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Anesthesia

for …

the obese patient.


Created by Sukolrat
• The prevalence of obesity is increasing.
• Cardiorespiratory problems, reflux,
diabetes andobstructive sleep apnea
are common.
• The highest risk group are of course
those patients presenting for
emergency surgery who are poorly
prepared.
• In the morbidly obese group,
standardized mortality was three times
that of the normal BMI group and
additional excess mortality was
observed in those patients with
diabetes mellitus, glucose intolerance,
systolic hypertension and smoking, but
Gold
• An understanding of these changes is
important for safe
• anesthesia in this patient group.
Careful pre-operative assessment
and evaluation
Definition
• BMI = weight (kg)/[height (m)]2
• IBW (kg) = height (cm) – 100 (men)/105
(women).
Figure 1 Typical gynaecoid fat
distribution.
•The ‘gynaecoid’ fat distribution is
more
frequently seen in women than in
men, but can be present in either sex.
•This is typically characterized by
subcutaneous fat and a peripheral fat
distribution.
Figure 2 Typical android fat
distribution.
•By contrast, the ‘android’ fat distribution
is more
usually seen in men, but again can be
seen in individuals of either gender. The
fat distribution is typically central often
intra-abdominal with relative sparing of
arms and legs.
•The android fat distribution is associated
with
greater metabolic activity and a greater
Respiratory function
• Increased minute ventilation to meet the
increase in oxygen consumption and carbon
dioxide production.
• Increased work of breathing because of the
reduction in chest wall and lung compliance.
Obese patients tend to take rapid shallow
breaths, leading to greater mismatching of
ventilation and perfusion.
• A reduction in functional residual capacity
(FRC) because the increased adipose tissue
in the chest wall and abdomen limits
diaphragmatic excursion
• Small airway closure occurs resulting in
• a rapid reduction in lung compliance with
increasing body mass index up to a body
mass index of 30
• Chronically hypoxic and develop secondary
polycythemia, pulmonary hypertension and
ultimately, right ventricular failure
• Many patients give a history of obstructive
sleep apnea (OSA). This is characterized by
intermittent airway obstruction at night with
loud snoring and intermittent awakening.
• OSA patients undergoing pre-operative
assessment generally require sleep studies
to assess the degree of nocturnal
hypoxemia and obstruction.
• Patients with established OSA may have an
Cardiac function
• Obesity cardiomyopathy due to fatty
infiltration may occur in patients with
long-standing disease.
• The heart has to cope with an increased
blood
volume and increased metabolic
demand.
• Increased cardiac output and end-
diastolic volume with left ventricular
distention and a reduction in ejection
(poorly contracting heart) and left
ventricular
diasystolic dysfunction (stiff non-
compliant
ventricle which fills poorly and requires
a high
filling pressure) Bi-ventricular failure
may
Follow.
• Severe hypertension is present in 5-
10% of
patients with morbid obesity and
• the role of obesity as a risk factor for
coronary disease is difficult to
evaluate because of the association
between obesity and hypertension,
diabetes mellitus and
hypercholesterolaemia, which are all
coronary risk factors.
• Cardiac arrhythmias may occur
secondary to chamber dilatation,
ischemic heart disease or fatty
Endocrine and metabolic
considerations
• Hypothyroidism and Cushing’s syndrome
may have a causal role in obesity.
• Abnormal lipid profiles are common. Many
are glucose intolerant and a substantial
subgroup develops diabetes mellitus. This is
frequently associated with insulin resistance
; many patients undergoing weight
reduction surgery show rapid resolution of
their diabetes.
• Up to 90% develop a fatty liver and this may
get worse after weight reduction surgery, in
particular after jejunal bypass
• Hiatus hernia, cholelithiasis are common
• Obesity is a recognized risk factor for the
development of hepatitis following volatile
• High risk of aspiration (a gastric
volume greater than 25 ml and a pH
less than 2.5) were present in 90% of
patients with morbid obesity from
gastro-oesophageal reflux.
Preoperative assessment
