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Anesthesia for the Bariatric Patient: Optimizing Safety and Managing Complications

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Bariatric Surgery Complications and Emergencies

Abstract

Patients undergoing bariatric surgery present many anesthetic challenges. In this chapter, we discuss various aspects of anesthetic management in this patient population. Predictors of difficult mask ventilation and difficult intubation, techniques to optimize preoxygenation, airway equipment, and criteria for extubation are addressed. Intraoperative monitoring, ventilation strategies, patient positioning, and injury prevention are also discussed. Morbid obesity affects the pharmacokinetics and pharmacodynamics of various anesthetic drugs, including induction agents, opioids, and muscle relaxants, requiring dosage adjustment. We introduce a multimodal pain management strategy to improve pain control and reduce side effects. Morbidly obese patients have a higher risk of postoperative respiratory complications, necessitating extra attention to postoperative management and disposition planning from the postoperative anesthesia care unit.

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References

  1. El-Solh AA. Clinical approach to the critically ill, morbidly obese patient. Am J Respir Crit Care Med. 2004;169(5):557–61.

    Article  PubMed  Google Scholar 

  2. Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885–91.

    Article  PubMed  Google Scholar 

  3. Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97(2):595–600. table of contents.

    Article  PubMed  Google Scholar 

  4. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21.

    Article  PubMed  Google Scholar 

  5. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110(4):891–7.

    Article  PubMed  Google Scholar 

  6. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000;92(5):1229–36.

    Article  CAS  PubMed  Google Scholar 

  7. Enterlein G, Byhahn C. American Society of Anesthesiologists task F. [Practice guidelines for management of the difficult airway: update by the American Society of Anesthesiologists task force]. Anaesthesist. 2013;62(10):832–5.

    Article  CAS  PubMed  Google Scholar 

  8. Ezri T, Medalion B, Weisenberg M, Szmuk P, Warters RD, Charuzi I. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anaesth. 2003;50(2):179–83.

    Article  PubMed  Google Scholar 

  9. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94(3):732–6. table of contents.

    Article  PubMed  Google Scholar 

  10. Mashour GA, Kheterpal S, Vanaharam V, Shanks A, Wang LY, Sandberg WS, et al. The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese. Anesth Analg. 2008;107(6):1919–23.

    Article  PubMed  Google Scholar 

  11. Berthoud MC, Peacock JE, Reilly CS. Effectiveness of preoxygenation in morbidly obese patients. Br J Anaesth. 1991;67(4):464–6.

    Article  CAS  PubMed  Google Scholar 

  12. Jense HG, Dubin SA, Silverstein PI, O'Leary-Escolas U. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1991;72(1):89–93.

    Article  CAS  PubMed  Google Scholar 

  13. Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102(6):1110–5. discussion 5A.

    Article  PubMed  Google Scholar 

  14. Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13(1):4–9.

    Article  PubMed  Google Scholar 

  15. Perilli V, Sollazzi L, Bozza P, Modesti C, Chierichini A, Tacchino RM, et al. The effects of the reverse Trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91(6):1520–5.

    Article  CAS  PubMed  Google Scholar 

  16. Adnet F, Borron SW, Dumas JL, Lapostolle F, Cupa M, Lapandry C. Study of the “sniffing position” by magnetic resonance imaging. Anesthesiology. 2001;94(1):83–6.

    Article  CAS  PubMed  Google Scholar 

  17. Goldberg ME, Norris MC, Larijani GE, Marr AT, Seltzer JL. Preoxygenation in the morbidly obese: a comparison of two techniques. Anesth Analg. 1989;68(4):520–2.

    Article  CAS  PubMed  Google Scholar 

  18. Gambee AM, Hertzka RE, Fisher DM. Preoxygenation techniques: comparison of three minutes and four breaths. Anesth Analg. 1987;66(5):468–70.

    Article  CAS  PubMed  Google Scholar 

  19. Coussa M, Proietti S, Schnyder P, Frascarolo P, Suter M, Spahn DR, et al. Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients. Anesth Analg. 2004;98(5):1491–5. table of contents.

    Article  PubMed  Google Scholar 

  20. Schumann R, Jones SB, Cooper B, Kelley SD, Bosch MV, Ortiz VE, et al. Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004–2007. Obesity. 2009;17(5):889–94.

    Article  PubMed  Google Scholar 

  21. Frappier J, Guenoun T, Journois D, Philippe H, Aka E, Cadi P, et al. Airway management using the intubating laryngeal mask airway for the morbidly obese patient. Anesth Analg. 2003;96(5):1510–5. table of contents.

    Article  PubMed  Google Scholar 

  22. Marrel J, Blanc C, Frascarolo P, Magnusson L. Videolaryngoscopy improves intubation condition in morbidly obese patients. Eur J Anaesthesiol. 2007;24(12):1045–9.

