Review

Perioperative care of the obese patient

M. Carron1 , B. Safaee Fakhr1 , G. Ieppariello1 and M. Foletto2
1 Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, and 2 Department of Surgical, Oncological and Gastroenterological

Sciences, Section of Surgery, University of Padua, Padua, Italy

Correspondence to: Dr M. Carron, Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Via V.
Gallucci, 13, 35121 Padua, Italy (e-mail: michele.carron@unipd.it)

Background: Obesity has become an increasing problem worldwide during the past few decades. Hence,
surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future,
and should be prepared to provide optimal management for these individuals. This review provides an
update of recent evidence regarding perioperative strategies for obese patients.
Methods: A search for papers on the perioperative care of obese patients (English language only) was
performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic
databases. The review focused on the results of RCTs, although observational studies, meta-analyses,
reviews, guidelines and other reports discussing the perioperative care of obese patients were also
considered. When data from obese patients were not available, relevant data from non-obese populations
were used.
Results and conclusion: Obese patients require comprehensive preoperative evaluation. Experienced
medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an ade-
quate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative
precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe
obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ven-
tilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long
procedures or revisional surgery.

Paper accepted 7 November 2019

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.11447

Introduction It is projected that 60 per cent of the world’s population

Obesity is defined as abnormal or excessive fat accumu-
lation that may impair health1,2 . BMI is a simple mea-
sure for classifying overweight and obesity in adults: BMI
over 25 kg/m2 and exceeding 30 kg/m2 respectively1,2 .
The WHO1,2 categorizes obesity as grade I (BMI 30–34
kg/m2 ), grade II (BMI 35–39 kg/m2 ) or grade III (BMI at
least 40 kg/m2 ).
The incidence and prevalence of obesity continue
to increase globally, in both developed and developing
countries1 . The worldwide prevalence of obesity nearly
tripled between 1975 and 2016. Overall, approximately 13
per cent of the world’s adult population (11 per cent of
men and 15 per cent of women) were obese in 20162 . The
USA has a particularly high prevalence of obesity: in 2013,
31⋅6 per cent of men and 33⋅9 per cent of women were
obese1 . In Europe, approximately 24 per cent of women
and 21 per cent of men were obese in the same year1 .
(3⋅3 billion people) will be overweight (2⋅2 billion) or
obese (1⋅1 billion) by 2030 if recent trends continue1,2 .
Obesity is of major importance because of its association
with increased morbidity and mortality2 . In 2010, over-
weight and obesity were estimated to cause 3⋅4 million
deaths, 3⋅9 per cent of years of life lost and 3⋅8 per cent of
disability-adjusted life-years worldwide1 . First-line treat-
ments for obesity include dietary modifications, physical
activity and behaviour modification2 . Bariatric surgery is
another option1,2 . An increasing number of obese patients
will present for surgery in the coming years, and physi-
cians should understand ways to optimize care for this
population.
Methods
PubMed, Scopus, Web of Science and Cochrane Library
electronic databases were searched in July 2019 using the

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e40 M. Carron, B. Safaee Fakhr, G. Ieppariello and M. Foletto

Medical Subject Heading (MeSH) terms listed in Table S1 Fig. 1 PRISMA flow chart showing selection of studies for this
(supporting information). The following search limits were review
applied: English language, full text and studies in humans.
Studies were selected independently by two authors, who Records identified through

Identification
screened the titles and abstracts to identify studies concern- database searching n = 49 205
PubMed n = 8058
ing the perioperative care of obese adults. Disagreements Scopus n = 31 414
were resolved by consensus or consultation with another Cochrane Library n = 7739
Web of Science n = 1994
author. RCTs were sought. The results of meta-analyses
of RCTs were used when available, instead of considering Records excluded because
the results of individual RCTs addressing the same issue. In not focused on
the absence of data from RCTs, or to complement or inte- perioperative care

Screening
n = 46 616
grate the findings of RCTs, observational studies, reviews,
guidelines and other reports were also considered. Recordsd screened
n = 2589

Results and discussion Duplicate records excluded

n = 580
Article selection

Eligibility
Records screened after
Of the 49 205 reports initially identified, 445 articles were removal of duplicates
n = 2009
selected and considered for this review (Fig. 1). The num-
Articles excluded because
ber of relevant publications increased over time (Fig. S1, not RCTs
supporting information). n = 1564
Included

