Obesity and anesthesia

Geresu G.
December, 2020
Contents

 Introduction
 Physiologic changes associated with obesity
 Anesthetic managements
 Preoperative evaluations
 Intraoperative managements
 Post-operative considerations

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Introduction
 Obesity is defined as an abnormally high amount of
adipose tissue compared with lean muscle mass (20% or
more over ideal body weight)
 A chronic metabolic disorder that is primarily induced
and sustained by an over consumption or
underutilization of caloric substrate
 It is a condition in which excess body fat may put a
person’s health at risk
 It is associated with increased morbidity and mortality

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  The definition of obesity includes the presence of
excessive body weight for the patient’s age, gender, and
height. It is often based on the following concepts
 IBW-weight associated with the lowest mortality rate for a
given height and gender. Calculated using broca’s index

IBW (kg) = height (cm) – x, x=100 for adult males and 105 for adult females

 LBW-total body weight minus fat tissue. It is a combination of

body cell mass, extracellular water, and non fat connective
tissue

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  TBW: actual weight of the patient
 The difference between normality and obesity is
arbitrary but the Body Mass Index (BMI) is normally
used to define obesity
 It can be calculated by dividing the patient’s weight in
kilograms by their height in meters squared (kg/m2).

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• WHO Classification of obesity
Body mass index(kg/m2) Classification

< 18.5 Underweight

18.5–24.9 Normal

25.0–29.9 Overweight

30.0–34.9 Obese

35.0–39.9 Morbidly-obese

>40 Extremely-obese

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Epidemiology

 Approximately 7% of the worldwide adult population is

obese
 Obesity is a global health problem and the prevalence
varies with socio-economic status
 It had became a disease of poor in developed world, but
in developing countries affluent are at risk to develop it
 There is also a recent trend to an increasing prevalence
of obesity in adolescents and children.
 Importantly 60-85% of obese schoolchildren will remain
obese as adults.

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  As the prevalence of obesity increases, so do its
associated health care costs.
 Currently, obesity is the sixth most important risk factor
for disease worldwide
 In addition to being associated with
major comorbid conditions, Including
diabetes, hypertension, and
cardiovascular disease
 It is also associated with a poor
quality of life

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Pathophysiology

 Obesity can have detrimental effects on many organ

systems.
 The most profound effects are on the endocrine,
cardiovascular, respiratory, gastrointestinal, immune,
musculoskeletal, and nervous systems.
 Clinically severely obese individuals have limited
mobility and may therefore appear to be asymptomatic
even in the presence of significant respiratory and
cardiovascular impairment.

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  Fat storage(distribution)
 A positive caloric balance is stored by the body as fat in
adipocytes
 This fat is primarily in the form of triglycerides w/c serve as
an efficient form of energy storage because of their high
caloric density and hydrophobic nature
 The storage of triglycerides is regulated by lipoprotein
lipase enzyme.
 Not all fat within the body is identical

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 Depending on fat distribution, two types of obesity
 Central obesity: increased fat distribution in abdominal
region. It is more common in men and is therefore known as
android fat distribution
 It is associated with increased metabolic activity and
increased risk of metabolic disturbance
 Excessive abdominal fat, central obesity is particularly
predictive for NIDDM, dyslipidaemia and cardiovascular
disease
 Peripheral obesity: increased fat distribution around buttock
and hip is more common in women and is known as gynecoid
fat distribution
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  It is currently accepted that a waist-to-hip ratio of more
than 1.0 in men and more than 0.8 in women is a strong
predictor of ischemic heart disease, stroke, diabetes,
and death independent of the total amount of body fat.

Risk of obesity-associated metabolic problems

Gender Increased Substantially increased

Men ≥94cm (37inches) ≥102cm (40 inches)

Women ≥80cm (31.5 inches) ≥88cm (34.5 inches)

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  Respiratory system
 Respiratory derangements associated with obesity are
related to the presence of redundant tissue in the upper
airway, thorax, and abdomen that affects lung volumes,
gas exchange, lung compliance, and work of breathing
 Obesity can produce an extrinsic restrictive pattern of
ventilation resulting from the added weight of the thoracic
cage or chest wall and abdomen
 This results in an overall decrease in functional residual
capacity (FRC), expiratory reserve volume, and total lung
capacity.

