ANESTHESIA for

BARIATRIC SURGERY
SPEAKER:- Dr. Bhaskar Pendyala
Moderator:- Dr. Narmada

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 CONTENTS
1. Preoperative Evaluation
2. Intraoperative Considerations
A. Equipment and Monitoring
B. Airway Management
C. Induction and Maintenance
D. Fluid Management
E. Mechanical Ventilation
F. Emergence
G. Monitored Anesthesia Care and Sedation
H. Regional Anesthesia
3. Postoperative Considerations
A. Ventilatory Evaluation and Management
B. Postoperative Analgesia
C. Monitoring
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 Preoperative Evaluation
Airway
• Anatomic changes associated with obesity which contribute to
difficult airway
Limitation of movement of atlantoaxial joint & cervical spine by upper
thoracic & lower cervical fat pads
Excessive tissue folds in mouth & pharynx
Short & thick neck
Thick submental fat pad
Suprasternal, presternal & post cervical fat pads
Large breasts in females

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• Obesity is an accepted risk factor for difficult mask ventilation; can be
safely managed with adequate positioning and airway resources
• Magnitude of BMI doesn’t significantly influence the difficulty of
laryngoscopy
• Influenced by  Increased age; male sex; TMJ pathology; MPG 3 & 4;
abnormal upper teeth
• Not influenced by  BMI; OSA; AHI
• Patient’s neck circumference has been identified as single best
predictor of problematic intubation in morbidly obese patients
• Probability of a problematic intubation
5% -- 40 cm (16 inches)
35% -- 60 cm (24 inches)

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Cardiopulmonary
• Previous anesthetic experiences (detailed by patients and previous
anesthetic records)
• Evaluated for
Systemic hypertension
Pulmonary hypertension
Signs of right & left ventricular failure
Ischemic heart disease
• Signs of cardiac failure can be masked due to excess adiposity
Elevated JVP
Pathological heart sounds
Pulmonary crackles
Hepatomegaly
Peripheral edema
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• Pulmonary hypertension – most commonly seen in obese – presents
with exertional dyspnea, fatigue & syncope
ECHO: tricuspid regurgitation
ECG: signs of RVH; tall precordial R waves; right axis deviation
 Higher the pulmonary artery pressure, more sensitive the ECG
CXR: underlying lung disease & prominent pulmonary arteries
• Evidence of OSA/OHS should be obtained preoperatively.
• Possibility of invasive monitoring, prolonged intubation & postoperative
ventilation must be discussed
• Patients using CPAP are advised to bring it to hospital owing to postoperative
use

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Metabolic
• High prevalence of insulin resistance and diabetes; need for glycemic
checks preoperatively and correction of abnormalities
• Assessment of therapies for glycemic control; last time and dose of
administration
• Electrolytes – particularly in poorly compliant and acutely ill patients
• Nutritional deficiencies – vitamin B12, Ca, Iron, folate
• Acute Polygastric Reduction Surgery (APGARS) neuropathy – a poly
nutritional multisystem disorder
Protracted postoperative vomiting, hyporeflexia, and muscular weakness
DDx: thiamine deficiency, B12 deficiency, GBS
Close attention to dosing and monitoring of NMBDs
• Chronic vitamin K deficiency; vit K analog or FFP administration
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Hematologic
• At increased risk for thromboembolic events; confirm
thromboprophylaxis during preoperative evaluation
• A combination of intermittent pneumatic compression devices with
heparin (greater doses may be needed than in non-obese) ,
recommended by American college of chest physicians
• A combination of short duration of surgery, lower extremity
pneumatic compression, and routine early ambulation may preclude
mandatory heparin anticoagulation, except in patients with a history
of previous DVT, a known hypercoagulable state, or a significant
family history of DVT.