Studies evaluated for

Pathophysiology of obesity
Fat distribution is an important aspect of obesity. Distri-
bution is classified as peripheral (gynaecoid, pear-shaped
or lower body obesity) or central (visceral, android,
apple-shaped or upper body obesity)3 . Central fat is
more important pathophysiologically because it is more
frequently associated with inflammation4 . Central adi-
pose tissue produces a number of bioactive substances
(adipocytokines or adipokines), which include chemokines
(such as leptin, resistin, visfatin, retinol binding protein
4) and cytokines (for example, tumour necrosis factor
α, interleukin (IL) 1, IL-6, IL-18). These substances
trigger systemic inflammation and interact with various
processes in many different organs4 . Adipocytokines and
chronic inflammation have a role in the development of
obesity-related metabolic dysfunction4 , and may explain
why obesity-related disorders are more common with
central, compared with peripheral, fat distribution3 – 6 .
Obesity-related diseases of relevance to anaesthetists and
surgeons are shown in Fig. 2 and Appendix S1 (supporting
information)7 – 59 .
Preoperative care
Comprehensive medical management
A thorough history, physical examination and laboratory
assessment relevant to obesity should be obtained33,60 – 64
(Table 1). Investigations should focus on identifying
qualittative synthesis
as RCTs
n = 445
obstructive sleep apnoea syndrome (OSAS), as well as
other obesity-related (Fig. 2) and non-obesity-related
conditions that may affect the perioperative course7 – 59 .
Weight loss (such as 5–10 per cent) should be encour-
aged before surgery65 to prevent or treat obesity-related
co-morbidities64 and to improve operating conditions
for the surgeon65 . Mean weight loss of 7⋅4 kg has been
shown to improve hypertension, hyperlipidaemia and
insulin resistance before bariatric surgery66 . The authors
of a systematic review67 reported that low-calorie diets
before bariatric surgery reduced the size of the liver (which
was enlarged because of fat deposition) by an average
of 14 per cent. Alternative methods, such as use of an
intragastric balloon or nutritional supplements, decrease
liver size by 32 and 20–43 per cent respectively67 . Reduc-
ing liver size improves liver retraction and access to the
gastro-oesophageal junction during laparoscopic bariatric
surgery67,68 .
Tobacco and alcohol use should be stopped at least
4 weeks before surgery60,61 . In the general population of
surgical patients, smoking cessation significantly decreases
the risk of total perioperative complications69 . Current
alcohol use is an independent predictor of postoperative

