Advertisement

The Morbidly Obese Pregnant Woman

  • Bhavani Shankar Kodali
  • Aviva Lee-Parritz

Summary

Obese women should be strongly encouraged to lose weight before conceiving to decrease obstetric and perinatal morbidity and mortality. Careful systemic evaluation should be performed at the first opportunity during pregnancy in morbidly obese women to determine the systemic pathophysiologic alterations of obesity. It is strongly recommended that the pregnant woman should be seen by an anesthesiologist at around 28 weeks gestation to determine the effect of pregnancy on various systems. A multidisciplinary approach should be instituted depending on the systemic findings. Careful evaluation of the airway should be performed, and an anesthetic plan formulated and communicated to the patient as well as the obstetrician. Regional anesthesia is most appropriate for labor and delivery. An early administration of epidural anesthesia is recommended, which will provide ample time to negate difficulties encountered during epidural placements. Continuous spinal anesthesia is a reasonable alternative. If general anesthesia is contemplated, a second pair of hands is a boon, and necessary airway backup equipment should be at hand. A multidisciplinary approach is the key to a successful outcome of pregnancy in morbidly obese women.

Keywords

Obese Patient Obstet Gynecol Obese Woman Cesarean Delivery Epidural Anesthesia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

Referencesfs

  1. 1.
    Sebire N, Jolly M, Harris J, et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord 2001;25:1175–1182.CrossRefPubMedGoogle Scholar
  2. 2.
    Baeten J, Bukusi E, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health 2001;91:436–440.PubMedGoogle Scholar
  3. 3.
    Stephansson O, Dickman P, Johansson A, Cnattingius S. Maternal weight, pregnancy weight gain, and the risk of antepartum stillbirth. Am J Obstet Gynecol 2001;184:463–469.CrossRefPubMedGoogle Scholar
  4. 4.
    Frankel H. Determination of body mass index. JAMA 1986;255:1292.CrossRefPubMedGoogle Scholar
  5. 5.
    National Institute of Health Consensus Development Conference Statement. Health implications of obesity. Ann Intern Med 1985;103:147–151.Google Scholar
  6. 6.
    Strauss R. Operative risk of obesity. Surg Gynecol Obstet 1978;146:286–290.PubMedGoogle Scholar
  7. 7.
    Kral J. Morbid obesity and related health risks. Ann Intern Med 1983:103:1043.Google Scholar
  8. 8.
    Must A, Jacques P, Dallal G, et al. Long term morbidity and mortality of overweight adolescents. N Engl J Med 1992;327:1350–1355.PubMedCrossRefGoogle Scholar
  9. 9.
    Kushner R. Body weight and mortality. Nutr Rev 1993;51:127–136.PubMedCrossRefGoogle Scholar
  10. 10.
    Brodsky J. Anesthetic management of the morbidly obese patient. Int Anesthesiol Clin 1986;24:93–103.PubMedGoogle Scholar
  11. 11.
    Mann G. The influence of obesity on health (first of two parts). N Engl J Med 1974;291:178–185.PubMedCrossRefGoogle Scholar
  12. 12.
    Buckley F. Anesthetizing the morbidly obese patient. ASA Refresher Courses 1989;243:1–6.Google Scholar
  13. 13.
    Hood D, Dewan D. Anesthesia and obstetric outcome in morbidly obese parturients. Anesthesiology 1993;79:1210–1218.PubMedGoogle Scholar
  14. 14.
