CURRENT THERAPY

J Oral Maxillofac Surg

63:1348-1353, 2005

Anesthetic Considerations for the Obese

and Morbidly Obese Oral and
Maxillofacial Surgery Patient
David W. Todd, DMD, MD*

The purpose of this article is to review the problems of anesthetic management of the obese patient and
review current literature on this topic. Obesity is associated with a wide spectrum of medical problems.
Anesthetic management requires being familiar with the pathophysiologic changes associated with
obesity as well as the specific management issues that can arise. We will review recommendations from
the literature on anesthesia management as they apply to the oral and maxillofacial surgeon.
© 2005 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 63:1348-1353, 2005

The definitions of obesity are variable, but a reliable
and easy to perform index is the body mass index
(BMI). This index of total body fat can easily be
calculated and is gender and age independent. It is
calculated by dividing the weight in pounds by total
height in inches and dividing again by total height in
inches. This result is multiplied by 703 (a conversion
factor) to arrive at kg/m2.1 Alternatively, and I believe
more conveniently, nomogram tables can be used to
calculate BMI (Fig 1).2 It is generally defined that
obesity is a patient with a BMI greater than 30 and
morbid obesity is a patient with a BMI greater than 35.
The BMI does have limitations and cannot be used for
heavily muscled individuals. Obesity can also be de-
fined as more than 20% above ideal body weight
(IBW) and morbid obesity more than 2 times IBW or
greater than 100 pounds above IBW.3 The trends
toward an increasingly obese population are clear in
the United States. Currently, 55% of American adults
are overweight and 1 in 5 Americans have a body
mass index of greater than 30 kg/m2; if current trends
continue this figure could reach 40% by the year
2025.4,5 Clearly the oral and maxillofacial surgeon
(OMS) will encounter obesity in his or her practice. It
is not unusual to see morbidly obese patients on a
regular basis in the author’s practice.
*Private Practice, Lakewood, NY.
Address correspondence and reprint requests to Dr Todd: 120
Southwestern Dr, Lakewood, NY 14750; e-mail: rdtodd@
madbbs.com
© 2005 American Association of Oral and Maxillofacial Surgeons
0278-2391/05/6309-0015$30.00/0
doi:10.1016/j.joms.2005.05.307
BMI is a useful objective tool and is frequently used
to study the effect of obesity in surgical and anes-
thetic outcomes. Davies et al6 studied obesity and day
case surgery in the United Kingdom and found no
increase in postoperative complication rates or un-
planned admission rates. Similarly, Dindo et al7 found
no increase in postoperative surgical complications
for 6,336 morbidly obese inpatients undergoing gen-
eral elective surgery. De Jong,1 however, felt that BMI
greater than 30 increased the risk for cosmetic office
based day surgery whether with sedation or general
anesthesia. In a review of pre-existing medical condi-
tions as a predictor of adverse outcomes, Chung et al8
found that obese patients were 4 times more likely to
develop intraoperative and postoperative pulmonary
complications. Similar reviews reached similar con-
clusions.9,10 A review of the pathophysiology of the
effects of obesity may help to clarify the role of BMI in
selecting patients for office based anesthesia in the
oral and maxillofacial (OMF) office.
It is important to understand the changes in the
pulmonary, cardiovascular, and gastrointestinal-meta-
bolic systems in the obese patient when considering
their management. In terms of the pulmonary system,
it is well established that hypoxemia is associated
with obesity through several mechanisms; increased
minute ventilation requirement at rest to meet the
metabolic needs of increased tissue mass, increased
work and energy cost of breathing, and changes in
lung volumes.11 Changes in lung volumes at rest in
the obese patient manifest as reduced functional re-
sidual capacity (FRC), vital capacity, and total lung
capacity. These decreases in lung volume decrease
exponentially with BMI.12 Because closing capacity is
unchanged in obesity, reduced FRC can result in lung

