Key points when giving anesthesia for morbid obese patients. based on ERAbS practice

48 Pages·2017·20.27 MB·English

Key points when giving anesthesia for morbid
obese patients.

based on ERAbS practice
J P Mulier
AZ Sint-Jan Brugge Belgium
Leuven 22 sept 2017
Publicationslist.org/jan.mulier Researchgate.com ESPCOP.org
2017 1
An increasing BMI
reduces life expectance

most in
Young, black and male pt.
Elderly, white man&woman

black male, white male, white woman, black woman

BMI 45, 20 years: 20 y 12 y 8 y 4 y
2017 2
BMI 45, 60 years: 1 y 6 y 5 y 0,5 y
ORIGINAL ARTICLES
The Obesity Paradox
Body Mass Index and Outcomes in Patients Undergoing Nonbariatric
General Surgery
John T. Mullen, MD, FACS,* Donald W. Moorman, MD, FACS,* and Daniel L. Davenport, PhD†
criticallyandchronicallyillpatients2–7aswellasofpatientsunder-
Objective:Wesoughttoexaminetheeffectofbodymassindex(BMI)on goingcertainprocedures8,9suggestthatoverweightandobesepa-
30-day morbidiMtyulalnednemtoarltality in a large cohort of patients undergoing tients may paraAdnonxaiclsalolfySuhragveery“b•etVteorl”umouetc2o5m0e,sNuthmanbe“rn1o,rmJualyl”2009
nonbariatricgeneralsurgery.
weightpatients. 118.000 pt 2005-2006
SummaryBackgroundData:Obesityhaslongbeenconsideredariskfactor
There have been surprisingly few studies that accurately
forpooroutcomesfromavarietyofsurgicalprocedures,yetrecentstudiesof
assesstheextenttowhichobesity,andmoregenerally,BMI,affects
criticallyandchronicallyillpatientssuggestthatoverweightandobesepatients surgicalrisk.Thosestudiesthathavedonesohavebeencontradic- 121 medical centers
mayparadoxicallyhavebetteroutcomesthan“normal”weightpatients.
tory.Afewstudieshaveshownthatobesepatientsareathigherrisk
Methods:AproAspecltivle ,dmualti-itnsatitu tio nal,risk-adjustedcohortstudyof forseverepostoperativecomplicationsaftervarioussurgicalproce-
118,707patientsundergoingnonbariatricgeneralsurgerywhowereincludedin dures.10–13However,otherthananincreasedriskofminorwound
theNationalSurgicalQualityImprovementProgramParticipantUsedatabasein
complications,severalotherstudieshavefailedtodemonstratean
2005and2006wasperformed.Outcomesandriskvariableswerecompared
increased risk of death or severe complications in obese patients
accormospsarNisIoHn-sdoeffinmeCedanBsMoteIstcsnl,asasntdursminougltaivlnalarleiyasbilsedolfog viasfrtiioacnrceerg,reB socsinofneo.rron-imultiple ustnadtiesrtgicoailngposwuregregryiv.1e4n–2t1heAirllsomfatlhlMessaeomsrtputladeilesiistzyaers e,ltihmeiirtesdinbgylea-ilnasctkitouf- Mortality risk
Results:Afteradjustingforallsignificantperioperativeriskfactors,therisk
tion,retrospectivedesignswithlimitedpatientfollow-up,andhet-
ohfigdheeastthraatcecsoirnditnhgmetuonBdoeMrwIreeixgbhhitbaiitnedddmairotervbieiedrslyesJo-bseh saepaeedxtnrreelmadteisona snhdipth,ewliothwtehset erogeneity in their definitions of obesity, the types of surgical
proceduresincluded,andtheoutcomesstudied.
ratesintheoverweightandmoderatelyobese.Overweight(oddsratio,0.85;
We conducted a prospective study of a large cohort of
95% CI, 0.75–0o.99)paned mroaderatteilvy oebes er(oidsdskrat.io , 0.73; 95% CI, patients undergoing nonbariatric general surgery to examine the BMI < 18.5
0.57–0.94) patients had a significantly lower risk of death than normal
effectofBMIonperioperativeoutcomes,particularly30-daymor-
weight patients. There was a progressive increase in the likelihood of a
bidityandmortality.Wehypothesizedthatpatientswhoareabove
complicationwithincreasingBMIclass,almostentirelyduetoincreasing andbelowthenormalrangeofBMIwouldhaveahigherriskof BMI > 40
ratesofwoundinfection.
adverseoutcomes.