    Garbaciak JJ, Richter M, Miller S, et al. Maternal weight and pregnancy complications. Am J Obstet Gynecol 1991;164:1306.Google Scholar
  15. 15.
    Mason E, Doherty C, Maher J, et al. Super obesity and gastric reduction procedure. Gastroenterol Clin N Am 1987;16:495.Google Scholar
  16. 16.
    Bray GA. Obesity. In Fauci AS, Marlin JB, Braunwald E, et al. (eds) Harrison’s Principles of Internal Medicine, 14th Ed. New York: McGraw-Hill, 1998:454–462.Google Scholar
  17. 17.
    Reisin E, Frohlich E. Cardiovascular and respiratory pathophysiological alterations. Arch Intern Med 1981;141:431–434.CrossRefPubMedGoogle Scholar
  18. 18.
    Oberg B, Poulsen T. Obesity: an anesthetic challenge. Acta Anaesthesiol Scand 1996;40:191–200.PubMedGoogle Scholar
  19. 19.
    Albert M, Hashimi M. Obesity and the heart. Am J Med Sci 1993; 306:117–123.Google Scholar
  20. 20.
    Amad K, Brennan J, Alexander J. The cardiac pathophysiology of chronic exogenous obesity. Circulation 1959;32:740–745.Google Scholar
  21. 21.
    Alaxander J. Obesity and cardiac performance. Am J Cardiol 1964; 14:860–865.CrossRefGoogle Scholar
  22. 22.
    De Divitiis O, Fazion S, Petitto M, et al. Obesity and cardiac function. Circulation 1981;4:477–482.Google Scholar
  23. 23.
    Aggarwal N, Shibutani K, SanFilippo J, Del Guercio L. Hemodynamic and respiratory changes in surgery of the morbidly obese. Surgery (St. Louis) 1982;92:226–234.Google Scholar
  24. 24.
    Bjerkedal T. Overweight and hypertension. Acta Med Scand 1957;159: 13–26.PubMedCrossRefGoogle Scholar
  25. 25.
    Kannel W, Brand N, Skinner J, et al. The relation of adiposity to blood pressure and development of hypertension: The Framingham study. Ann Intern Med 1967;67:48–59.PubMedGoogle Scholar
  26. 26.
    Malcom R, Von J, O’Neil PM, et al. Update on the management of obesity. South Med J 1988;81:632–639.Google Scholar
  27. 27.
    Backman L, Freyschuss V, Hallberg D, Melcher A. Cardiovascular function in extreme obesity. Acta Med Scand 1973;193:437–446.PubMedCrossRefGoogle Scholar
  28. 28.
    Alexander J. Obesity and the circulation. Mod Concepts Cardiovasc Dis 1963;32:799–803.PubMedGoogle Scholar
  29. 29.
    Messerli P, Nunez B, Ventura H, Snyder D. Overweight and sudden death. Increased ventricular ectopy in cardiopathy of obesity. Arch Intern Med 1987;147:1725–1728.CrossRefPubMedGoogle Scholar
  30. 30.
    Lauer M, Anderson K, Kannei W, Levey D. The impact of obesity on left ventricular mass and geometry. JAMA 1991;266:231–236.CrossRefPubMedGoogle Scholar
  31. 31.
    Alaxander J. The cardiomyopathy of obesity. Prog Cardiovasc Dis 1985;27:325–334.Google Scholar
  32. 32.
    Ford L. Heart size. Circ Res 1976;39:297–303.PubMedGoogle Scholar
  33. 33.
    Paul D, Hoyt J, Boutros A. Cardiovascular and respiratory changes in response to change of posture in the very obese. Anesthesiology 1976; 45:73–78.PubMedGoogle Scholar
  34. 34.
    Teeple E, Ghia J. An elevated pulmonary wedge pressure resulting from an upper respiratory obstruction in an obese patient. Anesthesiology 1983;59:66–68.PubMedGoogle Scholar
  35. 35.
    Luce J. Respiratory complication in obesity. Chest 1980;78:626–631.PubMedGoogle Scholar
  36. 36.
