ANAESTHESIA FOR OBESE

PATIENTS

DR. THOMAS
SPECIALIST IN ANAESTHESIA,
AL BUKARIYA GENERAL HOSPITAL,
 OBESITY
• Obesity is one of the most common nutritional
disorders
• Adipose tissue is a normal constituent of the
human body that serves the important function of
storing energy as fat for mobilization in response
to metabolic demands. Obesity is an excess body
fat frequently resulting in a significant
impairment of health. The body cannot store
proteins &carbohydrates, so excess proteins &
carbohydrates are converted to fat in the body.
An imbalance between energy intake &
expenditure causes obesity
• obesity is defined as a bodyweight 20% or more
Body mass index (BMI)
• A measure of obesity is the Body mass index
(BMI)
• A BMI of 28 for men and 27 for women
correspond to 20% above Ideal body weight
• Body mass index (BMI) = weight in kgs
height in meters2
• Eg. A man with 150 kg and 1.8 M tall has a BMI
of 47 which is more than 100% above the ideal
body weight. A similar patient with weight 80
kg has BMI of 25.
• A BMI higher than 28 is associated with
increased morbidity due to stroke, IHD, DM 3-
Obesity – Incidence
• Saudi Arabia:
 Among the 15 to 70 year age group the
prevalence of obesity is 20.26%.It is alarmingly
high in the infertile Saudi females.
• USA:
 A BMI >30. 1980….14.5%

1998….22%
300,000 deaths in the US in each year are
associated with obesity .
• In the black females older than 45, there is a
incidence of 60%
Pathogenesis
Aetiology:
A complex multifactorial disease.
» Prevalence increases with age
» Genetic factors are present
» Environment also has some influence.
» Others are Cushing's syndrome,
hypothyroidism, disorders of
hypothalamus, insulinoma
Pathogenesis
• The current availability of caloric dense foods &
sedentary life style promote weight gain
• If daily energy intake exceeds energy expenditure by
2 % then the cumulative effect after one year is about
2 to 3 kg increase in body weight
• The dietary composition has only a minor role in the
pathogenesis of obesity
• Surplus calories are converted to triglycerides and
stored in the adiposities. This storage is regulated by
the enzyme lipoprotein lipase. This activity of the
enzyme varies in different parts of the body
• A central (abdominal) distribution is common in men
and peripheral distribution of fat (hip, buttocks &
thighs) common in females
• Abdominal fat deposits are metabolically more active
and are thus associated with a higher incidence of
Physiological disturbances

1. Obstructive sleep apnea: (OSA)

 5% obese patients develop OSA
 characterized by frequent episodes of apnea
during sleep; airway obstruction
manifesting as snoring & day time
somnolence due to interrupted sleep during
night
 physiological changes of OSA include arterial
hypercarbia, polycythemia, SHT, pulmonary
hypertension and right ventricular failure
Physiological disturbances
2. Obesity hypoventilation syndrome:
 long term consequence of OSA
 Nocturnal episodes of central apnea reflects
progressive desensitization of respiratory
centers for hypercarbia
 at its extreme obesity hypoventilation
syndrome ends in Pickwickian syndrome
 Pickwickian syndrome is characterized by
obesity, daytime sleep, arterial hypoxemia,
polycythemia, hypercarbia, respiratory
acidosis, pulmonary HT& RV failure
 Physiological disturbance
3. Respiratory system:
 restrictive ventilation defect:
 due to weight added to thoracic cage & abdominal weight
impeding diaphragm motion especially in supine position
 results in decrease in FRC, ERV & TLC
 FRC decrease to the point of closing capacity & resulting in
V/Q mismatch, R – L shunting & arterial hypoxemia
 anaesthesia adds to these changes such that a 50%
decrease in FRC occurs( normally FRC 20% decreases)
 PEEP improves FRC and oxygenation at the expense of
cardiac output
 decreased FRC impairs the ability of obese pts to tolerate
apnea such as during laryngoscopy & intubation
Physiological disturbances
• Gas exchange:
– arterial oxygenation may deteriorate
markedly on induction of anesthesia &
increased FIO2 needed to maintain an
acceptable PaO2
– administration of ventilatory depressant
drugs and supine position will aggravate
the hypoxemia & can lead to CO2
retention
 Physiological disturbances