• Evaluating the severity of cardiorespiratory
compromise.
• Careful airway assessment to decide safe airway
management.
• Assessment of acid aspiration risk (this also influences
airway
management).
• Confirmation of the presence of conditions associated
with
obesity (e.g. diabetes).
• Examination of potential sites for venous access, which
may
be problematic.
• Examination of the spine if epidural or spinal
PERI-OPERATIVE CARE
• It may include the patient’s usual
medications, and antacid, H2 blocker
or inhibitor to reduce gastric acidity.
• Prophylaxis against deep vein
thrombosis should also be
commenced pre-operatively.
• Patient monitoring including intra-
arterial monitoring saturation and
CO2 monitoring should be
commenced before the induction of
Management
• Appropriate monitoring facilities should
be available, because noninvasive
blood pressure monitoring is inaccurate
and unreliable in the obese patient.
Arterial cannulation and direct
monitoring is preferred. In some very
minor cases,it is acceptable to use a
large blood pressure cuff around the
upper arm.
• Central venous monitoring may be
necessary for venous access, and aids
fluid management, particularly in those
with cardiac compromise.
• Special beds
• Warming is very important, as peri-
operative shivering increases the
stress response as well as oxygen
consumption and can herefore lead
to hypoxia and myocardial ischemia.
• Various techniques have been
advocated for intubation. Some
authorities recommend a fiber optic
intubation. most authorities would
recommend pre-oxygenation and
rapid sequence induction ‘difficult
intubation’ complicates 13% of
• Technique and positioning are very
important. The second assistant,
placing a hand on the patient’s chest
and retracting anterior chest wall soft
tissues away from the chin. Careful
positioning of the patient’s head and
shoulders make airway management
and intubation easier
• Due to the high risk of reflux and
aspiration, any patient who is
morbidly obese should have the
airway protected by intubation
• The patient should be positioned protect pressure points. If
the arms are
placed out on arm boards, this allows easy access, but it is
important that
these boards do not become abducted beyond 70 from the
patient’s side
(risk of brachial plexus injury)
• Appropriate ventilation is important, for example pressure
controlled
ventilation avoiding nitrousoxide a combination of high-
inspired
oxygen concentration and the application of positive end-
expiratory pressure.
• Pharmacological considerations: the changes in blood
volume,cardiac
output, adipose tissue and total body water content, short
acting drugs with
low lipid solubilities are generally preferred.
• Intravenous agents – propofol kinetics appear unaltered,
but
recovery from thiopental and benzodiazepines may be
prolonged.
• Volatile anaesthetics – there is little evidence that recovery
• Muscle relaxants – pseudocholinesterase activity is
increased,
but doses of suxamethonium less than 1 mg/kg have been
shown
to provide adequate vocal cord paralysis. The dose and
duration
of action of atracurium is unaltered. Vecuronium has a
prolonged
duration of action and the dose should be calculated according
to
lean body weight
• Opioids – the doses of alfentanil and remifentanil should be
calculated according to lean body weight. Although this
restriction
does not apply to other opioids, careful titration of all opioids
is
warranted because of their respiratory depressant effect.
• Where possible, obese patients should be extubated awake
and in a
sitting position.
POSTOPERATIVE CARE
• Postoperative analgesia undoubtedly
provides very good analgesia with good
respiratory function.
• Postoperative urine output and renal
function Fluid requirement should be
tailored to the patient’s body surface area
and not to the usual recipe.
• Thromboembolic complications are more
common in obese patients. Adequate
prophylaxis for deep venous thrombosis is
essential and early mobilization should be
encouraged.
• Wound infections – longer incisions, greater
CONCLUSION
• These challenges include airway
problems, cardio-vascular problems
and the potential for peri-operative
complications, in particular deep vein
thrombosis and respiratory
complications.
• appropriately adapted techniques
with the use of short-acting drugs
and surgery