    Fox G. Anaesthesia for intestinal short circuiting in hte morbidly obese with reference to the pathophysiology of gross obesity. Can Anaesth Soc J 1975;22307–322.PubMedCrossRefGoogle Scholar
  37. 37.
    Anderson J, Rasmussen J, Eriksen J. Pulmonary function in obese patients scheduled for jejuno-ileostomy. Acta Anaesthesiol Scand 1977; 21:346–351.Google Scholar
  38. 38.
    Bodell GN. Pulmonary function in obese persons. J Clin Invest 1955; 37:1049.Google Scholar
  39. 39.
    Burnwell CS, Raben ED, Whaley RD, et al. External obesity associated with alveolar hypoventilation: a Pickwickian syndrome. Am J Med Sci 1956;21:811.Google Scholar
  40. 40.
    Berger K, Ayappa I, Chatr-Amontri B, et al. Obesity hypoventilation syndrome as a spectrum of respiratory disturbances during sleep. Chest 2001;120:1231–1238.CrossRefPubMedGoogle Scholar
  41. 41.
    Montserrat J, Ferrer M, Hernandez L, et al. Effectiveness of CPAP treatment in daytime function in sleep apnea syndrome: a randomized controlled study with an optimized placebo. Am J Respir Crit Care Med 2001;164:608–613.PubMedGoogle Scholar
  42. 42.
    Lam A, Grace D, Penny F, Vezina W. Prophylactic intravenous cemitidine reduces the risk of acid aspiation in morbidly obese patients. Anesthesiology 1983;59:A242.Google Scholar
  43. 43.
    Vaughan R, Bauer S, Wise L. Volume and pH of gastric juice in obese patients. Anesthesiology 1975;43:686–689.PubMedGoogle Scholar
  44. 44.
    Philippe J, Guillaume F, Mohamed M, et al. Gastric residue is not more copious in obese patients. Anesth Analg 2001;93:1621–1622.Google Scholar
  45. 45.
    Kissebah A, Bydelingum N, Murray R, et al. Relation of body height and fat distribution to metabolic complications of obesity. J Clin Endocrinol Metab 1982:130–144.Google Scholar
  46. 46.
    Mabie W, Ratts T, Ramanathan K, Sibai B. Circulatory congestion in obese hypertensive women. A subset of pulmonary edema in pregnancy. Obstet Gynecol 1988;72:553–558.PubMedGoogle Scholar
  47. 47.
    Eng M, Butler J, Bonica JJ. Respiratory function in pregnant obese women. Am J Obstet Gynecol 1975;123:241–245.PubMedGoogle Scholar
  48. 48.
    Blass NH. Regional anesthesia in the morbidly obese patient. Reg Anesth 1979;4:20–22.Google Scholar
  49. 49.
    Pilkington S, Carli F, Dakin MJ, et al. Increase in Mallampati score during pregnancy. Br J Anaesth 1995;74:638–642.PubMedGoogle Scholar
  50. 50.
    Lewis D, Chessor A, Edwards M, et al. Obstructive sleep apnea during pregnancy resulting in pulmonary hypertension. South Med J 1998;91:761–762.PubMedGoogle Scholar
  51. 51.
    O’Brien TF. Lower esophageal sphincter pressure (LSP) esophageal function in obese humans. J Clin Gastroenterol 1980;2:145–148.PubMedGoogle Scholar
  52. 52.
    Brock-Utne J, Dow T, Dimopoulos G, et al. Evidence refuting a role for increased abdominal pressure in the pathogenesis of heartburn associated with pregnancy. Br J Anaesth 1981;53:381–384.PubMedGoogle Scholar
  53. 53.
    Kliegman R, Gross T. Perinatal problems of the obese mother and her infant. Obstet Gynecol 1985;66:299–306.PubMedGoogle Scholar
  54. 54.
    Johnson S, Kolberg B, Verner M, Railsback L. Maternal obesity in pregnancy. Surg Gynecol Obstet 1987;164:431–437.PubMedGoogle Scholar
  55. 55.
    Gross T, Sokol R, King K. Obesity and pregnancy: risk and outcome. Obstet Gynecol 1980;56:446–450.PubMedGoogle Scholar
