ArticleLiterature Review

Anesthesia for bariatric surgery

Authors:
  • Tufts University School of Medicine VA Boston
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Abstract

Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The 'ramped' upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. Intra-operative hypoxaemia can be treated with the combination of PEEP and recruitment manoeuvres, and attention to airway management at emergence is critical. Local anaesthetic wound infiltration and non-steroidal anti-inflammatory drugs should be part of multimodal opioid-sparing postoperative analgesia. Implementation of bariatric clinical-care pathways seems beneficial. Considering the prevalence of sleep apnoea in these patients, outpatient bariatric surgery remains controversial, but is probably safe for certain procedures, provided there is strict adherence to preoperative eligibility and home-care protocols.

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... Local anesthetics have been advised for analgesia in bariatric surgery [6,[8][9][10]. In addition to the importance of reducing opioid consumption, reducing postoperative pain is another very important goal after surgery. ...
... The main goal of a multimodal approach to pain in bariatric surgery is to reduce opioid consumption to a minimum or to leave the patient completely opioid-free. Particularly, for the bariatric population, which has a high prevalence of obstructive sleep apnea syndrome, there is a well-documented risk of complications because of increased severity of apneic events with the use of opioids [8,16]. Furthermore, reducing side effects of opioids like nausea and vomiting and delayed bowel function may shorten hospital stay, reduce costs, and increase patient satisfaction. ...
... Local anesthesia as an addition to a multimodal analgesic strategy is often used because of their known benefits with no systemic adverse effects in therapeutic dosages. Therefore, local anesthetics are often advised for bariatric surgery [6,[8][9][10]. Before our study, evidence for this approach to use local anesthetics in bariatric surgery was limited and interpretation of the results was difficult because all studies used different routes of administration. ...
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Introduction: A multimodal pain treatment including local anesthetics is advised for perioperative analgesia in bariatric surgery. Due to obesity, bariatric surgery patients are at risk of respiratory complications. Opioid consumption is an important risk factor for hypoventilation. Furthermore, acute postoperative pain is an important risk factor for chronic postsurgical pain. In this study, we aimed to evaluate whether preperitoneal anesthesia with bupivacaine would reduce pain and opioid consumption after bariatric surgery. Methods: One hundred adults undergoing laparoscopic bariatric surgery were randomized to receive either preperitoneal bupivacaine 0.5% or normal saline before incision. Postoperative opioid consumption, postoperative pain, and postoperative recovery parameters were assessed for the first 24 h after surgery. One year after surgery, chronic postsurgical pain and influence of pain on daily living were evaluated. Results: Postoperative opioid consumption during the first hour after surgery was 2.8 ± 3.0 mg in the bupivacaine group, whereas in the control group, it was 4.4 ± 3.4 mg (p = 0.01). Pain scores were significantly reduced in this first hour at rest and at 6 h during mobilization on the ward. One year after surgery, the incidence of chronic postsurgical pain was 13% in the bupivacaine group versus 40% in the placebo group. Conclusion: This study shows that preperitoneal local anesthesia with bupivacaine results in a reduction in opioid consumption and postoperative pain and seems to lower the incidence rate of chronic postsurgical pain after laparoscopic bariatric surgery.
... Bupivacaine is a local anaesthetic which temporarily blocks neurotransmission, thereby providing analgesia for 4-8 h. Every patient in our study received bupivacaine infiltration, which contributed to multimodal analgesia, and this corroborates other studies [10,15,16]. Morphine is an efficacious opioid analgesic but is associated with significant adverse effects including airway or respiratory compromise, which may be severe in bariatric patients [3,6,9,11,12]. ...
... Diclofenac and parecoxib are non-steroidal anti-inflammatory drugs (NSAID) and opioid-sparing analgesics with few adverse effects [12,16,[19][20][21]. Two thirds of patients in our study received NSAID, which enhanced multimodal analgesia. ...
... Two thirds of patients in our study received NSAID, which enhanced multimodal analgesia. Our study confirms that multimodal analgesia involving NSAID, reduces opioid requirement and side-effects but without NSAID-related adverse effect as shown in other studies [12,16,[19][20][21]. ...
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Background Postoperative pain and analgesia present challenges in bariatric surgery patients. Multimodal analgesia may provide better efficacy, less complications and expedite fast-track bariatric surgical care. There are no studies of the broader topic of perioperative analgesia and the overall impact. This study highlights the impact of multimodal intraoperative analgesia on fast-track bariatric surgery. Methods This observational study examined the perioperative outcome data of 412 consecutive laparoscopic bariatric surgery patients over a 6-year period. Perioperative outcome and variables were analysed and compared between different intraoperative analgesia types. ResultsMean BMI was 49, mean age was 42 and male:female ratio was 1:4. About 82% of patients received multimodal intraoperative analgesia, comprising various combinations of bupivacaine infiltration and intravenous acetaminophen, morphine, tramadol, parecoxib or diclofenac. Morphine was administered in 83% of patients and tramadol in 17%. Multimodal intraoperative analgesia provided better postoperative analgesia, shorter postanaesthesia care unit (PACU) duration, lower postoperative opioid requirement, less postoperative vomiting, earlier postoperative oral intake, earlier ambulation and shorter hospital stay compared to unimodal intraoperative morphine analgesia (p = 0.0001). Multimodal analgesia comprising tramadol + acetaminophen + diclofenac provided better postoperative analgesia, shorter PACU duration, lower postoperative opioid requirement, earlier ambulation, shorter hospital stay and less postoperative hypopnoea compared to patients who received morphine (p = 0.0001). Conclusions Multimodal intraoperative analgesia provides better postoperative analgesia, less complications and better perioperative outcomes and facilitates fast-track bariatric surgical care. Tramadol is suitable, efficacious and safe and associated with the best perioperative outcomes in bariatric surgery patients.
... r Perioperative noninvasive ventilation (NIV) has been proposed as an attractive strategy to reduce postoperative morbidity and improve perioperative outcomes in patients undergoing general anesthesia [1]. Many factors, including obesity, anesthetic drugs, and surgery, act together to affect perioperative respiratory function, mainly through the reduction in lung volume and formation of lung atelectasis [2][3][4]. These effects can be attenuated by NIV applied as http://dx. ...
... However, whether there is an advantage of perioperative NIV in obese patients has not been well established. Some authors support the use of preoperative NIV, before induction of anesthesia; compared with conventional preoxygenation, it significantly improves oxygenation in morbidly obese patients [4]. In contrast, others have reported that the changes in oxygenation are not different compared with controls, and the duration of safe apnea after anesthesia induction is not significantly prolonged in obese patients treated with NIV compared with those treated with standard preoxygenation [5][6][7]. ...
... Preoxygenation increases the oxygen reserves in the body and prolongs the safe period of apnea after induction of anesthesia [2][3][4][5]. After standard preoxygenation and anesthesia induction, Jense et al. found a significant negative linear correlation (r = À0.83; ...
Article
Background: Perioperative noninvasive ventilation (NIV) has been proposed to reduce postoperative morbidity and improve perioperative outcomes in patients undergoing general anesthesia. Whether it is advantageous to apply NIV just before and after general anesthesia in obese patients has not been yet established. Objectives: To perform a qualitative review and meta-analysis to assess the effectiveness and tolerability of perioperative NIV in obese patients. Methods: All studies in English language performed in clinical setting that compared the application of NIV with standard care just before and after induction of general anesthesia in obese adults (body mass index [BMI]≥35 kg/m(2)) were included. Data on oxygenation, respiratory function, complications, and outcomes were extracted. Results: Twenty-nine articles were selected and used in the qualitative review. Eleven studies including 768 patients were used for subsequent meta-analyses. Compared with standard preoxygenation, NIV was associated with a significant improvement in oxygenation (P<.0001) before tracheal intubation. Benefits in oxygenation (P<.0001), clearance of carbon dioxide (P<.0001), and pulmonary function testing (P<.0001) after general anesthesia were observed with NIV compared with standard care. Postoperatively, NIV was associated with a decreased risk of respiratory complications (relative risk [RR] = .33; 95% confidence interval [CI] .16-.66; P = .002), but not of reintubation after tracheal extubation (RR = .41; 95% CI .09-1.82]; P = .3657) and unplanned intensive care unit admission (RR = .43; 95% CI .16-1.15; P = .0937). NIV-related complications in obese patients were mainly due to intolerance and ranged from 7% to 28% of cases. NIV-related anastomotic leakage and adverse events were not reported. Conclusions: Results from this review and meta-analysis suggest that NIV is well tolerated and effective in improving perioperative care in obese patients. The application of NIV before and after general anesthesia should be considered and promoted in relevant cases.
... In the postoperative setting, the use of opioids should be minimized and if needed, used with caution (Table 4, Q 4.5) [93,98,103,114,115,[120][121][122][123][124][125][126][127][128]. A multimodal analgesic model minimizing the necessity for the administration of opioids includes the use of paracetamol, non-steroidal antiinflammatory drugs, local anesthetics for incisional infiltration, epidural analgesia and peripheral nerve blocks. ...
... A multimodal analgesic model minimizing the necessity for the administration of opioids includes the use of paracetamol, non-steroidal antiinflammatory drugs, local anesthetics for incisional infiltration, epidural analgesia and peripheral nerve blocks. Although other strategies such as ketamine, magnesium, intravenous lidocaine, and alpha 2-agonists like clonidine and dexmedetomidine seem promising, high quality supportive evidence regarding their use in this setting is lacking ( Table 4, Q 4.6 [93,103,114,115,120,121,123,126]; Table 4, Q 4.7 [114,115,121,122,126,129]). When practical and as an adjunct for postoperative pain management, regional anesthesia should be considered as part of multimodal analgesia in open weight loss surgery ( [114,115,120,121]. ...
... A multimodal analgesic model minimizing the necessity for the administration of opioids includes the use of paracetamol, non-steroidal antiinflammatory drugs, local anesthetics for incisional infiltration, epidural analgesia and peripheral nerve blocks. Although other strategies such as ketamine, magnesium, intravenous lidocaine, and alpha 2-agonists like clonidine and dexmedetomidine seem promising, high quality supportive evidence regarding their use in this setting is lacking ( Table 4, Q 4.6 [93,103,114,115,120,121,123,126]; Table 4, Q 4.7 [114,115,121,122,126,129]). When practical and as an adjunct for postoperative pain management, regional anesthesia should be considered as part of multimodal analgesia in open weight loss surgery ( [114,115,120,121]. ...
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Background The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%–94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established. Objectives To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties. Setting The meeting was held in Amsterdam, the Netherlands. Methods A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the “Amsterdam Delphi Method” was utilized including controlled acquisition of feedback, aggregation of responses and iteration. Results Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized. Conclusion This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS.
... No presente estudo, os voluntários do Gpós fizeram o uso de pressão positiva na sala de recuperação pós-anestésica (RPA) logo após a extubação. Este resultado favorável frente ao uso do equipamento pode ser em decorrência da correção da hipoventilação do paciente obeso, pois uma das características do obeso mórbido é a hipoventilação alveolar devido ao acúmulo de gordura na região abdominal e alterações na mecânica ventilatória (Shah et al., 2009; Chau et al., 2012) e após ser submetido à anestesia geral, a hipoventilação pode ser agravada nas primeiras horas na RPA room (Moore et al., 2011;Schumann 2011). A pressão positiva, portanto, pressuriza as vias aéreas superiores nas primeiras horas após anestesia e melhora a ventilação alveolar em áreas possivelmente colapsadas em decorrência do procedimento cirúrgico prevenindo a formação de atelectasias no pós-operatório (Schumann 2011). ...
... Este resultado favorável frente ao uso do equipamento pode ser em decorrência da correção da hipoventilação do paciente obeso, pois uma das características do obeso mórbido é a hipoventilação alveolar devido ao acúmulo de gordura na região abdominal e alterações na mecânica ventilatória (Shah et al., 2009; Chau et al., 2012) e após ser submetido à anestesia geral, a hipoventilação pode ser agravada nas primeiras horas na RPA room (Moore et al., 2011;Schumann 2011). A pressão positiva, portanto, pressuriza as vias aéreas superiores nas primeiras horas após anestesia e melhora a ventilação alveolar em áreas possivelmente colapsadas em decorrência do procedimento cirúrgico prevenindo a formação de atelectasias no pós-operatório (Schumann 2011). ...