1348
DAVID W. TODD
FIGURE 1. Nomogram for BMI. (Reprinted with permission from
Barker et al.2)
David W. Todd. Anesthetics for the Obese OMF Patient. J Oral
Maxillofac Surg 2005.
volumes below closing capacity in normal tidal venti-
lation (Fig 2).13 Ventilation/perfusion mismatches de-
velop from the closure of small airways resulting in
right to left shunt and arterial hypoxemia. Anesthesia
compounds these problems with a greater reduction
in observed FRC in obese patients compared with
non-obese patients.14 The reduction in FRC also leads
to reduced capacity of obese individuals to tolerate
periods of apnea.
Patient positioning aggravates these lung volumes
and contributes to the poor respiratory reserve in
obese patients. A comparison of patient positioning
showed the reverse Trendelenburg position to be
most optimal, followed by 30° back up semi-Fowler
position; the least optimal was supine position as
defined by safe apnea periods and recovery times.15
Not surprisingly, obese patients suffer from a greater
percentage of postoperative atelectasis for a longer
period of time compared with the non-obese patient
after general anesthetic.16
It is estimated that 5% of obese patients will have
obstructive sleep apnea (OSA). The patient should be
questioned about symptoms such as episodes of ap-
nea or hypopnea during sleep, snoring, and daytime
1349
sleepiness. Other features that help to identify pa-
tients with OSA include BMI greater than 30, hyper-
tension, polycythemia, hypoxia/hypercapnea, and
right ventricular hypertrophy on electrocardiogram
or echocardiography.14 Obviously, sedative medica-
tions compound the problem of maintaining an ade-
quate airway for OSA patients.
Airway assessment for the obese patient can be
difficult; individual tests such as Mallampati score
seem to have less predictive value in the obese pa-
tient.17 It has been recommended that a thorough
evaluation include: assessment of head and neck flex-
ion and rotation, jaw mobility and mouth opening,
inspection of the oropharynx and dentition, as well as
questioning regarding previous history of difficulty
with intubation and symptoms of OSA. In a recent
review, Juvin et al18 found that none of the classic
predictive risk factors were satisfactory in obese pa-
tients. In his study, Juvin found that difficult tracheal
intubation is more common in obese patients com-
pared with lean patients and found the rate to be
approximately 15.5%.18 The question of whether this
is true is controversial in the literature with studies
showing more frequency19-22 and studies showing no
increased incidence.23-26 Although controversy re-
mains on the issue of difficulty of the airway in the
obese, all references agree that a rapid fall in arterial
oxygenation occurs when the airway is compromised
because of the changes in lung volumes, increased
oxygen demand, and increased CO2 production.
Cardiovascular disease dominates the morbidity
and mortality in obesity and manifests itself in the
form of ischemic heart disease, hypertension, and
cardiac failure.13 Obesity has been shown by the Fra-
mingham study to be an important risk factor for
cardiovascular disease in patients younger than 50
years of age. Risk of coronary artery disease, myocar-
dial infarction, and sudden death was increased in the
obese in both sexes.3 Abbasi et al27 studied the rela-
FIGURE 2. Representation of the effects of obesity on FRC. (Reprinted
with permission from Adams and Murphy.13)
David W. Todd. Anesthetics for the Obese OMF Patient. J Oral
Maxillofac Surg 2005.
1350
tionship between obesity, insulin resistance, and cor-
onary heart disease and found that increased BMI and
steady state glucose concentration were both inde-
pendently associated with 9 cardiac risk factors. Mes-
serli et al28 investigated the association between obe-
sity and sudden death and studied 15 obese
hypertensive patients without other cardiac disease
and found the incidence of PVCs to be 10 times
higher than control patients using Holter monitoring.
Sudden unexplained death is 13 times more likely in
morbidly obese patients compared with their non-
obese counterparts.29 Approximately 50% to 60% of
obese patients have mild to moderate hypertension
and 5% to 10% have severe hypertension.30 Diaz31
found that BMI bears a positive linear correlation with
blood pressure.
Patients with morbid obesity and hypertension are
at risk for a specific form of obesity induced cardiac
dysfunction. This dysfunction was once thought to be
caused by fatty infiltration of the heart. Obesity is
associated with an increase in blood volume and car-