  56. 56.
    Tracey T, Miller G. Obstetric problems of the massively obese. Obstet Gynecol 1968;33:204–208.Google Scholar
  57. 57.
    Perlow J, Morgan M, Montgomery D, et al. Perinatal outcome in pregnancy complicated by massive obesity. Am J Obstet Gynecol 1992; 167:958–962.PubMedGoogle Scholar
  58. 58.
    Garbaciak J, Richter M, Miller S, et al. Maternal weight in pregnancy complications. Obstet Gynecol 1985;152:238–245.Google Scholar
  59. 59.
    Krotkiewski M, Bjornetorp P, Sjostrom L, et al. Impact of obesity on metabolism in men and women: importance of regional adipose tissue distribution. J Clin Invest 1983;72:1150.PubMedCrossRefGoogle Scholar
  60. 60.
    Maeder E, Barno A, Mecklenburg F. Obesity: a maternal high risk factor. Obstet Gynecol 1975;45:669–671.PubMedCrossRefGoogle Scholar
  61. 61.
    Kaunitz A, Hughes J, Grimes D, et al. Causes of maternal mortality in the United States. Obstet Gynecol 1985;65:605–612.PubMedGoogle Scholar
  62. 62.
    Rochat R, Koonin L, Atrash A, Jewett J. Maternal mortality in the United States: report from the maternal mortality collaborative. Obstet Gynecol 1988;72:91–97.PubMedGoogle Scholar
  63. 63.
    May W, Greiss F. Maternal mortality in North Carolina: a four year experience. Am J Obstet Gynecol 1989;161:555–561.PubMedGoogle Scholar
  64. 64.
    Endler G, Mariona F, Solol R, Stevenson L. Anesthesia-related mortality in Michigan 1972–1984. Am J Obstet Gynecol 1988;158:187–193.Google Scholar
  65. 65.
    Sachs B, Oriol N, Ostheimer G, et al. Anesthetic related maternal mortality 1954–1985. J Clin Anesth 1989;1:333–338.CrossRefPubMedGoogle Scholar
  66. 66.
    Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology 1997;86:277–284.CrossRefPubMedGoogle Scholar
  67. 67.
    Wolfe HM, Sokol RJ, Marties SM, et al. Maternal obesity: A potential source of error in sonographic prenatal diagnosis. Obstet Gynecol 1990;76:339.PubMedGoogle Scholar
  68. 68.
    Johnson JW, Longmate JA, Frentzen B. Excessive maternal weight and pregnancy outcome. Am J Obstet Gynecol 1992;167:353–372.PubMedGoogle Scholar
  69. 69.
    Peckham CH, Chrstianson RE. The relationship between pre-pregnancy weight and certain obstetric factors. Am J Obstet Gynecol 1971;111:1–7.PubMedGoogle Scholar
  70. 70.
    Ratner RE, Hamme LH, Isada NB. Effects of gestational weight gain in morbidly obese women. 1. Maternal morbidity. Am J Perinatol 1991;8:21–24.PubMedCrossRefGoogle Scholar
  71. 71.
    Kaiser PS, Kirby RS. Obesity as a risk for cesarean section in a low-risk population. Obstet Gynecol 2001;97:39–43.CrossRefPubMedGoogle Scholar
  72. 72.
    Crane SS, Wojtowycz MA, Dye D, et al. Association between pre-pregnancy obesity and the risk of cesarean delivery. Obstet Gynecol 1997; 89:213–216.CrossRefPubMedGoogle Scholar
  73. 73.
    Chauhan SP, Magann EF, Carroll CS, et al. Mode of delivery for the morbidly obese with prior cesarean delivery: vaginal versus repeat cesarean section. Am J Obstet Gynecol 2001;185:349–354.CrossRefPubMedGoogle Scholar
  74. 74.
    Kumari AS. Pregnancy outcome in women with morbid obesity. Int J Gynaecol Obstet 2001;73:101–107.CrossRefPubMedGoogle Scholar
  75. 75.
    Cnattingius S, Bergstrom R, Lipworth L, Kramer MS. Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med 1998;338:147–152.CrossRefPubMedGoogle Scholar
