Good morning. Thank you, Kyle. And thanks, everyone, like Kyle, Dr. Radhika Pooja, and my co-authors, Todd and Teresa. Without them, it's not possible to write this chapter. Hope you guys had a good flight coming here. I have a lot of ground to cover. My slides are a little busy, too, but I have highlighted stuff for you guys to follow on. I'll be touching only the most important points on each slide and like what you guys need to. And then if you have more questions, we can go with the panel discussion. I have no disclosures. So my objectives would be define obesity, talk about its prevalence, talk about, discuss about pathophysiological effects of obesity on multi-organ systems, and as well as review some of the current evidence-based acute care management for conditions affected by obesity. So some of the formulas, just to, so the definitions, like there are two definitions, like for two to 18 years, we use CDC criteria greater than 95th percentile BMI. And kids who are less than two years, we use the WHO criteria greater than 97.7th percentile. And there are other classifications, like class two, class three, BMI is greater than 120% and 140%, different definitions, tables. Coming to epidemiology, so one in five of US children are adolescents or obese, and almost 20% of kids aged two to 19 years are affected by obesity. You see a lot of high rates in Hispanic, non-Hispanic, black children, and low-income families. Coming to pathophysiological effects, so we'll come with a case, as we did in the chapter. So we have a 12-year-old male with a BMI, very obese, severe obesity, BMI of 45, comes to ED, has URI symptoms, fever. In the ED, he has, like, you know, he's tachycardic, tachypneic, hypotensive, hypoxic, requiring 40% on Venturi mask, satting only 85%. He's flu-positive. He gets flu-resuscitated. And he gets antibiotics. He gets tamiflu. His chest X-ray shows some bilateral pulmonary infiltrates. He's on high-flow nasal cannula, 40 liters, and he's requiring 100% FiO2, still hypoxic. So coming to pharmacology, regarding the sedatives and analgesics, like, we all know, like, drugs are lipophilic and hydrophilic. So some of the drugs we use, lipophilic or fentanyl, Versed and Propofol. So instead of using, like, higher doses, like, that may cause respiratory depression, use multiple small loading doses so that you can prevent respiratory depression. And for maintenance dosing, use lean body weight for maintenance dosing. Hydrophilic medications, the most common ones we use for, say, ketamine, Prestidex. So use either lean body weight or, like, you know, ideal body weight can be used. Antimicrobials, there are both types of hydrophilic or lipophilic. But you can use total body weight. Or if they are exceeding that, you can use adult flat dose. But always, always make sure, like, you're monitoring the drug levels to have a very good therapeutic effect. So coming to respiratory system, so we all know, so we've all been there. And, like, we have treated and we have seen obese kids have been in big trouble with the respiratory system. So what's going on with them? So you have a lot of abdominal pressure. Like, when someone's in pain, it pushes the diaphragm cranially. That causes airway collapse, atelectasis, decreased FRC. And they also have obstructive sleep apnea as well. So all these things actually leading to high risk of respiratory failure and intubation complications. So they are, like, you know, high risk for any. They are difficult to bag mask ventilate. And they are, like, you know, it's a high risk intubation if you are going for obese kid. So coming back to our case, the kid is still hypoxic on, comes to ICU. So kid hypoxic on high flow nasal cannula, placed in BiPAP, 10 over 5, not cutting it. So escalated to 18 over 10, with 100% of IR2. Chest x-ray also shows, that's the chest x-ray showing, like, you know, right lobe pneumonia, as well as some bilateral infiltrates. So coming to airway management. So as I said, it's high risk intubation. We all know that. So bag mask, they are difficult to bag mask ventilate. So that's because of increased upper airway obstruction. Maybe using oral airway to alleviate some of that. And also the chest wall mask also plays into that. 2% bag mask valve is helpful as well. So this is a very interesting study from NEARS. Like, it was published in 2024. So almost more than 23,000 subjects, all 8.2% were obese. They observed, like, you know, severe hypoxemia was observed in obese kids, as well as they were difficult to bag mask. And apneic oxygenation was very helpful during intubation. And obese kids had higher odds of severe peri-intubation hypoxemia. So coming, this is another interesting study about non-invasive ventilation. It was published in 2021 by Derica et al. So they actually compared intubation rates between high flow as well as CPAP or BiPAP candidates. So they had, like, subjects of 1700s, like between two to 19 years of age. And they observed, like, higher odds of endotracheal intubation with someone who was put on high flow nasal cannula than CPAP or BiPAP initially. But they also observed that, like, you know, so when someone started on CPAP or BiPAP early, they had prolonged medical and physical