sábado, 3 de septiembre de 2011

Obesidad infantil

Complicaciones metabólicas de la obesidad infantil
D. Yeste, y A. Carrascosa
Servicio de Pediatría, Unidades de Endocrinología y Obesidad Pediátrica, Hospital Universitario Vall d' Hebron, Barcelona,
Universidad Autónoma de Barcelona, Barcelona, España
An Pediatr (Barc). 2011;75(2):135.e1-135.e9
 La obesidad es el trastorno nutricional más frecuente durante la infancia y adolescencia. El incremento de su prevalencia y de la intensidad del exceso ponderal han puesto de manifiesto las numerosas e importantes comorbilidades asociadas a la misma. La hiperinsulinemia y la resistencia a la insulina son el eje central del desarrollo posterior de estados de intolerancia a la glucosa, diabetes tipo 2 y/o síndrome metabólico. El depósito de grasa en el espacio visceral abdominal y en el espacio miocelular, y no la obesidad per se, es el principal factor independiente de riesgo para desarrollar resistencia a la insulina y el síndrome metabólico. Otros elementos del síndrome metabólico, como la dislipemia y la hipertensión pueden también estar ya presentes en los ni˜nos y adolescentes obesos y están estrechamente relacionados con el grado de adiposidad y con la presencia de resistencia a la insulina. En el transcurso de los últimos año se ha comprobado que la persistencia de la obesidad y de sus alteraciones metabólicas en la edad adulta incrementa de forma significativa el riesgo de presentar enfermedad cardiovascular degenerativa precoz y determina una menor esperanza de vida.

 Sobrepeso/obesidad y características del fluido gástrico en cirugía pediátrica del mismo día: implicaciones para las guías de ayuno y riesgo de aspiración pulmonar
Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk.
Cook-Sather SD, Gallagher PR, Kruge LE, Beus JM, Ciampa BP, Welch KC, Shah-Hosseini S, Choi JS, Pachikara R, Minger K, Litman RS, Schreiner MS.
Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4399, USA. sather@email.chop.edu
Anesth Analg. 2009 Sep;109(3):727-36.
BACKGROUND: The safety of 2-h preoperative clear liquid fasts has not been established for overweight/obese pediatric day surgical patients. Healthy children and obese adults who fasted 2 h have small residual gastric fluid volumes (GFVs), which are thought to reflect low pulmonary aspiration risk. We sought to measure the prevalence of overweight/obesity in our day surgery population. We hypothesized that neither body mass index (BMI) percentile nor fasting duration would significantly affect GFV or gastric fluid pH. In children who were allowed clear liquids up until 2 h before surgery, we hypothesized that overweight/obese subjects would not have increased GFV over lean/normal subjects and that emesis/pulmonary aspiration events would be rare. METHODS: Demographics, medical history, height, and weight were recorded for 1000 consecutive day surgery patients aged 2-12 yr. In addition, 1000 day surgery patients (age 2-12 yr) undergoing general endotracheal anesthesia were enrolled. After tracheal intubation, a 14-18F orogastric tube was inserted and gastric contents evacuated. Medications, fasting interval, GFV, pH, and emetic episodes were documented. Age- and gender-specific Center for Disease Control and Prevention growth charts (2000) were used to determine ideal body weight (IBW = 50th percentile) and to classify patients as lean/normal (BMI 25th-75th percentile), overweight (BMI > or = 85th to <95th percentile), or obese (BMI > or = 95th percentile). RESULTS: Of all day surgery patients, 14.0% were overweight and 13.3% were obese. Obese children had lower GFV per total body weight (P < 0.001). When corrected for IBW, however, volumes GFV(IBW) were identical across all BMI categories (mean 0.96 mL/kg, sd 0.71; median 0.86 mL/kg, IQR 0.96). Preoperative acetaminophen and midazolam contributed to increased GFV(IBW) (P = 0.025 and P = 0.001). Lower GFV(IBW) was associated with ASA physical status III (P = 0.024), male gender (P = 0.012), gastroesophageal reflux disease (P = 0.049), and proton pump inhibitor administration (P = 0.018). GFV(IBW) did not correlate with fasting duration or age. Decreased gastric fluid acidity was associated with younger age (P = 0.005), increased BMI percentile (P = 0.036), and African American race (P = 0.033). Emesis on induction occurred in eight patients (50% of whom were obese, P = 0.052, and 75% of whom had obstructive sleep apnea, P = 0.061). Emesis was associated with increased ASA physical status (P = 0.006) but not with fasting duration. There were no pulmonary aspiration events. CONCLUSIONS: Twenty-seven percent of pediatric day surgery patients are overweight/obese. These children may be allowed clear liquids 2 h before surgery as GFV(IBW) averages 1 mL/kg regardless of BMI and fasting interval. Rare emetic episodes were not associated with shortened fasting intervals in this population

