International Journal of Pediatric Otorhinolaryngology (2009) 73, 8995

www.elsevier.com/locate/ijporl

Obesity and risk of peri-operative complications in children presenting for adenotonsillectomy

Olubukola O. Nau a,*, Glenn E. Green b, Sarah Walton a, Michelle Morris a, Sudheera Reddy a, Kevin K. Tremper a
a b

Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA Pediatric Otorhinolaryngology, University of Michigan, Ann Arbor, MI, USA

Received 27 July 2008; received in revised form 21 September 2008; accepted 28 September 2008 Available online 8 November 2008

KEYWORDS
Obesity; Overweight; Adenotonsillectomy; Peri-operative complications

Summary Background: Adenotonsillectomy (T&A) is a very common surgical procedure in children. With the rising prevalence of childhood overweight and obesity, our goal was to describe the prevalence of overweight/obesity in children presenting for T&A in our institution. We also sought to compare the frequency of peri-operative complications and the likelihood of being admitted following T&A between overweight/obese and normal weight children. Methods: We examined our peri-operative database and extracted clinical, demographic and anthropometric information on 2170 children who underwent T&A between January 2005 and February 2008. Children were classied into normal weight, overweight and obese using published body mass index (BMI) criteria. The incidences of perioperative complications were compared between the BMI categories. We also examined factors contributing to the likelihood of admission following T&A. Results: The overall prevalence of overweight and obese was 20.7%. Overweight/ obese children were more likely to have intra-operative desaturation ( p = 0.004), multiple attempts at laryngoscopy ( p < 0.001), difcult mask ventilation ( p = 0.001), and post-induction and post-anesthesia care unit (PACU) upper airway obstruction ( p < 0.001). Additionally, overweight and obese children were more likely to be admitted following T&A. BMI showed a moderate positive correlation with postoperative length of stay (LOS). Multiple logistic regression analysis showed that BMI and presence of medical co-morbidities were independent predictors of LOS. Conclusion: Overweight and obese children presenting for T&A have a higher incidence of peri-operative complications and are more likely to be admitted and stay for longer than their healthy weight peers. Published by Elsevier Ireland Ltd.

* Corresponding author. Department of Anesthesiology, University of Michigan, Room UH 1H247, Ann Arbor, MI 48109-0048, USA. Tel.: +1 734 936 4280; fax: +1 734 936 9091. E-mail address: onau@med.umich.edu (O.O. Nau). 0165-5876/$ see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.ijporl.2008.09.027

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O.O. Nau et al. the square of the height in meters (BMI = kg/m2). Children were classied as normal weight (BMI < 85th percentile), overweight (BMI > 85th and < 95th percentile), or obese (BMI ! 95th percentile) using age and gender-specic reference growth charts from the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) [8]. The indications for T&A such as recurrent tonsillitis, sleep disordered breathing (SDB) were noted. SDB was dened by history of habitual loud snoring with or without observed cessation of breathing by the parents or caregivers. The proportion of overweight and obese patients between male and female patients was compared. We also noted the presence of medical co-morbidities such as hypertension, bronchial asthma and diabetes. These diagnoses were based on the parents or caregivers report at the time of surgery or from the patients outpatient clinic notes. Complications were described under several broad headings. Airway complications included difcult mask ventilation (measured using a four-point scale previously described by Han et al. [9]), difcult laryngoscopy (dened by Cormack and Lehane [10] grade >2), more than one attempt at laryngoscopy (multiple laryngoscopy), signicant desaturation (dened by any recorded intra-operative SPO2 value < 90%), and dental injury. All desaturation events were recorded by continuous pulse oximetry. Anesthesia care in our facility is 100% supervised by attending pediatric anesthesiologists. The method and choice of induction of anesthesia is at the discretion of the attending staff. Typically the rst attempt at mask ventilation and laryngoscopy are performed by an anesthesiology resident, a pediatric anesthesia fellow, or a nurse anesthetist. In all cases mask ventilation was accomplished with a disposable, clear plastic mask (King Systems Corporation Noblesville, IN), while laryngoscopy was performed with a beroptic laryngoscope handle and blade (Heine Inc., Dover, NH). Upper airway obstruction was dened as, requirement of oral or nasal airway adjuvant to maintain airway patency. Hypertension was dened as history of or use of anti-hypertensive medications. Diabetes was dened based on the use of oral hypoglycemic agents or insulin. The length of stay (LOS) following surgery was noted. LOS was measured in days; and a value of zero meant the child was discharged on the day of surgery. Additionally because majority (76%) of patients were same-day discharge (after a few hours PACU stay), we dichotomized LOS into admitted or not for ease of intergroup comparison. Correlation coefcients between LOS and BMI, age, SDB diagnosis (yes or no) and

