Perioperative Considerations and Anesthetic Management of the Morbidly Obese PatientThomas J. Ebert, M.D., Ph.D. Milwaukee, Wisconsin
309Page 1Obesity is a national epidemic with major health consequences. The morbidly obese (MO) patient only has aone in seven chance of a normal life expectancy (1). The cost of health care treatment for the obese population is 5-9% of national health care expenditures and is approaching $100 billion per year (2). Based upon NIH guidelines, body mass index (BMI) (kg/m
2
) is used to classify adult obesity into three classes: Class I = BMI 30-34.9, Class II =BMI 35-39.9, and extreme obesity, Class III, with a BMI > 40 kg/m
2
(3). Most consider morbid obesity to refer to patients with a BMI
≥
35 kg/m
2
. Morbid obesity is associated with an increased prevalence of physical ailments,including hypertension, coronary heart disease, congestive heart failure, stroke, osteoarthritis, type II diabetes,insulin resistance, glucose intolerance, hypercholesterolemia, gallstones, cholecystitis, cholelithiasis, and obstructivesleep apnea. The frequency and severity of co-morbid conditions increases proportionally to weight of the patient.The preoperative evaluation of the MO patient must consider how the additional ailments may add to the risk of anesthetic management. Typically underlying conditions including cardiac disease and angina must be stable andoptimally managed either medically or via surgical or cardiologic interventions. Similarly, pulmonary function,diabetes and glucose levels should be addressed and optimized. Once pre-operative conditions are addressed, theimmediate perioperative management of the MO patient must be carefully planned. The choice of anesthetic drugsand monitors should optimized to the patient condition. One challenging issue presents early - the placement of anIV. Extra adipose tissue often hides superficial veins, thereby requiring alternative approaches in the antecubitalspace or in the internal or external jugular vein.The blood pressure (BP) cuff is commonly an oversized cuff and, due to the shape of the arm, often does not fitcorrectly. The length of the cuff bladder should equal at least 80% of the measured arm circumference and thewidth should equal at least 40% of the measured arm circumference at the midpoint of the upper arm. Cuffs that aretoo small will overestimate the true BP. There should be a low threshold for placing an arterial line for accurate andinstantaneous BP readings and for easy access to blood sampling to determine hemoglobin content and the partial pressures of oxygen and carbon dioxide. The arterial line provides an additional benefit in the post-operative periodas a means to monitor these variables.In further planning of the perioperative management of the MO patient, additional issues must be considered to provide optimal care and these are reviewed below.Full Stomach: Need for Rapid Sequence IntubationMany consider MO patients to be at risk for acid aspiration syndrome, a serious cause of anesthesia-relatedmorbidity and mortality. Risk for this syndrome occurs when there is 1) low pH of gastric contents, 2) increasedgastric volume, and/or 3) gastroesophageal reflux, from an inadequate esophageal to gastric barrier pressure.Despite a high prevalence of risk factors, acid aspiration syndrome has been reported as a rare event, occurring in1:3216 anesthetics (4), and is not uniquely associated with a BMI
≥
35 kg/m
2
. However, aspiration could beassociated with gagging and vomiting in 67% of the cases, with laryngoscopy in 33%, and with extubation in 36%.Then why consider obese patients at increased risk for acid aspiration syndrome? Perhaps because there areconflicting data on gastric pH, volume and barrier pressure in MO patients. Most anesthesiologists consider agastric pH < 2.5 and residual gastric fluid volume of
≥
25mL to be critical factors in the risk for pulmonaryaspiration and lung injury. In patients, Vaughan observed that more than 70% of obese individuals had acombination of gastric volumes
≥
25 mL and pH
≤
2.5 compared to only 5% in non-obese individuals (5).Readdressing this issue 23 years later, Harter found a substantially lower incidence of combined high gastric volumeand low pH in fasted, obese patients compared with lean patients (6). They explained the lower incidence of “atrisk” patients compared to earlier work as a difference in preoperative medicines. Vaughan et al. used Innovar®,containing fentanyl and droperidol and diphenhydramine while Harter provided none. Additional work suggests nocorrelation between gastric volume and fasting duration (7). Morbidly obese patients given 300 ml of clear fluid prior to surgery had similar ranges of gastric volumes and pHs to those who fasted longer than six hours (8). Thesefindings are supported by studies of gastric emptying rates that indicate no difference between obese and non-obese patients (9).Various studies in non-obese patients have reported resting intra-gastric pressures to range from 5 to 11 mm Hg,and increases in intra-gastric pressures to 25 mm Hg during succinylcholine-induced fasciculations. Barrier pressurehas been shown to be the same in obese and non-obese individuals (10). Although these data are interesting, there isinsufficient evidence to implicate barrier pressure as a causal link to aspiration.One common technique to lessen the chance for pulmonary aspiration is to apply cricoid pressure, but the protection this affords is questionable. Properly applied pressure presumably compresses the esophagus against thevertebral body. In an observational study using MR imaging, the cricopharyngeal muscle, rather than theesophagus, was lying posterior to the cricoid in 18 of 19 subjects. During cricoid pressure the esophagus was
Leave a Comment