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 General anesthesia accentuates these changes
 A 50% decrease in FRC occurs in obese anesthetized
patients compared with a 20% decrease in non-obese
individuals.
 The decrease in FRC impairs the ability of obese patients
to tolerate periods of apnea, such as during direct
laryngoscopy for endotracheal intubation
 Because of the obese patient's increased body mass,
oxygen consumption and carbon dioxide production are
increased. To maintain normocapnea, obese patients must
increase minute ventilation, which also increases the work
of breathing.

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  Airway
 Obese patients tend to have short, fat necks making both
mask ventilation and direct laryngoscopy technically more
challenging.
 A BMI of >40 is associated with a 13% risk of difficult
intubation.
 The increased bulk of soft tissues in the upper airway
make them prone to partial obstruction with the loss of
consciousness

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 Obstructive sleep apnea(OSA)
 Defined as cessation of breathing for longer than 10 seconds
during sleep
 At least 5% of morbidly obese patients will have OSA
 The disease is cause by passive collapse of the pharyngeal
airway during deeper planes of sleep, resulting in snoring and
intermittent airway obstruction.
 Resultant hypoxaemia and hypercapnia results in arousal and
disruption of quality sleep thus causing the characteristic
daytime somnolence
 Pulmonary and systemic vasoconstriction, polycythaemia, right
ventricular failure and cor pulmonale can all occur.

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  Obesity Hypoventilation Syndrome(OHS)
 Is the long-term consequence of OSA characterized by
nocturnal episodes of central apnea (apnea without
respiratory efforts)
 Reflects progressive desensitization of the respiratory
center to nocturnal hypercarbia
 At its extreme, OHS culminates in pickwickian syndrome,
w/c is characterized by obesity, daytime hypersomnolence,
arterial hypoxemia, polycythemia, hypercarbia, respiratory
acidosis, pulmonary hypertension, and right ventricular
failure.

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  CVS
 Obesity is associated with a number of cardiac risk factors
 These include hypertension, ischaemic heart disease
(IHD), cardiomyopathies, cardiac failure, arrhythmias,
sudden cardiac death and dyslipidaemias.
 Increased visceral fat is a cardiovascular risk factor even
when the BMI is normal.
 In patients with clinically severe obesity, cardiac function is
best at rest and exercise is poorly tolerated.

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  Gastrointestinal
 There is an increased incidence of hiatus hernia in the
obese.
 The volume and acidity of gastric contents is often
increased and as stated earlier, intubation might be
difficult
 Risk of delayed gastric emptying is higher
 Obese patients have high risk of having liver and biliary
tract disease

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  Pharmacokinetics
 volumes of distribution, binding and elimination of drugs
are unpredictable.
 This uncertainty necessitates that the anaesthetist pay
more attention to the clinical end points of drug action
such as loss of verbal contact, tachycardia etc. rather than
focusing specifically on whether to dose on ideal, lean or
actual body weight

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  The apparent volume of distribution for a fat-soluble
drug such as thiopentone is increased because of the
lipophilic nature and therefore the dose should be
increased
 Suxamethonium should be given at a dose of 1mg/kg
actual body weight.
 Slow emergence after use of fat-soluble volatile agents
may be due to central sensitivity as much as due to
delayed release from adipose stores.

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Drug dosing guidelines

Drug Induction Maintenance

Propofol Lean body weight TBW (infusion)
Thiopentone /Etomidate Lean body weight
Suxamethonium Total body weight
Vecuronium Lean/ideal body weight
Cis/Atracurium Ideal body weight
Rocuronium Lean/ideal body weight
Morphine Lean body weight
Fentanyl/sulfentanil Total body weight
Remifentanil Lean/ideal body weight
Midazolam Lean/ideal body weight
Lidocaine /bupivacaine Lean body weight
Paracetamol Lean/ideal body weight
Antibiotics/anticholinesterase Adjusted body weight
s

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Anesthesia management in Obese Patients

 Preoperative evaluation
 A thorough preoperative evaluation is necessary for all
patients with clinically severe obesity coming for surgery
 History taking and physical examination should focus on the
cardiovascular and respiratory systems and airway evaluation
 Under estimate of cardiorespiratory disease is possible even
with history, P/E and ECG
 The anesthesia provider should inquire about the presence of
chest pain, shortness of breath at rest or with minimal
exertion, and palpitations, and the position in which the
patient sleeps.