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Perioperative care of the obese patient
Fig. 2 Main obesity-related diseases7 – 59
Major depression (OR 1·21)
Bipolar disorder (OR 1·47)
Alzheimer’s disease (RR 2·04); any dementia (RR 1·64)
Postoperative cognitive dysfunction (RR 1·27)
Hypertension (OR 4·8)
Heart failure (RR 1·90 M; RR 2·12 F)
Ischaemic heart disease (adjusted HR 1·64)
Myocardial infarction (adjusted HR 2·02)
Atrial fibrillation (adjusted HR 1·52 M; adjusted HR 1·46 F)
Diabetes mellitus (adjusted RR 7·28)
Dyslipidaemia (adjusted OR 2·2)
Metabolic syndrome
Stroke (OR 2·16)
Myocardial infarction (OR 2·01)
Atrial fibrillation (adjusted HR 1·52 M; adjusted HR 1·46 F)
Hypercoagulability
Stroke, myocardial infarction (OR 1·57)
Deep venous thrombosis (RR 2·50)
Pulmonary embolism (RR 2·21)
Non-alcoholic steatohepatitis (RR 4·6); cirrhosis (RR 4·1)
Renal disease (OR 1·38 hypertension; OR 1·4 type 2 diabetes)
Most of these are relevant to the anaesthetist because they are associated with an increased risk of perioperative complications. Ratio values are shown in
parentheses. OR, odds ratio; RR, relative risk; HR, hazard ratio; DMV, difficult mask ventilation; DEI, difficult endotracheal intubation; FEV1, forced
expiratory volume in 1 s. For more details see Appendix S1 (supporting information).
pneumonia, sepsis, septic shock, superficial surgical-site
infection, wound disruption and prolonged hospital stay70 .
Preoperative initiation of continuous positive airway
pressure (CPAP), ideally at least 4 weeks before surgery,
may be considered, particularly if OSAS is severe or
obesity hypoventilation syndrome is present, to attenu-
ate some of the cardiometabolic abnormalities of these
disorders71 . For patients who do not respond adequately to
CPAP, non-invasive positive pressure ventilation (NIPPV)
is an option13 . Preoperative inspiratory muscular training
can increase inspiratory muscular strength and improve
postoperative oxygenation in obese patients72 . Conversely,
preoperative incentive spirometry does not significantly
improve respiratory function after bariatric surgery73 .
It is recommended that chronic medications are con-
tinued until the day of surgery and resumed promptly
thereafter to avoid withdrawal57 . Oral hypoglycaemic
agents (such as metformin) should be discontinued
1–2 days before operation and restarted when patients
resume eating. Long-acting insulin should be switched
to an intermediate-acting form 1–2 days before surgery,
and perioperative intravenous insulin/glucose/potassium
may be considered74 . Close perioperative blood glu-
cose monitoring is recommended to avoid extremes
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Obstructive sleep apnoea (OR 6·0 for ↑10% bodyweight)
DMV (OR 3·39), DEI (OR 3·46) or both (OR 4·12)
Postoperative desaturation (OR 2·27)
Postoperative respiratory failure (OR 2·43)
Postoperative reintubation (OR 2·05)
Postoperative cardiac adverse events (OR 2·07)
Postoperative ICU transfer (OR 2·81)
Obesity hypoventilation syndrome
Cardiac event or cor pulmonale (OR 9)
Postoperative respiratory failure (OR 10·9)
Postoperative heart failure (OR 5·4)
Postoperative prolonged intubation (OR 3·1)
Postoperative ICU transfer (OR 10·9)
Respiratory disease
Respiratory complications with severe ↓FEV1 (OR 2·97)
Cardiovascular complications with severe ↓FEV1 (OR 2·02)
Asthma (RR 2·7)
Postoperative respiratory complications (OR 2·94)
Gastro-oesophageal reflux disease (OR 1·94)
Postoperative complications (OR 10·9)
Osteoarthritis (RR 1·12 hip; RR 1·25 knee)
Gout (RR 2·67)
of glycaemia47 – 49 . Patients with a perioperative blood
glucose level exceeding 180 mg/dl have a significantly
increased risk of infection, reintervention and death48 .
Standard fasting guidelines for adults recommend avoid-
ing clear liquids for at least 2 h before surgery, and solids or
non-human milk for 6 h or more75 . Obesity itself is not an
independent predictor of pulmonary aspiration; thus, these
guidelines are appropriate for most obese patients, and rou-
tine aspiration prophylaxis is unnecessary76 . However, pro-
phylaxis should be considered when risk factors are present
(such as symptomatic gastro-oesophageal reflux, increased
gastric volume, anticipated difficult airway)57 . Oral carbo-
hydrate conditioning before major abdominal surgery has
metabolic and clinical benefits that may be useful for obese
patients61 .
Airway assessment
Obesity is associated with morphological features that may
adversely affect airway management. Difficult mask ven-
tilation has been reported in 8⋅8 per cent of obese77 and
11 per cent of morbidly obese78 patients. Reported diffi-
cult tracheal intubation rates vary widely79 – 87 , from 3⋅3
per cent86 to 16⋅7 per cent80 of obese patients. Predic-
tors of difficult airways are similar to those in non-obese
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Table 1 Preoperative assessment for obese patients undergoing
anaesthesia
Physiological parameters
Fat distribution*
Waist circumference; waist-to-hip ratio†
Upper airway
Obstructive sleep apnoea syndrome‡
Laboratory tests§
Electrocardiography
Complete blood count
Haemostasis
Fasting serum glucose¶
Lipid profile#
Kidney function**
Hepatic function††
Additional assessments (if indicated)
Echocardiography
Ergometry
Chest radiography
Spirometry
Arterial blood gas analysis
Polysomnography‡
Index of inflammation‡‡
Serum uric acid
Endocrine function
*Peripheral fat distribution describes a physique in which fat is located
primarily in the arms, legs and buttocks, and the abdominal fat is pre-
dominantly extraperitoneal. In contrast, central fat distribution describes
a physique in which excessive fat is located primarily in the trunk, with
a high intraperitoneal fat content3 . †Waist circumference is highly cor-
related with intra-abdominal fat content. Central obesity is defined by
a waist circumference of at least 94 cm in men and at least 80 cm in
non-pregnant women. Cut-off points indicating higher cardiometabolic
risks are over 102 cm for men and over 88 cm for women. In the
presence of peripheral obesity, waist-to-hip ratios of less than 0⋅9 for
men and below 0⋅8 for women confer protection against cardiometabolic
risks62 – 64 . ‡The standard for diagnosing obstructive sleep apnoea syn-
drome (OSAS) is polysomnography12 – 14 . However, polysomnography is
time-consuming, expensive and frequently difficult to achieve. Alterna-
tively, several preoperative screening questionnaires have been developed
to identify patients at highest risk of OSAS12 – 14 . The STOP-Bang (Snor-