  76. 76.
    Waller DK, Millis JL, Simpson JL, et al. Are obese women at higher risk for producing malformed offspring? Am J Obstet Gynecol 1994;170:541.PubMedGoogle Scholar
  77. 77.
    Bilenka B, Ben-Shlomo I, Cozacov C, et al. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity. Acta Obstet Gynecol Scand 1995;74:42–44.PubMedGoogle Scholar
  78. 78.
    Printen KJ, Scott D. Pregnancy following gastric bypass for the treatment of morbid obesity. Am Surg 1982;48:363–365.PubMedGoogle Scholar
  79. 79.
    Deital M, Stone E, Kasssaml HA, et al. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr 1988;7:147–153.Google Scholar
  80. 80.
    Satmar-Fones G. Some psychiatric aspects of morbidly obese patients in relation to jejunoileal and gastric bypass procedures. Can J Surg 1984;27:133.Google Scholar
  81. 81.
    Houston M, Raynor B. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. Am J Obstet Gynecol 2000;182:1033–1035.CrossRefPubMedGoogle Scholar
  82. 82.
    Hodgkinson R, Hussain FJ. Cesearean section associated with gross obesity. Br J Anaesth 1980;52:919–923.PubMedGoogle Scholar
  83. 83.
    Morrow C, Hernandez W, Townsend D, Disaia P. Pelvic celiotomy in the obese patient. Obstet Gynecol 1977;127:335.Google Scholar
  84. 84.
    Douglas MJ, Flanagan ML, McMorland GH. Anesthetic management of a complex morbidly obese parturient. Can J Anaesth 1991;38:900–903.PubMedGoogle Scholar
  85. 85.
    Shnaider R, Ezri T, Szmuk P, Larson S. Combined spinal-epidural anesthesia for cesarean section in a patient with peripartum dilated cardiomyopathy. Can J Anaesth 2001;48:681–683.PubMedGoogle Scholar
  86. 86.
    Patel J. Anaesthesia for LSCS in a morbidly obese patient. Anaesth Intensive Care 1999;27:216–219.PubMedGoogle Scholar
  87. 87.
    Buckley FP, Robinson NB, Simonowitz DA, Dellinger ED. A comparison of anesthetic and analgesic regimens for upper abdominal surgery. Anesthesia 1983;38:840–851.Google Scholar
  88. 88.
    Narang VP, Linter SP. Failure of extradural blockade in obstetrics: a new hypothesis. Br J Anaesth 1988;60:402–404.PubMedGoogle Scholar
  89. 89.
    Wallace DH, Currie JM, Gilstrap LC, Santos R. Indirect sonographic guidance for epidural anesthesia in obese pregnant patients. Reg Anesth 1992;17:233–236.PubMedGoogle Scholar
  90. 90.
    Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology 1997;86: 778–784.CrossRefPubMedGoogle Scholar
  91. 91.
    Faure E, Moreno R, Thisted R. Incidence of postdural puncture headache in morbidly obese parturients. Reg Anesth 1994;19:361–363.PubMedGoogle Scholar
  92. 92.
    Blass NH, Abouleish A, Dalmeida R. Low thoracic epidural anesthesia for massively obese parturients. Anesthesiology 1994;81:A1172.Google Scholar
  93. 93.
    Bailey PL, Lu JK, Pace NL, et al. Effects of intrathecal morphine on the ventilatory response to hypoxia. N Engl J Med 2000;343:1228–1234.CrossRefPubMedGoogle Scholar
  94. 94.
    Norris MC. Are combined spinal-epidural catheters reliable? Int J Obstet Anesth 2000;9:3–6.CrossRefPubMedGoogle Scholar
  95. 95.
    Suzuki N, Koganemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia. Anesth Analg 1996;82:1040–1042.CrossRefPubMedGoogle Scholar
  96. 96.