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• Preoperative prophylactic placement of IVC filter considered in
patients with
Venous stasis disease
Central obesity
OHS and/or OSA
BMI

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 Intraoperative considerations
Equipment and Monitoring
• Specially designed tables/2 regular size operating tables may be required
Regular table  200 kg;
Special tables with greater width & girth available  455 kg
Strapping along a malleable bean bag helps keep them from falling off the OT table

• Careful selection of properly sized BP cuff & its location

Cuff with bladders that encircle a minimum of 75% of the upper arm circumference or
preferably the entire arm should be used
Invasive BP monitoring – not only in cardiac patients but also when BP cuff doesn’t fit
properly

• Peripheral IV access difficulty – central venous catheterization may be required

even for perioperative fluid management
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Positioning
• Supine positioning – ventilatory impairment; IVC and aortic
compression
• Head up posture – longest safe apnea period during induction

Intraoperative PEEP & Head up

posture

alveolar - arterial O2 total respiratory

CO
tension difference compliance

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• Prone position – ensure freedom of abdominal movement
• Lateral decubitus allows better diaphragm excursion
• Carpal tunnel syndrome – most common mononeuropathy after
bariatric surgery
• Particular care for protecting pressure areas to avoid pressure sores,
neural injuries and rhabdomyolysis

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Airway management
• Adequate preoxygenation is vital as in obese  Rapid desaturation
after loss of consciousness owing to O2 consumption & FRC.
• Addition of head-up position & 100% O2 prolongs non-hypoxic apneic
period in obese patients
Head-up achieved either by Reverse Trendelenburg or Semi-sitting posture
also prevent aspiration & facilitate visualisation during laryngoscopy
• Pre-op use of NIPPV/application of CPAP during induction  delay
peri-induction hypoxemia.
• Passive apneic oxygenation by using nasal canula/LMAs

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• Anticipated difficulty in Bag-mask ventilation & intubation
• Patient can be counselled & planned for awake fiberoptic intubation with
minimal sedative-hypnotic use while using topical/Regional Anesthesia
• Sedation with Dexmedetomidine  Adequate anxiolysis & analgesia without
respiratory depression
• Experienced colleague along with surgeon for surgical access to airway must
be present
• Direct laryngoscopy can be attempted keeping alternative intubating
tools available (Intubating stylet, Video laryngoscope, LMA) with
proper positioning.
• “Ramped” position obtained by “Stacking” towels/folded blankets to position
tip of the chin at a higher level than chest to facilitate laryngoscopy & tracheal
intubation.

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Induction and Maintenance
• Commonly use RSI  concerns of hypoxemia, gastric regurgitation &
aspiration during induction & intubation

• Larger doses of induction agents may be required  blood volume, muscle

mass & cardiac output increase linearly with degree of obesity

• Any of the commonly available IV agents can be used

• Increased dose of Sucinylcholine  Increase in pseudocholinesterase

activity
• Succinylcholine – preferred due to rapid onset & limited duration
• Rocuronium can also be considered but duration of action >> Sch
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• Continuous infusion of short acting IV agent (Propofol) or any
inhalational agent or combination can be used for maintenance
• Desflurane, Isoflurane & Sevoflurane – minimally metabolized
• Desflurane – adequate hemodynamic stability & slightly faster washout
• N2O use limited by high O2 demand

• Short acting opioid analgesics preferred to minimize post op

respiratory depression.
• Remifentanyl/Fentanyl carefully titrated to clinical effects are the common
choices
• Dexmedetomidine – no clinically significant adverse effects on respiration –
can be used and an anesthetic adjunt -- post op opioid requirement

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• Profound muscle relaxation  laparoscopic bariatric surgery –
facilitate ventilation; maintain an adequate working space for
visualization & safe manipulation of laparoscopic instruments
• Collapse of pneumoperitoneum & tightening of patient musculature around
port site – early indication of inadequate muscle relaxation
• Vecuronium, Rocuronium & Cisatracurim – useful NDMB agents for
maintenance

• Pneumoperitoneum < 15mm Hg ; if IAP > 20mm Hg  Caval

compression & CO

• Cephalad displacement of diaphragm & carina – ET tube displacement

from main stem bronchus
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• Proper placement of Nasogastric tube with intragastric balloon  size
the gastric pouch; perform leak test with saline /Methylene blue
• Tight ET tube cuff to avoid aspiration
• NG tubes completely removed before gastric division to avoid unplanned
stapling or transection