ing, Tiredness, Observed apnoeas, raised blood Pressure, BMI over 35
kg/m2 , Age above 50 years, Neck circumference exceeding 40 cm (at least
41 cm for women and 43 cm for men), male Gender) questionnaire is
the most widely used tool to predict the syndrome. One point is assigned
for each positive feature; a total score of 5 or more represents a signifi-
cant risk of OSAS15 . §Appropriate laboratory assessments used in obesity
management; the first five are the most important64 . ¶Blood glucose lev-
els should be below 130 mg/dl before operation and maintained below
180 mg/dl after surgery47 – 49 . #Lipid profile should include high-density
lipoprotein–cholesterol and triglycerides50,51 . **Kidney function assess-
ment should include at least serum creatinine measurement64 . ††Hepatic
function tests should include measurement of serum aspartate aminotrans-
ferase (AST) and alanine aminotransferase (ALT) levels, and AST/ALT
ratio64 . ‡‡Index of inflammation should include high-sensitivity C-reactive
protein and ferritin assays64 .
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M. Carron, B. Safaee Fakhr, G. Ieppariello and M. Foletto
patients61 . In obese patients, male sex, presence of OSAS
and large neck circumference (over 40 cm) are the most
commonly reported independent risk factors for diffi-
cult airway management79 – 87 . Although preparations for
potentially difficult mask ventilation or intubation must
be considered in all obese patients, they are particularly
important in patients with these risk factors60,61,88 .
Postoperative care planning
The Obesity Surgery Mortality Risk Score was developed
to predict the risk of death in obese patients. It considers
five variables associated with perioperative mortality: BMI
at least 50 kg/m2 (odds ratio (OR) 3⋅60), age 45 years or
more (OR 1⋅64), male sex (OR 2⋅79), hypertension (OR
2⋅78) and susceptibility to pulmonary embolus (previous
thrombosis, pulmonary embolus, inferior vena cava filter,
right heart failure, obesity hypoventilation syndrome) (OR
2⋅62). Based on this risk score, the mortality risk is low (0⋅3
per cent) with one variable, intermediate (1⋅9 per cent) with
two or three variables and high (7⋅6 per cent) with four
or five variables89 . Postoperative care in a monitored set-
ting should be planned for high-risk obese patients (older
patients, BMI at least 50 kg/m2 , moderate to severe OSAS,
metabolic syndrome, obesity hypoventilation syndrome,
other major co-morbidities), especially after major, revi-
sional or open surgery, or when parenteral opioids, or use
of CPAP or NIPPV, is anticipated after operation14,89,90 .
Drug dosing
Obesity is associated with physiological and anthropo-
metric changes that alter the pharmacokinetics of most
drugs. Knowledge of optimal drug dosing scalars is nec-
essary for safe and effective anaesthesia91 . Except for
non-depolarizing neuromuscular blocking agents (for
which ideal bodyweight may be appropriate) and succinyl-
choline and sugammadex (for which actual bodyweight is
recommended), lean bodyweight is the preferred dosing
scalar for common anaesthetic agents, analgesics and local
anaesthestics91 .
Equipment and monitoring
Appropriate operating tables and other equipment
are required for safe anaesthesia in obese patients
(Fig. 3)57,60,61 . Minimum standards for monitoring all
patients during anaesthesia and recovery should be
followed97 . Monitoring depth of anaesthesia (for example,
using a bispectral index monitor) should be considered
to avoid accidental awareness during surgery98 , particu-
larly when total intravenous anaesthesia is used or when
end-tidal anaesthetic concentrations are not monitored
during inhalational anaesthesia in obese patients61,99 .
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Perioperative care of the obese patient
Fig. 3 Obese patient positioning
Patient positioning
Adequate immobilization (wide hook and loop
fastener strapping)
Arms and feet supported
Protection of pressure areas (gel pads and padding)
Prevention of neural injury
Bariatric operating table
High capacity operating table
Shoulder, leg and foot supports
Armboards and table extensions
The correct ramped position involves elevation of the upper body, neck and head so that an imaginary horizontal line can be drawn from the sternal notch
to the external ear92 . This position facilitates mask ventilation and improves intubating conditions (odds ratio 2⋅4)92 – 95 . The 30∘ reverse Trendelenburg
position improves lung volumes and pulmonary compliance3,19,96 . It provides a longer safe apnoea period than the 30∘ back-up Fowler or horizontal supine
position3,19,96 .
When neuromuscular blockade is planned, monitoring of
neuromuscular function (most commonly with a periph-
eral nerve stimulator) is mandatory for the safe conduct
of anaesthesia to reduce the likelihood of residual muscle
weakness after surgery100 .
Preanaesthesia medications
Obesity is a risk factor for nosocomial infections, par-
ticularly surgical-site infections. The frequency of these
infections in obese patients ranges from 1 to 21⋅7 per
cent, depending on the procedure101 . Antibiotic prophy-
laxis significantly reduces surgical-site infections after elec-
tive surgery101,102 and should follow standard guidelines
for perioperative antimicrobial prophylaxis103 . Cefazolin
2 g is widely used as antibiotic prophylaxis for many
procedures102 but may be inadequate in patients with class
III obesity104 . For patients weighing 120 kg or more, 3 g
should be considered103 .
In the general population of surgical patients, preop-
erative dexamethasone 4–5 mg reduces the likelihood of
postoperative nausea and vomiting (PONV) in the first
24 h after surgery (OR 0⋅31)105 . Dexamethasone is supe-
rior to ondansetron for preventing nausea at 4–6 h, and
vomiting at 4–6 and 24 h after laparoscopic surgery106 .
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Ramped position
Using ramping device/pillows and/or blankets under a patient’s
head and shoulders
Configuring the operating table into a back-up position
Reverse Trendelenburg position
Ear to sternal notch in the same horizontal plane
In obese patients, a multimodal approach to PONV pro-
phylaxis is preferred60 . A combination of dexamethasone,
ondansetron and haloperidol has been shown to signif-
icantly reduce PONV and rescue antiemetic use after
laparoscopic sleeve gastrectomy107 .
Oral pregabalin and gabapentin are beneficial for post-
operative pain prophylaxis108,109 . In addition to improving
sleep, melatonin can improve pain the day after surgery110 .