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A obesidade é, por si, um fator de risco independente para o surgimento de complicações respiratórias pós-operatórias. O objetivo do estudo foi investigar os efeitos da aplicação de pressão positiva antes, durante e depois do procedimento cirúrgico − em obesos submetidos à cirurgia bariátrica, sobre os volumes e capacidades pulmonares e a mobilidade toracoabdominal. Foram estudados 40 indivíduos com índice de massa corporal entre 40 e 55 kg/m2 e idade entre 25 e 55 anos, submetidos a avaliação pré e pós-operatória e alocados nos grupos: Gpré: tratamento com pressão positiva nas vias aéreas antes da cirurgia; Gpós: pressão positiva nas vias aéreas após a cirurgia; Gintra: pressão positiva nas vias aéreas durante a cirurgia; Gcontrole: fisioterapia convencional conforme rotina hospitalar. Foram avaliadas cirtometria toracoabdominal em três níveis e ventilometria: frequência respiratória, volume corrente, volume minuto e capacidade vital. Os resultados indicaram que, na análise intragrupo, houve aumento significativo da frequência respiratória e queda da capacidade vital para todos os grupos no pós-operatório. O volume corrente apresentou queda significativa somente no Gintra. Não houve diferença significativa nos três níveis de mobilidade toracoabdominal no Gpré. Concluiu-se que a utilização da pressão positiva no pós-operatório de cirurgia bariátrica não promove a manutenção da frequência respiratória e capacidade vital nos seus valores pré-operatórios. Entretanto, quando utilizada no pré-operatório, contribuiu para a manutenção do volume minuto, do volume corrente e da mobilidade toracoabdominal nos três níveis. Palavras-chave: Cirurgia bariátrica. Obesidade mórbida. Pressão positiva nas vias aéreas. Modalidades de fisioterapia.
... Benzodiyazepinlere karşı duyarlılık artmıştır. Kas gevşeticiler gibi hidrofilik ilaçların dağılım hacmi ve yarılanma ömürleri genellikle değişmemektedir (14). ...
... Nöromüsküler blokerler gibi suda çözünen ilaçların doz ayarlaması ise doz aşımını önlemek için ideal vücut ağırlığına göre yapılmalıdır. Neostigminin ayarlanmış vücut ağırlığına göre verilmesi önerilmektedir.Sugammadeks ile ilgili obez hastalarda kanıtlanmış yeterli veri olmamakla birlikte çoğu çalışmada ideal veya yağsız vücud ağırlığına göre verilmesi gerektiği belirtilmektedir ( (2,12,14,15). ...
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Her anesteziyolog çalışma hayatında morbid obezite cerrahisi geçirecek herhangi bir hastaya anestezi vermek zorunda kalabilir. Bu cerrahi uygulamalarında, hastaların hem fizyolojik, anatomik hem de yandaş hastalıklara bağlı değşiklikler nedeniyle uygulanan anestezi riskli ve komplikedir. Obezite günümüzde artmış perioperatif mortalite ve morbiditeye yol açan, ve yandaş hastalıklar ile ilişkilendirilen önemli sağlık sorunlarından biridir. Obeziteye bağlı olarak birçok organ sistemi etkilenebilir ve vücutta pek çok değişiklikler görülebilir. Obez hastaların preoperatif değerlendirmesinde, obez olmayanlara göre farklı güçlükler bulunmaktadır. Bu değerlendirme sırasında hastaların havayolu, kardiyovasküler, solunum ve endokrin sistemle ilgili önemli fizyolojik değişiklikler saptanabilmektedir. Preoperatif dönemde yandaş hastalıkların varlığı ve şiddeti saptanmalı ve ek hastalıkların özellikleri göz önünde bulundurulmalıdır. Bu sebeplerle obezite cerrahisi öncesi hastaların detaylı şekilde değerlendirilmesi ve mevcut sorunların önceden saptanması önem arz etmektedir (1,2).
... Obez hastalarda değişen anatomi ve fizyoloji nedeniyle, anestezi planı yapılırken dikkatli olunmalıdır. Preoperatif muayene, perioperatif anestezi yönetimi ve postoperatif dönem diğer hasta gruplarına göre farklılık göstermektedir (14). Boyun ve meme bölgesindeki yağ artışının yol açabileceği zor hava yolu açısından hastalar değerlendirilmeli, zor ventilasyon ve entübasyon bekleniyorsa öncesinde hazırlık yapılmalıdır. ...
... Postoperatif ağrı tedavisinde opioidlerden kaçınılmalıdır. Tramadol, non-steroid antienflamatuvar ilaçlar veya lokal anestezik infiltrasyonları daha kullanışlıdır (14). ...
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Obesity is a common health problem with serious complications. Medical and surgical methods can be used in treatment. Laparoscopic sleeve gastrectomy (LSG) is a widely used surgical procedure. LSG is a high-risk surgery because of the effects of both existing obesity and the applied laparoscopic technique. Anesthesia plan from preoperative examination to perioperative management and postoperative care should be done carefully. We aimed to share our experience in the anesthetic management of a patient who underwent a LSG operation which was performed for the first time in our hospital. © 2019 by The Medical Bulletin of İstanbul Haseki Training and Research Hospital.
... During bariatric surgery, morbidity or mortality risks increase synchronously with the increased body mass index (BMI) and common fat spreading (1) . Airway management is harder because of desaturation of oxygen expeditiously, difficult mask ventilation and difficult intubation (2) . Therefore, obese patients are likely to have airway morbidity more than the non-obese. ...
... Neuromuscular blockers can improve airway management. Moreover, rapid sequence induction is indicated because bariatric patients have many criteria for difficult airway (2) . But the choice of neuromuscular blocker is still controversial. ...
... The safety and efficacy of local anesthetic in perioperative care is well recognized. The primary advantages of local anesthetic agents are that they act directly on the tissue to which they are administered and they lack the systemic effects of opioids, such as nausea, sedation, and opioidinduced ventilatory impairment [5][6][7]. Analgesia requirements in patients with obesity can vary due to differing physiology and comorbidities; therefore, understanding analgesia administration in bariatric procedures and utilizing a multimodal approach is particularly important. There have been studies conducted on the effectiveness of intraperitoneal local anesthetic in laparoscopic procedures including bariatric surgery. ...
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Background Effective analgesia after bariatric procedures is vital as it can reduce post-operative opioid use. This leads to less nausea which may be associated with shorter post-operative length of stay (LOS). Understanding analgesic requirements in patients with obesity is important due to the varied physiology and increased number of comorbidities. Objectives The aim of this study was to evaluate the efficacy of intraperitoneal instillation of local anesthetic (IPILA) to reduce opioid requirements in patients undergoing laparoscopic bariatric surgery. Methods A double-blinded randomized control trial was conducted to compare intraperitoneal instillation of ropivacaine to normal saline in 104 patients undergoing bariatric surgery. The primary endpoint was pain in recovery with secondary endpoints at 1, 2, 4, 6, 24, and 48 h post-operatively. Further endpoints were post-operative analgesic use and LOS. Safety endpoints included unexpected reoperation or readmission, complications, and mortality. Results There were 54 patients in the placebo arm and 50 in the IPILA. Pain scores were significantly lower in the IPILA group both at rest (p = 0.04) and on movement (p = 0.02) in recovery with no difference seen at subsequent time points. Equally, IPILA was independently associated with reducing severe post-operative pain at rest and movement (adjusted odds ratio [aOR] 0.28, 95% CI 0.11–0.69, p = 0.007 and aOR 0.25, 95% CI 0.09–0.62, p = 0.004, respectively). There was no significant difference in LOS, opioid use, antiemetic use, morbidity, or mortality between the intervention and placebo groups. Conclusion The administration of ropivacaine intraperitoneally during laparoscopic bariatric surgery reduces post-operative pain in the recovery room but does not reduce opioid use nor LOS.
... However, bariatric patients are known to require higher sedative doses than non-obese individuals which lead to increased sedation risks. 34 In addition, a higher BMI has been thought to be associated with an increased risk of cardio-pulmonary complications during procedural sedation. This may be due to obstructive sleep apnea, pulmonary hypertension, and restrictive lung disease, which are reported to be common in obese patients. ...
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Aim: To evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG). Materials and methods: After Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods. Results: A total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups. Conclusion: Preoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.
... Postoperative pain, nausea, and vomiting are relevant events since they lead to discomfort and contribute to greater morbidity [1][2][3] . In the post-anesthesia care unit (PACU), managing postoperative pain is essential for the respiratory system to be able to adapt after the deflation of the pneumoperitoneum, as well as for more comfortable, safer, and earlier patient recovery. ...
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BACKGROUND AND OBJECTIVES: Compare anesthesia techniques with sufentanil and intraoperative infusion of remifentanil or dexmedetomidine, and to then analyze their associations with the incidence of pain and other complications in the post-anesthesia care unit. METHODS: A retrospective analytical observational study conducted in a reference center for bariatric surgery in São Paulo, São Paulo State, Brazil. Patients (n=120) included in the study were randomly selected using this site’s anesthesia records for bariatric surgery. Four 30-patient groups were established: G1 - induction with 0.5 µg.kg⁻¹ sufentanil associated with the continuous infusion of remifentanil; G2 - induction with 0.7 µg.kg⁻¹ sufentanil associated with the continuous infusion of remifentanil; G3 - induction with 0.5 µg.kg⁻¹ sufentanil associated with the continuous infusion of dexmedetomidine; and G4 - induction with 0.7 µg.kg⁻¹ sufentanil associated with the continuous infusion of dexmedetomidine. Significance was set at p<0.05. RESULTS: The incidence of pain in the post-anesthesia care unit was 52.5% (n=63). It was considered intense in 36.11% of these cases. The incidence of pain in the post-anesthesia care unit was lower in patients receiving a continuous infusion of dexmedetomidine relative to those who received remifentanil infusion. Sufentanil dosage in anesthesia induction did not influence the incidence of pain (G1=G2>G3=G4; p<0.05). The occurrence of respiratory complications did not differ significantly between the groups. CONCLUSION: The use of dexmedetomidine proved to be better for analgesia in the post-anesthesia care unit, and it did not increase the risk of respiratory complications when compared to the continuous infusion of remifentanil, regardless of the sufentanil dose used for induction.
... Among patients who had bariatric surgery, in addition to standard monitoring of ASA, different applications have been performed in terms of arterial cannulation for invasive blood pressure monitoring and blood gas analysis and routine administration of central venous catheterisation for difficult vascular access or central venous pressure measurement (11,12). It is suggested that the arm blood pressure cuff should be large enough to cover the arm circumference of the cases who were administered non-invasive blood pressure (13,14). ...
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Objective: In the present study, we aimed to retrospectively evaluate the preoperative characteristics, intraoperative and postoperative results of patients who underwent laparoscopic obesity surgeries. Methods: After obtaining the approval of the Ethics Committee, records of patients who underwent laparoscopic obesity surgery from January 2013 to December 2016 were reviewed. Demographic characteristics, medications used in anaesthesia and analgesia, the duration of recovery unit/hospital stay, intensive care unit/mechanical ventilation requirements and complications were recorded. Results: A total of 329 ASA II-III patients over a 3-year period were operated. Thiopental and propofol were administered at induction, sevoflurane, isoflurane and desflurane were administered for the maintenance, and vecuronium and rocuronium were administered to aid in neuromuscular blockage. The mean durations of recovery unit and hospital stays were 30.80±6.01 minutes and 4.27±1.68 days, respectively. The hypnotic agent, muscle relaxant or inhalation anaesthetics used did not have a significant effect on the duration of recovery unit and hospital stay. Mask ventilation and intubation were noted to be difficult in 5.5% and 8.5% of the cases, respectively. The presence of obstructive sleep apnoea syndrome and high body mass index and Mallampati scores significantly increased difficult mask ventilation and difficult intubation rates. Four patients were transferred to intensive care unit for close monitoring. Two patients were re-operated on, two patients had rhabdomyolysis, one patient had Wernicke's encephalopathy and two patients had peripheral neuropathy. Perioperative mortality did not occur in any patient. Conclusion: We believe that appropriate patient selection, the use of well-designed anaesthesia and surgical protocols play important roles in increasing the success rate of patient outcomes and early and late complications in laparoscopic obesity surgery.
... After laparoscopy, many patients, due to pain, may remain with limited and superficial inbreathing. This leads to decreased tidal volume and perpetuates the maintenance of intraoperative atelectasy determining oxygen desaturation, late post-anesthetic care unit (PACU) discharge and discomfort [1][2][3] . POP control in the PACU is critical for respiratory system adjustment after pneumoperitoneum deflation and also for a more comfortable, safer and earlier recovery. ...