diac output. The increased cardiac output is largely
the result of ventricular dilatation which causes in-
creased wall stress and hypertrophy. The combina-
tion of hypertrophy and dilatation is termed “eccen-
tric hypertrophy” and manifests as reduced
compliance, pulmonary edema, and systolic dysfunc-
tion.3,13 This can manifest clinically as both right and
left sided heart failure.30,32,33 The morbidly obese
have limited mobility and can appear to be asymp-
tomatic even with significant cardiovascular disease.
A more thorough cardiac workup is necessary for the
morbidly obese patient than would otherwise be
needed for a given age.
The obese patient is at increased risk for aspiration
with anesthesia. The risk is increased by high residual
gastric volume and low gastric pH in the fasting obese
patient.34,35 The risk of aspiration is also increased by
an increased incidence of hiatal hernia and from the
increased intra-abdominal pressure. It is recom-
mended by Adams and Murphy13 that all morbidly
obese patients receive prophylaxis against acid aspi-
ration even if they do not declare any symptoms of
heartburn or reflux.
Alteration of the pharmacokinetics of various drugs
can be anticipated because of differences in the vol-
ume of distribution and clearance in the obese pa-
tient. For lipid soluble agents, the steady state volume
of distribution will be larger in the obese person, the
serum concentration for a given dose will be lower,
and the terminal elimination half-life of the drug will
be greater. It is most ideal to use drugs with short
half-life so that residual effect is limited in the post
anesthetic period. In 1 study involving midazolam,
the elimination half-life was markedly longer in the
obese subjects compared with normal weight con-
ANESTHETICS FOR THE OBESE OMF PATIENT
trols (8.4 hours vs 2.7 hours).36 Despite this effect,
larger initial doses are required to achieve effect and
dosing is based on total body weight (TBW). Fentanyl
and sufentanyl distribute as extensively in excess
body mass as in lean tissues. Therefore, it is recom-
mended that initial dosing be based on TBW with
maintenance on IBW.37 IBW in kilograms is calculated
by subtracting 100 for adult males and 105 for adult
females from their height expressed in centimeters.
Remifentanyl has similar pharmacokinetics in obese
and non-obese patients and dosing should be based
on IBW. Remifentanyl may be the ideal drug in the
obese patient because of its short half-life and non-
specific enzymatic degradation.38
Pseudocholinesterase activity increases linearly
with weight, and this factor in combination with the
larger extracellular fluid compartment means that a
larger dose of succinylcholine is required in the obese
individual. Therefore, dosing for succinylcholine is
based on TBW.39,40 Propofol has a systemic clearance
and volume of distribution that correlate with TBW
but it has high affinity for excess fat and well perfused
organs. It is recommended that initial dosing be based
on IBW and maintenance based on TBW. I could find
no specific references for methohexital, but thiopen-
tal dosing is based on TBW and is expected to have a
prolonged duration of action.41 Despite these recom-
mendations, the net pharmacokinetic effect in the
obese patient is uncertain, making endpoints such as
heart rate, blood pressure, and sedation more impor-
tant than empirical drug dosing (Table 1).
In terms of practical considerations for the OMS
faced with an obese patient who expresses high den-
tal anxiety or who requires a procedure where a
sedation or general anesthetic would be required, the
first decision point may be whether the patient can be
safely treated in the office environment or the hospi-
tal. The following considerations may be helpful.
1. Calculate BMI: In calculating BMI, a more objec-
tive assessment of the level of overweight is
developed. Increasing BMI correlates with in-
creased blood pressure, increased insulin resis-
tance, increased risk of ischemic heart disease,
risk of difficult airway (at least in some studies),
increased risk of aspiration, and decreased lung
volumes. Using a nomogram table to calculate
BMI, the subjective evaluation of a patient’s level
of overweight can be more objectively mea-
sured. A patient with a BMI over 35 is consid-
ered morbidly obese and should give caution to
possible difficult anesthetic management and
would likely not be a good candidate for office
based sedation or general anesthesia. A patient
with a BMI over 30 is obese and should demand
a more thorough consideration of other ele-
DAVID W. TODD 1351