 ¿Influencia el IMC elevado los gastos de niños a los que se les realiza adenoamigdalectomía?
Does high BMI influence hospital charges in children undergoing adenotonsillectomy?
Nafiu OO, Chimbira WT, Woolford SJ, Tremper KK, Reynolds PI, Green GE.
Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA. onafiu@med.umich.edu
Obesity (Silver Spring). 2008 Jul;16(7):1667-71. Epub 2008 Apr 17.
BACKGROUND: Obesity is a highly prevalent chronic problem with health and fiscal consequences. Data from adults and nonsurgical pediatric patients suggest that obesity has serious implications for the US economy. OBJECTIVE: Our goal was to describe the impact of BMI on hospital charges in children undergoing adenotonsillectomy (AT). METHODS AND PROCEDURES: We carried out a retrospective comparative analysis of the electronic anesthesia record and the charges from billing data from a large tertiary institution on children aged 3-18 years who had AT during the year 2005-2007. The main outcome measures were mean total hospital charges, likelihood of admission, and length of hospital stay (LOS). RESULTS: Of 1,643 children, 68.9% were aged <10 years, 76% were whites, and 74.1% had private commercial insurance. Most (75.3%) children were discharged on the day of surgery. Obese and overweight children were more likely to be admitted than their normal-weight peers (X(2)=26.3, P<0.001). Among those admitted, BMI showed a positive correlation with LOS (r=0.20, P<0.001). Obese and overweight patients had significantly higher total hospital charges than their healthy-weight counterparts (P=0.001). Anesthesia, postanesthesia care unit (PACU), and pharmacy and laboratory charges were also higher for obese than normal-weight children (P<0.05). DISCUSSION: Overweight and obese children undergoing AT accrued higher hospital charges and had longer postoperative LOS than their healthy-weight peers. If these findings are extendable to other surgical procedures, they could have far-reaching implications for the US economy.


Anestesia para pacientes pediátricos con síndrome de Prader-Willi: informe de dos casos
Anesthesia for pediatric patients with Prader-Willi syndrome: report of two cases.
Tseng CH, Chen C, Wong CH, Wong SY, Wong KM.
Department of Anesthesiology, Chang Gung Children's Hospital, Taoyuan, Taiwan, R.O.C.
Chang Gung Med J. 2003 Jun;26(6):453-7.
Prader-Willi syndrome (PWS) is a sporadic disorder of chromosome abnormalities with an estimated prevalence of 1 in 15,000. It mainly affects the central nervous system, and often involves the hypothalamus. Both general and regional anesthesia for these patients is difficult mainly due to morbid obesity. Other common problems include hypotonia, disturbance in thermoregulation, arrhythmia, cor pulmonale, diabetes mellitus, behavior problems, and convulsions. We report on 2 pediatric patients with PWS receiving general anesthesia. The first patient experienced life-threatening episodes of severe hypoxemia in the postanesthesia care unit (PACU) as well as in the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (CPAP) was suggested by the pediatric pulmonary medicine specialist, and thereafter the patient's condition improved. The clinical course of the second patient was uneventful except for transient intermittent episodes of bronchospasms during emergence. In addition, we discuss differences between these 2 cases and our strategy for the prevention of perioperative complications for PWS patients in the future.

Dr. Enrique Hernández-Cortez
Anestesiología y Medicina del Dolor
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