• Lung compliance & resistance:

– increasing obesity causes decrease in
compliance & resistance
– due to accumulation of fat in & around the
chest wall, & increased pulmonary blood volume
– decrease lung compliance causes decreases in
FRC & impaired gas exchange
– these changes leads to rapid shallow
breathing & increased work of breathing,
mostly during supine position
Physiological disturbances
4. Cardiovascular system:
Mild to moderate SHT is present in 50 to 60%
Each kg of fat contains 3000 M of blood vessels
Cardiac output is increased by 0.1litre/ min for each
Kg weight gain, cardiomegaly & SHT reflect
increased CO
Hyperinsulinemia also contribute to SHT by
activating sympathetic nervous system
Pulmonary hypertension is common due to chronic
arterial hypoxemia & increased pul. blood volume
Obesity is an independent risk factor for IHD –
more common in those with central distribution of
fat. Other factors like SHT, DM,
Physiological disturbances
Cardiovascular system:
SHT leads to concentric LVH & progressively
non-compliant LV which when combined with
hypervolemia increases the risk of CHF
Fatty infiltration of myocardium is uncommon
and is not responsible for CHF
Cardiac arrhythmias may be precipitated by
arterial hypoxemia, hypercarbia & IHD
Ventricular dysfunction & hypertrophy
increases with the duration of obesity
Physiological disturbances

5. Gastro-intestinal system:
Obese patients are at increased risk of aspiration
pneumonia due to increased intra-abdominal
pressure, delayed gastric emptying & high
incidence of hiatal hernia
Abnormal LFT & fatty liver changes are common
Volatile anesthetic agents are defluorinated to a
greater extent, but no evidence of exaggerated
anesthetic induced hepatic dysfunction
Gall bladder & biliary tract disease is increased to 3
folds in obese patients, may be due to abnormal
Physiological disturbances

6. Diabetes mellitus:
Glucose tolerance curves are often
abnormal & incidence of DM is increased
to several folds in obese patients.
There is resistance of peripheral tissues
to the effects of insulin in the presence
of increased fat, this results in NIDDM
Physiological disturbances

7. Thrombo-embolic disease:
The risk of DVT in obese patients
undergoing surgery is double that of
non-obese
This is due to polycythemia, increased
intra-abdominal pressure and
immobilization leading to venous stasis &
increased pressure in deep veins
Pharmacokinetics of drugs
• The physiological changes associated with
obesity lead to alteration in drug distribution,
binding & elimination of many drugs
• Hepatic clearance of drugs is not altered
• Renal clearance of drugs is increased due to
increased RBF & GFR
• Drug dosage calculation based on actual body
weight can result in excessive plasma
concentration as the fat has a low blood flow
• The calculation of the initial dose should be
based on Ideal Body Weight (lean body mass)
• Ideal body weight can be assumed as 100kg
for men and 80 kg for females
Treatment of Obesity