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BACKGROUND AND OBJECTIVES: Postoperative pain in obese patients is a noxious event for their recovery delaying hospital discharge and increasing the chance of complications. This study aimed at determining pain frequency in the post-anesthetic care unit and at investigating factors associated to moderate to severe pain in obese patients submitted to gastroplasty, relating them to potential complications. METHODS: This is an observational and prospective study including 84 patients submitted to general anesthesia with sevoflurane for laparoscopic gastroplasty. Patients were evaluated in the post-anesthetic care unit for pain intensity by the verbal and numerical scale (Ramsay scale), presence of nausea, vomiting and respiratory complications. Logistic regression model was used to determine pain-related independent variables. RESULTS:There has been no pain at admission to the post-anesthetic care unit in 61.63% of patients. In the multivariate analysis, fentanyl as compared to sufentanil was the only independent factor associated to pain (OR 3.07 - IC95% 1.17 - 6.4). There has been no difference between the type of opioid used and the presence of nausea and vomiting (p>0.05). Ramsay scale scores were not different between opioids used in the intraoperative period (p>0.05). CONCLUSION: The only independent factor associated to pain in the post-anesthetic care unit was the type of opioid used for anesthetic induction. Postoperative pain is still a frequent event affecting most patients, and analgesic protocols have to be implemented to minimize the effects that undertreated pain may induce.
... This may be due to sleep apnea, pulmonary hypertension, and restrictive lung disease, which are more common in patients with obesity. Additionally, airway management in obese patients may prove to be more difficult due to rapid oxygen desaturation, challenges with mask ventilation and intubation, and increased susceptibility to the respiratory depressant effects of sedatives [10]. As a result, many institutions require an anesthesia consultation on all patients with a BMI of 40 and above prior to any endoscopic procedures in order to plan out the safest and most efficacious method of sedation. ...
Article
This article reviews the data for diagnostic and uncomplicated therapeutic upper endoscopy, which show it is safe and effective to perform the procedure under moderate sedation with a combination of benzodiazepine and opioids. For more complex procedures or for superobese patients anesthesia support is recommended. Performing endoscopy in this population should alert providers to plan carefully and individualize sedation plans because there is no objective way to quantify this risk pre-endoscopically.
... The variations in Western Australian anaesthetic practice in our cohort occurred despite several reviews and published guidelines on anaesthetic considerations for bariatric surgery 3,4,20 . This may be due to the fact that these guidelines were not strongly supported by solid evidence. ...
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Bariatric surgery is a rapidly growing and dynamic discipline necessitating a specialised anaesthetic approach coordinating high-risk patients with appropriate postoperative intensive care (ICU) support. The relationship between the anaesthetic and ICU utilisation after bariatric surgery is poorly understood. All adult bariatric surgery patients admitted to any ICU over a five-year period between 2007 and 2011 in Western Australia were identified from hospital admission records and crossreferenced against the Western Australian Department of Health Data Linkage Unit database. During the study period 12,062 patients underwent bariatric surgery with 581 (4.8%) patients admitted to ICU immediately following surgery. The mean preoperative ASA score was 3.3 (standard deviation 1.1) with 76.9% of patients assessed by their anaesthetist for the first time on the day of surgery. Blood pathology (75%) and ECG (46.3%) were the most common preoperative investigations. Intraoperatively, 2.1% of patients had a grade 4 intubation with only 3.4% of patients requiring video-assisted intubation. Despite being deemed at high risk, 23.6% of patients were managed with 20 Gauge or smaller intravenous access. Anaesthetic complications were extremely uncommon (0.5% of all bariatric cases) but accounted for 9.7% of all postoperative ICU admissions. Smoking history, but not body mass index (P=0.46), was the only significant prognostic factor for respiratory or airway-related anaesthetic complications (P=0.012). In summary, the anaesthesia management of bariatric surgery varied widely in Western Australia, with smoking as the only significant preoperative risk factor for respiratory or airway-related anaesthesia complications.
... Table 5., showed that 11.1% were complicated (2 cases with bleeding and 2 cases with perforations) and complicated cases were significantly higher regarding age. [11]. Patients with BMI score ≥35 or greater who have cormobidities or those with BMI score > 40, regardless of co-morbidities, are regarded as morbidly obese [12]. ...
... A pilot study in morbidly obese adolescents (mean body mass index 49.6 kg/m 2 ) showed enhanced CL while V d was comparable to that in lean adults after dosing based on ideal body weight [79]. Although the results suggest that a loading dose of fentanyl may be based on total body weight followed by maintenance doses based on ideal body weight and/or lean body weight [80,81], obese patients are more at risk for respiratory side effects of opioids [82][83][84][85][86]. ...
Article
Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R 2 = 0.71, B max 876 mL/min, K 50 16.3 kg) and alfentanil (R 2 = 0.70, B max (fixed) 420 mL/min, K 50 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R 2 = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R 2 = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.
... A pilot study in morbidly obese adolescents (mean body mass index 49.6 kg/m 2 ) showed enhanced CL while V d was comparable to that in lean adults after dosing based on ideal body weight [79]. Although the results suggest that a loading dose of fentanyl may be based on total body weight followed by maintenance doses based on ideal body weight and/or lean body weight [80,81], obese patients are more at risk for respiratory side effects of opioids [82][83][84][85][86]. ...
Conference Paper
Background Fentanyl and its newer derivatives sufen-tanil, alfentanil and remifentanil are strong opioid anal-gesics frequently used in pediatricpatients. Despite this extensive use insufficient information on the PK of these drugs in neonates, infants, children and adolescents is available. The goal of this analysis was to perform a thor-ough review of the PK properties of fentanyl and its deriv-atives in children of all age groups. Methods PubMed was searched using specific terms re-lated to the pharmacology of fentanyl and its derivatives in the paediatric population. Original articles and reviews regarding the PK, PD, efficacy and safety were included. A meta-analysis of PK data was conducted using a ran-dom effects model. Individual PK data was re-analysed for subgroups. Results Of the retrieved 372 articles, clinical studies were the most frequent, followed by case series, case and short reports, and reviews. Fentanyl and its derivatives show a satisfactory safety profile in children. Forty four eligible PK studies contained data from 821 paediatric patients, including more than 46 preterm infants, 64 neonates, 115 infants and toddlers, 188 children, and 28 adolescents. Special populations comprised preterm infants, children with chronic renal or liver disease, undergoing extracor-poreal circulation, or with obesity. Pooled mean fentanyl clearance (CL) was 14.56 (95% CI 12.16, 16.74) mL/min/kg and volume of distribution (Vd) was 5.46 (2.64, 10.27) L/kg. Mean sufentanil CL was 19.43 (12.77, 26.09) mL/min/kg and Vd was 2.39 (1.63, 3.15) L/kg. Alfentanil CL was 6.23 (4.44, 8.02) mL/min/kg and Vd was 0.57 (0.42, 0.72) L/kg. There was only weak correlation between body weight (BW) and both CL and Vd of fentanyl (r2=0.22 and r2=0.43, p=0.0054 and p<0.0001) in preterm infants, neonates and young infants. Sufentanil CL correlated strongly with BW (r2=0.67, p<0.0001) and age (r2=0.62, p<0.0001). Alfen-tanil CL exhibited strong correlation with both age and BW (r2=0.71 and 0.72, both p<0.0001). There was an iden-tical correlation with both age and BW for Sufentanil Vd (both r2=0.81, p<0.0001) and Alfentanil Vd (both r2=0.59, both p<0.0001). While remifentanil CL correlated equally strong with age and BW (r2=0.73 vs. 0.69, both p<0.0001), BW had a greater impact on the Vd than age (r2=0.73, vs. 0.63, both p<0.0001). Conclusion There are profound differences between the fentanyl derivatives and their PK correlations with BW. Fu-ture studies should be designed to assess the PK and PD of fentanyl and its derivatives in all paediatric subpopulations.
... Erlandsson and colleagues used electrical impedance tomography to determine optimal levels of PEEP in bariatric surgery patients with a mean BMI of 49 ± 8 kg/m 2 and found a value of 15 cm H 2 O to be appropriate before the installation of capnoperitoneum [24]. Based on these studies, PEEP values [28]. Nevertheless, in the setting of laparoscopic bariatric surgery, the recommended PEEP levels might still fall below the actual demand. ...
Article
Full-text available
Background: Bariatric surgery has proven a successful approach in the treatment of morbid obesity and its concomitant diseases such as diabetes mellitus and arterial hypertension. Aiming for optimal management of this challenging patient cohort, tailored concepts directly guided by individual patient physiology may outperform standardized care. Implying esophageal pressure measurement and electrical impedance tomography-increasingly applied monitoring approaches to individually adjust mechanical ventilation in challenging circumstances like acute respiratory distress syndrome (ARDS) and intraabdominal hypertension-we compared our institutions standard ventilator regimen with an individually adjusted positive end expiratory pressure (PEEP) level aiming for a positive transpulmonary pressure (P L) throughout the respiratory cycle. Methods: After obtaining written informed consent, 37 patients scheduled for elective bariatric surgery were studied during mechanical ventilation in reverse Trendelenburg position. Before and after installation of capnoperitoneum, PEEP levels were gradually raised from a standard value of 10 cm H2O until a P L of 0 +/- 1 cm H2O was reached. Changes in ventilation were monitored by electrical impedance tomography (EIT) and arterial blood gases (ABGs) were obtained at the end of surgery and 5 and 60 min after extubation, respectively. Results: To achieve the goal of a transpulmonary pressure (P L) of 0 cm H2O at end expiration, PEEP levels of 16.7 cm H2O (95% KI 15.6-18.1) before and 23.8 cm H2O (95% KI 19.6-40.4) during capnoperitoneum were necessary. EIT measurements confirmed an optimal PEEP level between 10 and 15 cm H2O before and 20 and 25 cm H2O during capnoperitoneum, respectively. Intra- and postoperative oxygenation did not change significantly. Conclusion: Patients during laparoscopic bariatric surgery require high levels of PEEP to maintain a positive transpulmonary pressure throughout the respiratory cycle. EIT monitoring allows for non-invasive monitoring of increasing PEEP demand during capnoperitoneum. Individually adjusted PEEP levels did not result in improved postoperative oxygenation.
... Postoperative pain Introduction Surgery for morbid obesity presents both surgeon and anesthesiologist a technical challenge. Physiologic responses to laparoscopic surgery, pneumoperitoneum, surgical complications, postoperative pain, and medical complications are some of the perioperative factors that affect recovery after bariatric surgery [1][2][3][4]. In this regard, pain after surgical procedures constitutes one of the most common causes of postoperative morbidity and renders the most important limitation for rehabilitation after a surgical intervention. ...
Article
Current evidence suggests that local anesthetic wound infiltration should be employed as part of multimodal postoperative pain management. There is scarce data concerning the benefits of this anesthetic modality in laparoscopic weight loss surgery. Therefore, we analyzed the influence of trocar site infiltration with bupivacaine on the management of postoperative pain in laparoscopic bariatric surgery. This retrospective randomized study included 47 patients undergoing primary obesity surgery between January and September 2014. Laparoscopic gastric bypass was performed in 39 cases and sleeve gastrectomy in 8 cases. Patients were stratified into two groups depending on whether preincisional infiltration with bupivacaine and epinephrine was performed (study group, 27 patients) or not (control group, 20 patients). Visual analogue scale (VAS), International Pain Outcomes questionnaire, and rescue medication records were reviewed to assess postoperative pain. VAS scores in the study group and sleeve gastrectomy group were lower than those in the control and gastric bypass groups in the first 4 h postoperatively without reaching statistical significance (p > 0.05). VAS scores did not differ in any other period of time. No statistically significant differences in pain perception were registered according to the patient's pain outcomes questionnaire or the need for rescue medication. The present study did not conclusively prove the efficacy of bupivacaine infiltration by any of the three evaluation methods analyzed. Nevertheless, preincisional infiltration provides good level of comfort in the immediate postoperative period when analgesia is most urgent.
... A pilot study in morbidly obese adolescents (mean body mass index 49.6 kg/m 2 ) showed enhanced CL while V d was comparable to that in lean adults after dosing based on ideal body weight [79]. Although the results suggest that a loading dose of fentanyl may be based on total body weight followed by maintenance doses based on ideal body weight and/or lean body weight [80,81], obese patients are more at risk for respiratory side effects of opioids [82][83][84][85][86]. ...
Article
Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients’ data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R² = 0.71, Bmax 876 mL/min, K50 16.3 kg) and alfentanil (R² = 0.70, Bmax (fixed) 420 mL/min, K50 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.
... Первый компонент -адекватная анальгезия. Как было сказано в разделе, посвященном обеспечению анестезии, опиоиды значительно снижают болевой порог, увеличивают частоту послеоперационной тошноты и рвоты, ухудшают проходимость верхних дыхательных путей, поэтому рекомендуется обеспечивать послеоперационную анальгезию нестероидными противовоспалительными средствами [39]. ...
