Background: Poor characterization of propofol pharmacokinetics and pharmacodynamics in the morbidly obese\r\n(MO) pediatric population poses dosing challenges. This study was conducted to evaluate propofol total\r\nintravenous anesthesia (TIVA) in this population.\r\nMethods: After IRB approval, a prospective study was conducted in 20 MO children and adolescents undergoing\r\nlaparoscopic surgery under clinically titrated propofol TIVA. Propofol doses/infusion rates, hemodynamic variables,\r\ntimes to induction and emergence, and postoperative occurrence of respiratory adverse events (RAE) were\r\nrecorded, along with intraoperative blinded Bispectral Index/BIS and postoperative Ramsay sedation scores (RSS).\r\nStudy subjects completed awareness questionnaires on postoperative days 1 and 3. Propofol concentrations were\r\nobtained at predetermined intra- and post-operative time points.\r\nResults: Study subjects ranged 9 ââ?¬â?? 18 years (age) and 97 - 99.9% (BMI for age percentiles). Average percentage\r\nvariability of hemodynamic parameters from baseline was Ã?Å? 20%. Patients had consistently below target BIS values\r\n(BIS < 40 for >90% of maintenance phase), delayed emergence (25.8 Ã?± 22 minutes), increased somnolence (RSS = 4)\r\nin the first 30 minutes of recovery from anesthesia and 30% incidence of postoperative RAE, the odds for which\r\nincreased by 14% per unit increase in BMI (p = 0.05). Mean propofol concentration was 6.2 mg/L during\r\nmaintenance and 1.8 mg/L during emergence from anesthesia.\r\nConclusions: Our findings indicate clinical overestimation of propofol requirements and highlight the challenges of\r\nclinically titrated propofol TIVA in MO adolescents. In this setting, it may be advantageous to titrate propofol to\r\ntargeted BIS levels until more accurate weight-appropriate dosing regimens are developed, to minimize relative\r\noverdosing and its consequences.
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