Venous thromboembolism (VTE) prophylaxis, including
mechanical methods (thromboembolic stockings, sequen-
tial alternating compressive devices), chemoprophylaxis
(low-dose subcutaneous unfractionated heparin or low
molecular weight heparin (LMWH)) and early postop-
erative mobilization, is recommended60,61,111 . The dose
and duration of treatment should be individualized60 .
Both once or twice daily LMWH may be suitable in
obese patients112 ; however, no data support the need for
twice-daily dosing for VTE prophylaxis60 . Fixed dosing
may be considered in obese patients113 . An increased dose,
adjusted to BMI, may be justified in obese patients with a
high risk of VTE (men, older age, high BMI, OSAS, obe-
sity hypoventilation syndrome, previous VTE)60,61 , with
no increased risk of bleeding112 . A prophylactic inferior
vena cava filter may be considered for patients with severe
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venous stasis or previous VTE, or those with a high risk of
complications from anticoagulant treatment60 .
Oral benzodiazepines cause little or no respiratory
depression and are generally appropriate for preoperative
anxiolysis in obese patients19,57 . If intravenous midazolam
is used, obese patients should be closely monitored, with
supplementary oxygen immediately available57 . Ketamine
plus clonidine or dexmedetomidine are other options, with
minimal adverse respiratory effects114,115 .
Intraoperative care
A safety briefing is recommended before an obese patient
enters the operating room. The need for additional oper-
ating room personnel (for example, to assist with posi-
tioning) should be identified. All operating room staff
should also be made aware of the proper positioning,
appropriate equipment, anaesthetic approach, specific sur-
gical procedure and plan for postoperative care, includ-
ing airway and respiratory support, analgesic strategy and
ultimate recovery location (regular ward, monitored unit
or ICU). Extra time should be allowed for positioning
the obese patient and initiation of anaesthesia57,60,61 . The
ramp position improves the likelihood of successful air-
way management in obese patients3,19,92 – 96 . The reverse
Trendelenburg position improves lung volume, oxygena-
tion and respiratory mechanics, particularly during laparo-
scopic surgery116 (Fig. 3).
The surgical team should be aware of the basic aspects
of airway management. An inadequate approach, inexperi-
enced staff, poor communication, poor teamwork and task
fixation have been shown to lead to major airway manage-
ment complications in obese patients117 . It is imperative to
establish a clear and appropriate management strategy and
follow guidelines if difficulties occur88,118 . Appropriate air-
way equipment should be immediately available88,118 .
Administering oxygen before induction of general anaes-
thesia aims to increase oxygen reserve, thereby extend-
ing the safe apnoea period (Fig. 4). Preoxygenation is
enhanced by augmenting functional residual capacity using
non-invasive ventilation120 – 126 , which increases the safe
apnoea period by 50 per cent123 . Use of second-generation
supraglottic devices before laryngoscope-guided intuba-
tion may extend the safe apnoea period by 50 per cent, com-
pared with preoxygenation with CPAP127 . Apnoeic oxy-
genation should be considered during laryngoscopy128 – 130 ;
buccal oxygen delivery has been shown to increase the safe
apnoea period 2⋅5-fold, significantly reducing the risk of
desaturation130 .
The choice of laryngoscope influences the likelihood of
successful tracheal intubation118 . A meta-analysis131 com-
bining data from 13 RCTs showed that videolaryngoscopes
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M. Carron, B. Safaee Fakhr, G. Ieppariello and M. Foletto
were superior to a traditional Macintosh laryngoscope,
increasing the success rate, reducing intubation time and
improving glottic visualization.
Second-generation supraglottic devices are preferred
for both rescue airway and routine use, rather than
first-generation, non-gastric access devices127,132 – 136 .
Supraglottic devices have been used successfully as tem-
porary ventilatory devices before laryngoscope-guided
tracheal intubation137 , conduits for endotracheal
tube insertion133,138 and primary airway devices dur-
ing surgery132,134,136 . They are most appropriate in
highly-selected obese patients undergoing short proce-
dures in the reverse Trendelenburg or head-up position60,61
and when used by experienced personnel136 .
Awake flexible fibre-optic intubation is the standard for
managing anticipated difficult intubation and is recom-
mended as an alternative to traditional laryngoscopy for
tracheal intubation in obese patients with a high risk of
difficult intubation60,61,118 . Videolaryngoscopy may also be
considered for awake intubation in obese patients139,140 .
Anaesthetic management
It is controversial whether rapid sequence induction of
anaesthesia with intravenous anaesthetic medications is
necessary in fasted obese patients with no aspiration risk
factors who are undergoing elective surgery141 . Rapid
sequence induction should be considered in those with
symptomatic gastro-oesophageal reflux or other conditions
predisposing to aspiration (such as diabetes mellitus, gas-
trointestinal disorders, emergency surgery). Cricoid pres-
sure during rapid sequence induction is probably useful for
preventing gastric aspiration141 , but may increase the diffi-
culty of airway management118 .
Induction of general anaesthesia with propofol (one of
the most commonly used induction agents) is ideally guided
by bispectral index monitoring142 . Propofol dosing based
on lean bodyweight may avoid hypotension143 , but addi-
tional propofol may be necessary to achieve adequate loss
of consciousness142 .
The superiority of inhalational or intravenous medica-
tions for maintaining anaesthesia after induction has not
been established in obese patients57,60,61 . Among inhala-
tional anaesthetics, desflurane may be the best option, as its
low lipophilicity and solubility limit distribution in adipose
tissues, promoting faster emergence and recovery144 – 149 .
A meta-analysis144 reported that times to eye opening
on command and tracheal extubation were decreased by
37 and 33⋅6 per cent respectively in patients receiving
desflurane compared with sevoflurane. These advantages
were confirmed for desflurane compared with propo-
fol or isoflurane145 . Furthermore, desflurane anaesthesia
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Fig. 4 Perioperative respiratory support