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 The présence of exertional dyspnea, fatigue, and syncope
sugests pulmonary hypertension
 If pulmonary hypertension is suspected, then avoidance of
hypoxemia, nitrous oxide, and other drugs that may
further worsen pulmonary vasoconstriction is warranted.
 Symptoms of OSA, such as snoring, apneic episodes
during sleep, daytime somnolence, morning headaches,
and frequent sleep arousals, should be sought
 A history of sleep apnea should raise the possibility of
upper airway abnormalities that may predispose to
difficulties with mask ventilation and tube placement

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  Symptoms of acid reflux, coughing, inability to lie flat
without coughing, or heartburn may indicate GERD or
delayed gastric emptying
 All morbidly obese patients should receive prophylaxis
against acid aspiration even if they do not declare any
symptoms of heartburn or reflux.
 Signs of left or right ventricular failure such as increased
jugular venous pressure, extra heart sounds, rales,
hepatomegaly, and peripheral edema may be very
difficult to elicit in the morbidly obese

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  A detailed assessment of the upper airway must be
performed to look for the following anatomic features:
 Fat face and cheeks,
 Short neck,
 Large tongue and tonsillar size,
 Excessive palatal and pharyngeal soft tissue,
 Restricted mouth opening
 Limited cervical and/or mandibular mobility,
 Large breasts,
 Increased neck circumference
 Mallampati score of 3 or higher.

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  Obese patients have unique issues that may contribute
to cardiovascular, pulmonary, and thromboembolic
complications.
 High-risk patients should be identified early to ensure
optimal management of co-existing diseases before
surgery
 The ease of peripheral venous cannulation should be
sought, if difficulty suspected patient should be
informed about possible central venous cannulation

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 Diagnostic tests
 ECG: RVH, LVH, arrhythmia, IHD, MI
 ECG may not always be reliable in the clinically severely obese
patient because of morphologic features such as
 (1) displacement of the heart by an elevated diaphragm,
 (2) increased cardiac workload with associated cardiac
hypertrophy,
 (3) increased distance between the heart and the recording
electrodes caused by excess adipose tissue in the chest wall
and possibly increased epicardial fat, and
 (4) the potential for associated chronic lung disease to alter
the ECG.

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  Transthoracic echocardiography is useful to evaluate
left and right ventricular systolic and diastolic function
as well as to identify pulmonary hypertension
 CXR may show signs of heart failure, increased vascular
markings, pulmonary congestion, pulmonary
hypertension, hyperinflated lungs, or other pulmonary
disease
 Blood gas analysis will be more helpful to guide
perioperative ventilatory management
 Preoperative sleep studies (polysomnography)

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  Premedication
 Most home medications should be continued
preoperatively, with the exception of oral hypoglycemics,
angiotensin-converting enzyme inhibitors, angiotensin
receptor blockers, and anticoagulants
 Patients taking histamine-2 receptor blockers,
nonparticulate antacids, or proton pump inhibitors should
be counseled to take these medications on the morning of
surgery
 Gastrokinetics in combination with H2 blockers and
antiacids need to be considered for aspiration prophylaxis

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  Antisialogogue if awake intubation planned
 The intramuscular and subcutaneous routes should be
avoided, since absorption is very unpredictable
 Preoperative DVT prophylaxis
 If OSA history, avoid opioids and sedative
premedication
 Preoperative nasal CPAP is considered to improve
perioperative outcome

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  Intraoperative
 Local or regional anesthesia is the anesthetic technique of
choice if possible
 General anesthesia with ETT is another alternative
 Induction of anesthesia is likely to be a particularly
hazardous time for the patient with an increased risk of
difficult or failed intubation.
 The anesthetic plan, including all risks, benefits, and
alternatives to general anesthesia, should be discussed
thoroughly with the patient and surgeon before the
operation.

