Peri Operative Management Of Morbid Obese Patients Undergoing Non-Bariatric Major Surgery
Ahmed Nasr Shazly Hafez;
Abstract
Overweight and obesity are characterized by an abnormal or excessive fat accumulation that presents a risk to health.
Obesity is primarily managed in primary care with nonsurgical interventions such as lifestyle and behavioral interventions. However, as these fail and weight continues to increase, management may include pharmacological intervention and/or surgery. Bariatric surgeries compared with lifestyle interventions, result in a greater decrease in cardiovascular risk factors, and achieve higher remission of type 2 diabetes.
The preoperative assessment facilitates the appropriate selection of patients suitable for bariatric surgery, enables timely identification and treatment of pre-existing medical conditions, and determines how and where each patient should be managed post operatively.
OSA is strongly associated with obesity. Because OSA is undiagnosed in an estimated 60-70% of patients, screening for OSA should be part of routine preoperative evaluation.
Because morbid obesity is one of the major risk factors for the development of pulmonary embolism, prophylaxis for DVT with low dose heparin in combination with intermittent pneumatic compression, are recommended. Also prophylaxis against acid aspiration is commonly used.
Most intravenous anesthetic drugs and opioids should be dosed according to lean body weight (not actual body weight), except for neuromuscular blocking drugs, which should be dosed according to ideal body weight.
During induction of general anesthesia, care must be taken as alterations in pulmonary function in the obese patient may result in severe hypoxemia even after short periods of apnea.
Positioning of the patient in the head elevated laryngoscopy position and the use of PEEP during mask ventilation and after intubation have been shown to reduce post-intubation atelectasis and improve arterial oxygenation.
Minor degree of residual neuromuscular blockade, particularly in the obese and OSA patients, can increase postoperative morbidities such as inadequate ventilation, hypoxia, and the need for re-intubation, so muscle relaxants should be used sparingly.
Preventive analgesia with non-opioids should reduce perioperative opioid requirements and lower opioid-related side effects as well as improve postoperative pain relief.
One of the major concerns in obese patients, particularly those with OSA, is the risk of airway obstruction after tracheal extubation. Thus, prior to tracheal extubation the patient must be fully awake, alert, and follow verbal commands.
In the PACU a semi-upright recovery position in OSA patients is recommended. The lateral decubitus position improves maintenance of the passive pharyngeal airway and increases its diameter compared with the supine position, and it can be combined with upper body elevation.
Although supplemental oxygen is beneficial for most patients, it should be administered with caution as it may reduce hypoxic respiratory drive and increase the incidence and duration of apneic episodes. Because obese patients might have unrecognized OSA, recurrent hypoxemia may be better treated with CPAP or bi-level positive airway pressure (BiPAP) along with oxygen rather than oxygen alone.
Obesity is primarily managed in primary care with nonsurgical interventions such as lifestyle and behavioral interventions. However, as these fail and weight continues to increase, management may include pharmacological intervention and/or surgery. Bariatric surgeries compared with lifestyle interventions, result in a greater decrease in cardiovascular risk factors, and achieve higher remission of type 2 diabetes.
The preoperative assessment facilitates the appropriate selection of patients suitable for bariatric surgery, enables timely identification and treatment of pre-existing medical conditions, and determines how and where each patient should be managed post operatively.
OSA is strongly associated with obesity. Because OSA is undiagnosed in an estimated 60-70% of patients, screening for OSA should be part of routine preoperative evaluation.
Because morbid obesity is one of the major risk factors for the development of pulmonary embolism, prophylaxis for DVT with low dose heparin in combination with intermittent pneumatic compression, are recommended. Also prophylaxis against acid aspiration is commonly used.
Most intravenous anesthetic drugs and opioids should be dosed according to lean body weight (not actual body weight), except for neuromuscular blocking drugs, which should be dosed according to ideal body weight.
During induction of general anesthesia, care must be taken as alterations in pulmonary function in the obese patient may result in severe hypoxemia even after short periods of apnea.
Positioning of the patient in the head elevated laryngoscopy position and the use of PEEP during mask ventilation and after intubation have been shown to reduce post-intubation atelectasis and improve arterial oxygenation.
Minor degree of residual neuromuscular blockade, particularly in the obese and OSA patients, can increase postoperative morbidities such as inadequate ventilation, hypoxia, and the need for re-intubation, so muscle relaxants should be used sparingly.
Preventive analgesia with non-opioids should reduce perioperative opioid requirements and lower opioid-related side effects as well as improve postoperative pain relief.
One of the major concerns in obese patients, particularly those with OSA, is the risk of airway obstruction after tracheal extubation. Thus, prior to tracheal extubation the patient must be fully awake, alert, and follow verbal commands.
In the PACU a semi-upright recovery position in OSA patients is recommended. The lateral decubitus position improves maintenance of the passive pharyngeal airway and increases its diameter compared with the supine position, and it can be combined with upper body elevation.
Although supplemental oxygen is beneficial for most patients, it should be administered with caution as it may reduce hypoxic respiratory drive and increase the incidence and duration of apneic episodes. Because obese patients might have unrecognized OSA, recurrent hypoxemia may be better treated with CPAP or bi-level positive airway pressure (BiPAP) along with oxygen rather than oxygen alone.
Other data
| Title | Peri Operative Management Of Morbid Obese Patients Undergoing Non-Bariatric Major Surgery | Other Titles | معالجة ما قبل وأثناء وبعد اجراء العمليات الجراحية الكبرى للمرضى مفرطي السمنة لغير عمليات علاج البدانة | Authors | Ahmed Nasr Shazly Hafez | Issue Date | 2016 |
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