AANA Journal Course

Update for Nurse Anesthetists

Anesthesia Case Management for Bariatric
Surgery
Jennifer Thompson, CRNA, MSN
Sandra Bordi, CRNA, MSN
Michael Boytim, CRNA, EdD
Sass Elisha, CRNA, EdD
Jeremy Heiner, CRNA, MSN
John Nagelhout, CRNA, PhD, FAAN
Objectives
At the completion of this course, the reader should be
able to:
1. Describe the pathophysiologic changes that are as-
sociated with morbid obesity.
2. Discuss commonly used weight-reduction drugs
and the dosing of commonly administered anes-
thetic drugs given to morbidly obese patients.
3. Compare and contrast the various surgical proce-
dures used for bariatric surgery.
4. List perioperative strategies that can be used to op-
timize oxygenation/ventilation in morbidly obese
patients.
5. Identify the postoperative complications associated
with bariatric surgery.
Introduction
Obesity is an epidemic that threatens the health of people
all over the world. By estimation of the International
Obesity Task Force, more than 1.7 billion people are
overweight or obese. Decreased physical activity and
overconsumption of high-fat foods are the main con-
tributing factors to the obesity epidemic. Conservative
interventions to the treatment of obesity include early
education, low-calorie diet, increased physical activity,
and, sometimes, medications. However, these treatments
are not always effective, and many obese people undergo
bariatric surgical procedures. There is a myriad of an-
esthesia challenges associated with these surgeries. A
thorough understanding of the anesthetic considerations
is essential to facilitate positive outcomes for the patients.
Pathophysiologic Changes of Obesity
Obesity is commonly associated with a variety of co-
morbidities, including diabetes, cardiovascular disease,
endocrinopathies, and osteoarthritis (Figure 1).
1
The
mechanisms underlying these complications are complex
and most often are interrelated.
*AANA Journal Course No. 31 (Part 1): AANA Journal course will consist of 6 successive articles, each with objectives for
the reader and sources for additional reading. At the conclusion of the 6-part series, a final examination will be published on
the AANA website. Successful completion will yield the participant 6 CE credits (6 contact hours).
6 CE Credits*
1
An increasing number of bariatric surgeries are per-
formed every year. A thorough understanding of the
pathophysiologic changes, surgical procedure, and
anesthesia case management for morbidly obese
patients and of the pharmacology of weight-reduction
and anesthetic drugs is essential to provide high-
quality anesthetic care. The various comorbidities
associated with obesity may complicate anesthetic
management. Anesthetists must perform a thorough
preoperative assessment to identify potential risk fac-
tors related to anesthesia and adequately prepare for
intraoperative management. Intubation, maintenance
of oxygenation, and pain management may be particu-
larly challenging, and various strategies are presented.
In addition, an obese patient is at higher risk for post-
operative complications. Signs and symptoms of sur-
gical complications may mimic medical complications,
making diagnosis difficult.
Keywords: Bariatric surgery, gastric banding, gastric
bypass, metabolic syndrome, obesity.
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148 AANA Journal April 2011 Vol. 79, No. 2 www.aana.com/aanajournalonline.aspx
Figure 1. Pathology of Obesity
CVA indicates cerebrovascular accident; DVT, deep venous thrombosis; PE, pulmonary embolism.
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The combination of related cardiovascular risk factors,
including central obesity, hyperglycemia, hypertension,
and dyslipidemia, is referred to as metabolic syndrome.
Patients with metabolic syndrome are at higher risk for
coronary artery disease (CAD) and experiencing major
cardiovascular events. Although each component is rec-
ognized as an individual risk factor, the clustering of these
risk factors puts a patient at an even greater surgical risk.
2
One of the most prevalent disorders associated with
obesity is type 2 diabetes resulting from insulin re-
sistance and hyperinsulinemia.
1
Hyperinsulinemia fre-
quently results in sodium retention, excessive circulating
catecholamines, and increased blood volume.
3
Patients
commonly have hypertriglyceridemia and low high-
density lipoprotein levels, which may contribute to CAD.
The American Heart Association reports that obesity
may be a major factor for developing heart disease.
1
Concentric ventricular hypertrophy, which develops
over time, results from increased systemic vascular resis-
tance. The incidence of hypertension increases propor-
tionally as body mass index (BMI) increases.
Fatty changes in the liver may lead to fibrosis and
hepatic failure. Nonalcoholic steatohepatitis often occurs
in obese children. Cholelithiasis is 6 times more common
in people who are obese as in normal-weight people.
3
Formation of gallstones also occurs at a higher rate due
to the increase in the total body cholesterol level and
greater biliary cholesterol excretion.
4
Commonly occurring respiratory abnormalities
include Pickwickian syndrome, obstructive sleep apnea,
decreased functional residual capacity, and increased
closing capacity, which all contribute to atelectasis and
rapidly occurring hypoxemia.
1
These respiratory changes
may also lead to polycythemia and cor pulmonale.
Obesity predisposes to osteoarthritis. Increased body
weight stresses bones and joints, and this condition is
especially common in elderly people. An increased risk
of stroke and thromboembolic disease is also prevalent.
4
A recent study determined that there may be an as-
sociation between obesity and various forms of cancer,
including esophageal, colon, rectum, liver, prostate,
breast, uterus, cervix, and non-Hodgkin lymphoma.