Conclusions:Overweightandmoderatelyobesepatientsundergoingnon- BMI<18.5 18.5<BMI<25 25<BMI<30 30<BMI<35 35<BMI<40 BMI>40

bariatricgeneralsurgeryhaveparadoxically“lower”crudeandadjustedrisks

ofmortalitycomparedwithpatientsata“normal”weight.Thisfindingisin METMHoOrDbSidity
contrasttoobservationsfromthegeneralpopulation,confirmingtheexis-
StudyPopulation
tenceofan“obesityparadox”inthispatientpopulation.
TheAmericanCollegeofSurgeons(ACS)NationalSurgical Morbidity risk
(AnnSurg2009F;I2G50U:R1E661–.1O72b)esityclassoddsratiosfor30-day QualityImprovementProgram(NSQIP)isarobustreportingsystem
mortalityandmorbidityafternonbariatricgeneral designedtoprovidereliable,risk-adjustedsurgicaloutcomesdatato
surgeryaregraphed.NormalBMIclasspatients surgicalservicesandadministratorsatmedicalcentersthroughout
areusedasreference.Thegraphshowstheunad- the private sector so that surgical quality can be assessed and
TheprevalejuncsteedofoodbdessirtaytiaomsoanngdatdhueltosdidnsthraetiUonsiateddjuSsttaetdesfohras improvedonanationallevel.22,23Weanalyzedthedatafromthe
beensteadilyincreasingoverthepastseveraldecadessuchthat
over30significantcomorbidandoperativerisk ParticipantUseDataFilecontaining152,490generalandvascular BMI < 18.5
todaynearly1facintoervs.erMyo3rbaidduitlytsisisdoebfienseed(baosd1yomramssoriendoefx2!1BMI" surgicalcasessubmittedtotheACSNSQIPin2005and2006by
#30kg/m2)asnpdenceifaicrlyco1minpleicvaetriyon2s0.adultsismorbidlyobese(BMI 121 hospitals throughout the United States. We excluded patients
#40kg/m2).1Obesityisassociatedwithseveralmedicalcomorbidi-
undergoing vascular and bariatric surgical procedures and those BMI > 35
ties,includingdiabetes,hypertension,andcoronaryarterydisease,
patientsforwhomheightwasnotrecorded.Weanalyzedthedata
andassuchobpeosstiotypehraatsivleoncgombpeleicnactioonnssiadnedreddeaathms.aSjoercornisdk,tfhaectmorajfoorrityoffthroesme themreemllaitiunsinagnd11h8y,p7e0r7tepnsaitoienntasm.ong obese patients and chronic ob-
poor outcomUesstudaifentserlacsdkursgtaeetriyst.ircHalwopwoweveeerrg,iviseegnvethreahilrsremtcae lnlitsassmtupdl eiemssizeosf,eospecrialely dstruactivenpuglmoenaryrdoiseasue asnd catncher-realatend va rioablevs ameongrweight !
wound infections
inthehighestBMIcategories,andgiventhelimitednumberofevDenattsaCounlldeecrwtieoignht patients, the reverse J-shaped relationship between
(ie, deaths and complications) to be analyzed. Third, many of the BMI and 30-day mortality persisted, with the highest rate in the
Fromthe*DepBasrttumdeiMenstoafreISu lrigm>eriyte,d B4ebtyhI0tshreae linDnceluacseoionnesesofMdleadrigcsealnC uemnbtebreraasndorf ipaatpiernettospreTriahctuievneA derCsriwsSkeuiNfgahScrtQtoaIgrnPsd,ctiehnoetlrlaleroocwtpyseesrdta atritatvateeoosvnian r1it3arhb5eeleovsva,erdraiwanbdeulieg3sh0,tc-idannacdeylumpdo oinsdstge-rautelyrgical risks in the future
HarvardMeudnicdaelrgSochinogoll,owBo-rsitsokn,suMrgaessraycihnuswethtisc;hatnhdetihmep†aDcteopfarBtmMenItonofoutcomeis obese. However, this relationship is understandably attenuated
Surgery,UnliveaersstitlyikoeflyKteontbueckdye,mLoexnisntgratotend,.K16e,1n8tu,2c1k,3y2.,38 operativesmomorebwidhiattyafatnedramdjoursttainligtyfoorutthceosmeerisskfofracptaotrise.nAtsnoutnhdeerrlgimoiintagtionof
The American CollegeThofisSsutrugdeoynsovNeartcioonmaelsSusrugcihcalliQmuitaalittiyonIsmpbryovietmsednetsignsausrgaicalporuorcesdtuudryesiisntbheothlacthkeoifnpfoaltlioewnt-2uapn0dboe1yuot7pnad ti3e0ntpsoestttoinpge.raDtiavteadays, 3
Programandptrhoespheocsptiivtael,spmarutlictii-piantsintigtuintiothnealACstSudNySQwIPitharecathreefsuolur3ce0-odfay paatrieentprospseucctihvtehlaytccoomllepclitceadtioinnsawshtiacnhdaarredliizkeedlyftaoshociocnurainccdoerldaiynegdftaoshion,
thedatausedfohlleorewin-.upTheoyfhaavelanrgoetvperoifipeudlaatinodnaroefnoptarteiespnotsnsiubnledeforrgothieng gensterriaclt defisnuicthioanssinbcyisidoendalichaetrendiass,uargreicnaoltcclaipntiucraeld.nurse reviewers.