1. Introduction
During the last three decades, the United States (US) has witnessed a tripling of the prevalence of childhood obesity making this an ongoing clinical and public health crisis [1]. This secular trend in the prevalence of obesity means that an increasing number of children presenting for anesthesia and surgery will be either overweight or obese. We recently showed that 31% of the pediatric surgical population at our institution was either overweight or obese [2]. Adenotonsillectomy (T&A) is one of the most common major surgical procedures performed in children [3]. Conservative estimates are that about 300,000 T&A are performed annually in the US [4]. Additionally, T&A is often performed for symptomatic relief of obstructive sleep apnea (OSA), a condition that is more prevalent in overweight and obese children [5]. Only a few studies have examined the subject of obesity in children presenting for T&A [6,7]. However these studies had small sample sizes and only focused on the morbidly obese child. There are currently no data specically describing the prevalence of overweight and obesity or the likelihood of peri-operative complications in this group of patients. Therefore, our study had two objectives: (1) to describe the prevalence of overweight and obesity in children presenting for T&A, and (2) to examine the association between BMI and peri-operative complications in the same group of patients.

2. Methods
The University of Michigan Institutional Review Board (Ann Arbor, MI) approved this retrospective review of our clinical information system (Centricity1 General Electric Healthcare, Waukesha, WI). This system was designed to serve not only clinical purposes, but also to collect data for observational research studies and it includes a structured, electronic pre-operative history and physical on every patient. Data are entered by residents, attending anesthesiologists, and certied registered nurse anesthetists (CRNA) as part of routine clinical duties. We reviewed data for the period between January 1 2005 and February 1 2008. We extracted the following data on all children who underwent T&A during the study period: age, gender, ethnicity, American Society of Anesthesiology (ASA) classication, height and weight. We routinely measure height and weight of all children prior to anesthesia and elective surgery at our institution. Body mass index (BMI) was calculated as weight in kg divided by

Obesity and risk of peri-operative complications in children presence or absence of co-morbidities were also computed. We excluded children aged below 3 years because these are routinely admitted following T&A in our institution. We also excluded children with secondary causes of obesity such as Prader-Willi syndrome, Cushings syndrome or the nephrotic syndrome from the study. Children with chronic lung disease, laryngo-tracheomalacia, neuromuscular disease and those with concurrent surgical procedures that could prolong the duration of anesthesia and surgery were also excluded.

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BMI, age, gender, SDB, and presence or absence of medical co-morbidity as independent variables. Multiple logistic regression models were constructed for the dependent variable and the independent variables that showed signicant correlation with LOS. An alpha level of 0.05 (two-tailed) was selected to indicate statistical signicance.