Article
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Guidelines for enhanced recovery after surgery (ERAS) are widely used and their efficiency was clearly demonstrated by numerous studies. Number of publications on this topic in bariatric surgery is significantly lower compared with other fields of surgery. However, the data accumulated allow to compose recommendations based on studies with high level of evidence. Authors review existing methods of enhanced recovery in their implementation into bariatric surgery. Enhanced recovery methods can be used to optimize all stages of perioperative care and include data on preoperative preparation, maintenance of electrolyte balance, prevention of postoperative nausea and vomiting, sufficient analgesia and safe discharge form hospital. Suggested guidelines for bariatric surgery are implied to be used by a multidisciplinary team.
... Over 220,000 bariatric procedures, including laparoscopic gastric-bypass surgery (LGBS), are performed annually worldwide and this number is increasing exponentially (2) . ...
... Numerous challenges involved with sedation may occur caused by pulmonary hypertension, sleep apnea, pulmonary conditions, and airway management difficulty, which are all more commonly found in the obese population. 121 Therefore, several significant factors need to be carefully evaluated in a pre-sedation assessment. Factors such as mouth opening, neck extension, and circumference need to be thoroughly evaluated before sedation procedures to maximize treatment safety. ...
Article
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Obesity is a pandemic and periodontitis is the sixth most prevalent disease in the world. These two noncommunicable diseases share several risk determinants. Epidemiologic evidence from the last 2 decades has established an increase in periodontitis prevalence in obese and overweight individuals. Biologic mechanisms potentially linking obesity and periodontal disease are adiposity-associated hyperinflammation, microbial dysbiosis, altered immune response, specific genetic polymorphisms, and increased stress. However, because of the lack of longitudinal interventional studies and randomized clinical trials, there is insufficient evidence to determine the cause-effect relationship between these two diseases. Despite this, the negative impact of obesity on oral health is well established. Several logistic and physiologic complications are associated with treating obese patients in a dental setting, and it requires an interprofessional team approach. Oral health care professionals need to be aware of the specific management considerations while rendering for this cohort, including modified practice facility and equipment, tailored supportive periodontal therapy, and heightened precaution during conscious sedation and surgical procedures.
... The larger the neck's circumference, the more difficult it is to perform direct observations using a laryngoscope. Other problems include restricted flexion/extension of the cervical spine, restriction of mouth opening, and enlarged soft tissue in the upper respiratory tract [147][148][149][150][151][152]. Moreover, the pharmacokinetics of fat-soluble anesthetics change. ...
Article
Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the "algorithm for patients with type T2D". With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, "recommendation" and "consideration", for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D. Supplementary information: The online version contains supplementary material available at 10.1007/s13340-021-00551-0.
Article
Introduction. The range of surgical procedures, the potential anatomical hazards, and the problems associated with patient co-morbidities make upper gastrointestinal surgery a stimulating specialty for surgeon and anaesthetist. In recent years, the near-universal move towards minimally invasive surgery and early ambulation have been mirrored in upper GI surgery, providing further challenges for the surgical team. The cases demonstrated here are not meant to reflect the vast range of upper GI surgical procedures, but highlight particular anaesthetic challenges associated with this type of surgery. Case 1 discusses the anaesthetic management of laparoscopic surgery, with specific concerns relating to the management of analgesia and post-operative nausea and vomiting. Case 2 discusses upper GI surgery in the morbidly obese, an increasingly common problem for surgeons generally, particularly in the developed world, and especially relevant to the upper GI surgeon practising bariatric surgical techniques. The final case focuses on the management of the patient undergoing oesophagectomy, and discusses the practical management, physiology and evidence-based rationale for treatment; from pre-operative anaesthetic assessment of the patient to post-surgical care in the high-dependency or intensive care setting.
Article
Studies have shown significant positive outcomes of bariatric surgery, including resolution of commonly associated comorbidities such as diabetes and dyslipidemia. Bariatric surgeons should be aware of the significant challenges anesthesiologists face when caring for the obese patient, particularly during minimally invasive laparoscopic bariatric surgery. This chapter reviews the anesthetic concerns regarding and perioperative adaptations for the bariatric patient.
Chapter
Adipositas korreliert oft mit einer Vielzahl von pathophysiologischen Veränderungen. Für die Anästhesiologie spielen hierbei insbesondere die kardiopulmonalen Einschränkungen eine wesentliche Rolle. Kardiovaskuläre Erkrankungen haben einen hohen Anteil am erhöhten perioperativen Risiko.
Thesis
En 20 ans, le nombre d’obèses en France a doublé y compris chez les femmes en âge de procréer. L’obésité chez les femmes enceintes est un facteur de risque indépendant bien connu de complications maternelles, foetales et néonatales. C’est également le principal facteur de risque du syndrome des apnées du sommeil (SAS). La prévalence et les effets du SAS en cours de grossesse sont encore mal connus. Objectifs : L’objectif principal de cette étude est d’établir la prévalence du SAS et sa gravité dans une population de femmes enceintes obèses sévères au 3e trimestre. Les objectifs secondaires étaient de déterminer les facteurs de risque de SAS en cours de grossesse, de comparer la morbidité maternelle, foetale et néonatale en fonction de la présence ou non d’un SAS et d’évaluer l’évolution des SAS à 6 mois du post-partum. Matériels et méthodes : Il s’agit d’une étude de cohorte prospective multicentrique chez des femmes enceintes dont l’IMC était supérieur ou égal à 35 kg/m² en début de grossesse. Les facteurs de risque de SAS avant et en cours de grossesse ont été recueillis à l’inclusion. Un SAS a été recherché entre 30 et 36 semaines d’aménorrhées par polygraphie ventilatoire nocturne. Puis, nous avons comparé la morbidité maternelle, foetale et néonatale dans les groupes SAS négatifs et SAS positifs. À 6 mois du post-partum, une 2e polygraphie a évalué la persistance du SAS. Résultats : Cent-soixante-dix patientes ont été incluses entre juillet 2011 et juillet 2014. La prévalence du SAS au 3e trimestre de la grossesse était de 42,4% (n=72), celle du SAS modéré à sévère était de 15,2% (n=16). Les facteurs prédictifs de SAS retrouvés étaient le ronflement à 30 SA et/ou son aggravation (p=0,0016) et le périmètre abdominale (p=0,03). Le SAS pendant la grossesse était un facteur de risque d’HTA gravidique (p=0,0067), de césarienne avant travail (p=0,0278) et le percentile des nouveau-nés était supérieur à ceux du groupe SAS négatif (p=0,03). À 6 mois du post-partum, le SAS avait disparu chez 13 patientes (26%). Ces patientes avaient un IMC inférieur à celles qui étaient toujours atteintes de SAS. Conclusion : le SAS au troisième trimestre de la grossesse est une pathologie fréquente chez les femmes enceintes obèses sévères et ses conséquences sur l’HTAG sont majeures. Le traitement du SAS par la ventilation par pression positive continue est bien toléré pendant la grossesse et permettrait de traiter l’HTAG due au SAS. Ainsi, chez ces patientes, un diagnostic précoce associé à une prise en charge adaptée devrait permettre de diminuer les complications que nous avons observées. La disparition du SAS à 6 mois de la grossesse suggère l’existence d’un SAS gestationnel.
Article
Background The number of obese pediatric patients requiring anesthesia is rapidly increasing. Although fentanyl is a commonly used narcotic during surgery, there are no pharmacokinetic (PK) data available for optimal dosing of fentanyl in adolescents with clinically severe obesity. Materials and Methods An institutional review board-approved exploratory pilot study was conducted in six adolescents aged 14–19 years undergoing bariatric surgery. Mean total body weight (TBW) and mean BMI were 137.4 ± 14.3 kg and 49.6 ± 6.4 kg/m2 (99.5th BMI percentile), respectively. Fentanyl was administered intravenously for intraoperative analgesia based on ideal body weight per standard of care. PK blood samples were drawn over a 24-h post-dose period. Fentanyl PK parameters were calculated by non-compartmental analysis. ResultsMean fentanyl AUC0–∞ was 1.5 ± 0.5 h·ng/mL. Systemic clearance of fentanyl was 1522 ± 310 mL/min and 11.2 ± 2.6 mL/min·kg TBW. Volume of distribution was 635 ± 282 L and 4.7 ± 2.1 L/kg TBW. While absolute clearance was increased, absolute volume of distribution was comparable to previously established adult values. Conclusions These results suggest that fentanyl clearance is enhanced in adolescents with clinically severe obesity while volume of distribution is comparable to previously published studies. Study registrationNCT01955993 (clinicaltrials.gov).
Article
Study objective: Laparoscopic sleeve gastrectomy is commonly performed under total intravenous anaesthesia (TIVA) or balanced anaesthesia using an intravenous and inhalation agent. It is still unclear which anaesthesia regimen is better for this group of patients. The present study has been conducted to compare the use of the inhalation anaesthesia technique using desflurane with the TIVA technique, using propofol and dexmedetomidine. Design: Prospective, randomised, double-blinded study. Setting: Menoufia Univeristy Hospital. Patients: This randomised trial was carried out on 100 morbidly obese patients undergoing laparoscopic sleeve gastrectomy. The patients were randomised into two equally sized groups; one group received the inhalation anaesthesia technique and the other received the TIVA technique. Interventions: All patients received general anaesthesia, which was induced by propofol, remifentanil, and rocuronium. Anaesthesia was maintained using desflurane in oxygen air mixture in the inhalation group, whilst anaesthesia was maintained by intravenous infusion of propofol and dexmedetomidine in the TIVA group. Measurements: Intra-operative vital signs, anaesthesia recovery time, postoperative nausea and vomiting, pain score, post-anaesthetic care unit (PACU) stay time, total first 24h post-operative analgesic needs and the onset of first bowel movement were recorded. Main results The TIVA group had lower intra-operative heart rates and mean arterial blood pressure (P<0.0001). The TIVA group also had a lower post-operative visual analogue score for pain assessment (VAS) (P<0.0001), lower total analgesic requirements (P<0.0001), a lower incidence of nausea (P=0.01) and vomiting (P=0.03), and shorter PACU stays (P=0.01). There was no significant difference between groups with regard to the onset of bowel movement (P=0.16). Conclusions: TIVA using propofol and dexmedetomidine is a better anaesthetic regimen than inhalation anaesthesia using desflurane for laparoscopic sleeve gastrectomy in morbidly obese patients. The TIVA technique provided better postoperative recovery with fewer postoperative side effects and analgesic requirements. Clinical trial registery number: NCT03029715.
Article
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Induction of general anesthesia and extubation at obese patients are a high-risk periods for hypoxemia. Preoxygenation before induction is considered to be sufficient when the end-tidal oxygen fraction is 90%. Tidal volume breathing through a well-sealed face mask for three minutes or four vital capacity breaths are two strategies of preoxygenation before anesthesia induction. Evidence suggests that obese patients desaturate faster with four vital capacity breaths than tidal volume breathing through a face mask. Additional techniques for peri-induction oxygenation include supplemental nasopharyngeal oxygen insufflation, semi-recumbent position, continuous positive airway pressure (CPAP), positive end-expiratory pressure (PEEP), and pressure support ventilation applied before induction of general anesthesia in the spontaneous ventilating patient. Airway complications and issues with oxygenation may present immediately on emergence from anesthesia at the time of tracheal extubation or may become manifest only in the postanesthesia care unit, resulting in significant morbidity and mortality. The Difficult Airway Society published guidelines in 2012 for management of tracheal extubation using a stepwise approach. Patients with obesity and obstructive sleep apnea are stratified into a category of extubation ‘‘at risk’’ of a major complication. Recommendations for awake tracheal extubation in this patient population include patient optimization (full reversal of neuromuscular blockade and return of protective airway reflexes), preoxygenation, placing the patient in a reverse Trendelenburg or semi-recumbent position, and suctioning of the oropharynx under direct vision. Logistic factors to be considered include selecting the operating room as the location for extubation and having skilled assistance, equipment (difficult airway trolley), and ABDOMINAL ANESTHESIA AND INTENSIVE CARE 48 monitoring (in particular capnography) available. The Difficult Airway Society guidelines also advocate the placement of an airway exchange catheter in patients for whom tracheal re-intubation is likely to be difficult. Conclusion: We can conclude that effective preoxygenation while induction in anesthesia at obese patients and oxygenation before extubation as well as in the postoperative period, means perioperative hard, lung and brain protection.