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 Airway management
 Management of the airway is one of the greatest challenges
associated with general anesthesia in the obese patient
 Tracheal intubation and positive pressure ventilation are
mandatory in the morbidly obese patient.
 The choice between awake and asleep intubation is difficult,
and depends upon the anticipated difficulties in a particular
patient along with the experience of the anaesthetist
 An emergency airway cart that provides access to rescue
intubating devices such as supra glottic devices, a flexible
bronchoscope, a light wand, and resuscitation drugs should
be immediately available

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  Significant OSA symptoms and actual body weight of
>175% IBW indicate altered upper airway morphology
and make control of bag and mask airway more difficult
so awake intubation is preferable
 Another approach is gently to attempt direct
laryngoscopy after anaesthetizing the pharnyx with
local anesthetic; if the laryngeal structures are not
visible, then awake fibreoptic intubation is the safest
course of action.
 Blind nasal intubation should be avoided by all but those
very skilled in the technique

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  The use of an intubating LMA has been shown to be
successful for tracheal intubation in 96% of obese
patients and for successful ventilation in less than 1
minute in 100% of obese patients.
 Bag and mask ventilation is likely to be difficult because
of upper airway obstruction and reduced pulmonary
compliance.
 Gastric insufflation during ineffective mask ventilation
will further increase the risk of regurgitation and
aspiration of stomach contents

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  Apart from awake fibreoptic intubation, the safest
technique is a rapid sequence induction using
succinylcholine following a period of adequate
preoxygenation
 HELP(Head elevated laryngoscopic position) remained
best position for ease intubation
 It is essential to have skilled anaesthetic assistance
together with adequate numbers of staff in order to turn
the patient should the need arise.

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 Equipment for cricothyroidotomy and transtracheal
ventilation should also be available.
 Correct position of the tracheal tube must be confirmed
by both auscultation and capnography
 Obese patients should not be allowed to breathe
spontaneously under anesthesia, as hypoventilation is
likely to occur, with consequent hypoxia and
hypercapnia.

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 External auditory meatus and sternal notch are
at the same level

Head elevated laryngoscopic position

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  Induction
 A combination of drugs can be used for the induction and
maintenance of general anesthesia in clinically severely
obese patients
 Total blood volume is likely to be increased, which would
tend to decrease the plasma concentration achieved
following intravenous injection of a drug.
 An increased dose of drug calculated based on total body
weight could result in an excessive plasma concentration

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  An initially higher dose of drug may be required for
loading to attain peak plasma concentration b/c of
increased cardiac output and plasma volume
 The most clinically useful approach is to calculate the
initial dose of drug to be injected into an obese patient
based on lean body weight rather than total body
weight
 Subsequent doses of drugs should be based on the
pharmacologic response to the initial dose
 Repeated injections of a drug, however, can result in
cumulative drug effects and prolonged responses

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  An increased incidence of fatty liver infiltration in obese
patients warrants caution when selecting drugs that
have been associated with postoperative liver
dysfunction
 Maintenance of anesthesia is best managed with drugs
with minimal potential for accumulation in adipose
tissue.
 Propofol, BZD , barbiturates, atracurium,
cisatracurium,and narcotics such as sufentanil and
fentanyl are highly lipophilic and accumulate in fatty
tissue when administered by infusion over a long period

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  Ketamine and dexmedetomidine may also be useful
anesthetic adjuncts in patients who are susceptible to
narcotic-induced respiratory depression.
 Usually, highly lipophilic drugs show a significant
increase in volume of distribution in obese patients, and
it would seem that dosing should be based on TBW
 Administration of hydrophilic substances, such as
muscle relaxants, should be based on lean body weight,
because their peak plasma concentrations are
independent of the volume of distribution

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  It is recommended that neuromuscular blockers be
dosed based on lean body weight and that the degree of
blockade be carefully monitored
 Because the level of plasma pseudocholinesterase and
the volume of distribution is increased, administration
of succinylcholine should be based on total body weight
rather than lean body weight
 Isoflurane is more lipophilic than either desflurane or
sevoflurane. Thus, desflurane and sevoflurane have
been marketed as the anesthetics of choice for obese
patients when fast recovery from anesthesia is desired.

