Since we published the PAAD on the AAP’s new pediatric obesity guidelines/recommendations (January 26, 2023) several readers asked me to clarify some of the issues raised in the AAP recommendations as they pertain to perioperative anesthetic care. I asked my co-author Lynne Maxwell to respond. Myron Yaster MD
We frequently care for children with obesity undergoing surgery for conditions which occur more commonly in this population than in children of normal weight, such as tonsillectomy for obstructive sleep apnea, hip or knee surgery for slipped capital femoral epiphysis or Blount’s disease. Perioperative planning for these patients must address risks associated with obesity such as airway obstruction, positioning, hypertension and metabolic derangements. As described in the guidelines, more of these patients may be taking medications for type 2 diabetes (T2DM) or to facilitate weight loss such as metformin or Glucagon-like peptide-1 receptor agonists (GLP-1 RAs). Contrary to the recommendations for stopping metformin 48 hours before surgery because of concerns for lactic acidosis, the benefit of improved glucose control afforded by the peptide-1 receptor agonists have led adult anesthesiologists to recommend that these drugs be continued in the perioperative period. Perioperative studies of long-acting GLP-1 RAs showed better glycemic control compared with placebo or standard care with insulin in the perioperative period without a higher risk for developing hypoglycemia. Side-effects, most frequently gastrointestinal in nature, are mostly mild and diminish over time. Historically, non-insulin glucose-lowering medications are stopped on the day of surgery. In light of the current evidence, continuation of these drugs is a safe and effective practice with regard to glycemic control and side-effects. We therefore recommend that all GLP-1 RAs be continued during the perioperative period. On the other hand, there are anecdotal reports that these drugs, especially the longer acting ones administered weekly subcutaneously, may exacerbate the delayed gastric emptying seen in patients with diabetes. It is not clear that this adverse effect occurs to the same extent in patients taking the drugs for weight loss and it is unknown whether this occurs in pediatric patients, in whom these drugs are only beginning to be used.
Reader response from Mark Schreiner MD I don’t think there is any data to demonstrate that the obese patient should be treated as if they had a “full stomach”. Whether or not they meet the criteria for having a potentially difficult airway is another matter.
Cook-Sather SD, Gallagher PR, Kruge LE, et al. Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk. AnesthAnalg. 9/2009 2009;109(3):727-736. Not in File.
Schreiner MS. Gastric fluid volume: is it really a risk factor for pulmonary aspiration? Anesthesia and analgesia. Oct 1998;87(4):754-6. doi:10.1097/00000539-199810000-00002