statistical validity of the data analysis or the conclusions derived by the
authors. surgery. Given the prospective collection of data in standardPiazetidents are folTlohweefidndtihngrotuhgahtouuntdetrhweeirighhtosppaittieanltscouunrdseergaonindganfotnerbariat-
Reprints:JohnTf.aMshuilolenn,bMyDin,dFeApCeSn,dDenetpanrutmrseentroefvSieuwrgeerrsy,aHnadrvcaordmMpleedteicaplatientdifsocl-hargerifcrogmenetrhaelshuorsgpeirtyalhauvpetaon3e0arldya2y-sfopldositnocpreeraasteidverliysk. oNfumrsoertality
School,BethloIwsr-auelp,DoeuacroonuetscsoMmeedsicdaaltCaeanrteerv,e3r3y0rBelrioaobkllein.eMAovree.o,vSetor,noe-uranarleyvsiisewerscocmolpleacretddawtaithfronmormcoaml wpuetiegrhitzepdataienndtspaistiennott’sunpeaxppeercmteedd.-These
man912,Boisstowne,lMl-pAo0w2e2r1e5d.Eb-ymtahile:[email protected],000patientisc,aolfrecorpdast,iednotcstaorre’sooffcfiocuersreecmoorsdts,likaneldytteolehpahvoenseufifnetreerdviaewrescewnitthweight
CISoSpNyr:ig0h0t03©-429030w29/h0b9oy/m2L50mip0po1ir-ne0c1ot6ht6tanW4il1li,a0m0s0&areWoilbkeinsseandmorethan9000aremorbpiadtliyents.lTohsseoafcc!u1ra0c%y oafndbordeyprwodeuigchibtialintyd toofhthaveedlaotwaehramveeabneealnbumin
DOI:10.1097/SLoAbe.0sbe0.1I3ne3a1d81daitdi8o9n3,5given that the data were collected fromp1re2v1iouslylevdeelms,obnostthratoefd.2w2–h2ic5h are well-known risk factors for adverse
differentmedicalcentersthroughouttheUnitedStatesandthefact surgicaloutcomes.41–43Underweightpatientssufferfromprotein-
thatwehavepublishedsimilarresultsconcerningtheimpactofBMI energymalnutrition,andthismajoraberrationinenergymetabolism
166 | wwwo.annpnearilospoefrsautirvgeeoryu.tccoommesinalargecohortofpatientsundergoing AnannadlsthoefSmuarlgneoruyris•heVdosltuamteeits2e5lf0,leNadumtobiemrp1a,ireJudlyim2m00un9ologic
vascularsurgery,39thefindingsofthisstudyarealmostcertainly response mechanisms. Patients with a BMI !18.5 kg/m2 who
generalizabletothepopulationatlarge. require general surgical procedures, especially those with recent
Themainlimitationofourstudyistheunavoidablefactthat weightlossandhypoalbuminemia,shouldperhapsreceiveashort
thepatientsgroupedaccordingtoBMIclassarenotcomparablein courseofperioperativenutritionalsupplementationinaneffortto
terms of their major independent risk factors for postoperative reducethisincreasedriskofpostoperativemortality.44,45
complicationsanddeath.Thisreflectsthecomplexityoftheinter- Thefactthatoverweightandmoderatelyobese(BMIclassII)
actions associated with BMI as a single clinical variable. We patientsundergoingnonbariatricgeneralsurgeryhavea“reduced”
initiallyadjustedforthosevariablesthatshouldtrulybeconsidered riskofpostoperativedeathisperhapsanunexpectedfindingofthis
independentofBMI—age,gender,andthecomplexityoftheoper- study.Conventionalwisdomamongphysiciansandsurgeonsisthat
ativeprocedure.Althoughevenafteradjustingforthoseriskfactors obesityanditsattendantmedicalcomorbiditiesmakesurgicalpro-
whichwedeemedtobeinherenttotheBMIclass,suchasdiabetes ceduresmorerisky,andthattheobesestateitselfmakestheconduct
170 | www.annalsofsurgery.com ©2009LippincottWilliams&Wilkins
The European Society for Perioperative Care of the Obese Patient
Key points to remember in anaesthesia
for the morbidly obese patient.