Many of these phenomena are hypothesized to be caused
by increased estrogen levels.
5
Pharmacology of Obesity-Related Drugs and
of Anesthetics
Antiobesity Medications. Medications that promote
weight loss have limited efficacy. Despite the enormous
potential market, efforts to develop effective drug thera-
pies have been disappointing. The US Food and Drug
Administration guidance for long-term weight-loss drugs
recommends that a 5% weight reduction be maintained
for 12 months after treatment initiation. Two drugs are
available for use: orlistat (Xenical [prescription form,
Roche, Basel, Switzerland]; Alli [over-the-counter form,
GlaxoSmithKline, Brentford, England]) and phentermine
(Adipex-P [North Wales, Pennsylvania]; others). When
used in combination with a comprehensive weight-loss
program, they can occasionally be effective in producing
weight loss in the range of 4 to 5.5 kg.
6
Orlistat is a lipase inhibitor that decreases the absorp-
tion of fat in the gastrointestinal tract. It has recently
been released as an over-the-counter medication. Side
effects are minor and mostly related to gastrointestinal
discomfort (Table 1). Phentermine, a sympathomimetic
agent, is approved for short-term use (up to 12 weeks)
as a weight-management drug. Tolerance, dependence,
abuse, and a relatively high number of adverse effects
limit its usefulness. Several antidepressant, antiepileptic,
and antidiabetic drugs may promote weight loss and are
used off-label for this indication.
6,7
Anesthesia Drugs and Obesity. Obesity causes physi-
ologic changes that can affect the pharmacokinetics and
pharmacodynamics of anesthetic agents. An overview of
these changes is given in Table 2. The common approach
to anesthetic drug administration is to dose water-soluble
drugs according to ideal body weight and lipid-soluble
drugs according to total body weight. Lean body mass in-
creases approximately 20% to 40% in obesity, so adding
30% to the ideal body weight is a convenient dose adjust-
ment. Table 3 shows weight calculations commonly used
for the dosing of medications.
Contradictory results from individual drug studies in
small patient groups are common; therefore, specific rec-
ommendations are frequently conflicting. A few general
observations can be made. Postoperative respiratory
depression is especially problematic in obese patients;
therefore, most clinicians favor short-acting drugs that
Drug Mechanism Side or adverse effects Precautions
Orlistat (Xenical; Alli) Lipase inhibitor: inhibits intestinal Fecal urgency, diarrhea, and abdominal May interfere with absorption
fat absorption by blocking hydrolysis pain; case reports of liver injury under of fat-soluble vitamins A, D,
of dietary triglycerides into free fatty investigation E, and K, requiring supple-
acids mentation
Phentermine Sympathomimetic agent similar Primary pulmonary hypertension and Rarely used; only for short-
(Adipex-P; others) to amphetamines many other sympathomimetic adverse term use; however, has a
effects possible; contraindicated in poor risk-benefit ratio
hypertension and diabetes
Table 1. Pharmacotherapy for Obesity
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allow for fast recovery. The inhalation agents desflurane
and sevoflurane produce excellent recovery profiles in
obese patients. Although desflurane is less soluble than
sevoflurane, clinical differences are minimal. Nitrous
oxide can be safely used in patients in whom a require-
ment for high oxygen concentrations does not preclude
its administration. Succinylcholine doses for intubation
are given according to total body weight to ensure excel-
lent intubating conditions, whereas the nondepolarizing
muscle relaxants used for operative maintenance are
given according to ideal body weight. Use of a nerve
stimulator to guide relaxant administration assists in
minimizing residual paralysis and reversal concerns.
Remifentanil infusion is an especially popular analge-
sic because of the drugs titratability and rapid offset
and is administered according to ideal body weight.
Dexmedetomidine is also a useful adjunct for sedation,
amnesia, and analgesia.
8
Specific dosing recommenda-
tions for some common anesthetic agents in obesity are
listed in Table 4.
Surgical Procedure
Because of the epidemic proportions of obesity within
the United States, the number of bariatric surgical pro-
cedures performed each year has increased. Bariatric
surgical programs mandate that before surgery, patients
participate in lifestyle modifications to lose weight and
learn how to incorporate healthy choices into daily life.
It has been demonstrated that preoperative weight loss
decreases all of the complications associated after laparo-
scopic gastric bypass.
9
Psychologists, dieticians, physical
therapists, and exercise specialists work with patients
Increased fat mass
Increased cardiac output
Increased blood volume
Increased lean body weight
Changes in plasma protein binding
Reduced total body water
Increased renal clearance
Increased volume of distribution of lipid-soluble drugs
Table 2. Pathophysiologic Changes in Obesity That
May Affect Pharmacokinetics
Table 3. Simplified Weight Calculations
BMI indicates body mass index; TBW, total body weight; IBW,
ideal body weight; and LBW, lean body weight.
BMI
BMI = TBW in kg/height in m
2
IBW in kg
IBW = height (cm) 100 for men or 105 for women
or
IBW = 0.8 TBW for men or 0.75 TBW for women
LBW
LBW = IBW 1.3
Table 4. Dosing Recommendations for Some Common Anesthetic Drugs in Obesity
TBW indicates total body weight; LBW, lean body weight; and IBW, ideal body weight.
Drug Dose recommendation Comments
Propofol Induction dose based on LBW; maintenance Increased fat mass does not affect initial
dose based on TBW distribution/redistribution during induction.