Article
Background: Continuous monitoring of arterial pressure is important in severely obese patients who are at particular risk for cardiovascular complications. Innovative technologies for continuous noninvasive arterial pressure monitoring are now available. In this study, we compared noninvasive arterial pressure measurements using the vascular unloading technique (Clearsight system; Edwards Lifesciences Corp, Irvine, CA) with invasive arterial pressure measurements (radial arterial catheter) in severely obese patients during laparoscopic bariatric surgery. Methods: In 35 severely obese patients (median body mass index, 47 kg/m), we simultaneously recorded noninvasive and invasive arterial pressure measurements over a period of 45 minutes. We compared noninvasive (test method) and invasive (reference method) arterial pressure measurements (sampling rate 1 Hz = 1/s) using Bland-Altman analysis (accounting for multiple measurements per subject), 4-quadrant plot/concordance analysis (2-minute interval, 5 mm Hg exclusion zone), and error grid analysis (calculating the proportions of measurements in risk zones A-E with A indicating no risk, B low risk, C moderate risk, D significant risk, and E dangerous risk for the patient due to the risk of wrong clinical interventions because of measurement errors). Results: We observed a mean of the differences (±SD, 95% limits of agreement) between the noninvasively and invasively assessed arterial pressure values of 1.1 mm Hg (±7.4 mm Hg, -13.5 to 15.6 mm Hg) for mean arterial pressure (MAP), 6.8 mm Hg (±10.3 mm Hg, -14.4 to 27.9 mm Hg) for systolic arterial pressure, and 0.8 mm Hg (±6.9 mm Hg, -12.9 to 14.4 mm Hg) for diastolic arterial pressure. The 4-quadrant plot concordance rate (ie, the proportion of arterial pressure measurement pairs showing concordant changes to all changes) was 93% (CI, 89%-96%) for MAP, 93% (CI, 89%-97%) for systolic arterial pressure, and 88% (CI, 84%-92%) for diastolic arterial pressure. Error grid analysis showed that the proportions of measurements in risk zones A-E were 89.5%, 10.0%, 0.5%, 0%, and 0% for MAP and 93.7%, 6.0%, 0.3%, 0%, and 0% for systolic arterial pressure, respectively. Conclusions: During laparoscopic bariatric surgery, the accuracy and precision of the vascular unloading technique (Clearsight system) was good for MAP and diastolic arterial pressure, but only moderate for systolic arterial pressure according to Bland-Altman analysis. The system showed good trending capabilities. In the error grid analysis, >99% of vascular unloading technique-derived arterial pressure measurements were categorized in no- or low-risk zones.
Article
Morbid obesity (MO) is becoming increasingly prevalent worldwide and is associated with both altered physiology and increased co-morbidities. Together, these can render the perioperative pain management in patients with MO particularly challenging. With the higher incidence of sleep-disordered breathing in this patient population, traditional opioid-centric pain management can often result in opioid-induced ventilatory impairment and increased morbidity and/or mortality. Multimodal analgesia strategies based on a step-wise, severity-based, opioid-sparing approach can improve patient safety and outcomes. These protocols should be standardized and implemented in the perioperative care of patients with MO. Further advancements in acute pain management have sought to identify and treat nociceptive and pro-nociceptive components (hyperalgesia, etc.) with both pharmacologic and non-pharmacologic measures. In addition to standardizing postoperative pain management, irrespective of the anesthetic and analgesic regimen used, some patients with MO will need extended monitoring for potential respiratory adverse events. In this review, we briefly describe the obesity-associated changes in physiology and their impact on the pharmacology of pain, and provide an evidence-based clinical update on the perioperative pain management in MO. We discuss the role of opioid-sparing pharmacological adjuvants and implementation of standardized protocols, and highlight future areas of research in perioperative pain management in this patient population.
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Chapter
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been employed as one surgical modality approach for multiple thyroid and parathyroid disease conditions with good results. The indication and patient selection is extended by the experience of surgeon, especially when considering including obesity patient and reoperation. With such special consideration, the surgeon must know the impact of body composition on the operation, consequences of previous neck surgery, and anesthetic consideration that affect the surgery. Many aspects of obesity have many influences on the outcome of surgery form preoperative/perioperative and postoperative care which will be discussed in detail. Reoperation is challenging due to the quality of the tissue and anatomy variation due to postoperative early fibrosis. The properly trained surgeon should be facile with the approach, know when is the right time to do the reoperation, and also understand specific consideration about how to perform reoperative TOETVA.
Chapter
Airway management is a cornerstone of anesthesia. Airway-related problems represent the most important anesthesia-related complications. Obesity is associated with an increased incidence of airway-related complications throughout the perioperative process. Obese patients have always been considered to have a higher likelihood of difficult intubation. The emergence of gastric bypass surgery has promoted a better understanding of anesthesia and airway control in obese patients. Simple measures such as proper positioning can improve laryngoscopy, respiration, and intubation in obese patients. Preoperative identification of predictors for difficult intubation, ventilation, or both can help with planning safe anesthesia induction and airway management, and it can decrease airway-related complications. Anesthesia staff training programs on airway management must be encouraged, and locally adapted recommendations for airway management should be established. Some measures are universally valid for improving airway management in obese patients. Proper positioning at induction and extubation is probably the most effective measure, and adequate preoxygenation, monitoring and full reversal of neuromuscular blocks as well as the use of continuous positive airway pressure (CPAP) in obstructive sleep apnea patients should be always considered.
Chapter
An important part of every bariatric patient’s perioperative management is proper positioning. When placed in a non-physiologic position, the obese patient can experience significant cardiopulmonary dysfunction. A spontaneously breathing obese patient should never lie supine, whether before, during, or immediately after surgery. Tilting the operating room table to the reverse Trendelenburg position during induction of anesthesia increases the patient’s oxygen reserves, which results in a longer safe apnea period. This position also facilitates bag-mask assisted ventilation. Ramping the patient’s upper body and head improves the view during direct laryngoscopy resulting in greater success with tracheal intubation. Standard operating room tables are not safe for extremely obese patients, so special attention is important when moving the table or when changing patient position to avoid accidents. For any surgical position, all dependent pressure points must be adequately padded and the patient’s head, neck, and extremities supported to prevent perioperative neurologic and muscle injuries.
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In recent years, conscious sedation has grown in popularity as an alternative to general anaesthesia in a primary setting due to its safety and efficiency. It is imperative to carry out a full patient assessment prior to treatment under conscious sedation. Conscious sedation is provided intravenously, by inhalation or oral route. Clinical and physical examination as well as medical, social and mental history play a fundamental role in selecting the right patient. In addition, to optimize safety of patients, it is necessary to follow available guidelines and standards, provide an appropriate environment and adequate staff training. CPD/Clinical Relevance: This article highlights the importance of pre-assessment prior to treatment under conscious sedation. The vast majority of adverse events during sedation occur as a result of inadequate pre-assessment and preparation.
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Morbidly obese individuals often require surgery, including bariatric (weight management) surgery. Acute pain management in the morbidly obese must consider the risk of chronic post-surgical pain, opioid dependence, and comorbidities (e.g. sleep-disordered breathing). A stepped, multimodal, opioid-sparing approach titrated to the type and severity of pain type should be taken, with co-administration of systemic and local anaesthetic agents when appropriate.
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To investigate the influence of intraoperative and preoperative positive pressure in the time of extubation in patients undergoing bariatric surgery. Randomized clinical trial, in which 40 individuals with a body mass index between 40 and 55kg/m(2), age between 25 and 55 years, nonsmokers, underwent bariatric surgery type Roux-en-Y gastric bypass by laparotomy and with normal preoperative pulmonary function were randomized into the following groups: G-pre (n=10): individuals who received treatment with noninvasive positive pressure before surgery for 1h; G-intra (n=10): individuals who received positive end-expiratory pressure of 10cm H2O throughout the surgical procedure; and G-control (n=20): not received any preoperative or intraoperative intervention. Following were recorded: time between induction of anesthesia and extubation, between the end of anesthesia and extubation, duration of mechanical ventilation, and time between extubation and discharge from the post-anesthetic recovery. There was no statistical difference between groups. However, when applied to the Cohen coefficient, the use of positive end-expiratory pressure of 10cm H2O during surgery showed a large effect on the time between the end of anesthesia and extubation. About this same time, the treatment performed preoperatively showed moderate effect. The use of positive end-expiratory pressure of 10cm H2O in the intraoperative and positive pressure preoperatively, influenced the time of extubation of patients undergoing bariatric surgery. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
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Background Previously published cohort studies in clinical populations have suggested that obstructive sleep apnea (OSA) is a risk factor for mortality associated with cardiovascular disease. However, it is unknown whether sleep apnea is an independent risk factor for all-cause mortality in a community-based sample free from clinical referral bias. Methods Residents of the Western Australian town of Busselton underwent investigation with a home sleep apnea monitoring device (MESAM IV). OSA was quantified via the respiratory disturbance index (RDI). Mortality status was determined in 397/400 participants (99.3%) after up to 14 years (mean follow-up 13.4 years) by data matching with the Australian National Death Index and the Western Australian Death Register. Univariate analyses and multivariate Cox proportional hazards modelling were used to ascertain the association between sleep apnea and mortality after adjustment for age, gender, body mass index, mean arterial pressure, total cholesterol, high-density lipoprotein cholesterol, diabetes, and medically diagnosed angina in those free from heart attack or stroke at baseline (n = 380). Results Among the 380 participants, 18 had moderate-severe OSA (RDI ≥15/hr, 6 deaths) and 77 had mild OSA (RDI 5 to <15/hr, 5 deaths). Moderate-to-severe OSA was independently associated with greater risk of all-cause mortality (fully adjusted hazard ratio [HR] = 6.24, 95% CL 2.01, 19.39) than non-OSA (n = 285, 22 deaths). Mild OSA (RDI 5 to <15/hr) was not an independent risk factor for higher mortality (HR = 0.47, 95% CL 0.17, 1.29). Conclusions Moderate-to-severe sleep apnea is independently associated with a large increased risk of all-cause mortality in this community-based sample.
Article
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Context Hypoxemia complicates the recovery of 30% to 50% of patients after ab- dominal surgery; endotracheal intubation and mechanical ventilation may be re- quired in 8% to 10% of cases, increasing morbidity and mortality and prolonging in- tensive care unit and hospital stay. Objective To determine the effectiveness of continuous positive airway pressure com- pared with standard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery.
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Due to constraints on resources and capacity, as well as advances in surgical technique and care, there has been progressive change toward converting surgical procedures to the outpatient setting when feasible. This study was designed to investigate the safety of laparoscopic adjustable gastric banding (LAGB) as an outpatient procedure for morbid obesity in Canada. This retrospective analysis included consecutive patients who underwent outpatient LAGB at the Surgical Weight Loss Centre in Ontario, Canada, beginning with our initial experience in February 2005 and continuing to July 2009. Eligible patients were morbidly obese adults whose outpatient clinic surgery had been performed by one of two experienced surgeons. A total of 1,641 patients were included in this analysis. The average presurgical body mass index was 46.7 kg/m2 (range 35.0 to 79 kg/m2). Fifteen patients (0.91%) experienced minor complications during surgery or within 30 days of surgery (dysphagia, n=5; wound infection, n=3; port infection, n=2; all other complications occurred in one patient each). Four patients required transfer to hospital from the clinic on the day of surgery, and three were admitted. None of the complications were serious and all were resolved. The device was explanted in two patients. The average time from sedation to discharge was <4 hours (h). The ability to treat patients within 4 h and the extremely low complication rates reported here contribute to a growing literature supporting the safe performance of LAGB in an outpatient setting for the treatment of morbid obesity.
Article
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Obstructive sleep apnea (OSA) is presumed to be a risk factor for postoperative morbidity and mortality, but the current evidence is incomplete. This retrospective matched cohort study tested the hypothesis that OSA is a risk factor for the development of postoperative complications. Hospital ethics approval was obtained for the conduct of this study. The patients who were selected for the study were >18 yr of age, diagnosed preoperatively with OSA, and scheduled to undergo elective surgery. A cohort of surgical patients without OSA was used as a comparator group based on a one-to-one match. Matching criteria included gender, age difference <5 yr, type of surgery, and a <5 yr difference between two surgery dates. Summary data are presented and conditional logistic regression was used to identify risk factors for postoperative complications. The 240 pairs of study subjects aged 57 +/- 13 yr included 184 (77%) males and 56 (23%) females. The OSA patients had a higher mean body mass index relative to their non-OSA counterparts (35 +/- 9 vs 28 +/- 6 kg . m-2, respectively) and a higher frequency of co-morbidities, including hypertension (48% vs 36%, respectively) and obesity (61% vs 23%, respectively). Also, the incidence of postoperative complications in the OSA patients was significantly greater (44% OSA group vs 28% non-OSA group; P < 0.05). The most commonly observed between-group difference was oxygen desaturation < 90% (17% OSA group vs 8% non-OSA group). The OSA patients who did not use home continuous positive airway pressure (CPAP) devices prior to surgery but required the use of a CPAP device after surgery had the highest rate of complications. Conditional logistic regression was used to diagnose OSA and pre-existing stroke as significant risk factors for developing postoperative complications. The hazard ratio for OSA was 2.0 (1.25-3.19). Patients with diagnosed OSA have an increased incidence of postoperative complications, the most frequent being oxygen desaturation.