4. Results
After excluding 18 records due to incomplete BMI data, we analyzed the data on 2170 children who had T&A. There were 1210 (55.8%) males and 960 (44.2%) females. The mean age of the population was 6.5 4.1 while the mean BMI was 19.1 5.2 kg/m2. The prevalence of overweight was 13.1% and obesity was 7.5%. As expected, BMI showed a moderate positive correlation with age (r = 0.53, p < 0.001) in the entire cohort of patients. There was no signicant difference in the prevalence of overweight or obesity between male and female patients (14.1% vs. 12.6% for overweight and 7.2% vs. 6.2% for obesity; , p > 0.05). The majority

3. Statistical analysis
Data analysis was carried out with SPSS V.15.0 (SPSS Inc., Chicago, IL). Basic descriptive statistics, including means, standard deviations and percentages were calculated for the demographic and anthropometric data. Pearsons Chi-square for categorical variables and one-way ANOVA were used to examine age and gender differences in the distribution of the descriptive variables. Correlation coefcients were calculated using LOS as a dependent variable and

Table 1 Demographic and clinical characteristics of healthy weight and overweight/obese adenotonsillectomy patients. Healthy weight (n = 1714) Male/female (n) Age (years) Height (m) Weight (kg) BMI (kg/m2) Race/ethnic categories (N) White African American Othersy ASA status Class I Class II Class III Indication for surgery (%) Recurrent tonsillitis SDB Medical co-morbidities (%) Asthma Diabetes Hypertension Post-op disposition (%) Admitted 982/732 6.8 (2.4) 1.16 (0.2) 24.0 (11.4) 17.0 (2.4) 761 139 108 42.9 53.2 6.9 66.4 23.3 24.0 0.8 1.1 18.7 Overweight/obese (n = 456) 284/172 10.5 (4.3) ** 1.42 (0.3) * 55.8 (23.9) ** 27.3 (5.5) ** 210 27 33 40.7 54.4 11.3 * 33.6 ** 76.7 ** 23.3 5.2 ** 8.5 ** 29.2 **

Values are means (S.D.) unless otherwise stated. * p < 0.05 (comparisons done with one-way ANOVA for continuous variables or Pearsons Chi-square test for categorical variables). ** p-Values < 0.001 (comparisons done with one-way ANOVA for continuous variables or Pearsons Chi-square test for categorical variables). y Hispanic, Asian, Native American, or unspecied. SDB, sleep disordered breathing.

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O.O. Nau et al.

Table 2 Frequency of peri-operative complications between healthy weight and overweight/obese children presenting for adenotonsillectomy. Complications Desaturation Difcult laryngoscopy Multiple laryngoscopy Grade 1 mask ventilation Grade 2 mask ventilation RSI Laryngospasm Upper airway obstruction Intra-operative PACU Healthy weight (n = 1714) 30.9 10.9 11.9 80.9 15.7 3.4 0.2 0.2 0.3 Overweight/obese (n = 456) 40.4 12.4 27.4 79.3 31.6 6.5 2.1 5.9 3.7 p-Value 0.004 0.55 0.001 0.69 0.001 0.03 0.001 0.001 0.001

All values generated with Pearsons Chi-square test. PACU, post-anesthesia care unit; RSI, rapid sequence induction.

(75.3%) of patients were discharged within 24 h of surgery. LOS for admitted patients ranged from 1 to 5 days and had a mean (S.D.) of 1.6 days (0.8 day). Obese and overweight children were more likely to be admitted than normal weight children (F = 14.04, df = 2, p < 0.001). Among those admitted, BMI showed a slight positive correlation with LOS (r = 0.20, p < 0.001). For the sample of 2170 patients, 61.9% had a pre-operative diagnosis of SDB. Preoperative diagnosis of SDB and overweight/obesity 2 were signicantly associated (X1df 179:1, p < 0.001). Patients with a pre-operative diagnosis of SDB were also more likely to be admitted than those 2 without a history of SDB (21.2% vs. 30.0%, X1df 9:4, p = 0.003). At the same time, pre-operative diagnosis of hypertension and diabetes were more frequent in overweight/obese than in normal weight children (Table 1). The distribution of other demographic and clinical parameters is shown in Table 1. The overall incidence of difcult laryngoscopy (Cormack and Lehane grades 3 or 4) was 12.3%. There was however no signicant difference in the proportion of children with difcult laryngoscopy between the healthy weight and overweight/obese children (Table 2). A higher proportion of overweight/obese