Before operation: preoxygenation After operation: respiratory support

Deep breaths or tidal volume breathing 2 min Supplementary oxygen

CPAP 8–10 cmH2O) 2–5 min CPAP (8–12 cmH2O)
PS (5–10 cmH2O) + PEEP (5 cmH2O) 2–5 min NIPPV (BIPAP 12/4 cmH2O*; PSV 5–10/5–10 cmH2O†)
Apnoeic oxygenation

During operation: lung protective mechanical ventilation

Driving pressure < 13–15 cmH2O

Low tidal volume PEEP Recuritment manoeuvre

FiO2 Respiratory rate
(6–8 ml per kg (10–12 cmH2O) (after endotracheal
(0·3–0·8) (target normocapnia)
predicted bodyweight) intubation)

This figure summarizes strategies to minimize the risk of hypoventilation and atelectasis, as well as improve oxygenation and respiratory function, during
the perioperative period. Intraoperative lung protective mechanical ventilation is a key aspect of perioperative pulmonary care, which may be enhanced by
preoperative and postoperative non-invasive respiratory support. Continuous positive airway pressure (CPAP) or non-invasive pressure positive ventilation
(NIPPV), delivered as bilevel positive airway pressure (BiPAP) or pressure support ventilation (PSV), may be considered for both prophylactic use in
high-risk obese patients (BMI over 50 kg/m2 , severe obstructive sleep apnoea syndrome, obesity hypoventilation syndrome, home CPAP therapy, opioid
therapy) and therapeutic use in the setting of oxygen desaturation, hypoventilation or respiratory failure. Values of CPAP and NIPPV suggested in the
literature119 are shown in parentheses. *With BiPAP: inspiratory peak airway pressure 12 cmH2 O and expiratory peak airway pressure 4 cmH2 O. †With
PSV: pressure support (PS) 5–10 cmH2 O and positive end-expiratory pressure (PEEP) 5–10 cmH2 O. FiO2 , fraction of inspired oxygen.