Article
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Obstructive sleep apnea is a common condition in the morbidly obese population. Many patients undergoing bariatric surgery require postoperative continuous positive airway pressure (CPAP) therapy. Few data have been published evaluating gastrointestinal anastomotic morbidity in patients receiving CPAP therapy immediately after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of the present study was to examine the short-term morbidity of postoperative CPAP in patients after LRYGB in a research setting. We retrospectively reviewed a prospectively collected database of 310 patients who underwent LRYGB from June 2005 to August 2006. The hospital and office charts and respiratory treatment records were reviewed from the completion of surgery until the first postoperative visit at 2 weeks. The data collected included age, gender, body mass index, presence of obstructive sleep apnea, in-patient CPAP use, and perioperative complications. Patients were divided into 2 groups: those who used immediate postoperative CPAP therapy and those who did not. Patients requiring revisional surgery and other bariatric procedures were excluded from the present series. Postoperative CPAP was required by 91 patients (29.3%) and 219 did not use CPAP (70.7%). The mean patient age was 47.2 and 43.9 years (P <.01), and the average body mass index was 52 and 46.4 kg/m(2) in the groups that did and did not require CPAP postoperatively, respectively (P <.0001). No anastomotic leaks occurred in either group, and the most common in-hospital complication, seen in 7 patients (2.2%), was basal atelectasis (3 in the postoperative CPAP group; P >.05), followed by wound infection in 4 patients overall (1.2%; 3 patients in the postoperative CPAP group; P >.05) and gastrointestinal bleeding in 1 patient (.32%) in the group without postoperative CPAP. The difference in overall morbidity, unrelated to the integrity of the anastomosis, between those who used CPAP postoperatively and those who did not was not significant (4.5% versus 3.6%, respectively; P >.05). The use of CPAP after LRYGB did not result in increased the morbidity in our patient series.
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Ambulatory surgery or outpatient surgery is becoming increasingly common. In 2002, 63% of all operations performed in the United States were ambulatory procedures. Bariatric procedures performed in the United States have increased from 16,200 in 1992 to approximately 205,000 in 2007. In 2002, our center began offering laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on an outpatient basis for select candidates at an ambulatory surgery center (ASC). We subsequently added laparoscopic adjustable gastric band procedures (LAGB) in 2005. Between 2002 and 2008, 248 LRYGB and LAGB patients were carefully selected for ASC surgery by the bariatric surgeon and medical director. Extensive preoperative education was mandatory for all surgical candidates. Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this overall experience, 5 patients (2%) required readmission within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent. LAGB surgery can be safely performed in an ASC setting in most patients. LRYGB can be performed safely in the ASC setting with careful scrutiny and cautious selection of patient candidates.
Article
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We compared tracheal intubation characteristics and arterial oxygenation quality during airway management of morbidly obese patients whose trachea was intubated under video assistance with the LMA CTrach (SEBAC, Pantin, France) or the Airtraq laryngoscope (VYGON, Ecouen, France) with that of the conventional Macintosh laryngoscope. After standardized induction of anesthesia, 318 morbidly obese patients scheduled for elective morbid obesity surgery received tracheal intubation with the LMA CTrach, the Airtraq laryngoscope, or the conventional Macintosh laryngoscope. Duration of apnea, time to tracheal intubation, and oxygenation quality during airway management were compared between the LMA CTrach and the laryngoscope groups. Patients' characteristics were similar in the three groups. The success rate for tracheal intubation was 100% with the LMA CTrach and the Airtraq laryngoscope. One patient of the Macintosh laryngoscope group received LMA CTrach intubation because of early arterial oxygen desaturation associated with unstable facemask ventilation. The duration of apnea was shorter with the LMA CTrach than that of the Airtraq laryngoscope and the Macintosh laryngoscope. The duration tracheal intubation was shorter with the Airtraq laryngoscope than with the Macintosh laryngoscopes and the LMA CTrach. During airway management, arterial oxygenation was of better quality with the LMA CTrach and the Airtraq laryngoscope than that of the Macintosh laryngoscope. Because LMA CTrach promoted short apnea time and the Airtraq laryngoscope allowed early definitive airway, both video-assisted tracheal intubation devices prevented most serious arterial oxygenation desaturation evidenced during tracheal intubation of morbidly obese patients with the conventional Macintosh laryngoscope.
Article
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Previously published cohort studies in clinical populations have suggested that obstructive sleep apnea (OSA) is a risk factor for mortality associated with cardiovascular disease. However, it is unknown whether sleep apnea is an independent risk factor for all-cause mortality in a community-based sample free from clinical referral bias. Residents of the Western Australian town of Busselton underwent investigation with a home sleep apnea monitoring device (MESAM IV). OSA was quantified via the respiratory disturbance index (RDI). Mortality status was determined in 397/400 participants (99.3%) after up to 14 years (mean follow-up 13.4 years) by data matching with the Australian National Death Index and the Western Australian Death Register. Univariate analyses and multivariate Cox proportional hazards modelling were used to ascertain the association between sleep apnea and mortality after adjustment for age, gender, body mass index, mean arterial pressure, total cholesterol, high-density lipoprotein cholesterol, diabetes, and medically diagnosed angina in those free from heart attack or stroke at baseline (n = 380). Among the 380 participants, 18 had moderate-severe OSA (RDI > or = 15/hr, 6 deaths) and 77 had mild OSA(RDI 5 to < 15/hr, 5 deaths). Moderate-to-severe OSA was independently associated with greater risk of all-cause mortality (fully adjusted hazard ratio [HR] = 6.24, 95% CL 2.01, 19.39) than non-OSA (n = 285, 22 deaths). Mild OSA (RDI 5 to < 15/hr) was not an independent risk factor for higher mortality (HR = 0.47, 95% CL 0.17, 1.29). Moderate-to-severe sleep apnea is independently associated with a large increased risk of all-cause mortality in this community-based sample.
Article
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Magnetic resonance imaging (MRI) provides high-resolution images of the upper airway and is useful for assessing conditions associated with increased tissue water content. To determine whether nasal continuous positive airway pressure (CPAP) changes awake upper airway morphology in obstructive sleep apnea (OSA), we performed awake upper airway MRI scans on five male patients with moderate to severe OSA before and after 4 to 6 wk of nasal CPAP therapy. MRI scans were performed using spin echo pulse sequences to examine detailed anatomy and inversion recovery sequences to assess mucosal water content. Patients did not have nasal CPAP applied during the MRI scans. Axial and sagittal images were obtained, and tracings were made of the upper airway, tongue, and soft palate. Utilizing computer graphics, cross-sectional areas and volumes were calculated for each anatomic structure. A subjective grading system was used to assess upper airway mucosal water content. Pharyngeal volume and minimum pharyngeal cross-sectional area increased (p less than 0.05) and tongue volume decreased (p less than 0.01) following chronic nasal CPAP therapy. The increase in pharyngeal volume occurred mainly in the oropharynx (p less than 0.01). Upper airway mucosal water content decreased in the oropharynx (p less than 0.05). We conclude that chronic nasal CPAP therapy during sleep in patients with OSA produces changes in awake upper airway morphology. These changes may be due to resolution of upper airway edema. The upper airway of patients with OSA can be accurately and repeatedly assessed using MRI.
Article
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Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of pharyngeal closure during sleep. The pathogenesis of OSAS is unclear. We hypothesized that the genioglossus (GG), the most important pharyngeal dilator muscle, would be abnormal in patients with OSAS. Further, because treatment with continuous positive airway pressure (CPAP) is very effective clinically in these patients, we investigated the effects of CPAP upon the structure and function of the GG. We studied 16 patients with OSAS (nine of them at diagnosis and seven after having been under treatment with CPAP for at least 1 yr) and 11 control subjects in whom OSAS was excluded clinically. A biopsy of the GG was obtained in each subject, mounted in a tissue bath, and stimulated through platinum electrodes. The following measurements were obtained: maximal twitch tension, contraction time, half-relaxation time, the force-frequency relationship, and the response to a fatiguing protocol. The percentage of type I ("slow twitch") and type II ("fast twitch") fibers was also quantified. Patients with OSAS showed a greater GG fatigability than did control subjects (ANOVA, p < 0.001). Interestingly, this abnormality was entirely corrected by CPAP. Likewise, the percentage of type II fibers was significantly higher in patients with OSAS (59 +/- 4%) than in control subjects (39 +/- 4%, p < 0.001) and, again, these structural changes were corrected by CPAP (40 +/- 3%, p < 0.001). These results show that the function and structure of the GG is abnormal in patients with OSAS. Because these abnormalities are corrected by CPAP, we suggest that they are likely a consequence, not a cause, of the disease.
Article
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To identify and assess the impact of postoperative complications in patients with unrecognized or known obstructive sleep apnea syndrome (OSAS) undergoing hip replacement or knee replacement compared with control patients undergoing similar operations. Although OSAS is a risk factor for perioperative morbidity, data quantifying the magnitude of the problem in patients undergoing non-upper airway operations are limited. This retrospective, case-control study from a single academic medical institution included patients diagnosed as having OSAS between January 1995 and December 1998 and undergoing hip or knee replacement within 3 years before or anytime after their OSAS diagnosis. Patients with OSAS were subcategorized as having the diagnosis either before or after the surgery and also, regardless of time of diagnosis, by whether they were using continuous positive airway pressure (CPAP) prior to hospitalization. Matched controls were patients without OSAS undergoing the same operation. Interventions were defined specifically as administration of a particular treatment in the context of each complication, eg, supplemental oxygen, implementation of additional monitoring such as oximetry for hypoxemia, or transfer to the intensive care unit (ICU) for cardiac ischemia concerns. Postoperative complications were assessed for all patients in the different categories and included respiratory events such as hypoxemia, acute hypercapnia, and episodes of delirium. Serious complications were noted separately, including unplanned ICU days, reintubations, and cardiac events. The length of hospital stay was also tabulated. There were 101 patients with the diagnosis of OSAS in this study and 101 matched controls. Thirty-six patients had their joint replacement before OSAS was diagnosed, and 65 had surgery after OSAS was diagnosed. Of the latter 65 patients, only 33 were using CPAP at home preoperatively. Complications were noted in 39 patients (39%) in the OSAS group and 18 patients (18%) in the control group (P=.001). Serious complications occurred in 24 patients (24%) in the OSAS group compared with 9 patients (9%) in the control group (P=.004). Hospital stay was significantly longer for the OSAS patients at a mean +/- SD of 6.8 +/- 2.8 days compared with 5.1 +/- 4.1 days for the control patients (P<.007). Adverse postoperative outcomes occurred at a higher rate in patients with a diagnosis of OSAS undergoing hip or knee replacement compared with a group of matched control patients.
Article
Background Class III obese patients have altered respiratory mechanics, which are further impaired in the supine position. The authors explored the hypothesis that preoxygenation in the 25 degrees head-up position allows a greater safety margin for induction of anesthesia than the supine position. Methods A randomized controlled trial measured oxygen saturation and the desaturation safety period after 3 min of preoxygenation in 42 consecutive (male:female 13:29) severely obese (body mass index > 40 kg/m) patients who were undergoing laparoscopic adjustable gastric band surgery and were randomly assigned to the supine position or the 25 degrees head-up position. Serial arterial blood gases were taken before and after preoxygenation and 90 s after induction. After induction, ventilation was delayed until blood oxygen saturation reached 92%, and this desaturation safety period was recorded. Results The mean body mass indexes for the supine and 25 degrees head-up groups were 47.3 and 44.9 kg/m, respectively (P = 0.18). The group randomly assigned to the 25 degrees head-up position achieved higher preinduction oxygen tensions (442 +/- 104 vs. 360 +/- 99 mmHg; P = 0.012) and took longer to reach an oxygen saturation of 92% (201 +/- 55 vs. 155 +/- 69 s; P = 0.023). There was a strong positive correlation between the induction oxygen tension achieved and the time to reach an oxygen saturation of 92% (r = 0.51, P = 0.001). There were no adverse events associated with the study. Conclusion Preoxygenation in the 25 degrees head-up position achieves 23% higher oxygen tensions, allowing a clinically significant increase in the desaturation safety period--greater time for intubation and airway control. Induction in the 25 degrees head-up position may provide a greater safety margin for airway control.