children required multiple attempts at laryngoscopy than their healthy weight peers (27.4% vs. 11.9%; p < 0.001). There was a highly signicant difference in the incidence of post-induction desaturation between overweight/obese and healthy weight patients (Table 2). Pearsons correlation matrix showing the association between LOS and age, BMI, presence or absence of SDB and presence or absence of medical co-morbidities is shown in Table 3. Interestingly LOS was not signicantly correlated with age; although the other parameters showed mild to moderate correlation with LOS. We constructed a logistic regression model to predict the likelihood of admission (LOS), based on age, BMI, presence of medical co-morbidity, and presence of SDB (Table 4). The results showed that BMI ( p < 0.001) and presence of medical comorbidities ( p < 0.05) were the only independent predictors of LOS.

5. Discussion
Our data shows that certain peri-operative complications (predominantly airway-related) are more

Table 3 Pearson correlation coefcients for factors associated with LOS (n). Parameter LOS BMI SDB Age Co-morbidity
LOS, Length of stay; BMI, body mass index; SDB, sleep disordered breathing. * p < 0.05. ** p < 0.001.

LOS

BMI 0.141 (2170)

**

SDB 0.08 (2108) 0.32 ** (1268)

**

Age 0.06 (2170) 0.52 ** (2170) 0.18 ** (2170)

Co-morbidity 0.11 ** (2102) 0.26 ** (2102) 0.06 * (2102) 0.12 ** (2102)

Obesity and risk of peri-operative complications in children

Table 4 Regression coefcients for model predicting whether patients are admitted or not (LOS) after tonsillectomy. Variables BMI SDB (yes/no) Co-morbidity Age Coefcient ( b) 0.04 0.23 0.31 0.37 S.E. 0.02 0.17 0.15 0.20 Wald X 2 6.7 1.7 3.9 3.4 p-Value 0.009 0.19 0.04 0.062

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SDB, sleep disordered breathing, BMI, body mass index.

frequent in overweight/obese children presenting for T&A than their healthy weight counterparts. We have also shown that the prevalence of overweight and obesity is high in this group of children and that whereas majority of children were discharged on the same day following T&A, overweight/obese children were more likely to be admitted and to have longer post-operative LOS than their lean peers. As the prevalence of overweight and obesity continues to increase in American children [1], it is reasonable to expect that an increasing number of children presenting for a surgical procedure like T&A will be either overweight or obese. The prevalence of overweight/obese observed in the present study is about 10% lower than estimates in the general pediatric population [10] and in our previously published data [2] of the general pediatric surgical population. This observation could be a reection of the known association of ATH and SDB with growth failure [11,12]. Some of the patho-physiologic explanations for growth failure in children with ATH and SDB include, increased sleep energy expenditure, nocturnal hypoxemia, alkalosis and impaired growth hormone secretion [13,14]. Our nding of overweight/obesity prevalence of 20% in this study may however reect a changing trend in the growth dysfunction in children with ATH: where growth failure used to be a feature, overweight/obesity is becoming increasingly common. Very few studies have looked at the incidence of peri-operative complications in obese children presenting for T&A [15,16]. These studies either did not primarily study overweight and obese children or only focused on obese children with OSA. Most also had comparatively smaller sample size. Our ndings however concurred with these studies that airway complications are common in the peri-operative period in children presenting for T&A. To date the most clearly dened risk factors for post-T&A complications have been OSA and presence of medical co-morbidity [15]. Our study shows that overweight and obesity are important pre-operative risk factors in these children. Children with higher BMI are also