    Tseuda K, Debrand M, Zeok SS, et al. Obesity supine sudden death syndrome: report of two morbidly obese patients. Anesth Analg 1979;58:345–347.Google Scholar
  97. 97.
    Abouleish EI. Epinephrine improves the quality of spinal hyperbaric bupivacaine for cesarean section. Anesth Analg 1987;66:395–400.PubMedGoogle Scholar
  98. 98.
    Norris MC. Height, weight and the spread of subarachnoid hyperbaric bupivacaine in the term parturient. Anesth Analg 1988;67:555.PubMedGoogle Scholar
  99. 99.
    Green NM. Distribution of local anesthetics within the subarachnoid space. Anesth Analg 1985;64:715–730.Google Scholar
  100. 100.
    Pitkanen MT. Body mass and spread of spinal anesthesia with bupivacaine. Anesth Analg 1987;66:127–131.PubMedCrossRefGoogle Scholar
  101. 101.
    McCullogh W, Littlewood DG. Influence of obesity on spinal anesthesia with isobaric 0.5% bupivacaine. Br J Anaesth 1986;58:610–614.Google Scholar
  102. 102.
    Milligan KR, Cramp P, Schatz D, et al. The effect of patient position and obesity on the spread of epidural analgesia. Int J Obstet Anesth 1993; 2:134–136.CrossRefPubMedGoogle Scholar
  103. 103.
    Gautam PL, Kathuria S, Kaul TK. Infiltration block for cesarean section in morbidly obese parturient. Acta Anaesthesiol Scand 1999;43: 580–581.CrossRefPubMedGoogle Scholar
  104. 104.
    Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetrics anesthesia. Anesthesiology 1992;77:67–73.PubMedGoogle Scholar
  105. 105.
    Lee JJ, Larson RH, Buckley JJ, Roberts RB. Airway maintenance in the morbidly obese. Anesthesiol Rev 1980;7:33–36.Google Scholar
  106. 106.
    Datta S, Briwa J. Modified laryngoscope for endotracheal intubation of obese patients. Anesth Analg 1981;60:120.PubMedGoogle Scholar
  107. 107.
    Parmet JL, Colonna-Romano P, Horrow JC, et al. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation. Anesth Analg 1998;87:661–665.CrossRefPubMedGoogle Scholar
  108. 108.
    Archer GW, Marx GF. Arterial oxygen tension during apnea in parturient women. Br J Anaesth 1974;46:358–360.PubMedGoogle Scholar
  109. 109.
    Berthould M, Peacock J, Reilly C. Effectiveness of preoxygenation in morbidly obese patients. Br J Anaesth 1991;67:464–466.Google Scholar
  110. 110.
    Gambee M, Hetzka R, Fisher D. Preoxygenation techniques: comparison of three minutes and four breaths. Anesth Analg 1987;1987: 468–479.Google Scholar
  111. 111.
    Practice guidelines for management of the difficult airway: a report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesiology 1993;78:597–602.Google Scholar
  112. 112.
    Harmer M. Difficult and failed intubation in obstetrics. Int J Obstet Anesth 1997;6:25–31.CrossRefPubMedGoogle Scholar
  113. 113.
    Godley M, Ramachandra Reddy AR. Use of LMA for awake intubation for cesarean section. Can Anaesth Soc J 1996;43:299–302.CrossRefGoogle Scholar
  114. 114.
    Cohn AI, Hart RT, McGraw SR, Blass NH. The Bullard laryngoscope for emergency airway management in a morbidly obese parturient. Anesth Analg 1995;81:872–873.CrossRefPubMedGoogle Scholar
  115. 115.
    Greenbelt DJ, Abernethy DR, Locniskar A, et al. Effect of age, gender, and obesity on midazolam kinetics. Anesthesiology 1984;61:27–35.Google Scholar
  116. 116.
    Weinstein JA. Pharmacodynamics of vecronium and atracurium in the obese surgical patient. Anesth Analg 1988;67:1149.PubMedGoogle Scholar