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight • 10% pre operative body weight reduction is important
(TBW) on operating list. If central obesity (weight >half if visceral obesity. Improves respiratory function and
height), look for metabolic syndrome. laparoscopic surgical access.
• Metabolic syndrome = visceral obesity plus diabetes, • “STOP BANG ”questionnaire ≥ 5 or Obesity
dyslipidaemia, hypertension. These are the high risk patients. Hypoventilation Syndrome (OHS) (paCO2 >45mmHg)
• Atrial fibrillation, long QT, heart failure, pulmonary -> regional or opioid free anaesthesia or postoperative
hypertension or a cardiomyopathy? CPAP.
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or • Mallampati and large neck circumference = difficult
bag under thorax. laryngoscopy /intubation.
• Pre-oxygenation and 10 cmH2O CPAP until the • Facemask ventilation is frequently problematic –needs
intubation. two hands ventilation and airways.
• Know the correct dosing scalars for induction agents and • Avoid laryngeal and supraglottic devices, endotracheal
muscular relaxants. tubes should be the default airway.
3. Key points in anaesthesia maintenance.
• Lung recruitment maneuvers after intubation followed by • Prefer loco regional anaesthesia. Avoid long working
sufficient PEEP even when oxygen saturation is normal. sedatives and opioids.
• Lung protective ventilation and beach chair position • Monitor the neuromuscular blockade (TOF and PTC ) to
when possible. provide sufficient depth if use neuromuscular blocking agents.
• Prefer water-soluble short acting drugs that are easy to • Monitoring anaesthesia depth limits the anaesthetic load
dose and to monitor. and avoids awareness.
4. Key points in anaesthesia emergence.
• Use Pressure Support Ventilation and evaluate breathing (if needed follow with recruitment).
frequency. • Extubation under CPAP in beach chair position when
• Be sure to have full neuromuscular blockade reversal. fully awake.
• Empty stomach and avoid suctioning endotracheal tube • Avoid sedation and use the lowest level of opioids.
5. Key points in postoperative care.
• Continue with CPAP mask if used before surgery. tromboprophylaxis.
• Beach chair position or better sitting up to 60°. • Look for SpO2 desaturations and hypercarbia.
• Sufficient pain and PONV treatment. • Be aware of rhabdomyolysis when prolonged surgery in
• Promote early mobilization and provide the sitting position.
Key points to remember in anaesthesia for the morbidly obese patient © www.Espcop.org 2017 4
Claire Nightingale, Michael Margarson, Paolo Pelosi, Thomas Gazynski, Luc de Baerdemaeker, Jan Mulier
Anaesthesia 2015, 70, 859–876 doi:10.1111/anae.13101
Guidelines
Peri-operative management of the obese surgical patient 2015
Association of Anaesthetists of Great Britain and Ireland
Society for Obesity and Bariatric Anaesthesia
Members of the Working Party: C. E. Nightingale,1 M. P. Margarson,1 E. Shearer,1 J. W. Redman,1
D. N. Lucas,2 J. M. Cousins,1 W. T. A. Fox,1 N. J. Kennedy,1 P. J. Venn,3 M. Skues,4 D. Gabbott,5
U. Misra,2 J. J. Pandit,7 M.T. Popat6 and R. Griffiths (Chair)7
1 Society for Obesity and Bariatric Anaesthesia, 2 Obstetric Anaesthetists’ Association, 3 Royal College of Anaesthetists,
4 British Association of Day Surgery, 5 Resuscitation Council (UK), 6 Difficult Airway Society, 7 Association of Anaesthe-
tists of Great Britain & Ireland
Summary
Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery
for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The
advice presented is based on previously published advice, clinical studies and expert opinion.
.................................................................................................................................................................
This is a consensus document produced by expert members of a Working Party established by the Association of
Anaesthetists of Great Britain and Ireland and the Society for Obesity and Bariatric Anaesthesia. It has been seen and
approved by the elected Board/Council of both organisations. All AAGBI guidelines are reviewed to ensure relevance/
accuracy and are updated or archived when necessary. Date of review: 2020.
Accepted: 10 March 2015
2017 5
(RCOG) have published joint guidance on manage-
• What other guidelines and statements are available
ment of women with obesity in pregnancy [3].
on this topic?