• Purpose is to decrease morbidity & not

to meet a cosmetic standard of
thinness

• A weight loss of 5 to 20 kg will

decrease systemic blood pressure and
enhance the control of diabetes
mellitus
Treatment of Obesity
• Behavioral therapy:
– life style alterations in the form of increased
physical activity
– exercise
• Medical treatment:
– serotonin inhibitors – acts as appetite
suppressants but also produce undesirable side-
effects . Ex: Fenfluramine
– sibutaramine – appetite suprresnts- inhibits
reuptake of serotonin & nor-epinephrine
– orlistat – is a lipase inhibitor not absorbed from
the stomach
• Surgical treatment:
– gastroplasty– most common – intestinal
obstruction & electrolytes are common after this
Management of Anaesthesia
• Pre-operative evaluation
– History
• Duration of obesity, other associated
problems
• Previous operations and anaesthesia
• Medical treatments.
– Investigations
• CBC, Urine examination
• LFT, RFT, ECG, ECHO,
• ABG, X ray Chest
Anaesthesia
• Assessment of Airway
– Difficulties with mask ventilation and tracheal
intubation may be present, due to
• Fat face, fat cheek
• Short neck
• Excessive palatal and pharyngeal soft tissues
• Restriction in mouth opening.
• Limited cervical and mandibular mobility.
• Large breasts.
• Awake tracheal intubation may be considered.
Anaesthesia
• Premedication
– Obese patients are at increased risk of
pulmonary aspiration, due to increased gastric
acidity, gastric fluid volume and intragastric
pressure.
• H2 receptor antagonists
• cimetidine, ranitidine, NPA
• Metoclopramide
• Ondansetron
– Narcotic premedication may be avoided.
– Anxiolytic- midazolam/diazepam/lorazepam
Anaesthesia
• Induction of Anaesthesia.
– Pulse oximeter, ECG, NIBP, Capnogram
– Venous access.
– Preoxygenation for 3 minutes.
– In predetermined patients awake intubation
– Induction with propofol, thiopentone may be
considered. Dose to be calculated on ideal body
weight.
– Cricoid pressure (Sellick’s) /short duration
larngoscopy/ endotracheal intubation with
cuffed tube
Anaesthesia
• Maintenance
– Controlled ventilation using large tidal
volume is the choice.
– PEEP may improve oxygenation but the
associated decrease in CO offsets the
benefits.
– Prone and head down position can further
decrease chest wall compliance and the
PaO2
– Desflurane,sevoflurane and Isoflurane are
better choices.
Anaesthesia
• extubation can be done after full
recovery from the depressant effects
of the anesthetics
• head-up position during recovery is
ideal
• post operative ventilation is more
likely to be required in obese patients
who have co-existing CO2 retention,
prolonged surgery especially abdominal
Post operative complications
• Arterial hypoxemia & hypoventilation
– it occurs after upper abdominal surgeries
– semi-sitting position & supplemental O2
can prevent this problem
– Wound infection – twice more common
than in non-obese
– Deep-vein thrombosis & pul embolism
• early post-op ambulation & heparin
prophylaxis can reduce these
complications
– Obstructive sleep apnea
Post operative analgesia
• Patient controlled analgesia
– doses based on ideal body weight
• Neur-axial opioids
– continuous infusion of LA & opioids
• NSAID’s
• Local analgesia
– local infiltration
– nerve blocks
Bibliography
 Anesthesia & Co-existing diseases.
Stoelting. 4th edition
 Harrison’s principles of Internal
medicine 15th edition
 Saudi journal of disability &
rehabilitation, Vol 8, No 3
 Anesthesia. Miller. 5th edition
Safety features in Anaesthesia Machine

Dr. Shailendra.V.L.
Specialist in Anaesthesia,
Al Bukariya General Hospital
Saudi Arabia.
Gas Supply
• Cylinder:
– colour
– high pressure releasing safety
system

• Pipeline supply:
– colour
– DISS
Yoke assembly

• pin index
• filter
• non-return valve
• bourden guage
Pressure regulator

• factory, preset valves

• master-slave mechanism
• oxygen failure warning devices
• high pressure relief valve
Flow meter
• bobbin
• background
• lighted
• knobs
– colour coded
– tough coded
– position
• oxygen downstream of all gases
• anti-hypoxic devices
– link 28
– ORMC
Vaporizer
• select-a-tec
• keyed bottle filling
• dial lock
•
Machine back-bar
• high pressure relief valve
• non-return valve
•
CO2 absorber & circle system
• non-return valves
• soda lime indicator
• baffles in the canister
• water trap
• corrugated tubes
•
•