Cardiac depression at high doses is a concern.
Thiopental Induction dose based on TBW High cardiac output, volume of distribution, and
lean body mass suggest a higher dose require-
ment. Reduce doses when excess cardiac
depression is a concern.
Succinylcholine Intubating dose based on TBW Increased fluid compartment and pseudocholin-
esterase levels require higher doses to ensure
adequate paralysis.
Rocuronium, All doses based on IBW Hydrophilic drugs given according to IBW will
vecuronium; ensure shorter duration and a more predictable
cisatracurium recovery in this respiratory challenged population.
Fentanyl Loading dose based on TBW; maintenance Increased distribution volume and elimination
dose based on LBW and response time correlate with degree of obesity.
Remifentanil Infusion rates based on IBW Distribution volumes and elimination rates are
similar to those for normal-sized people. Fast off-
set requires planning for postoperative analgesia.
Dexmedetomidine Infusion rates of 0.2 g/kg/min Useful as an adjunct. Lower than usual infusion
rates are recommended to minimize adverse
cardiac side effects.
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to change their habits and behaviors that contribute to
obesity. Furthermore, medical optimization of the pa-
tients coexisting morbidities is essential before surgical
intervention.
There are several variations related to the surgical
procedures that can be performed. Presently, the most
common surgical approach for bariatric surgery is lapa-
roscopy. Furthermore, there is a decrease in the morbid-
ity and mortality associated with laparoscopic gastric
bypass with robotic assistance.
10
The goal of bariatric
surgery is to reduce the patients caloric intake by re-
stricting the amount of food that is able to be consumed
(gastric restriction procedure) or, by a dual mechanism,
to restrict and decrease the amount of absorption from
the gastrointestinal tract (mixed restrictive and malab-
sorptive procedure).
11
Operative mortality ( 30 days
postoperatively) is estimated to be approximately 0.1%
for restrictive procedures and 1% for mixed restrictive
and malabsorptive procedures.
12
The most common
types of bariatric surgical procedures are laparoscopic
adjustable gastric banding and the Roux-en-Y technique.
Types of Gastric Bypass Procedures
Restrictive Procedures. Vertical banded gastroplasty is
a restrictive procedure that involves the surgical creation
of a gastric pouch. The procedure involves making a hole
in the middle of the body of the stomach. Stapling of the
stomach from the superior aspect of the fundus to the
newly created hole is accomplished. The surgeon then
fashions a tissue band through the hole that surrounds
the remainder of the gastric body near the esophago-
gastric junction. Thus, a gastric pouch remains that can
accommodate 25 to 30 mL and restricts the amount of
food that can be consumed. An illustration of vertical
banded gastroplasty is shown in Figure 2A.
Vertical banded gastroplasty was the most popular
surgical intervention for bariatric surgery from the mid
1980s until the early 1990s. Disadvantages to vertical
banded gastroplasty include difficulty eating foods that
are high in protein, which facilitates the consumption
of soft calorie-dense foods, gastroesophageal reflux, and
abdominal discomfort. Patients would frequently regain
weight, and only 26% were satisfied with the result of
the surgery.
12
Laparoscopic Adjustable Gastric Banding (LAGB)
has become a popular alternative to more invasive mal-
absorptive surgical procedures and is one of the most
common restrictive weight-loss surgeries performed in
the United States. This system offers 2 distinct advan-
tages compared with vertical banded gastroplasty: The
tension on the band is adjustable, and the system is
removable. Laparoscopic adjustable gastric banding is
associated with a shorter duration of hospitalization, de-
creased pulmonary complications, and overall decreased
morbidity and mortality compared with other bariatric
surgical options.
13
There are several adjustable bands,
including Lap Band (Alleran Inc, Irvine, California),
Realize Adjustable Gastric Band (Ethicon Endo-Surgery
Inc, Cincinnati, Ohio), and the Swedish adjustable gastric
band. The gastric band is placed immediately distal to the
gastroesophageal junction. An illustration of the LAGB is
shown in Figure 2B. Contained within the silicone band,
Figure 2. Restrictive Bariatric Surgical Procedures
A. Vertical banded gastroplasty
B. Laparoscopic adjustable gastric band
C. Sleeve gastrectomy
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a balloon is inflated to decrease the size of the proximal
aspect of the stomach. The balloon is inflated with saline
via an access port that is positioned subcutaneously. The
pouch that is created holds approximately 100 to 200 g
of food. Distention of the pouch causes satiety resulting
from afferent sensory and visceral neural innervation.
Identification of patients who are ideal candidates for
LAGB improves the postoperative percentage of weight
loss. Increased age, increasing BMI, hyperinsulinemia,
type 2 diabetes, and polycystic ovarian syndrome are as-
sociated with a lower percentage of weight lost after sur-
gical intervention.
14
It has been demonstrated that weight
loss with LAGB frequently results in complete resolution
or improvement of type 2 diabetes, hypertension, and
dyslipidemia.
15
The indications and contraindications for
having LAGB are included in Table 5.
14
Numerous potential complications are associated with
LAGB surgery. An analysis of 7 years of data from 2,909
patients related to the safety of the LAGB includes the
following complications and frequencies: band slippage,
4.5%; port-related problems, 3.3%; and reoperation for
weight gain, 0.4%. One or more of these complications
were experienced by 12.2% of patients.