Article
To reevaluate and update evidence-based best practice recommendations published in 2004 for anesthetic perioperative care and pain management in weight loss surgery (WLS), we performed a systematic search of English-language literature on anesthetic perioperative care and pain management in WLS published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. We identified relevant abstracts by using key words, retrieved full text articles, and stratified the resulting evidence according to systems used in established evidence-based models. We updated prior evidence-based best practice recommendations based upon interim literature. In instances of controversial or inadequate scientific evidence, the task force reached consensus recommendations following evaluation of the best available information and expert opinion. The search yielded 1,788 abstracts, with 162 potentially relevant titles; 45 were reviewed in detail. Despite more information on perioperative management of patients with obstructive sleep apnea (OSA), evidence to support preoperative testing and treatment or to guide perioperative monitoring is scarce. New evidence on appropriate intraoperative dosing of muscle relaxants allows for greater precision in their use during WLS. A novel application of -2 agonists for perioperative anesthetic care is emerging. Key elements that may enhance patient safety include integration of the latest evidence on WLS, obesity, and collaborative multidisciplinary care into clinical care. However, large gaps remain in the evidence base.
Article
Background: The intubating laryngeal mask airway (ILMA) was designed using the characteristics of healthy-weight subjects but was shown to be an effective airway device in morbidly obese patients. The authors compared airway management quality in morbidly obese and lean patients with use of the ILMA. Methods: Fifty morbidly obese and 50 lean patients (mean body mass indexes, 42 and 27 kg/m, respectively) were enrolled in this prospective study. After induction of general anesthesia, characteristics of airway management were judged on safety and efficiency parameters, including success rate at ventilation and intubation and airway management quality criteria, such as the number of patients who required adjustment maneuvers, the number of failed tracheal intubation attempts, the total duration of airway management, and an overall difficulty visual analog scale score. Results: The ILMA was successfully inserted and adequate ventilation through the ILMA was achieved in all 100 patients. The success rates of tracheal intubation through the ILMA were similar in obese and lean patients (96% and 94%, respectively). The numbers of failed blind tracheal access attempts and patients who required airway-adjustment maneuvers were significantly reduced in obese patients as compared with lean patients. Four obese patients experienced transient episodes of oxygen desaturation (oxygen saturation < 90%) before adequate bag ventilation was established with the ILMA. Conclusion: The authors confirmed that the ILMA was an efficient airway device for airway management of both lean and obese patients. In the conditions of this study, the authors observed that airway management with the ILMA was simpler in obese patients as compared with lean patients.
Article
Background: Obstructive sleep apnea (OSA) is prevalent in the morbidly obese population. The need for routine preoperative testing for OSA has been debated in bariatric surgery publications. Most investigators have advocated the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) in the postoperative setting; however, others have reported pouch perforations or other gastrointestinal complications as a result of their use. From a review of our experience, we present an algorithm for the safe postoperative treatment of patients with OSA without the use of CPAP or BiPAP. Methods: From January 2003 to December 2007, 1095 laparoscopic Roux-en-Y gastric bypasses were performed at our institution. Preoperative testing for OSA was not routinely performed. A prospective database was maintained. The data included patient demographics, co-morbidities (including OSA and CPAP/BiPAP use), perioperative events, complications, and follow-up information. Patients with known OSA were not given CPAP/BiPAP after surgery. They were observed in a monitored setting during their inpatient stay, ensuring continuous oxygen saturation of >92%. All patients used patient-controlled analgesia, were trained in the use of incentive spirometry, and ambulated within a few hours of surgery. The outcomes were compared between the OSA patients using preoperative CPAP/BiPAP versus those with OSA without preoperative CPAP/BiPAP versus patients with no history of OSA. Results: A total of 811 patients were included in the study group with no known history of OSA. Of the 284 patients with a confirmed diagnosis of OSA, 144 were CPAP/BiPAP dependent. Statistically significant differences were present in age distribution and gender, with men having greater CPAP/BiPAP dependency. No significant differences were found in body mass index, length of stay, pulmonary complications, or deaths. One pulmonary complication occurred in the OSA, CPAP/BiPAP-dependent group, three in the OSA, non-CPAP group, and six in the no-known OSA group. No anastomotic leaks or deaths occurred in the series. Conclusion: Postoperative CPAP/BiPAP can be safely omitted in laparoscopic Roux-en-Y gastric bypass patients with known OSA, provided they are observed in a monitored setting and their pulmonary status is optimized by aggressive incentive spirometry and early ambulation.
Article
One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.
Article
Estimates of the procedure incidence for bariatric surgery have been derived primarily from surveys of bariatric surgeons or from inpatient data sources. New population-representative databases of outpatient surgery are available that enable accurate estimations of bariatric surgery case volumes. The 2006 National Hospital Discharge Survey, National Inpatient Sample, and National Survey of Ambulatory Surgery were assessed for bariatric surgery procedures. Data were compared with inpatient data from 1993 to 2007. Procedure costs were estimated. The incidence of bariatric surgery has plateaued at approximately 113,000 cases per year. Open gastric bypass now constitutes only 3% of all cases but costs $4,800 less than laparoscopic procedures. Laparoscopic gastric banding is performed in 37% of all bariatric surgery cases and costs the same as laparoscopic gastric bypass to perform. Complication rates have fallen from 10.5% in 1993 to 7.6% of all cases in 2006. Bariatric surgery costs the health economy at least $1.5 billion annually. Despite predictions of continued growth of bariatric surgery, it appears that the annual incidence for these operations has remained stable since 2003. Most operations are performed laparoscopically, but open gastric bypass is substantially less costly than laparoscopic operations. Despite its simplicity, laparoscopic gastric banding costs the same as gastric bypass. There is no cost savings associated with ambulatory bariatric surgery.
Article
Obstructive sleep apnea (OSA) is a largely underdiagnosed, common condition, which is important to diagnose preoperatively because it has implications for perioperative management. Our purpose in this study was to identify independent clinical predictors of a diagnosis of OSA in a general surgical population, develop a perioperative sleep apnea prediction (P-SAP) score based on these variables, and validate the P-SAP score against standard overnight polysomnography. A retrospective, observational study was designed to identify patients with a known diagnosis of OSA. Independent predictors of a diagnosis of OSA were derived by logistic regression, based on which prediction tool (P-SAP score) was developed. The P-SAP score was then validated in patients undergoing overnight polysomnography. The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of these, 3884 patients (7.17%) had a documented diagnosis of OSA. Three demographic variables: age > 43 years, male gender, and obesity; 3 history variables: history of snoring, diabetes mellitus Type 2, and hypertension; and 3 airway measures: thick neck, modified Mallampati class 3 or 4, and reduced thyromental distance were identified as independent predictors of a diagnosis of OSA. A diagnostic threshold P-SAP score > or = 2 showed excellent sensitivity (0.939) but poor specificity (0.323), whereas for a P-SAP score > or = 6, sensitivity was poor (0.239) with excellent specificity (0.911). Validation of this P-SAP score was performed in 512 patients with similar accuracy. The P-SAP score predicts diagnosis of OSA with dependable accuracy across mild to severe disease. The elements of the P-SAP score are derived from a typical university hospital surgical population.
Article
Mask ventilation is the most fundamental skill in airway management. In this review, we summarize the current knowledge about difficult mask ventilation (DMV) situations. Various definitions for DMV have been used in the literature. The lack of a precise standard definition creates a problem for studies on DMV and causes confusion in data communication and comparisons. DMV develops because of multiple factors that are technique related and/or airway related. Frequently, the pathogenesis involves a combination of these factors interacting to cause the final clinical picture. The reported incidence of DMV varies widely (from 0.08% to 15%) depending on the criteria used for its definition. Obesity, age older than 55 yr, history of snoring, lack of teeth, the presence of a beard, Mallampati Class III or IV, and abnormal mandibular protrusion test are all independent predictors of DMV. These signs should, therefore, be recognized and documented during the preoperative evaluation. DMV can be even more challenging in infants and children, because they develop hypoxemia much faster than adults. Finally, difficult tracheal intubation is more frequent in patients who experience DMV, and thus, clinicians should be familiar with the corrective measures and management options when faced with a challenging, difficult, or impossible mask ventilation situation.
Article
Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis. It has been shown that during general anesthesia, obese patients have a greater risk of atelectasis than nonobese patients. Preventing atelectasis is important for all patients but is especially important when caring for obese patients. We randomly allocated 66 adult obese patients with a body mass index between 30 and 50 kg/m(2) scheduled to undergo laparoscopic bariatric surgery into 3 groups. According to the recruitment maneuver used, the zero end-expiratory pressure (ZEEP) group (n = 22) received the vital capacity maneuver (VCM) maintained for 7-8 s applied immediately after intubation plus ZEEP; the positive end-expiratory pressure (PEEP) 5 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 5 cm H(2)O of PEEP; and the PEEP 10 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 10 cm H(2)O of PEEP. All other variables (e.g., anesthetic and surgical techniques) were the same for all patients. Heart rate, noninvasive mean arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao(2) gradient (A-a Pao(2)) were measured intraoperatively and postoperatively in the postanesthesia care unit (PACU). Length of stay in the PACU and the use of a nonrebreathing O(2) mask (100% Fio(2)) or reintubation were also recorded. A computed tomographic scan of the chest was performed preoperatively and postoperatively after discharge from the PACU to evaluate lung atelectasis. Patients in the PEEP 10 group had better oxygenation both intraoperatively and postoperatively in the PACU, lower atelectasis score on chest computed tomographic scan, and less postoperative pulmonary complications than the ZEEP and PEEP 5 groups. There was no evidence of barotrauma in any patient in the 3 study groups. Intraoperative alveolar recruitment with a VCM followed by PEEP 10 cm H(2)O is effective at preventing lung atelectasis and is associated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period in obese patients undergoing laparoscopic bariatric surgery.
Article
Morbidly obese patients show impaired pulmonary function during anesthesia and paralysis, partly due to formation of atelectasis. This study analyzed the effect of general anesthesia and three different ventilatory strategies to reduce the amount of atelectasis and improve respiratory function. Thirty patients (body mass index 45 +/- 4 kg/m) scheduled for gastric bypass surgery were prospectively randomized into three groups: (1) positive end-expiratory pressure of 10 cm H2O (PEEP), (2) a recruitment maneuver with 55 cm H2O for 10 s followed by zero end-expiratory pressure, (3) a recruitment maneuver followed by PEEP. Transverse lung computerized tomography scans and blood gas analysis were recorded: awake, 5 min after induction of anesthesia and paralysis at zero end-expiratory pressure, and 5 min and 20 min after intervention. In addition, spiral computerized tomography scans were performed at two occasions in 23 of the patients. After induction of anesthesia, atelectasis increased from 1 +/- 0.5% to 11 +/- 6% of total lung volume (P < 0.0001). End-expiratory lung volume decreased from 1,387 +/- 581 ml to 697 +/- 157 ml (P = 0.0014). A recruitment maneuver + PEEP reduced atelectasis to 3 +/- 4% (P = 0.0002), increased end-expiratory lung volume and increased Pao2/Fio2 from 266 +/- 70 mmHg to 412 +/- 99 mmHg (P < 0.0001). PEEP alone did not reduce the amount of atelectasis or improve oxygenation. A recruitment maneuver + zero end-expiratory pressure had a transient positive effect on respiratory function. All values are presented as mean +/- SD. A recruitment maneuver followed by PEEP reduced atelectasis and improved oxygenation in morbidly obese patients, whereas PEEP or a recruitment maneuver alone did not.
Article
Morbid obesity (MO), obstructive sleep apnea (OSA), and neck circumference (NC) are widely believed to be independent risk factors for difficult tracheal intubation. In this study, we sought to determine whether these factors were associated with increased risk of difficult intubation in patients undergoing bariatric surgery. The predictive factors tested were OSA and its severity, as determined by apnea-hypopnea index (AHI), gender, NC, and body mass index (BMI). All sequentially enrolled MO patients underwent preoperative polysomnography. Severity of OSA was quantified using AHI and the American Society of Anesthesiologists' OSA severity scale. All patients had a standardized anesthetic that included positioning in the "ramped position" for direct laryngoscopy. One hundred eighty consecutive patients were recruited, 140 women and 40 men. The incidence of OSA was 68%. The mean BMI was 49.4 kg/m(2). The mean AHI was 31.3 (range, 0-135). All the patients' tracheas were intubated successfully without the aid of rescue airways by anesthesiology residents. Six patients required three or more intubation attempts, a difficult intubation rate of 3.3%. There was an 8.3% incidence of difficult laryngoscopy, defined as a Cormack and Lehane Grade 3 or 4 view. There was no relationship between NC and difficult intubation (odds ratio 1.02, 95% confidence interval 0.93-1.1), between the diagnosis of OSA and difficult intubation (P = 0.09), or between BMI and difficult intubation (odds ratio 0.99, 95% confidence interval 0.92-1.06, P = 0.8). There was no relationship between number of intubation attempts and BMI (P = 0.8), AHI (P = 0.82), or NC (P = 0.3). Mallampati Grade III or more predicted difficult intubation (P = 0.02), as did male gender (P = 0.02). Finally, there was no relationship between Cormack and Lehane grade and BMI (P = 0.88), AHI (P = 0.93), or OSA (P = 0.6). Increasing NC was associated with difficult laryngoscopy but not difficult intubation (P = 0.02). In MO patients undergoing bariatric surgery in the "ramped position," there was no relationship between the presence and severity of OSA, BMI, or NC and difficulty of intubation or laryngoscopy grade. Only a Mallampati score of 3 or 4 or male gender predicted difficult intubation.