    Article  CAS  PubMed  Google Scholar 

  23. Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, et al. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology. 2009;110(4):878–84.

    Article  PubMed  Google Scholar 

  24. American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2014;120(2):268–86.

    Article  Google Scholar 

  25. Griffin J, Terry BE, Burton RK, Ray TL, Keller BP, Landrum AL, et al. Comparison of end-tidal and transcutaneous measures of carbon dioxide during general anaesthesia in severely obese adults. Br J Anaesth. 2003;91(4):498–501.

    Article  CAS  PubMed  Google Scholar 

  26. Xue Q, Wu X, Jin J, Yu B, Zheng M. Transcutaneous carbon dioxide monitoring accurately predicts arterial carbon dioxide partial pressure in patients undergoing prolonged laparoscopic surgery. Anesth Analg. 2010;111(2):417–20.

    Article  PubMed  Google Scholar 

  27. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology. 2011;115(5):946–54.

    Article  PubMed  Google Scholar 

  28. Hannenberg AA, Sessler DI. Improving perioperative temperature management. Anesth Analg. 2008;107(5):1454–7.

    Article  PubMed  Google Scholar 

  29. Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369(5):428–37.

    Article  CAS  PubMed  Google Scholar 

  30. Chalhoub V, Yazigi A, Sleilaty G, Haddad F, Noun R, Madi-Jebara S, et al. Effect of vital capacity manoeuvres on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery. Eur J Anaesthesiol. 2007;24(3):283–8.

    Article  CAS  PubMed  Google Scholar 

  31. Shibutani K, Inchiosa Jr MA, Sawada K, Bairamian M. Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients: derivation of dosing weight ("pharmacokinetic mass"). Anesthesiology. 2004;101(3):603–13.

    Article  CAS  PubMed  Google Scholar 

  32. Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The effects of cisatracurium on morbidly obese women. Anesth Analg. 2004;99(4):1090–4. table of contents.

    Article  CAS  PubMed  Google Scholar 

  33. Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The pharmacodynamic effects of rocuronium when dosed according to real body weight or ideal body weight in morbidly obese patients. Anesth Analg. 2004;99(4):1086–9. table of contents.

    Article  PubMed  Google Scholar 

  34. Schumann R, Jones SB, Ortiz VE, Connor K, Pulai I, Ozawa ET, et al. Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obes Res. 2005;13(2):254–66.

    Article  PubMed  Google Scholar 

  35. Alvarez A, Singh PM, Sinha AC. Postoperative analgesia in morbid obesity. Obes Surg. 2014;24(4):652–9.

    Article  PubMed  Google Scholar 

  36. Feld JM, Laurito CE, Beckerman M, Vincent J, Hoffman WE. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can J Anaesth. 2003;50(4):336–41.

    Article  PubMed  Google Scholar 

  37. Govindarajan R, Ghosh B, Sathyamoorthy MK, Kodali NS, Raza A, Aronsohn J, et al. Efficacy of ketorolac in lieu of narcotics in the operative management of laparoscopic surgery for morbid obesity. Surg Obes Relat Dis. 2005;1(6):530–5. discussion 5–6.

    Article  PubMed  Google Scholar 

  38. Ding Y, White PF. Comparative effects of ketorolac, dezocine, and fentanyl as adjuvants during outpatient anesthesia. Anesth Analg. 1992;75(4):566–71.

    Article  CAS  PubMed  Google Scholar 

  39. Sasse KC, Ganser J, Kozar M, Watson RW, McGinley L, Lim D, et al. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn? Obes Surg. 2008;18(5):530–4.

    Article  PubMed  Google Scholar 

  40. Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005;94(4):505–13.

    Article  CAS  PubMed  Google Scholar 

  41. Tufanogullari B, White PF, Peixoto MP, Kianpour D, Lacour T, Griffin J, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg. 2008;106(6):1741–8.

    Article  CAS  PubMed  Google Scholar 

  42. Blaudszun G, Lysakowski C, Elia N, Tramer MR. Effect of perioperative systemic alpha2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2012;116(6):1312–22.

    Article  CAS  PubMed  Google Scholar 

  43. Schmid RL, Sandler AN, Katz J. Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes. Pain. 1999;82(2):111–25.

    Article  CAS  PubMed  Google Scholar 

  44. Ryu JH, Kang MH, Park KS, Do SH. Effects of magnesium sulphate on intraoperative anaesthetic requirements and postoperative analgesia in gynaecology patients receiving total intravenous anaesthesia. Br J Anaesth. 2008;100(3):397–403.

    Article  CAS  PubMed  Google Scholar 

  45. Cabrera Schulmeyer MC, de la Maza J, Ovalle C, Farias C, Vives I. Analgesic effects of a single preoperative dose of pregabalin after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20(12):1678–81.

    Article  PubMed  Google Scholar 

  46. Chang CY, Challa CK, Shah J, Eloy JD. Gabapentin in acute postoperative pain management. Biomed Res Int. 2014;2014:631756.