  117. 117.
    Bentley JB, Vaughan RW, Gandolfi AJ, Cork RC. Halothane biotrans-formation on obese and nonobese patients. Anesthesiology 1982;57:94–97.PubMedGoogle Scholar
  118. 118.
    Bentley JB, Vaughan RW, Miller MS, et al. Serum inorganic fluoride levels in obese patients during and after enflurane aneshesia. Anesth Analg 1979;58:409–412.PubMedGoogle Scholar
  119. 119.
    Higuchi H, Satoh T, Arimura S, et al. Serum inorganic fluoride levels in mildly obese patients during and after sevoflurane anesthesia. Anesth Analg 1993;77:1018–1021.PubMedGoogle Scholar
  120. 120.
    Strube PJ, Hulands GH, Halsey MJ. Serum fluoride levels in morbidly obese patients: enflurane compared with isoflurane anaesthesia. Anaesthesia 1987;42:685–689.PubMedGoogle Scholar
  121. 121.
    Juvin P, Vadam C, Malek L, et al. Postoperative recovery after desflurane, propofol, or isoflurane anesthesia among morbidly obese patients: a prospective, randomized study. Anesth Analg 2000;91:714–719.CrossRefPubMedGoogle Scholar
  122. 122.
    Cork RC, Vaughan RW, Bentley JB. General anesthesia for morbidly obese patients—an examination of postoperative outcomes. Anesthesiology 1981;54:310–313.PubMedGoogle Scholar
  123. 123.
    Shankar KB, Moseley H, Kumar Y, Vemula V. Arterial to end-tidal carbon dioxide tension difference during Caesarean section anaesthesia. Anaesthesia 1986;41:698–702.PubMedGoogle Scholar
  124. 124.
    Hedenstierna G, Santesson J. Breathing mechanics, dead space and gas exchange in the extremely obese, reathing spontaneously and during anaesthesia with intermittent positive pressure ventilation. Acta Anaesthesiol Scand 1976;20:248–254.PubMedGoogle Scholar
  125. 125.
    Salam MR, Dalal FY, Zygmunt MP, et al. Does PEEP improve intraoperative arterial oxygenation in grossly obese patients? Anesthesiology 1978;48:280–281.CrossRefGoogle Scholar
  126. 126.
    Soderberg M, Thompson D, White T. Respiration, circulation and anaesthetic management in obesity. Investigation before and after jejunal bypass. Acta Anaesthesiol Scand 1977;21:55–61.PubMedCrossRefGoogle Scholar
  127. 127.
    Joris J, Sottiaux T, Chiche JD, et al. Bi-level CPAP (BIPAP) reduces the postoperative restrictive pulmonary syndrome in obese patients afer gastroplasty. Br J Anaesth 1994;72(suppl 1):A111.Google Scholar
  128. 128.
    Eriksen J, Andeson J, Rasmussen JP. Postoperative pulmonary function in obese patients after upper abdominal surgery. Acta Anaesthesiol Scand 1977;21:336–341.PubMedGoogle Scholar
  129. 129.
    Fox GS, Whaley DG, Beven D. Anaesthesia for the morbidly obese. Br J Anaesth 1981;53:811–816.PubMedGoogle Scholar
  130. 130.
    VanDercar DH, Martinez AP, DeLisser EA. A potential contraindication for patient-controlled analgesia. Anesthesiology 1991;74:623–624.PubMedGoogle Scholar
  131. 131.
    Rawal N, Sjostrand U, Christofferson E, et al. Comparison of intramuscular and epidural morphine for postoperative ambulation and pulmonary function. Anesth Analg 1984;63:583–592.PubMedGoogle Scholar

Copyright information

© Springer-Verlag New York, Inc. 2004

Authors and Affiliations

  • Bhavani Shankar Kodali
  • Aviva Lee-Parritz

There are no affiliations available

Personalised recommendations