title: Evaluation of propofol anesthesia in morbidly obese children and adolescents.
abstract: BACKGROUND
  Poor characterization of propofol pharmacokinetics and pharmacodynamics in the morbidly obese (MO) pediatric population poses dosing challenges. This study was conducted to evaluate propofol total intravenous anesthesia (TIVA) in this population.
  
  
  METHODS
  After IRB approval, a prospective study was conducted in 20 MO children and adolescents undergoing laparoscopic surgery under clinically titrated propofol TIVA. Propofol doses/infusion rates, hemodynamic variables, times to induction and emergence, and postoperative occurrence of respiratory adverse events (RAE) were recorded, along with intraoperative blinded Bispectral Index/BIS and postoperative Ramsay sedation scores (RSS). Study subjects completed awareness questionnaires on postoperative days 1 and 3. Propofol concentrations were obtained at predetermined intra- and post-operative time points.
  
  
  RESULTS
  Study subjects ranged 9 - 18 years (age) and 97 - 99.9% (BMI for age percentiles). Average percentage variability of hemodynamic parameters from baseline was ≈ 20%. Patients had consistently below target BIS values (BIS < 40 for >90% of maintenance phase), delayed emergence (25.8 ± 22 minutes), increased somnolence (RSS ≥ 4) in the first 30 minutes of recovery from anesthesia and 30% incidence of postoperative RAE, the odds for which increased by 14% per unit increase in BMI (p ≤ 0.05). Mean propofol concentration was 6.2 mg/L during maintenance and 1.8 mg/L during emergence from anesthesia.
  
  
  CONCLUSIONS
  Our findings indicate clinical overestimation of propofol requirements and highlight the challenges of clinically titrated propofol TIVA in MO adolescents. In this setting, it may be advantageous to titrate propofol to targeted BIS levels until more accurate weight-appropriate dosing regimens are developed, to minimize relative overdosing and its consequences.
authors.affiliation: Department of Anesthesia and Paediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH, 45229, USA ; University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Vidya
authors.initials: V
authors.lastname: Chidambaran
authors.affiliation: Department of Anesthesia and Paediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH, 45229, USA ; University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Senthilkumar
authors.initials: S
authors.lastname: Sadhasivam
authors.affiliation: Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Diepstraten
authors.affiliation: Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
authors.forename: Hope
authors.initials: H
authors.lastname: Esslinger
authors.affiliation: Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
authors.forename: Shareen
authors.initials: S
authors.lastname: Cox
authors.affiliation: Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
authors.forename: Beverly M
authors.initials: BM
authors.lastname: Schnell
authors.affiliation: Department of Anesthesia and Paediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH, 45229, USA ; University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Samuels
authors.affiliation: Division of Paediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA ; University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Inge
authors.affiliation: Division of Clinical Pharmacology and Department of Paediatrics, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, USA ; University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Vinks
authors.affiliation: Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, Netherlands ; Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Catherijne A
authors.initials: CA
authors.lastname: Knibbe
keywords: Adolescents; Anesthetic depth; Bariatric; Bispectral index; Morbidly obese; Pediatric; Propofol; Total intravenous anesthesia