    PubMed  PubMed Central  Google Scholar 

  47. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a systematic review. Reg Anesth Pain Med. 2012;37(2):193–209.

    Article  CAS  PubMed  Google Scholar 

  48. Cottam DR, Fisher B, Atkinson J, Link D, Volk P, Friesen C, et al. A randomized trial of bupivicaine pain pumps to eliminate the need for patient controlled analgesia pumps in primary laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17(5):595–600.

    Article  PubMed  Google Scholar 

  49. Sherwinter DA, Ghaznavi AM, Spinner D, Savel RH, Macura JM, Adler H. Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized controlled trial. Obes Surg. 2008;18(12):1581–6.

    Article  PubMed  Google Scholar 

  50. Cohen AR, Smith AN, Henriksen BS. Postoperative opioid requirements following roux-en-y gastric bypass in patients receiving continuous bupivacaine through a pump system: a retrospective review. Hosp Pharm. 2013;48(6):479–83.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Michaloudis D, Fraidakis O, Petrou A, Farmakalidou H, Neonaki M, Christodoulakis M, et al. Continuous spinal anesthesia/analgesia for perioperative management of morbidly obese patients undergoing laparotomy for gastroplastic surgery. Obes Surg. 2000;10(3):220–9.

    Article  CAS  PubMed  Google Scholar 

  52. Casati A, Putzu M. Anesthesia in the obese patient: pharmacokinetic considerations. J Clin Anesth. 2005;17(2):134–45.

    Article  CAS  PubMed  Google Scholar 

  53. Panni MK, Columb MO. Obese parturients have lower epidural local anaesthetic requirements for analgesia in labour. Br J Anaesth. 2006;96(1):106–10.

    Article  CAS  PubMed  Google Scholar 

  54. Carvalho JC. Ultrasound-facilitated epidurals and spinals in obstetrics. Anesthesiol Clin. 2008;26(1):145–58. vii-viii.

    Article  PubMed  Google Scholar 

  55. Kranke P, Apefel CC, Papenfuss T, Rauch S, Lobmann U, Rubsam B, et al. An increased body mass index is no risk factor for postoperative nausea and vomiting. A systematic review and results of original data. Acta Anaesthesiol Scand. 2001;45(2):160–6.

    CAS  PubMed  Google Scholar 

  56. Ziemann-Gimmel P, Hensel P, Koppman J, Marema R. Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2013;9(6):975–80.

    Article  PubMed  Google Scholar 

  57. Ziemann-Gimmel P, Goldfarb AA, Koppman J, Marema RT. Opioid-free total intravenous anaesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis. Br J Anaesth. 2014;112(5):906–11.

    Article  CAS  PubMed  Google Scholar 

  58. Bamgbade OA, Rutter TW, Nafiu OO, Dorje P. Postoperative complications in obese and nonobese patients. World J Surg. 2007;31(3):556–60. discussion 61.

    Article  PubMed  Google Scholar 

  59. Ahmad S, Nagle A, McCarthy RJ, Fitzgerald PC, Sullivan JT, Prystowsky J. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107(1):138–43.

    Article  PubMed  Google Scholar 

  60. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112(2):282–7.

    Article  PubMed  Google Scholar 

  61. Ireland CJ, Chapman TM, Mathew SF, Herbison GP, Zacharias M. Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery. Cochrane Database Syst Rev. 2014;8, CD008930.

    PubMed  Google Scholar 

  62. Davidson JE, Callery C. Care of the obesity surgery patient requiring immediate-level care or intensive care. Obes Surg. 2001;11(1):93–7.

    Article  CAS  PubMed  Google Scholar 

  63. Helling TS, Willoughby TL, Maxfield DM, Ryan P. Determinants of the need for intensive care and prolonged mechanical ventilation in patients undergoing bariatric surgery. Obes Surg. 2004;14(8):1036–41.

    Article  PubMed  Google Scholar 

  64. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–70.

    Article  PubMed  Google Scholar 

  65. Pai MP, Paloucek FP. The origin of the “ideal” body weight equations. Ann Pharmacother. 2000;34(9):1066–9.

    Article  CAS  PubMed  Google Scholar 

  66. Hume R. Prediction of lean body mass from height and weight. J Clin Pathol. 1966;19(4):389–91.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth. 2010;105 Suppl 1:i16–23.

    Article  CAS  PubMed  Google Scholar 

  68. Balki M, Lee Y, Halpern S, Carvalho JC. Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients. Anesth Analg. 2009;108(6):1876–81.

    Article  PubMed  Google Scholar 

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Ma, H., Jones, S. (2016). Anesthesia for the Bariatric Patient: Optimizing Safety and Managing Complications. In: Herron, D. (eds) Bariatric Surgery Complications and Emergencies. Springer, Cham. https://doi.org/10.1007/978-3-319-27114-9_2

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