length of stay in PICU. So you, like, more than high, the reason they observed was, like, high flow couldn't alleviate some of the pathophysiological effects of obesity causing, pathophysiological effects causing respiratory compromise through obesity. So the BiPAP or CPAP is suggested to start, or, like, you know, if you start on high flow, high flow still hypoxic, probably moving to CPAP or BiPAP sooner than later may be helpful. So coming back to recommendations for airway management. So apneic oxygenation, nothing new, but, like, you know, I'm just stressing on stuff. Apneic oxygenation is very, very essential. Use of video laryngoscopy, more experienced person intubating the kid, and use of appropriate dose of medications. The use of appropriate dose of medications from near study, they found that, like, you know, lot of times they were difficult. The intubation complication arised from, like, inappropriate dosing, either overdosing or underdosing, than, like, actually, there were some structural abnormalities, like upper airway obstruction, but, like, most majority of the time they noticed, like, inappropriate dosing of medications. Having a difficult airway algorithm, using supraglottic airways, a limiting number of attempts. So coming to invasive ventilation. So use idle body weight for tidal volumes. Use higher peeps to alleviate some of the airway collapse, decreased functional residual capacity. So, like, you know, we have, like, we tend to limit our inspiratory pressures. I will show, there will be another slide I wanted to show. So sometimes just using the recommended inspiratory pressures would actually cause underventilation and hypoxia. So just keep in mind that, and you may need to adjust according to that. Using esophageal pressure monitoring would actually help to optimize peep and transpulmonary pressure. Extubation to higher, extubation on a higher peep is suggested just to alleviate, not for lung reasons, but just to alleviate the pathophysiological effects of obesity. An extubation to an IV, just to counter the upper airway obstruction, or, like, you know, the chest wall mass. So this is one of the co-author, actually, like, you know, got it from his own, from his institute. So you can see the top one is the airway pressure. The second one is the esophageal pressure, and the third one is transpulmonary, and this is the flow loop. So you can see the peep's set at 10, but if you look at the, if you look at the transpulmonary and the exhalation, it's actually negative. But once they actually go up the peep to 20, then you can see they're actually, the exhalation is positive, and, like, you know, there is no airway collapse. So appropriate peep, higher peeps, is actually important to actually prevent, like, airway collapse, open, collapse, open, and, like, you know, to prevent the lung injury as well with that. So coming to cardiovascular system. So we have increased metabolic demands, increased metabolic demands, leading to elevated total body and plasma volume, increased cardiac output from there, increased venous return, and, like, you know, you have hyperdynamic circulation, increased cardiac filling pressure. Moreover, like, you have increased peripheral resistance from obesity that actually causes increased left ventricular afterload, and then, like, you know, there is remodeling of the left ventricle on that. So chronic changes, nothing new, so we all know. So we have increased ventricular wall thickness, left ventricular wall thickness, and we have eccentric and concentric left ventricular hypertrophy at the same time. Like, we have enlargement of atria, hypertrophy of the right ventricle, and leading to fatigue and, like, heart failure. So hypertension, so primary hypertension is less prevalent in children, but due to increase in obesity prevalence, like, the primary hypertension seems to creep into pediatrics as well, but very rarely you see a hypertensive crisis from primary hypertension in children. If you get a kid with hypertensive crisis in ICU, you should be looking for secondary causes for hypertensive crisis in obese children. Very, very rarely they're present with any hypertensive crisis. Arrhythmias, so we have a list of EKG changes. They can be, you have a lot of EKG changes due to wall hypertrophy, or, like, you know, there's increased distance between the electrode and the heart, like, chest wall distance, and also, like, if you have transposition of heart due to movement, push a, transposition of heart due to elevated diaphragm. So all this can cause, like, EKG changes, but you rarely see any EKG changes in adolescents. How, come on, how often we see EKG changes in adolescent kid coming to ICU, but if you do see ECG changes in adolescents, then probably it's from some other thing, so just make sure, like, you investigate further for any potential cardiac anomalies. So, coming to cardiac arrest. So very, very little literature, like, but this is an article published in 2010 by Srinivas et al. for American Heart Association. There were, like, almost 1,500 CPR events, in that, like, 17% were obese kids. They found that the CPR was inferior quality in obese kids, and they had lower odds of survival, or lower odds for