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The prevalence of obesity is increasing. The highest risk group are of course those patients presenting for emergency surgery who are poorly prepared. Understanding these changes is important for safe anesthesia in this patient group.
The prevalence of obesity is increasing. The highest risk group are of course those patients presenting for emergency surgery who are poorly prepared. Understanding these changes is important for safe anesthesia in this patient group.
The prevalence of obesity is increasing. The highest risk group are of course those patients presenting for emergency surgery who are poorly prepared. Understanding these changes is important for safe anesthesia in this patient group.
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