has been associated with better early postoperative oxy-
genation and lung function than propofol anaesthesia149 .
No differences between desflurane and propofol anaes-
thesia in incidence of rhabdomyolysis or postoperative
cognitive dysfunction in older obese patients have been
identified150,151 . Compared with sevoflurane or desflu-
rane, propofol anaesthesia has a lower risk of PONV
in the general population152 , but data are conflicting in
obese patients, with some studies finding benefit153,154 and
others146 reporting no benefit. No significant differences
have been observed in analgesia requirements or postanaes-
thesia care unit (PACU) discharge times between inhala-
tional and intravenous anaesthesia in obese patients145 .
Analgesia
Multimodal analgesia strategies should be adopted in
obese patients to reduce or eliminate use of opioids
after surgery155,156 . These strategies include use of
non-opioid analgesics, such as intravenous acetaminophen
(paracetamol) and non-steroidal anti-inflammatory
drugs, ketamine114,157 , α-2 agonists (clonidine,
dexmedetomidine)114,158 – 161 , magnesium161 – 163 and local
or regional anaesthesia164 – 168 . Intraperitoneal local anaes-
thetic (for example, 40 ml of bupivacaine 0⋅25 per cent)
reduces postoperative pain and opioid consumption166 – 168 .
Ultrasound-guided transversus abdominis plane blocks
have been used successfully169 . If intraoperative opioids
are required, a short-acting opioid (such as remifentanil)
is preferred for obese patients57,60,61 . Opioid-free anaes-
thesia using propofol, ketamine and dexmedetomidine
reduces PONV compared with inhalational anaesthesia
and opioids170 . Regional anaesthesia may have several
advantages over general anaesthesia for selected surgi-
cal procedures57,60,61 . Ultrasound guidance is useful for
regional techniques when the anatomy is unfavourable, as
occurs more commonly with obesity57 .
Neuromuscular blockade
Administration of neuromuscular blocking agents at induc-
tion of anaesthesia facilitates airway management171 . Both
succinylcholine and rocuronium may be used to rapidly
achieve favourable intubation conditions172 . However,