Table 1. WEIGHT-BASED DOSING OF COMMON IV ANESTHETICS

Drug Dosing Implications

Propofol IBW Increased absolute dose, reduced dose per unit body weight; high affinity
for excess fat
TBW (maintenance)
Thiopental TBW Prolonged duration of action
Midazolam, diazepam TBW Prolonged sedation because larger initial doses are needed to achieve effect

Succinylcholine TBW Plasma cholinesterase activity increases with body weight

Fentanyl, sufentanil TBW Increased Vd and elimination half-time correlates positively with the degree
of obesity; distributes as extensively in excess body tissue as in lean tissue

Remifentanyl IBW Pharmacokinetics are similar in obese and nonobese patients

Alfentanyl IBW Elimination may be prolonged
Data from references 13 and 41.
David W. Todd. Anesthetics for the Obese OMF Patient. J Oral Maxillofac Surg 2005.

ments of the physical assessment and medical
history to decide whether they are a good can-
didate for office based anesthesia.
2. Comorbidities: Investigation of comorbidities
for the obese and morbidly obese patient will
need to be carried out more intensively com-
pared with a non-overweight person of the same
age. Attention should focus on systemic hyper-
tension, signs of right or left sided failure, is-
chemic heart disease, and diabetes mellitus. Cig-
arette smoking combined with BMI of greater
than 30 kg/m2 causes increased pulmonary com-
plications.
3. Recognition of societal stigma: Obese patients
and especially morbidly obese patients needing
OMF care may be quite emotionally sensitive
regarding their obesity. Studies have shown that
obese persons are less likely to be selected for
jobs, promotions, and higher education.42 Em-
pathy and compassion will be needed when
addressing obesity as a decision factor for treat-
ment.
4. Physical facilities and patient positioning: Treat-
ing the obese patient requires a review of the
physical facilities to ensure that operating chairs
or tables can accommodate the weight require-
ments of obese and morbidly obese individuals.
In addition, the OMS should be familiar with the
exacerbations of decreased lung volumes with
supine and Trendelenburg positions. A more
upright position such as reverse Trendelenburg
is most favorable for lung volumes but can make
some procedures in the maxilla more difficult.
5. Measurement of blood pressure: The appropri-
ately sized blood pressure cuff must be used and
should encompass 75% of the circumference of
the upper arm. Comparable and accurate read-
ings can be taken from an appropriately sized
cuff on the forearm or wrist. Falsely elevated
blood pressure measurements will be obtained if
the cuff used is too small for the arm.
6. IV access: In the obese patient, intravenous ac-
cess can be difficult to obtain. During the pre-
operative assessment, intravenous access should
be evaluated. In the bariatric literature for mor-
bidly obese patients, central lines and venous
cutdowns have to be used in some instances to
gain intravenous access.
7. Airway assessment: There is not universal agree-
ment in the literature that the obese patient has
a more difficult airway, but a more thorough
airway assessment is wise in choosing candi-
dates for office based anesthetic. Traditional air-
way assessment tools such as Mallampati classi-
fication may not be predictive of airway
difficulty. If a difficult airway is encountered and
the patient cannot easily be ventilated by mask,
then endotracheal intubation would be the best
way to protect the airway. If difficult laryngos-
copy is encountered, then the laryngeal mask
airway (LMA) may be a good tool because ease
of placement has been found to be independent
of ease of laryngoscopy.43-45 However, the LMA
classic does not protect against aspiration of
stomach contents. The intubating LMA has been
reviewed by Frappier et al46 for morbidly obese
patients who found a 96.3% success rate and
found it to be a safe and effective technique for
these patients. It can be anticipated that creation
of a surgical airway in an emergency would be
complicated by excess adipose tissues obscur-
ing desirable landmarks.
8. Prophylaxis against aspiration: Recommenda-
tions for aspiration prophylaxis for the obese
patient undergoing office based anesthesia are
lacking. In the literature for the morbidly obese
1352
patient, it is recommended that an H2 blocker
such as ranitidine 150 mg orally and a prokinetic
agent such as metoclopramide 10 mg orally be
taken 12 hours and 2 hours before surgery, re-
spectively.13 Some also advocate a nonparticu-
late antacid such as 30 mL of bicitra to reduce
acidity of gastric contents. Certainly if the obese
patient complains of frequent reflux symptoms
or heartburn, medical evaluation and treatment
should be undertaken if possible before the
planned procedure. If reflux symptoms and fre-
quent heartburn are present, then strong con-
sideration for protection of the airway should be
considered.
9. Drug choice: The ideal drug choice for the OMS
to use for the obese patient who has been se-
lected as a good candidate for office based an-
esthetic is hard to determine. The goals of man-
agement in terms of drug therapy are to choose
agents that are easily titratable, have short dura-
tion of action, and do not distribute to fatty
tissues. Desflurane is the inhalational agent that
has been suggested as the anesthetic of choice
for morbidly obese patients because it most
closely fits the objectives outlined above.47,48
This is a drug that few OMSs would have in their
office.49 Halothane may show considerable dep-
osition in adipose tissue with possibly pro-
longed recovery from anesthetic. In addition,
there may be increased risk of halothane hepa-
titis in obese patients. Sevoflurane has increased
biotransformation in mildly obese patients but
increased serum fluoride levels do not seem to
cause problems clinically.
Ketamine might seem an ideal agent for the obese
patient selected for sedation because of less respira-
tory depression and bronchodilation. However, the
tachycardia, hypertensive effect, and increased myo-
cardial oxygen consumption limit its usefulness to
young healthy obese patients who have not yet devel-
oped comorbidities. In addition, increased intragastic
pressure caused by ketamine may exacerbate the risk
of aspiration. Propofol has been used in the obese and
morbidly obese population both as an induction agent
as well as a maintenance agent. Prolonged recovery
can be anticipated in the obese patient and increased
absolute dose will be required. In terms of narcotic,
remifentanyl would seem the ideal drug because of a
short half-life and lack of appreciable accumulation.38
However, this again is a drug that most OMSs would
not have in their office armamentarium. Fentanyl
would be expected to have a larger volume of distri-
bution and elimination half-life in the obese patient.
Finally, midazolam and diazepam would be expected
to have an increased absolute dose and prolonged
ANESTHETICS FOR THE OBESE OMF PATIENT
duration of action because of a larger initial dose to
achieve serum concentration and distribution to fatty
tissues.47
In conclusion, the OMS can expect to manage
obese and morbidly obese patients in their practice in
increasing number. In those patients who desire or
require an office based sedation or general anesthetic,
careful evaluation of patients must take into account
the potential complications of obesity and comorbidi-
ties. The most important decision will be which
obese patient can be managed safely in the office
environment and which are best managed in an am-
bulatory care center or hospital. The literature would
suggest that the morbidly obese (BMI ⬎ 35) are not
ideal candidates for most office settings.
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