Article
Many manufacturers are producing videolaryngoscopes (VLSs) with differing specifications, user interfaces, and geometry. It is clinically relevant to know the relative performance of the blades. Visualization of the glottis and intubation are often problematic in (extremely) obese patients, and the new video technology may offer better functionality and performance. Although many tracheal intubations with direct laryngoscopy are performed with an unstyletted endotracheal tube, it is recommended to use a stylet for intubation using videolaryngoscopy. In this study, we compared 3 VLSs in morbidly obese patients undergoing intubation for elective surgery and tested whether it is feasible to intubate the tracheas of morbidly obese patients without using a stylet. One hundred fifty consecutive adult morbidly obese patients (body mass index >35 kg/m(2)) were randomly selected to receive one of 3 VLSs: GlideScope, Storz V-Mac, and McGrath. Direct laryngoscopy scored the best possible view of the glottis; subsequently, the respective VLS was used, and the patient's trachea was intubated. Common preprocedural (e.g., Mallampati grade) and intraprocedural (Cormack-Lehane grade) metrics of intubation difficulty were measured, as well as the dependent variables of intubation time, number of attempts, and subjective difficulty. All 3 VLSs tested offered an equal or better view of the glottis compared with traditional direct laryngoscopy. The number of attempts necessary to intubate the trachea differed significantly among VLSs (average 2.6 +/- 1.0 attempts for the GlideScope, 1.4 +/- 0.7 for the Storz, and 2.9 +/- 0.9 for the McGrath VLS). The average intubation times were 33 +/- 18 s for the GlideScope, 17 +/- 9 s for the Storz, and 41 +/- 25 s for the McGrath VLS. In this study, the VLS with the Macintosh blade (Storz VLS) had a better overall satisfaction score, intubation time, number of intubation attempts, and necessity of extra adjuncts, compared with the 2 other tested devices.
Article
Respiratory function is impaired in obese patients undergoing laparoscopic surgery. This study was performed to determine whether repeated lung recruitment combined with PEEP improves respiratory compliance and arterial partial pressure of oxygen (Pa(O2)) in obese patients undergoing laparoscopic gastric banding. Sixty patients with BMI >30 kg m(-2) were randomized, after induction of pneumoperitoneum, to receive either PEEP of 10 cm H2O (Group P), inspiratory pressure of 40 cm H2O for 15 s once (Group R), Group R recruitment followed by PEEP 10 cm H2O (Group RP), or Group RP recruitment but with the inspiratory manoeuvre repeated every 10 min (Group RRP). Static respiratory compliance and Pa(O2) were determined after intubation, 10 min after pneumoperitoneum (before lung recruitment), and every 10 min thereafter (after recruitment). Results are presented as mean (SD). Pneumoperitoneum decreased respiratory compliance from 48 (3) to 30 (1) ml cm H2O(-1) and decreased Pa(O2) from 12.4 (0.3) to 8.8 (0.3) kPa in all groups (P<0.01). Immediately after recruitment, compliance was 32 (1), 32 (2), 40 (2), and 40 (1) ml cm H2O(-1) and Pa(O2) was 9.1 (0.3), 9.1 (0.1), 11.9 (0.1), and 11.9 (0.1) kPa in Groups P, R, RP, and RRP, respectively (P<0.01). Ten and 20 min later, Pa(O2) in Group R decreased to 9.2 (0.1) kPa and compliance in Group PR decreased to 33 (2) ml cm H2O(-1), respectively (P<0.01). Group RRP recruitment strategy was associated with the best intraoperative respiratory compliance and Pa(O2) in obese patients undergoing laparoscopic gastric banding.
Article
Morbidly obese patients are at elevated risk of perioperative pulmonary complications, including airway obstruction and atelectasis. Continuous positive airway pressure may improve postoperative lung mechanics and reduce postoperative complications in patients undergoing abdominal surgery. Forty morbidly obese patients with known obstructive sleep apnea undergoing laproscopic bariatric surgery with standardized anesthesia care were randomly assigned to receive continuous positive airway pressure via the Boussignac system immediately after extubation (Boussignac group) or supplemental oxygen (standard care group). All subjects had continuous positive airway pressure initiated 30 min after extubation in the postanesthesia care unit via identical noninvasive ventilators. The primary outcome was the relative reduction in forced vital capacity from baseline to 24 h after extubation. Forty patients were enrolled into the study, 20 into each group. There were no significant differences in baseline characteristics between the groups. The intervention predicted less reduction in all measured lung functions: forced expiratory volume in 1 s (coefficient 0.37, SE 0.13, P = 0.003, CI 0.13-0.62), forced vital capacity (coefficient 0.39, SE 0.14, P = 0.006, CI 0.11-0.66), and peak expiratory flow rate (coefficient 0.82, SE 0.31, P = 0.008, CI 0.21-0.1.4). Administration of continuous positive airway pressure immediately after extubation maintains spirometric lung function at 24 h after laparoscopic bariatric surgery better than continuous positive airway pressure started in the postanesthesia care unit.
Article
Several studies have shown that videolaryngoscopes can provide better laryngeal exposure than conventional laryngoscopy. These studies, however, did not exclusively focus on patients with an anticipated difficult intubation. The aim of the present study was to assess whether a videolaryngoscope would provide better laryngeal exposure than conventional laryngoscopy and therefore facilitate intubation in cases of difficult laryngoscopy. One hundred and twelve patients with an estimated difficult intubation, scheduled to undergo surgical operations, requiring general anaesthesia and endotracheal intubation, were included in the study. Direct laryngoscopy with a Macintosh blade was performed, followed by videolaryngoscopy and intubation attempt(s). The laryngeal views obtained by each method were recorded according to the Cormack/Lehane scale. The percentage of Cormack-Lehane I and II views obtained by conventional laryngoscopy rose from 63.4 to 90.2% (P < 0.0005) with videolaryngoscopy, whereas Cormack-Lehane III and IV views declined from 36.6 to 9.8% (P < 0.0005). Intubation was successful in 98.2% of the cases. In patients with an anticipated difficult airway, videolaryngoscopy significantly improved the laryngeal exposure thus facilitating endotracheal intubation.
Article
In obese patients, concomitant use of clonidine and ketamine might be suitable to reduce the doses and minimize the undesired side effects of anesthetic and analgesic drugs. In this study, we evaluated the perioperative effects of administration of clonidine and ketamine in morbidly obese patients undergoing weight loss surgery at a university hospital in Rome, Italy. A total of 50 morbidly obese patients undergoing open biliopancreatic diversion for weight loss surgery were enrolled. The patients were randomly allocated into a study group (n = 23) receiving a slow infusion of ketamine-clonidine before anesthesia induction and a control group (n = 27) who received standard anesthesia. The hemodynamic profile, intraoperative end-tidal sevoflurane and opioid consumption, tracheal extubation time, Aldrete score, postoperative pain assessment by visual analog scale, and analgesic requirements were recorded. The patients in the study group required less end-tidal sevoflurane, lower total doses of fentanyl (3.8 +/- 0.3 gamma/kg actual body weight versus 5.0 +/- 0.2 gamma/kg actual body weight, respectively; P <.05) and had a shorter time to extubation (15.1 +/- 5 min versus 28.2 +/- 6 min, P <.05). The Aldrete score was significantly better in the postanesthesia care unit in the study group. The study group consumed less tramadol than did the control group (138 +/- 57 mg versus 252 +/- 78 mg, P <.05) and had a lower visual analog scale score postoperatively during the first 6 hours. The preoperative administration of low doses of ketamine and clonidine at induction appears to provide early extubation and diminished postoperative analgesic requirements in morbidly obese patients undergoing open bariatric surgery.
Article
Noninvasive positive-pressure ventilation (NPPV) with pressure support-ventilation and positive end-expiratory pressure are effective in providing oxygenation during intubation in hypoxemic patients. We hypothesized administration of oxygen (O2) using NPPV would more rapidly increase the end-tidal O2 concentration (ETO2) than preoxygenation using spontaneous ventilation (SV) in morbidly obese patients. Twenty-eight morbidly obese patients were enrolled in this prospective randomized study. Administration of O2 for 5 min was performed either with SV group or with NPPV (pressure support = 8 cm H2O, positive end-expiratory pressure = 6 cm H2O) (NPPV group). ETO2 was measured using the anesthesia breathing circuit, and is expressed as a fraction of atmospheric concentration. The primary end-point was the number of patients with an ETo(2) >95% at the end of O2 administration. Secondary end-points included the time to reach the maximal ETO2 and the ETO2 at the conclusion of O2 administration. A larger proportion of patients achieved a 95% ETO2 at 5 min with NPPV than SV (13/14 vs 7/14, P = 0.01). The time to reach the maximal ETO2 was significantly less in the NPPV than in the SV group (185 +/- 46 vs 222 +/- 42 s, P = 0.02). The mean ETO2 at the conclusion of O2 administration was larger in the NPPV group than the SV group (96.9 +/- 1.3 vs 94.1 +/- 2.0%, P < 0.001). A modest, although significant, increase in gastric distension was observed in the NPPV group. No adverse effects were observed in either group. Administration of O2 via a facemask with NPPV in the operating room is safe, feasible, and efficient in morbidly obese patients. In this population NPPV provides a more rapid O2 administration, achieving a higher ETO2.
Article
Obstructive sleep apnea (OSA) is present in a significant proportion of the population, but the majority of patients remain undiagnosed. It is crucial that anesthesiologists and surgeons recognize the increased perioperative risks associated with undiagnosed OSA. We present a systematic review of the literature on the perioperative management of surgical patients with OSA. The scope of this review is restricted to publications in all surgical specialties and in the adult patient population. The main search key words were: "perioperative care," "sleep apnea," "obstructive sleep apnea," "perioperative risk," and "perioperative care." The databases Medline, Embase, Biological Abstract, Science Citation Index, and Healthstar were searched for relevant English language articles from 1966 to March 2007. The literature supports an increased perioperative risk in OSA patients. The American Society of Anesthesiologists guidelines support the routine screening for OSA during preoperative assessment, and methods of OSA screening are discussed in this review. This review suggests a number of perioperative management strategies to reduce surgical risk in patients with OSA. However, apart from the consensus-based American Society of Anesthesiologists guidelines, it is important to note that evidence-based recommendations are lacking in the literature. This review suggests ways to screen for OSA in the preoperative setting and proposes perioperative management strategies. The ultimate goal is to reduce the perioperative risk of OSA patients but, to realize that goal, research will be needed to determine whether screening for OSA and/or adapting specific perioperative management approaches translates into a lessening of adverse events in surgical patients with undiagnosed OSA.
Article
The effect of obesity on the disposition and action of vecuronium was studied in 14 surgical patients. After induction of anesthesia with thiopental and maintenance of anesthesia by inhalation of nitrous oxide and halothane, seven obese patients (93.4 +/- 13.9 kg, 166% +/- 30% of ideal body weight, mean +/- SD) and seven control patients (60.9 +/- 12.3 kg, 93% +/- 6% of ideal body weight) received 0.1 mg/kg of vecuronium. Plasma arterial concentrations of muscle relaxant were determined at 1, 3, 5, 10, 15, 20, 30, 45, 60, 90, 120, 150, 180, 210, 240, 300, and 360 min by a spectrofluorometric method. Simultaneously, neuromuscular blockade was assessed by stimulation of the ulnar nerve and quantification of thumb adductor response. Times to 50% recovery of twitch were longer in the obese than in the control patients (75 +/- 8 versus 46 +/- 8 min) as were 5%-25% recovery times (14.9 +/- 4.0 versus 10.0 +/- 1.7 min) and 25%-75% recovery times (38.4 +/- 13.8 versus 16.7 +/- 10.3 min). However, vecuronium pharmacokinetics were similar for both groups. When the data were calculated on the basis of ideal body weight (IBW) for obese and control patients, total volume of distribution (791 +/- 303 versus 919 +/- 360 mL/kg IBW), plasma clearance (4.65 +/- 0.89 versus 5.02 +/- 1.13 mL.min-1.kg IBW-1), and elimination half-life (119 +/- 43 versus 133 +/- 57 min) were not different between groups.(ABSTRACT TRUNCATED AT 250 WORDS)