survival to discharge as well. They found that, like, you know, the CPR was inadequate, like, inadequate depth was used due to abdominal pressure, like, there was impaired blood flow coming back, and there was also decreased chest wall complaints, like, as we talked about in the respiratory system about different pathophysiological effects causing lung collapse. Inappropriate medication dosing as well, and also, like, you know, variable delivery of electrical energy. So those are some of the things they found in this study. After that, there was not so many studies done on cardiac arrest in obese kids. So some of the recommendations, use high-quality, just pay attention to the quality of CPR as we pay attention to any other, but obese kids tend to get inferior-quality CPR, so make sure we get high-quality CPR for them. And use mechanical CPR devices if appropriate, where you can use them. Not a lot of data, actually, like where you can use mechanical CPR devices yet. Try to compensate for obesity pathophysiological effects. And using higher defibrillation energy, you can't get the RASC back. And there are, like, some case reports about, like, manuals to decrease impedance, chest wall impedance, like when you're doing defibrillation, like, you know, just try to push a little bit deeper than, like, just doing it, like, you know, over. But there is not a lot of evidence to that as well. So, but it's there, I just wanted to put it out. Coming back, coming to ECMO, so a lot of times, like, effect of obesity on ECMO, via ECMOs are unknown. So there was this article published, had, like, 41 children, like, between two to 18 years old. So as we know, kids have, like, smaller blood vessels, like, but on top of it, like, you know, if you're obese, you need, like, you know, higher flow volumes, sorry, high cardiac output, like, you need high flow. So you're delivering high flow through smaller cannula is, like, a big challenge, so central cannula, they might need a central cannulation. They also found in the study that, like, you know, kids with lower, lower, lower cardiac output, or, like, lower volumes, inadequate flows, had poorer outcomes. The mortality had no significant association on that. So congenital heart disease, majority of the time, they have obese congenital heart disease, have high, have elevated risks of post-operative complications, increased length of stay, increased mechanical ventilation days. They have worsened pulmonary hypertension, depending on the lesion, depending on, depending on what kind of congenital heart disease you are, like, but overall, like, you know, the literature shows that you have increased complications. Heart transplantation, similar to congenital heart disease, they have elevated graft loss, like, they have, like, cardiolograft, vasculopathy, and, like, increased mortality rates in post-transplant children. Coming to nutritional support, we all, we all, like, you know, depend on dietitian, as well as we calculate by ourselves, so most of the time, we tend to over-calculate or under-calculate, rather than, like, we are calculating the calorie requirement exactly. So that's where the indirect calorimetry comes. It's gold standard. If you don't have one, like, you can use Coffield or food agriculture organization, WHO, the equation without any adjusted factor. In this table, I just wanted to highlight, like, you know, so majority of the time, so, or, like, you know, in a lot of ICUs, you tend to actually, like, underfeed or, like, you know, provide them with, like, lower calories for obesity, but there is no data to support that. There is no data to support either way. The outcomes are different. So evidence currently recommends, like, providing equivalent calories for both obese and non-obese kids. There is a strong association. There is a strong association with chronic kidney disease, end-stage renal disease, and pediatric obesity. So one of the study by Kadura, like, he had, like, you know, one-fourth of PICU patients developed, like, AKI within first seven days of admission, and there was severe kidney injury, the severity of the kidney injury increases the odds of death by day 28, and that leading to elevated use of CRRTs, mechanical ventilation, prolonged ICU stays. Similar to heart transplantation, like, you know, sorry. So recommendations, like, for renal is, like, early identification of AKI, avoid fluid overload, avoiding nephrotoxic drugs. So renal transplantation, like, similar to heart transplantation, they have elevated risks of, like, surgical wound complications, post-operative issues, prolonged hospitalization, graft, there is acute or delayed graft function rejection, and graft versus host disease. So similar, majority of the time, post-transplant, congenital heart disease, obese, they tend to have, like, you know, complications from that. So venous thromboembolism, obesity itself is, like, you know, increases the risks of VTE, because, like, you have increased fibrolysis, increased activity of coagulation cascade, and you have endothelial dysfunction from that. So if you have any other risk factors, like coagulation factor deficiencies, hematological malignancies, you're on oral contraceptive pills, you're