12
The overall
incidence of erosion of the stomach under the gastric
band is 1.96%. Postoperative mortality within 30 days or
fewer is approximately 0.06% to 0.1%.
12,16
A rare com-
plication called Barrett esophagus can occur after LAGB.
Barrett esophagus occurs due to chronic gastroesophageal
reflux, which causes esophageal erosion and predisposes
patients to malignant changes. The overall incidence is
unknown; however, cellular dysplasia and esophageal
adenocarcinoma that is related to gastroesophageal reflux
disease can occur after gastric banding.
17
A compre-
hensive list of complications associated with LAGB are
included in Table 6.
12
Sleeve Gastrectomy is accomplished by decreasing
the size of the stomach to approximately 20% of its
original size by removing a substantial portion of the
stomach. This procedure is most frequently performed
laparoscopically and involves resection of a substantial
portion of the gastric fundus and body to create a tube-
like opening from the gastroesophageal junction to the
pyloric valve. The reconstructed stomach ideally will
have a total gastric volume of between 100 and 200 mL.
18
This procedure is shown in Figure 2C. In general, pa-
tients lose between 30% and 50% of excess body weight
within 1 year.
Combined Restrictive and Malabsorptive Procedures.
Roux-en-Y gastric bypass (RYGB) is the most common
combined restrictive and malabsorptive form of gastric
bypass surgery in the United States. The National
Institutes of Health has determined that the most ef-
Table 6. Complications Associated With Bariatric
Surgery
(Adapted from Matarasso et al.
12
)
Adjustable gastric band
Gastric mucosal erosion around the band
Gastritis
Erosion of gastric mucosa under the band, causing perforation
Filling port malfunction
Gastric prolapse
Malposition of the band
Barrett esophagus
Dysphagia
Gastroesophageal reflux
Malabsorptive procedures
Bowel obstruction
Wound dehiscence
Leakage and/or ulcers at the sites of anastomosis
Nutritional deficiency
Incisional hernia
Gastrojejunostomy stenosis
Potential complications of both types of
procedures
Hemorrhage
Dumping syndrome (more common in gastric bypass)
Postoperative respiratory insufficiency
Deep vein thromboembolism
Pulmonary embolism
Sepsis
Table 5. Indications and Contraindications to Laparo-
scopic Adjustable Gastric Banding
(Adapted from Dixon and OBrien.
14
)
Indications
Body mass index 40 kg/m
2
Failure to lose weight with dietary restrictions and pharmaco-
logic therapy for > 1 y
Obesity for > 5 y
Understanding of the surgical and anesthetic risks and benefits
Willingness to adhere to lifelong dietary restrictions
Acceptable operative risk
Comorbid diseases that improve with weight loss (eg, diabe-
tes, metabolic syndrome, cardiovascular disease)
Contraindications
Unreasonable surgical risk
Untreated hypothyroidism
Gastrointestinal inflammatory disease (eg, ulcers, Crohn dis-
ease, ulcerative colitis)
Severe cardiopulmonary disease
Pain intolerance to implantable devices
Alcohol and/or drug addiction
Severe cognitive disabilities
Allergy to silicone
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fective surgical treatment for obesity is RYGB.
19
The
procedure is frequently accomplished via a laparoscopic
approach with or without robotic assistance, and there
are a number of variations of this technique.
10
A small
gastric pouch (15-20 mL) is constructed from the cardia
portion of the stomach near the gastroesophageal junc-
tion and restricts the amount of food that the patient
can eat at one time. The pouch is attached to the distal
duodenum and becomes the Roux limb or alimentary
limb, where food and fluids travel and are absorbed.
The biliopancreatic limb is formed proximally from the
duodenum, and the distal resected end is anastomosed to
the ileum to form a common small intestinal limb. This
procedure is illustrated in Figure 3A.
A polypeptide called ghrelin is primarily secreted by
the stomach and small intestine. When secreted, this
hormone stimulates appetite. Since removal of various
portions of the stomach and duodenum occurs as part
of malabsorptive procedures for obesity, another mecha-
nism of weight loss is associated with decreased plasma
ghrelin levels. It has been demonstrated that ghrelin
values are up to 47% lower in patients who have under-
gone the RYGB procedure compared with equally obese
nonsurgical patients.
20
There has been substantial interest in which bariatric
surgical procedure is most effective, LAGB or RYGB.
The major advantage of the LAGB is that it is revers-
ible; however, the percentage of excess body weight
loss is less variable and consistently greater with the
RYGB.
18,21
Reversal of comorbidities is greatest after
LAGB. Perioperative complications were more likely to
occur during RYGB than during LAGB, but long-term
reoperation rates were lower and patient satisfaction was
higher with the RYGB gastric bypass procedure.
21
Adams
and colleagues
22
determined that the long-term mortality
after RYGB is decreased from any cause and from diseases
specifically attributed to obesity. A list of bariatric surgi-
cal procedures and the percentage of excess body weight
lost within the first year is listed in Table 7.
21
Because of the intricacy associated with this pro-
cedure, complications such as leaks from the distal
and proximal sites of anastomosis, bowel obstruction,
vitamin deficiency, and intestinal stenosis can occur.
12,18
Dumping syndrome occurs in approximately 10% of pa-
tients who undergo any type of gastric bypass surgery.