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Fluid management
• Excess adipose tissue– masks peripheral perfusion making fluid
balance difficult to assess
• Access of the surgical site in obese necessitate larger incisions &
extensive dissection
• For the same surgery blood loss – Obese >> Non obese
• Hypovolemia  hemodynamic instability; PONV ; ATN
• ATN – 2% of patients undergoing bariatric surgery
• Associated risk factors 
1. BMI > 50kg/m2
2. Prior history of renal disease
3. Intraoperative hypotension
4. Prolonged surgery time
• Rapid IV infusion of fluids  avoided as pre-existing congestive heart
failure is common in obese 21
Mechanical ventilation
• Obese patients likely exposed to
Higher Tidal Volume – miscalculation of IBW/PBW
Higher airway pressures – respiratory system compliance
• Greater inflation pressure tolerated in obese – extra adipose tissue
attenuates lung overdistension
• 6-8 ml/kg PBW Tidal Volume recommended
• PEEP  only ventilatory parameter consistently shown to improve
respiratory function in obese
• Inspiratory O2 fraction (FiO2) should be titrated to minimum level that
assures acceptable oxygenation levels, but avoid reabsorption
atelectasis – FiO2 < 0.8 in obese patients
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• Various recruitment maneuver techniques exist
a simple one by Pelosi et al.  series of 3 short (6 seconds) inflations with
PCV to administer a large tidal volume by reaching an inspiratory pressure of
40-55 cm H2O

• Thus higher pressures needed – compensate decreased chest wall

compliance, achieving an adequate transpulmonary pressure to avoid
alveolar collapse

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• Combination of Recruitment maneuver + PEEP

• Opening & patency of small airway units

• Improve ventilation perfusion matching

• Less atelectasis; improved oxygenation; shorter stay in PACU;

postoperative pulmonary complications after laparoscopic bariatric
surgery
• Attention should be paid to avoid decrease in venous return & CO

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Emergence
• Patient should be extubated in the semi recumbent position and
recovered in the sitting position
• Mandatory presence of two anesthesia providers; Supplemental
oxygen; observation period of at least 5 minutes advised
• Risk of hypoventilation in the immediate postoperative period, leading
to hypercapnia with or without hypoxemia

• Non-invasive monitoring techniques and increasing use of CPAP

• Use of Lifting devices such as HoverMatt, patient transfer devices (PTD),
and mechanical sling lifting devices for transport of morbidly obese
patients to and from the operating table
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Walter Henderson maneuver

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Monitored Anesthesia Care and Sedation
• Monitoring the adequacy of ventilation and oxygenation

• Higher risk of sedation induced respiratory depression; careful

titration of BZDs, opioids and propofol

• Thorough airway examination and preparation for unintended airway

management and unplanned tracheal intubation

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 Regional Anesthesia
• Distinct advantages
1. Minimal/reduced manipulation of airway
2. Administration of fewer medications with cardiopulmonary depression
3. Reduced risk of PONV
4. Better postoperative pain control
5. Impr4oved Postoperative outcomes
• Disadvantages include
1. Increased risk of block failure
2. Increased risk of complication related to regional anesthesia

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Neuraxial anesthesia
Physiological changes associated with neuraxial anaesthesia
• Pulmonary:- Lung volumes, FRC, oxygenation and ventilation are
altered in these individuals
• Supine & Trendelenburg positioning during neuraxial anaesthesia can lead to
deterioration of lung volumes & further reduction in FRC
• FRC can fall below closing capacity leading to small airway collapse,
atelectasis, ventilation-perfusion mismatch & hypoxia
• Measure O2 saturation in sitting & supine postures to indicated the degree of
pulmonary reserve prior initiating neuraxial anesthesia
• Cardiovascular:- Caval compression  CO  HR
• Increased accounts of cardiac arrest in morbidly obese in supine posture SA
• ASA guidelines recommend regional anesthesia OSA patients to reduce
systemic opioid use
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Position and Placement
• Sitting posture – identification of midline
Patient’s back parallel to the edge of the bed to prevent lateral needle
deviation away from midline – may cause increased depth of epidural/spinal
spaces & can result in block failure
• Anatomical landmarks are often obscured
Drawing a line from cervical vertebral spinal processes to uppermost portion
of gluteal cleft – approximate midline
Iliac clefts also difficult to palpate -- Horizontal line from patient skin folds
going perpendicular to the vertical line