an adolescent who's smoking, and then on top of it, you're obese, you are, like, very, you have increased your risk by many fold, so you have to be very careful in monitoring them for, like, you know, VTE. So make sure, like, you know, if someone comes in obese with some of these risk factors, like, make sure you are closely monitoring them for VTE. So endocrinology, so obesity is high risk for prediabetes and type 2 diabetes due to increased insulin resistance. So usually, managing decay or diabetes, they require, like, higher insulin doses. So burns, there was this article actually published in 1972 first, fat boys get burned, and then again, they reproduce it in 1998 to actually look at it. So the heading looks far, like, a little bit interesting, but what they found was, like, obese kids had, like, you know, lower fine motor skills, and they were slow to move, so they got easily burned on that. So that was the article they published, same institution published after 20 years, and they still found something. So in obese, there is obese burned kids, like, you know, they have increased incidence of multi-organ dysfunction, increased ICU stay, increased length of stay, increased requirement for blood transfusions, and they get a lot of respiratory interventions, and also they have heightened risk of respiratory pathogen colonization as well. But they didn't find any difference or any significant association with mortality, but there was increased morbidity. Most of the time, it's due to, like, very slow healing, and as well as, like, you know, functional impairment and increased complications that are causing the increased ICU stay, hospital stay. So there was another study by Stevens et al, like, you know, they looked at different formulas for resuscitation, Parkland, Cincinnati, Galveston formula, they recommended Parkland, Cincinnati, because they found Galveston formula tend to over-resuscitate in overweight patients, so if you're resuscitating burns patient, probably Parkland, Cincinnati formula. So some of the recommendations are, like, you know, close monitoring to recognize multi-organ dysfunction early, analyze for any need for blood transfusions, avoid any impending respiratory complications, address fluid resuscitation, not avoid, like, under or over-resuscitation. Coming to sepsis, sepsis and obesity is defined as, like, it's a, obesity itself is a chronic low-grade inflammation. On top of it, like, you know, so you have an insult, and the body responds to it with a massive inflammatory response, so it's defined as chronic low-grade ultra-inflammatory state, which triggers a massive inflammatory response to the insult. So in a study, like, 454 PICU patients, they found, like, 41% being obese or overweight children. They had increased use of CRRTs ECMOs in this patient. So there, and they also found there was increased odds of multi-organ dysfunction leading, like, acute kidney injury, cardiorespiratory decompensation, requiring a lot of procedures, like CRRT ECMO. And they also found there's increased length of stay and increased risk of, risk and progression to multi-organ dysfunction. Coming to COVID, we all know obesity on the, from a lot of literature on the adult side, same thing, a little different, but, like, obesity is a risk factor for pediatric patients as well, like, get hospitalized. Even the hospitalized patients, they are highly likely to get critical illness. If you have comorbidities, like, you know, you are highly likely to get, like, MIS-C, and there is increased PICU length of stay, but there is no change in mortality, like, which was high, like, obese adult patient, COVID patients had higher mortalities, as we saw, but pediatrics, we haven't seen that. Coming to critical care outcomes, there's a meta-analysis done in 2019 and 2022. So they found that, like, you know, it's associated with higher ICU mortality and increased hospital length of stay. So there is, I know that people will ask me about, like, the obesity, the obesity paradox in pediatric trauma patient. There are, like, you know, literature on both sides of this argument, like, you know, there are four articles saying, like, there is increased odds of hospital length of stay, increased mortality, and there are articles saying, like, obesity is protective, this is one article, and there are other articles saying there is no significant association. So I don't have, like, you know, enough evidence to actually conclude on one side, but we need a lot of research to say, like, you know, how do we grow from here? So what's the outcome? So in conclusion, like, you know, pediatric obesity complicates acute care and critical illness management. Early recognition and personalized treatment strategies are essential, more research is needed. Definitely more research is needed. We had to do a lot of phishing from different, different articles, like, you know, because it's meant, obesity was just mentioned as, like, couple of, maybe three, four lines or four paragraph, not, like, you know, obesity-focused, pediatric obesity-focused research there. Thank you.

pediatric obesity

critical illness

airway management

pharmacology dosing

multi-organ dysfunction

thromboembolism risk