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e46
succinylcholine may reduce the safe apnoea period173 , and
rocuronium followed by reversal with sugammadex may
allow earlier re-establishment of spontaneous ventilation
(compared with succinylcholine) if airway management is
difficult174 . For laparoscopic bariatric surgery, deep neuro-
muscular blockade improves operating conditions175 – 177 ,
reducing complications related to poor surgical condi-
tions and postoperative pain compared with moderate
blockade176,177 . Male sex and older age may concur to
reduce surgeon satisfaction during laparoscopic bariatric
surgery under deep neuromuscular blockade178 . Com-
plete recovery from neuromuscular blockade should be
confirmed with a peripheral nerve stimulator before
extubation97,179 – 181 . Sugammadex should be considered
for fast reversal of rocuronium-induced neuromuscular
blockade182,183 . In the general population, sugammadex is
superior to neostigmine (the traditional reversal agent),
exhibiting greater efficacy and a lower likelihood of adverse
events (OR 0⋅47), particularly respiratory (OR 0⋅36)
and cardiovascular (OR 0⋅23) events, and postoperative
weakness (OR 0⋅45)184 .
Intraoperative lung ventilation
Optimal ventilation and oxygenation improve postopera-
tive outcomes19,185 . Protective intraoperative mechanical
ventilation has been associated with a reduced incidence
of postoperative pulmonary complications, which can
prolong hospital stay and increase mortality186,187 . Pro-
tective intraoperative mechanical ventilation is defined
as the combination of low tidal volume, appropriate
positive end-expiratory pressure (PEEP) and low driv-
ing pressure (airway plateau pressure minus PEEP)
(Fig. 4)19,185,187,188 . Temporary hyperinflation of the lungs
with recruitment manoeuvres reverses atelectasis and
improves intraoperative oxygenation and respiratory
function19,185,188,189 . These manoeuvres are recommended
after induction of anaesthesia in haemodynamically stable
obese patients19,185,188,189 and whenever severe oxygen
desaturation occurs, and they may reduce the risk of
postoperative pulmonary complications188 . Limiting the
fraction of inspired oxygen to below 0⋅8 is important,
as higher levels can promote resorption atelectasis and
worsen inflammatory lung injury (Fig. 4)185 .
In obese patients, the ‘best PEEP’ – balancing main-
tenance of end-expiratory lung volume with avoidance
of hyperinflation – is a matter of debate. A PEEP of
10 cmH2 O is often used190 – 196 and has been shown to
improve respiratory function19,197 , particularly when
applied after a recruitment manoeuvre19,185 . However,
higher PEEP levels may be necessary in some obese
patients to optimize lung volumes, regional ventilation
© 2020 BJS Society Ltd
Published by John Wiley & Sons Ltd
M. Carron, B. Safaee Fakhr, G. Ieppariello and M. Foletto
distribution and oxygenation196,198 , and a PEEP of 16–18
cmH2 O may be more appropriate198 . Nevertheless,
increasing the PEEP may increase the risk of postoper-
ative pulmonary complications if a concomitant rise in
airway plateau pressure increases the driving pressure187 .
Reducing intra-abdominal pressure during pneumoperi-
toneum increases respiratory compliance and reduces
airway pressures199 . Slow abdominal insufflation with a
maximum intra-abdominal pressure of less than 15 mmHg
is advised, when possible199,200 . High peak airway pressures
and prolonged surgery have been associated indepen-
dently with an increased risk of postoperative pulmonary
complications186,187 .
Fluid and temperature management
Restrictive fluid management has been associated with
fewer postoperative complications than liberal fluid man-
agement in the general population201 . Proper fluid balance
is therefore suggested61 . Goal-directed fluid therapy may
be useful to optimize intraoperative fluid management202 .
Compared with a conservative/restrictive approach, liberal
intraoperative fluid management during bariatric surgery
does not reduce the incidence of rhabdomyolysis203 nor
increase intraoperative urine output204 .
Perioperative hypothermia should be avoided205 . Use of
standard intraoperative methods (active forced-air warm-
ing, heated intravenous fluids) for preventing a decline in
body temperature is suggested in obese patients206,207 .
Postoperative care
Obese patients have an increased risk of extubation fail-
ure, which can be reduced by careful intraoperative man-
agement and an appropriate awakening plan117,208,209 . Full
monitoring should be maintained until discharge from the
PACU. The patient should be placed in a head-elevated
or semiseated position57,61 . Standard oxygen therapy may
be used to maintain preoperative arterial partial pressure
of oxygen levels60,61 . As the beneficial effects of protec-
tive intraoperative mechanical ventilation may be lost after
extubation188,189 , CPAP or NIPPV may be considered after
extubation185 . The safety and efficacy of CPAP or NIPPV
have been established in the perioperative period210 , and
they should be considered in high-risk obese patients
(Fig. 4)61,119,211 . These modalities counteract upper air-
way obstruction, reduce hypoventilation and atelectasis,
improve gas exchange and respiratory function, relieve dys-
pnoea and decrease breathing effort in obese patients after
surgery. They may therefore lower the risk of acute respi-
ratory failure after surgery119 . In obese patients requiring
opioids, CPAP in the early postoperative period improves
sleep-disordered breathing and ameliorates the respiratory
www.bjs.co.uk BJS 2020; 107: e39–e55
Perioperative care of the obese patient
depressant effects of these drugs212 . Use of a continuous
high-flow nasal cannula is another option in selected obese
patients213 .
When intravenous opioids are required after operation,
patient-controlled analgesia (such as fentanyl or morphine)
is recommended, instead of a continuous infusion. A longer
than usual lock-out period between doses should also be
considered61 . Analgesia by the enteral route should be
commenced as early as possible61 .
Before discharge to the regular surgical ward, all obese
patients should be observed in the PACU for at least
1 h when unstimulated for evidence of hypoventilation,
such as oxygen desaturation or apnoeas or hypopneas
with associated desaturation14,60 . When routine PACU dis-
charge criteria are met, many obese patients can be dis-
charged safely to an unmonitored hospital bed. However,
all high-risk obese patients should be assessed by an anaes-
thetist to determine the need for additional respiratory sup-
port and/or monitoring60,61 .
Overview
Obese patients undergoing surgery require comprehen-
sive preoperative evaluation. Obesity-related conditions
that may affect the perioperative course should be inves-
tigated. Obese patients should be prepared well in advance
of surgery. Anaesthesia and surgical staff experienced in
caring for obese patients should manage these individuals.
Specialized equipment is required, and proper monitor-
ing is recommended for safe anaesthesia. The anaesthetic
approach, specific surgical procedure and plan for post-
operative care should be shared with the entire operating
room team before the patient enters the room. Appropri-
ate airway management, careful anaesthetic management
and an adequate ventilation strategy (extending beyond the
immediate postextubation period) may improve postoper-
ative outcomes for obese patients. Additional periopera-
tive precautions are necessary to reduce complications in
patients with severe morbid obesity, metabolic syndrome,
untreated or severe OSAS, or obesity hypoventilation syn-
drome; those receiving home ventilatory support or post-
operative opioid therapy; and obese patients undergoing
open operations, long procedures or revisional surgery.
Acknowledgements
The authors thank G. Bizzotto, anaesthetist, for invalu-
able contributions to the graphics in this paper. M.C.
has received payments for lectures from Merck Sharp &
Dohme (MSD), Rome, Italy.
Disclosure: The authors declare no other conflict of interest.
© 2020 BJS Society Ltd
Published by John Wiley & Sons Ltd
e47
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