18
It occurs when food from the stomach is rapidly trans-
ported or dumped into the duodenum. The severity of
the abdominal cramping and nausea associated with this
phenomenon varies from mild to severe. This side effect
is more common after gastric bypass compared with
LAGB. Treatment includes medications such as acarbose
(Precose, Bayer Corp, West Haven, Connecticut) or
surgical reintervention. A comprehensive list of compli-
cations associated with malabsorptive bariatric surgical
procedures is listed in Table 6.
12
Biliopancreatic Diversion With Duodenal Switch in-
cludes a hemigastrectomy or sleeve gastrectomy to create
a 75- to 100-mL pouch. The ileum is connected directly
Figure 3. Mixed Restrictive and Malabsorptive Bariatric Surgical Procedures
A. Roux-en-Y gastric bypass
B. Biliopancreatic diversion with duodenal switch
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to the gastric pouch, completely bypassing the duode-
num and jejunum (alimentary limb). The distal portion
of the biliopancreatic limb is then reconnected 100 cm
from the ileocecal valve.
18
Thus, in addition to being
restrictive due to the gastric sleeve, the now substantially
shorter small intestine offers less intestinal surface area
for absorption to occur. A representation of this proce-
dure is shown in Figure 3B.
Biliopancreatic diversion with duodenal switch is
most often performed for patients who are described as
superobese (BMI 55 kg/m
2
). Prachand and colleagues
23
determined that excess body weight loss of more than
50% was achieved in 83.9% of patients having biliopan-
creatic diversion with duodenal switch and 70.4% with
Roux-en-Y 1 year postoperatively.
The development of gallstones commonly occurs after
gastric bypass procedures, and some surgeons perform a
cholecystectomy simultaneously. Inadequate absorption
of proteins, iron, calcium, and fat-soluble vitamins (A, D,
E, and K) can occur, and multivitamin supplementation
is recommended.
18
A new procedure under investigation to determine the
safety and efficacy in treating obesity is an implantable
gastric stimulator. A pulse generator the size of a cardiac
pacemaker is implanted on the surface of the stomach.
The afferent impulses that are sensed by the brain allow
the person to feel satiated. In the future, as new surgical
techniques, technological advances, and the discovery
of new medications occur, the treatment of obesity will
become safer and more effective.
Anesthetic Management
Preoperative Evaluation. Preoperative evaluation of
a bariatric surgical patient should include an evaluation
by a multidisciplinary team and focus on the identifica-
tion, treatment, and optimization of modifiable health
concerns. Many bariatric surgical candidates have already
been diagnosed and medically managed for comorbid
conditions by their primary care physicians; therefore,
the additional need to perform extensive diagnostic tests
is minimal. A candid discussion between the surgeon
and patient regarding realistic expectations, lifestyle
alterations, diet modifications, and exercise is neces-
sary. Common criteria for bariatric surgery include the
following: a BMI of 40 kg/m
2
or more or of 35 kg/m
2
or
more with comorbid conditions, failure of nonoperative
weight-loss efforts, absence of contraindications, and a
well-informed, compliant, and motivated patient with a
good support system.
24
Absolute contraindications for
bariatric surgery include a lack of understanding of the
procedural risks, severe liver disease with accompany-
ing portal hypertension, uncontrolled severe obstructive
sleep apnea with pulmonary hypertension, and unstable
or terminal illness.
25
A thorough history and physical examination, vital
signs, baseline laboratory studies, and informed consent
should be obtained during the initial assessment, and,
if needed, referral to and consultation with appropriate
subspecialties should be accomplished. Risk identifica-
tion and risk reduction should be priorities that can assist
in the identification of appropriate surgical candidates.
The Obesity SurgeryMortality Risk Score has been de-
signed and validated to predict the risk of mortality in
patients undergoing bariatric surgery.
26
One point is as-
signed to each of 5 preoperative variables:
1. BMI 50 kg/m
2
or more
2. Male gender
3. Hypertension
4. Risk for pulmonary embolism (history of venous
thromboembolism, pulmonary hypertension, and/or
obesity hypoventilation)
5. Older than 45 years
A score of 0 or 1 is classified as A or lowest risk,
2 or 3 as B or intermediate risk, and 4 or 5 as C or
high risk, with mortality ranging from 0.2% for an A clas-
sification, to 1.3% for a B classification, to 2.4% for a C
classification.
26
A primary goal of the preoperative assessment is treat-
ment and optimization of comorbid conditions. Obese
patients frequently have comorbid conditions such as
hypertension, CAD, diabetes, venous thromboembolism,
and/or obstructive sleep apnea. Patients referred to cardi-
ology for suspicion of CAD should undergo an exercise
or dobutamine stress echocardiogram to evaluate cardiac
function.
25
Bariatric surgery can be safely performed on
patients with known CAD without major increases in
perioperative mortality and cardiac complications, pro-
vided the patients have been thoroughly evaluated and
appropriately managed.
27
Patients suspected of having obstructive sleep apnea
should undergo polysomnography and receive treatment
preoperatively and throughout the perioperative period.
Treatment modalities include continuous positive airway
pressure, noninvasive positive-pressure ventilation, and
bilevel positive airway pressure.
24,28
Pulmonary function
should be evaluated to anticipate the need for postopera-
tive controlled ventilation.