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• USG imaging to identify spinal processes  reduce number of needle
passes & decrease time for spinal block in morbidly obese
• Prepuncture USG to predict epidural depth
• Inaccurate depth due to compression of subcutaneous fat & decreased image
quality due to overlying fat are the limitations
• It is found helpful asking the patient whether the pinpoint is felt
midline (or left/right to it)
• In most cases, standard needles (9 -10 cms) are sufficient; longer
needles (16 cms) sometimes needed & must be careful

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Spinal anesthesia
• Reasonable if airway examination – normal; No cardiopulmonary
compromise; duration < 90 min
• Use of large gauge stiff epidural needle as a guide for the smaller flexible
spinal needle makes it easier.
• Decreased CSF volumes confirmed by MRI suggested that effective spinal
local anesthetic is reduced in obese patients compared to non obese

• Due to soft tissue movement into intervertebral foremen due to

increased IAP

• Direct positive correlation between height of block and degree of obesity

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• Large buttocks place spine in Trendenlenburg position exaggerating
cephalad spread

• To avoid high block, ramp is placed under chest

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Epidural Anesthesia
• The advantages of epidural over spinal are titratable dosing of local anesthetics,
ability to prolong the block, decreased risk of excessive motor block, more
controllable hemodynamic changes, and utilization for postoperative analgesia
• Hood and Dewan demonstrated an increased initial failure rate of epidural
catheters in obese labouring patients—42% compared to 6% in the nonobese
control group.
• Hodgkinson and Hussain demonstrated that the height of an epidural block for a
given volume of local anesthetic is proportional to BMI and maternal weight but
not height.
• The ligamentum flavum has a mild grip on the epidural catheter, body
repositioning allows the epidural catheter to be pulled into or out of the
subcutaneous fat.
• Before securing the epidural catheter, a patient should move from an upright
sitting position to a lateral position
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• In cases of inadvertent dural puncture, catheters may be threaded
into the subarachnoid space for continuous spinal analgesia.
• Avoid accidental administration of an epidural dose of local anesthetic
through the spinal catheter that will increase risk of a high spinal,
respiratory compromise, and loss of the airway patency.
• These catheters should be carefully marked so that they are not
mistaken for an epidural catheter

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Peripheral nerve blocks
• Technically challenging; increased failure rate (which is proportional
to BMI)
• Highest failure rate  Continuous Supraclavicular, Paravertebral,
Superficial cervical plexus & epidural blocks
• Local anesthetic dosage should be based on IBW
• Reports confirm increased success rates in the obese underlying
peripheral nerve blocks with ultrasound

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 Postoperative consideration
Ventilatory evaluation and management
• Increased incidence of atelectasis ion morbidky obese after GA
• Initiation of CPAP/BiPAP has been advocated
• Despite the theoretical risk, the use of NIPPV doesn’t seem to increase
the incidence of major anastomotic leakage after gastric bypass surgery
• Postoperative CPAP may improve oxygenation but doesn’t facilitate CO2
elimination
• Adequate analgesia, use of elastic binder for abdominal support, early
ambulation, deep breathing exercises and incentive spirometry are all
useful adjuncts to avoid postoperative hypoventilation and atelectasis
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Postoperative analgesia
• The goal of pain management in these individuals is not only to
provide adequate analgesia but also to facilitate early mobilization
and adequate respiratory function.

1. Multimodal analgesics – opioid sparing

2. Regional anaesthesia/analgesia techniques

3. Early mobilization – to prevent complications like pressure ulcerations,

thromboembolic events, pneumonia

4. Facilitate adequate respiratory function – supplemental oxygen and head

end elevation
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Monitoring
• Obese patients who have received either neuraxial or parenteral
opioids require careful postoperative monitoring for respiratory
depression; however, routine admission to intensive or high acuity
care units is not recommended

• All patients receiving neuraxial opioids should be monitored for

adequacy of ventilation (respiratory rate, depth of respiration)
oxygenation(pulse oximetry when appropriate)
level of consciousness

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THANK YOU

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