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  Monitoring
 The extent of surgery and concomitant comorbid
conditions should determine the need for and extent of
monitoring beyond routine monitoring
 The technical difficulty of placing invasive hemodynamic
monitors may be increased in this patient population
 Routine ASA standard monitors should be employed
 Alternative to standard blood pressure cuffs include
noninvasive blood pressure monitoring systems that
detect blood pressure in the radial artery or in the finger

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  TEE and PAC can be used intra-operatively in patients
with heart failure, pulmonary hypertension, or other
medical conditions that make continuous assessment of
volume status or cardiac function
 Adequacy of fluid administration and peripheral
perfusion should be assessed using UOP and capillary
refill

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 Fluid management
 Calculation of fluid requirements in the obese patient should be
based on lean body weight with a goal of euvolemia
 Achieving this goal in the obese population may be very
difficult, however, especially since there is a high association
between severe obesity and diastolic dysfunction
 Large volume fluid administration (15–40 ml/kg TBW) during
elective surgery has many potential benefits including a
reduction in postoperative nausea, earlier recovery and
prevention of rhabdomyolysis
 In patients with preexisting cardiac disease, large fluid loads
may not be tolerated well, and development of pulmonary
edema is more likely

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  Extubation
 Tracheal extubation is considered when obese patients are
fully awake and alert, and have recovered from the
depressant effects of the anesthetics
 Placing the patient in the semi-upright position (30
degrees or more head up), provision of PSV with PEEP or
CPAP until extubation, oxygen supplementation, and
placement of a nasopharyngeal airway to help maintain
airway patency.
 The adequacy of ventilation should be assessed and
monitored for at least 24 to 48 hours postoperatively

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  If the patient was on CPAP or BIPAP ventilation at home,
this ventilation mode should be resumed
postoperatively
 Any sign suggestive of respiratory fatigue or
cardiovascular instability should be evaluated and
treated immediately.
 If obese patients require reintubation, it is best
performed in a controlled fashion rather than in an
emergent situation

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  The decision about when to discharge patients to a
regular hospital room or to home can be difficult in
obese patients
 A patient can be safely discharged to hospital ward or
home when pain is adequately controlled and the
patient is no longer at significant risk of postoperative
respiratory depression.

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  Post-operative pain control
 Effective postoperative pain control should be mandatory
in any surgical process
 Opioids are the mainstay of analgesic therapy for
postoperative pain control;
 However, they are associated with sedation and
respiratory depression, which coupled with the obese
patient’s risks of OSA, sensitization to the depressant
effects of opioids, and dosing challenges, lead frequently
to undertreatment of pain.

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  The most preferred method to be employed is a
multimodal approach to postoperative pain control
 This includes use of techniques that decrease narcotic
requirements
 Peripheral and central nerve block with continuous
infusion of local anesthetic with or without small doses
of opioids is an effective method for postoperative
analgesia in obese patients

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  Supplementation with NSAIDs, α2-receptor, NMDA
receptor antagonists, sodium channel blockers, or other
nonopioid analgesics is highly recommended
 PCA parenteral opioidsi s a good option. Dosages of
opioids are best based on lean body weight
 For an open procedure, epidural analgesia
supplemented by nonsteroidal antiinflammatory drugs
(NSAIDs) and acetaminophen provides effective pain
control without the side effects of opioids

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 Regional anesthesia
 The use of regional Anaesthesia in the obese reduces the
risks from difficult intubation and acid aspiration and also
provides safer and more effective postoperative analgesia
 RA, including spinal anesthesia, epidural anesthesia, and
peripheral nerve block, may be technically difficult in obese
patients
 It is estimated that the risk of a failed block is about 1.5
times higher in patients with a BMI of more than 30 kg/m2
than in patients with a low BMI
 There is also a higher likelihood of block-related
complications

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  A distinct advantage of regional anesthesia in the obese
patient is the ability to limit the amount of
intraoperative and postoperative opioid use
 The success rate for blocks is significantly higher when
ultrasonographic guidance is used to assist in needle
placement
 Obese patients require as much as 20% less local
anesthetic for spinal or epidural anesthesia than non
obese patients

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  This can lead to an unpredictable spread of local
anesthetic and variability in block height
 It is difficult to reliably predict the sensory level of
anesthesia that will be achieved by neuraxial blockade in
these patients
 Blocks extending above T5 risk respiratory compromise,
and cardiovascular collapse secondary to autonomic
blockade.
 These reasons mandate to always be prepared to
convert to general anesthesia and have the necessary
equipment and assistance immediately to hand
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Class work
 A 42 years old, 108 kg, 168 cm tall woman
diagnosed with stage II cervical cancer scheduled for
total abdominal hysterectomy.
 What is the BMI and obesity category?
 Discuss briefly the anesthetic consideration for this patient
▪ Preoperative evaluation and preparation
▪ Intraoperative managements
▪ Post-operative considerations

7 minutes
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Class ends!!

Thank you all