Patients at risk for postoperative venous thromboem-
bolism (venous stasis disease, BMI 60 kg/m
2
, truncal
Adjustable gastric banding, 25%-80%
Sleeve gastrectomy, 65%-75%
Vertical gastric banding, 50%-60%
Roux-en-Y gastric bypass, 50%-70%
Biliopancreatic diversion with duodenal switch, 65%-75%
Table 7. Percentage of Excess Body Weight Lost by
Type of Bariatric Surgery Within the First Year
(Adapted from Maggard et al.
21
)
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obesity, prior venous thromboembolism, and known
hypercoagulable states) may be considered for placement
of an inferior vena cava filter before bariatric surgery.
Although expert consensus concerning dosing guidelines
does not exist, prophylactic anticoagulation is commonly
ordered by most bariatric surgeons.
25
Heparin, 5,000 IU,
is administered subcutaneously before surgery and then
every 12 hours in combination with the use of pneumatic
compression devices. Early ambulation is also suggested
for effective thromboprophylaxis.
29
Some surgeons prefer
the administration of low-molecular-weight heparin such
as enoxaparin.
Preoperative endoscopy is not routinely performed
and is reserved for patients with symptomatic reflux,
dyspepsia, or dysphagia. As mentioned earlier, lipid
deposition in hepatocytes may induce liver damage and
cause simple fatty infiltration or cirrhosis. The terms
nonalcoholic fatty liver disease and nonalcoholic steato-
hepatitis are used to describe inflammatory changes that
occur in the liver with or without fibrosis. Some bariatric
surgeons routinely perform liver biopsies during bariatric
procedures to diagnose and stage nonalcoholic fatty liver
disease/nonalcoholic steatohepatitis.
24
It is suggested that each bariatric surgical candidate
undergo an electrocardiogram and chest radiograph
testing to further investigate cardiopulmonary risk.
24,25
In patients with diabetes, the serum glucose level should
be maintained at less than 150 mg/dL. A hemoglobin A
1c
value of less than 7% is desirable to reduce surgical risk.
24
Commonly recommended laboratory tests are listed in
Table 8.
With the exception of insulin and oral hypoglycemic
agents, patients should continue their usual medication
regimen.
29
Antibiotic therapy is instituted to decrease
the risk of postoperative wound infection. Medications
for anxiolysis, analgesia, and aspiration and venous
thromboembolism prophylaxis are commonly adminis-
tered preoperatively. Aspiration prophylaxis medications
include histamine-2 blockers, antacids, and metoclo-
pramide.
A thorough airway examination should be completed
to identify the possibility of a difficult airway. There is
controversy regarding whether obesity is a predictor of
difficult endotracheal intubation. Mallampati scores of 3
or greater, neck circumferences greater than 43 cm at the
thyroid cartilage, a decreased thyromental distance, and
a high BMI are all predictors of potential difficult endo-
tracheal intubation.
30
Invasive monitoring using arterial
and central venous pressures should be considered in
patients with poor cardiopulmonary function. In addi-
tion, a central venous catheter should be considered in
obese patients in whom venous access is challenging or
as otherwise indicated from the patients health history.
Intraoperative Anesthetic Management. Morbidly
obese (MO) patients present many challenges during the
intraoperative period. Major areas of concern include
airway management, maintenance of oxygenation, patient
positioning, and monitoring.
General endotracheal anesthesia is the technique of
choice for laparoscopic bariatric surgery. Rapid-sequence
induction with cricoid pressure remains important to
avoid gastric aspiration in obese patients with symp-
tomatic gastroesophageal reflux or other predisposing
conditions such as diabetes mellitus and gastrointestinal
disorders.
31
However, the necessity of rapid-sequence in-
duction with cricoid pressure because of a presumed risk
of aspiration in an obese, fasting patient with no other
risk factors is controversial.
32
A prudent approach to a known or highly suspected
difficult airway would be an awake, fiberoptic intuba-
tion. If tracheal intubation with direct laryngoscopy is
planned, appropriate positioning, preoxygenation, and
preparation of emergency airway equipment is essential.
Traditional teaching has emphasized the supine sniff-
ing position to aid in airway instrumentation. In MO
patients, multiple studies have demonstrated that creat-
ing a blanket ramp or reconfiguring the operating table
to a 30 back-up position provides optimal conditions
for successful intubation.
29,33
In these studies, aligning
the external auditory meatus with the sternum horizon-
tally has been shown to improve the laryngoscopic view
(Figure 4). If airway management and intubation prove
difficult, emergency airway adjuncts, including a gum
elastic bougie, laryngeal mask airway, video laryngo-
scope, or fiberoptic endoscope, may be used.
Because of alterations in pulmonary function, such
as reduced functional residual capacity and oxygen re-
serves, MO patients are likely to experience rapid oxygen
desaturation during the induction of general anesthesia,
and increased atelectasis may develop throughout the
case (Figure 5). Maximizing the oxygen content in the
lungs before tracheal intubation is important to decrease
these risks. The application of continuous positive airway
pressure during preoxygenation, induction with the
patient in a head-up position, along with the addition of
positive end-expiratory pressure (PEEP) and mechanical
ventilation by mask after induction have been shown to
prevent atelectasis and desaturation.
