San Diego—A survey by the Society for Pediatric Anesthesia (SPA) found that many ambulatory surgery centers (ASCs) do not have specific body mass index percentile criteria for case suitability, despite widespread agreement that childhood obesity is associated with increased perioperative morbidity and should be accounted for in the patient’s ASA classification.
“The amount of pediatric ambulatory surgery performed in the United States has been increasing on a yearly basis,” said Audra Webber, MD, an associate professor of anesthesiology and perioperative medicine at the University of Rochester School of Medicine and Dentistry, in New York. “In addition, the number of obese pediatric surgical patients in the United States continues to rise, and in fact, more and more children are being diagnosed with obesity at earlier ages.
“At the intersection of these two issues, we see that childhood obesity is at an all-time high, and obese and severely obese children are presenting for ambulatory surgery at increasing rates,” Webber said.
Webber and her colleagues sought to determine whether BMI percentile is used as a selection criterion for pediatric ambulatory surgery and, if so, the percentile cutoff used. They also assessed the association between BMI percentile and choice of ASA physical status classification. (The survey was created and distributed prior to publication of the ASA’s new pediatric physical status examples, which are available here: https://bit.ly/33J0kOb.)
“This is important because ASA physical status is frequently used to determine a child’s suitability for ambulatory surgery and is used in surgical outcomes analyses,” Webber explained. “It is also important to remember that in pediatric anesthesia we do not use straight BMI to categorize patients into obese/nonobese categories. Instead, BMI percentile by age/sex is the measurement of significance.”
To help answer these questions, the investigators emailed the questionnaire to the 3,245 SPA members in July 2020. The survey comprised 10 questions regarding anesthesiologists’ approach to caring for children with obesity, including classification of ASA physical status, and 10 other questions addressing criteria that anesthesiologists used to determine ASC eligibility as a care setting for obese pediatric patients.
Pediatric ASCs More Likely To Use BMI Criteria
In a presentation during the 2021 annual meeting of the American Society of Anesthesiologists (abstract A3007), Webber reported that a total of 455 SPA members responded to the survey, a 14.0% response rate. Among respondents, the majority had practices that were predominantly pediatric (81.7%) and worked at ASCs (58.2%).
The survey found that although the overwhelming majority of respondents (94.6%) believed that obese children have more perioperative complications than nonobese children, and considered obesity status when assigning ASA physical status (96.8%), only 54.5% of the ASCs represented by the respondents had specific BMI percentile criteria for pediatric patients. It was also found that pediatric-only ASCs were more likely to use BMI percentile criteria (Figure 1) than ASCs that treated adults and children (Figure 2; adjusted odds ratio [aOR], 4.1; 95% CI, 2.3-7.4; P<0.001), regardless of the academic affiliation of the ASC (aOR, 1.2; 95% CI, 0.6-2.2; P=0.64).
Among those ASCs that employed BMI percentile criteria, 46.7% used a BMI cutoff greater than the 95th percentile, while 45.6% used a cutoff greater than the 99th percentile (Figure 3).
“This is considered obesity and morbid obesity, respectively, in pediatric patients,” Webber explained.
Perhaps not surprisingly, the patient ages when these cutoffs were applied also varied markedly. Indeed, 52.2% of ASCs applied them to all ages, 8.0% at 12 to 24 months, 8.8% at 25 to 36 months and 31.0% at greater than 36 months. Finally, 74.6% of these ASCs used BMI percentile criteria for all surgeries, while the remainder utilized BMI percentile criteria for certain types of surgical procedures.
“Our survey found a majority of pediatric anesthesiologists provide care to patients at ambulatory surgery centers,” Webber concluded. “However, about half of ambulatory centers do not use BMI percentile as exclusion criteria for pediatric patients, even though the majority of respondents think that pediatric obesity contributes to more perioperative complications.
“Finally,” she added, “if BMI percentile criteria are utilized at an ambulatory center, the application of criteria is variable across the United States. There is no overall consensus.”
Given such variability, the investigators said more research is required to establish best practices for obese and severely obese pediatric patients undergoing surgeries at ASCs.
For Peter J. Davis, MD, using BMI percentile as a bellwether for excluding children from ambulatory surgery is a challenging undertaking, given the many variables that can potentially come into play when making that decision.
“When it comes to pediatric patients undergoing ambulatory surgery, we already know the incidence of those complications that really make a difference in outcomes,” he told Anesthesiology News. “And we find that those complications occur at all BMI percentiles, whether patients are nonobese or obese.
“It also depends on how an ASC is set up,” continued Davis, the Dr. Joseph H. Marcy Endowed Chair in Pediatric Anesthesiology at UPMC Children’s Hospital of Pittsburgh. “Each center probably comes with its own criteria in terms of how it is staffed, which may determine which patients can be operated on.”
—Michael Vlessides
Davis reported financial relationships with Paion/Acacia Pharma. He is a member of the Anesthesiology News editorial advisory board. Webber reported no relevant financial disclosures.
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