obesity status. Anesthesia and surgery durations (mean SD) are reported for each of the surgical groups by obesity status. Standard deviations are not shown to simplify the graphic presentation. Details are as below (anesthesia duration in obese vs nonobese patients, surgery duration in obese vs nonobese patients): transplant surgery (455 95 vs 429 184 min, 340 81 vs 271 154 min), neurosurgery (267 161 vs 250 151 min, 166 131 vs 152 125 min), cardiac surgery (173 96 vs 166 94 min, 106 80 vs 104 77 min), orthopedic surgery (169 119 vs 181 131 min, 105 96 vs 113 107 min), vascular surgery (167 91 vs 162 81 min, 79 49 vs 94 70 min), dental and
oral surgery (162 69 vs 182 85 min, 107 59 vs 123 77 min), plastic surgery (150 91 vs 136 75 min, 95 80 vs 84 74 min), ophthalmologic surgery (125 44 vs 118 53 min, 76 44 vs 71 47 min), obstetrics and gynecology (106 73 vs 108 84 min, 63 58 vs 67 74 min), general surgery (103 60 vs 94 79 min, 60 53 vs 53 71 min), urologic surgery (92 57 vs 105 76 min, 49 48 vs 61 67 min), ENT surgery (91 63 vs 88 65 min, 53 54 vs 52 57 min), thoracic surgery (85 48 vs 121 95 min, 38 32 vs 68 75 min), all other surgery (58 0 vs 43 10 min, 30 0 vs 19 7 min), and oncologic surgery (56 44 vs 49 34 min, 26 32 vs 22 25 min).
Table 4 Analysis of sex, obesity, and age on anesthesia and surgery durationsa Anesthesia duration
Variable Female Sex Obesity Age
Regression coefficient estimate (95% confidence interval) 0.94 ( 3.11 to 1.22) 1.30 ( 1.33 to 3.94) 0.05 (0.02–0.07)
Surgery duration
Wald v2
P-value
0.73 0.94 14.55
0.39 0.33
![[Pediatric anesthesia in ear nose throat (ENT) surgery].](/assets/img/hold.png)