34,35
Safe intraoperative ventilation of MO patients poses a
substantial challenge to anesthesia providers. This chal-
Complete blood cell count
Comprehensive metabolic panel
Liver function tests
Glucose/hemoglobin A
1c
Prothrombin time/partial thromboplastin time
Lipid profile
Table 8. Suggested Preoperative Laboratory Testing
156 AANA Journal April 2011 Vol. 79, No. 2 www.aana.com/aanajournalonline.aspx
lenge is especially important when considering the nega-
tive pulmonary effects of the pneumoperitoneum during
bariatric surgery. Complete muscle relaxation is crucial
during these procedures to facilitate ventilation and
prevent collapse of the pneumoperitoneum. Numerous
strategies to maintain intraoperative oxygenation and
lung volumes in MO patients have been recommended.
The use of high tidal volumes, alveolar recruitment
maneuvers, positive end-expiratory pressure, and high
oxygen concentrations have been studied extensively, and
none are conclusively superior. Increasing tidal volumes
more than 13 mL/kg in MO patients has been found to
increase peak inspiratory pressures and end-expiratory
airway pressures but does not substantially improve
arterial oxygen tension.
36
When compared with the
supine position, the use of a 30 reverse Trendelenburg
position during bariatric surgery reduces the alveolar-
to-arterial oxygen difference, increases total ventilatory
compliance, and reduces peak airway pressures. Alveolar
recruitment by repeated sustained lung inflation to 50
cm/H
2
O followed by the addition of 12 cm/H
2
O of posi-
tive end-expiratory pressure during mechanical ventila-
Figure 4. Optimal Body Position for Successful Intubation of Morbidly Obese Patients
Figure 5. Oxygen Desaturation in Morbidly Obese
Patients
www.aana.com/aanajournalonline.aspx AANA Journal April 2011 Vol. 79, No. 2 157
tion can increase intraoperative PaO
2
but may result
in hypotension that requires vasopressor support.
37
Mechanical ventilation using pressure-controlled instead
of volume-controlled ventilation results in improved ox-
ygenation in MO patients.
38
Table 9 summarizes various
strategies for intraoperative ventilatory management
while protecting against ventilator-induced lung injury.
39
Safe positioning of obese patients may require a spe-
cially designed operating table or 2 regular tables joined
together. Standard-size operating tables have a maximum
weight limit of approximately 200 kg, but operating
tables with a weight maximum of 455 kg are available.
Pressure sores, neural injuries, and rhabdomyolysis are
more common in MO patients and patients with dia-
betes.
25
Special care should be given to positioning and
padding pressure points before and throughout the surgi-
cal process because changes in operating table position or
surgical manipulation may cause body shifts.
As with all patients, invasive arterial monitoring may
be considered for obese patients with concomitant car-
diopulmonary disease. The conical shape of the upper
arm may present difficulties in obtaining an accurate
noninvasive blood pressure reading, and invasive moni-
toring may be deemed necessary. To avoid inaccurate
readings, appropriate cuff size includes a bladder that
encircles a minimum of 75% of the upper arm circumfer-
ence or the entire arm.
25
Comparable and accurate blood
pressure readings can be obtained from the wrist or ankle
with appropriately sized cuffs.
Patients may be admitted to the surgical suite with
hypovolemia due to bowel preparation and preoperative
fasting. In addition, obese patients are frequently receiv-
ing antihypertensive medications that increase the po-
tential for hypotension during induction. This potential,
coupled with the propensity for postoperative acute renal
failure, highlights the importance of fluid replacement.
Because of higher blood volumes in MO patients, abso-
lute values calculated for fluid requirements during bar-
iatric surgery may seem high (eg, 4-5 L). Regardless, the
development of fluid overload is possible, and vigilance
in monitoring volume status is imperative.
Delayed recovery from anesthesia may occur due to
sequestration of lipid-soluble anesthetic drugs in MO
patients. Special consideration should be taken to ensure
the patient has fully recovered protective airway reflexes,
adequate respirations, and complete muscle strength
before extubation. In addition, placing the patient in the
reverse Trendelenburg position improves alveolar re-
cruitment and distention, decreases atelectasis, and may
help to improve oxygenation throughout emergence.
25
Postoperative Management. Pathophysiologic changes
in obese patients, along with coexisting diseases, affect
Table 9. Ventilatory Management of Morbidly Obese Patients
HOB indicates head of bed; CPAP, continuous positive airway pressure; FIO
2
, fractional inspired oxygen concentration; PEEP, positive
end-expiratory pressure; BiPAP, bilevel positive airway pressure.
(Adapted from Sprung et al.
39
)
Goal/recommendation Rationale/additional information
Prevent hypoxemia during induction
HOB elevated (back-up Fowler or reverse Trendelenburg) 30 May increase the safe apnea period during induction
Use of CPAP during induction
Preoxygenate with 100% O
2
Prevent/reverse atelectasis
Restrict the use of FIO
2
to < 0.8 during maintenance of anesthesia Use of a high FIO
2
concentration during anesthesia accelerates
the onset and the amount of atelectasis.
Recruitment (vital capacity) maneuver after intubation by using Monitor for adverse effects (bradycardia, hypotension).
sustained (8-10 seconds) pressure 40 cm/H
2
O
Maintain lung recruitment
Use PEEP (10-12 cm/H
2
O) Monitor for hypotension or decreasing arterial oxygenation
(PEEP-induced increase in pulmonary shunt fraction).
