Obesity.

‫ذكرت صحيفة "ديلي ميل" البريطانية‪ ،‬اليوم‪ ،‬وفاة أسمن رجل في‬ ‫‪‬‬
‫العالم‪ ،‬ويدعى "كيث مارتين" عن عمر يناهز ‪ 44‬عا ًما‪ ،‬بعدما أصيب‬
‫بالتهاب رئوي حاد‪.‬‬
‫وكان يزن قرابة نصف طن‪ ،‬حيث بلغ وزنه أكثر من ‪ 440‬كيلو جرا ًما‪،‬‬ ‫‪‬‬
‫وكان يستهلك نحو ‪ 20‬ألف سعرة حرارية يوميا ً‪.‬‬

‫‪2014 / 12 / 5‬‬ ‫‪‬‬

Causes:
1-Excessive caloric intake & inadequate
activity.
2-Genetic factors.
3-Endocrine causes e.g: Cushing’s syndrome,
Diabetes Mellitus,Hypothyroidism,
Hypopituitary syndrome.
Definitions:
-B.M.I : Body Mass Index
= weight (kg)/(height)2 (m2).

WHO classification:
1. < 18.5  Underweight.
2. 18.5-24.9  Normal.
3. 25-30  Overweight (Pre-obese).
4. > 30  Obesity.
5. > 40  Extreme (Morbid) obesity.
1. Respiratory System:

-Possibility of difficult intubation.

-Decreased compliance,lung volumes &
capacities
 Inadequate gas exchange & hypoxia.
-Pulmonary vaso-constriction  Right
ventricular hypertrophy & failure.
-Increased work of breathing.
-Increased oxygen consumption & carbon
dioxide production.
-Decreased ventilatory response to carbon dioxide resulting
in the following syndromes:

I. Obstructive Sleep Apnea Syndrome.

( 30 apneic episodes of more than 20 seconds
over 7 hours )

II. Obesity Hypoventilation Syndrome  Resulting in

hypoventilation , hypercapnea , pulmonary hypertension.

III. Pickwickian Syndrome:

-Hypoventilation , hypoxia , hypercapnea , pulmonary
hypertension , cyanosis induced polycythemia , right heart
failure & somnolence.
2. Cardio-vascular System:

-Increased blood volume & cardiac output.

-Cardiomegally,left ventricular hypertrophy &
failure.
-Hypertension,hyperlipidemia & ischemic heart
disease.
-CVA , DVT & varicose veins.
 First named in 1956 by Burwell , who believed
that the syndrome was described in 1837 by
a Charles Dickens character in the
posthumous papers of the Pickwick club.
3. Gastro-intestinal System:

-Increase intra-abdominal pressure.

-Gastro-esophageal reflux.
-Hiatus hernia.
-Risk of regurgitation & hyperacidity.
-Delayed gastric emptying.
-Gall bladder stones.
-Fatty infiltration of the liver.
4. Endocrine System:

-Insulin resistance & type II diabetes mellitus.

5. Pharmacological:

-Decrease in total body water & lean body mass &

increased body fat  Alters Vd of many drugs.
-Vd is increased for fat soluble drugs leading to
slower clearance.

6. Psychological problems:
-Increase biotransformation of
methoxyflurane,enflurane & halothane  Increase in
serum level of floride ions.
-Isoflurane & desflurane  No significant increase in
the rate of biotransformation  The volatile agents of
choice.
-Fat soluble drugs
[Opioids,Benzodiazepines,Barbiturates]  Increased
Vd & decreased elimination(except fentanyl).
-Water soluble drugs  Similar to other non-obese
patients.
-Pseudo-cholinesterase activity is increased  Larger
doses of scoline are needed.
History:
-Full history concerning all symptoms.

Physical examination:
-Evaluation of airways for intubation.
-Consider awake fiberoptic intubation in cases
of anticipated difficulties.
-Evaluation of arterial & venous access.
-Evaluation of all other systems.
Pre-operative tests:
-ECG.
-CXR.
-CBC.
-Glucose & serum electrolytes.
-ABG’s.
-Liver function tests.
-Pulmonary function tests.
Premedication:
-Patients are at increased risk of pulmonary
aspiration.
-Antacids & H2-blockers.
-Metoclopramide (Plasil).
-Avoid sedatives & opioids.
1. Airways & Ventilatory management:

-Preparation for a difficult intubation.

-Importance of pre-oxygenation.
-Rapid sequence induction & intubation.
-Capnography to confirm endotracheal intubation.
-Pulse oximetry for detection of hypoxia.
-Inspired oxygen should be > 50%.
-Apply positive pressure ventilation because
spontaneous ventilation predisposes to hypoxia
& atelectasis.
2. Cardio-vascular management:
-Patients need larger B.P cuffs to avoid false
readings of blood pressure.
-Arterial line.
-CVP line.

3. Positioning:

-Problems of the width of the table.

-Care to protect pressure points.
-Whenever possible,try to place the patient in the
operative position prior to induction of
anesthesia.
Regional anesthesia:
-May be technically difficult to perform.
-Patients require 20-25% less local anesthetic because
of epidural fat & distended epidural veins.

Extubation criteria:
-Muscle relaxants should be adequately reversed.
-Respiratory rate < 30/minute.
-VT > 5ml/kg.
-VC = 10-15ml/kg.
-Patient is hemodynamically stable.
-Patient is fully awake & alert.
Post-operative:
-Respiratory failure is the major post-operative
problem.
-Risk of hypoxia extends for several (4-7) days into the
post-operative period.
-Supplementary oxygen for longer than usual.
-Patient should be nursed sitting up.
-Early ambulation as possible.
-Aggressive pulmonary care & physiotherapy.

Other common post-operative complications:

-Wound infection.
-DVT & pulmonary embolism