title: Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk.
abstract: 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.
authors.affiliation: 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
authors.forename: Scott D
authors.initials: SD
authors.lastname: Cook-Sather
authors.forename: Paul R
authors.initials: PR
authors.lastname: Gallagher
authors.forename: Lydia E
authors.initials: LE
authors.lastname: Kruge
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Beus
authors.forename: Brian P
authors.initials: BP
authors.lastname: Ciampa
authors.forename: Kevin Conor
authors.initials: KC
authors.lastname: Welch
authors.forename: Sina
authors.initials: S
authors.lastname: Shah-Hosseini
authors.forename: Jieun S
authors.initials: JS
authors.lastname: Choi
authors.forename: Reshma
authors.initials: R
authors.lastname: Pachikara
authors.forename: Kim
authors.initials: K
authors.lastname: Minger
authors.forename: Ronald S
authors.initials: RS
authors.lastname: Litman
authors.forename: Mark S
authors.initials: MS
authors.lastname: Schreiner
mesh_terms: D000768:Anesthesia, General / Q000592:standards; D015992:Body Mass Index; D002648:Child; D002675:Child, Preschool; D005215:Fasting; D005260:Female; D005750:Gastric Juice / Q000378:metabolism*; D005766:Gastrointestinal Contents / Q000737:chemistry; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D009765:Obesity / Q000150:complications*; D050177:Overweight / Q000150:complications*; D053120:Respiratory Aspiration / Q000517:prevention & control*; D013514:Surgical Procedures, Operative / Q000379:methods* / Q000592:standards