Avoid lung overdistension
Use tidal volume of 6-10 mL/kg of ideal body weight
Keep peak-inspiratory pressure < 30 cm/H
2
O
Consider mild permissive hypercapnia if necessary
Maintain postoperative lung expansion
Use CPAP or BiPAP immediately after tracheal extubation
Keep upper body elevated
Maintain good pain control
Use incentive spirometry
Encourage early ambulation
Increase the ventilation rate to control excessive hypercapnia
instead of using large tidal volumes or high ventilatory pres-
sures.
158 AANA Journal April 2011 Vol. 79, No. 2 www.aana.com/aanajournalonline.aspx
not only the intraoperative management but also the
postoperative management. Early identification of com-
plications is essential. Postoperative complications in MO
bariatric surgical patients are derived from pathophysi-
ologic changes due to obesity, coexisting diseases, and
the surgical procedure.
The pulmonary changes in obese patients, such as
increased chest wall resistance, decreased functional re-
sidual capacity, and forced vital capacity, along with the
effects of intraoperative mechanical ventilation result in
a substantial incidence of postoperative atelectasis and
hypoxemia. Therefore, optimizing oxygen administration
by placing the patient in the head-up position increases
functional residual capacity and decreases the work of
breathing.
Patients who have obstructive sleep apnea are at
increased postoperative risk for respiratory failure.
40,41
ASA practice guidelines suggest that patients receiving
continuous positive airway pressure or bilevel positive
airway pressure preoperatively should receive it imme-
diately postoperatively.
41
These ventilatory support mo-
dalities prevent alveolar collapse during expiration and
allow alveolar recruitment during inspiration.
40,42
They
also act to displace the tongue and soft tissues, thereby
preventing airway obstruction. Concerns that continu-
ous positive airway pressure may cause gastric insuffla-
tion and distention resulting in anastomotic failure have
largely been discredited.
43
The surgical approach for bariatric surgery also con-
tributes to postoperative pulmonary complications. Open
abdominal approaches reduce functional residual capac-
ity and forced expiratory volume in 1 second more than
laparoscopic approaches. In addition, they are also as-
sociated with more postoperative pain than laparoscopic
approaches, resulting in tachypnea, shallow breathing,
and impairment of respiratory mechanics.
42
Regardless
of the surgical approach, inadequate postoperative pain
management can lead to hypoxemia, hypercarbia, and
atelectasis.
44
Management of postoperative pain in MO patients is
challenging. Morbidly obese patients have exaggerated
respiratory depression from opioids. A multimodal ap-
proach to postoperative pain may be superior. However,
in patients with obstructive sleep apnea, the respiratory
depressant effects are more pronounced; therefore, opioid-
sparing techniques help avoid respiratory complications.
41
Multimodal approaches to postoperative pain manage-
ment include intravenous opioid administration based
on ideal body weight, local anesthetics injected into the
wound or port site, neuraxial anesthesia, and the use of
nonsteroidal anti-inflammatory agents.
45,46
Investigations
have shown that an infusion of dexmedetomidine de-
creases postoperative opioid requirements.
8,45,46
Another
current pain management alternative is the continuous
intraperitoneal infusion of bupivacaine.
47
Anastomotic leak is the most common cause of sur-
gically related mortality in bariatric patients.
48,49
Signs
and symptoms of an anastomotic leak are listed in Table
10. These symptoms are often subtle and nonspecific,
making early diagnosis difficult.
49
Other physiologic changes associated with morbid
obesity, such as greater blood volume, polycythemia,
sedentary lifestyle, and venous stasis, increase the risk
of deep venous thrombosis and pulmonary embolism.
Consequently, pulmonary embolism is the second
most common cause of mortality related to bariatric
surgery.
44,48
Postoperative signs and symptoms of pulmonary
embolism include tachypnea, tachycardia, chest pain,
hypoxemia, arrhythmias, and a feeling of doom.
43
Differential diagnosis of pulmonary embolism may be
challenging because many of these symptoms mimic a
bowel leak.
48
The anesthetic management for bariatric surgery pres-
ents many challenges. These include managing comorbid
conditions, airway management, oxygenation, fluid and
medication calculation, and postoperative pain manage-
ment. A thorough understanding of the pathophysiologic
changes, pharmacology of weight-loss drugs and anes-
thetic agents, and perioperative course will allow a high-
quality, safe surgical experience.
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AUTHORS
Jennifer Thompson, CRNA, MSN, is academic and clinical instructor at
Kaiser Permanente School of Anesthesia/California State University Fuller-
ton Department of Nursing, Pasadena, California. Email: Jen.l.thompson
@kp.org.
Sandra Bordi, CRNA, MSN, is academic and clinical instructor at Kai-
ser Permanente School of Anesthesia/California State University Fullerton
Department of Nursing.
Michael Boytim, CRNA, EdD, is assistant director at Kaiser Perma-
nente School of Anesthesia/California State University Fullerton Depart-
ment of Nursing.
Sass Elisha, CRNA, EdD, is assistant director at Kaiser Permanente
School of Anesthesia/California State University Fullerton Department of
Nursing.
Jeremy Heiner, CRNA, MSN, is academic and clinical instructor at
Kaiser Permanente School of Anesthesia/California State University Ful-
lerton Department of Nursing.
John Nagelhout, CRNA, PhD, FAAN, is director of Kaiser Permanente
School of Anesthesia/California State University Fullerton Department of
Nursing.