likely to require oro-pharyngeal airway to maintain airway patency following induction of general anesthesia, they are more likely to require multiple attempts at laryngoscopy and have a higher incidence of signicant desaturation. While it may be argued that the skill of the laryngoscopist could affect the documented incidence of difcult airway, we have no reason to suspect that the effect of operator skill will only operate on the overweight or obese children. In all likelihood and in routine clinical practice, the more experienced laryngoscopist is often responsible for managing the airway in patients with potentially difcult airway. Unfortunately we do not have a record of the years of experience of the residents and nurse anesthetists involved in the care of the patients in this study. Overweight and obese children presenting for T&A therefore deserve extra vigilance in the peri-operative period including use of airway adjuvant, having optimal airway management equipments on hand and supplemental oxygen administration in the PACU. Our nding of a higher prevalence of pre-existing medical co-morbidities such as hypertension and diabetes in overweight/obese children agrees with published observations by others [17,18] and ourselves in the general pediatric surgical population [19]. There is still no data on how these medical comorbidities contribute to peri-operative outcome in children. There is clearly a need to prospectively study the impact of these diseases on the perioperative outcome in children with the ultimate goal of identifying risk factors for complications. Consistent with published data, majority of patients in this study were discharged within a few hours of surgery [2022]. Ambulatory T&A is now established to be a safe procedure in most patients. The duration of hospital stay following T&A varies from a few hours to several days [20]. Previously published factors associated with admission after T&A include age less than 3 years, OSA with signicant polysomnographic desaturation, post-operative pain, dehydration, bleeding and presence of craniofacial disorders [3,20]. To our knowledge, no previous study has examined the role of BMI on the likelihood of admission and the post-operative LOS following T&A in children. Our ndings suggest that BMI is an independent predictor of likelihood of admission following T&A. This may be related to the higher prevalence of OSA in obese children and the fact that this group has a higher incidence of peri-operative complications [21]. Despite the well-documented benets of day case AT: reduced hospital cost, reduced waiting time and increased patient and parental satisfaction [3,22], it may be prudent to advise parents of overweight and

94 obese children about an increased possibility of their child being admitted following T&A. Some limitations of the present study deserve consideration. Since this was a retrospective study, mechanisms used to explain outcome differences between overweight, obese and normal weight children can only be speculative. It should also be noted that we used a clinical diagnosis for SDB. While we realize that overnight polysomnography (PSG) is the gold standard for OSA diagnosis [23,24]; this is an expensive tool that is often not readily available. To this end our institution and others [25] do not routinely require pre-operative PSG in children before T&A. Our clinical SDB diagnosis was based on a history of habitual loud snoring which has been shown to be a very useful screening tool: nearly all habitual snorers have a positive sleep study [26]. We therefore applied a clinically relevant and useful pre-anesthetic tool to identify the children with SDB. Future prospective studies should consider pre-operative PSG for proper diagnosis of OSA in these children. One of the most vexing issues for the anesthesiologist is whether children with OSA should be routinely admitted after general anesthesia and surgery and if they are, how long the patient should be monitored. Unfortunately, there are inconclusive data in the literature to predict which patients can be safely managed as an outpatient as opposed to which requires mandatory admission and close monitoring [27]. It is commonly reported that early and late respiratory complications occur frequently in children with severe OSA following general anesthesia and surgery [24]. However, since many children with SDB may not have had PSG prior to being reviewed by the anesthesiologist, it may be necessary to advise parents or caregivers about the possibility of prolonged PACU stay or even admission. It is certainly prudent to suggest that children with habitual snoring, who are obese or have other medical co-morbidities should (when feasible) be referred for overnight PSG to quantify the severity of their OSA. Where PSG is impossible (for logistic or scal reasons), obese children who are habitual snorers deserves close monitoring after anesthesia and surgery. Whether these children should all be admitted overnight or longer remains to be seen. In conclusion, we have shown in a large population of children undergoing T&A, that overweight/ obese children were more likely to have airwayrelated peri-operative complications than their lean peers. Additionally, multiple regression analysis conrmed the importance of BMI and presence of medical co-morbidities in predicting the likelihood of being admitted following T&A in children. With the growing epidemic of childhood obesity, it is

O.O. Nau et al. prudent to assume that more children presenting for T&A may be either overweight or obese and have medical co-morbidities like diabetes, hypertension and asthma and may therefore require in-patient care.

Conict of interest
None.

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