The first Association of Anaesthetists of Great • Why were these guidelines developed?
Britain and Ireland (AAGBI) guidelines on the There is an increased recognition that obese
peri-operative management of the obese patient patients present a different set of challenges and
were published in 2007 [1]. In 2012, a consensus require specific peri-operative care compared with
statement on anaesthesia for patients with morbid non-obese patients. These guidelines are intended
obesity was published by the Society for Obesity to inform anaesthetists about best practice manage-
and Bariatric Anaesthesia (SOBA) [2]. The Centre ment of obese surgical patients throughout the
for Maternal and Child Enquiries (CMACE) and peri-operative period, as members of a multidisci-
the Royal College of Obstetricians and Gynaecologists plinary team.
.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.
©2015TheAuthors.AnaesthesiapublishedbyJohnWiley&SonsLtdonbehalfofAssociationofAnaesthetistsofGreatBritainandIreland 859
Recommendations
1.  Every hospital should nominate an anaesthetic lead for obesity.
2.  Operating lists should include the patients’ weight and body mass index (BMI).
3.  Experienced anaesthetic and surgical staff should manage obese patients.
4.  Additional specialised equipment is necessary.
5.  Central obesity and metabolic syndrome should be identified as risk factors.
6.  Sleep-disordered breathing and its consequences should always be considered in the obese.
7.  Anaesthetising the patient in the operating theatre should be considered.
8.  Regional anaesthesia is recommended as desirable but is often technically difficult and may be impossible
to achieve.
9.  A robust airway strategy must be planned and discussed, as desaturation occurs quickly in the obese
patient and airway management can be difficult.
10.  Use of the ramped or sitting position is recommended as an aid to induction and recovery.
11.  Drug dosing should generally be based upon lean body weight and titrated to effect, rather than dosed to
total body weight.
12.  Caution or avoid the use of long-acting opioids and sedatives.
13.  Neuromuscular monitoring should always be used whenever neuromuscular blocking drugs are used.
14.  Depth of anaesthesia monitoring should be considered, especially when total intravenous anaesthesia is
used in conjunction with neuromuscular.
15.  Appropriate prophylaxis against venous thromboembolism (VTE) and early mobilisation are recommended
since the incidence of venous thromboembolism is increased in the obese.
16.  Postoperative intensive care support should be considered, but is determined more by co-morbidities and
surgery than by obesity per se.
2017 6
REVIEW
WorldJSurg(2016)40:2065–2083
DOI10.1007/s00268-016-3492-3
CURRENT Enhanced recovery after bariatric surgery SCIENTIFICREVIEW
O
PINION
GuidelinesforPerioperativeCareinBariatricSurgery:Enhanced
AdrianAlvareza,BasavanaG.Goudrab,andPreetMohinderSinghc
Recovery After Surgery (ERAS) Society Recommendations
Purposeofreview A.Thorell1•A.D.MacCormick2,3•S.Awad4,5•N.Reynolds4•D.Roulin6•
Enhancedrecoveryaftersurgery(ERAS)methodologyhasdemonstratedconsistentbenefitsinpatients N.Demartines6•M.Vignaud7•A.Alvarez8•P.M.Singh9•D.N.Lobo10
undergoingcolorectal,urologicalandthoracicsurgeries.Principlesoftheseprotocolsandtheiradvantages
areexpectedtoextendintoothersurgicalspecialtiessuchasbariatricsurgery.Inthisreview,we
summarizethecomponentsofERASprotocolsforbariatricsurgeryandpresenttheevidenceonthe
emergingroleofERASprinciplesinobesepatients.
Recentfindings
ManyrecenttrialshaveevaluatedERASprotocolsforbariatricsurgery.Mostoftheseprotocolsoriginate Publishedonline:4March2016
frommodificationswithintheindividualhospital-basedconventionalperioperativecarestrategies.Studies !Socie´te´InternationaledeChirurgie2016
demonstratethat‘ERASbased’carerequiresevidence-basedmodificationsinallpreoperative,
intraoperativeandpostoperativephase.Despitealackofstandardizationinprotocolsatpresent,benefits
suchasdecreasedlengthofhospitalstay,rapidpatientturnover,shorteroperatingroomtimesandlower Abstract
healthcarecostshavebeenwelldemonstratedrepeatedly. Background Duringthelasttwodecades,anincreasingnumberofbariatricsurgicalprocedureshavebeenper-
Summary formedworldwide.Thereisnoconsensusregardingoptimalperioperativecareinbariatricsurgery.Thisreviewaims
ERASforbariatricsurgeryisinitsearlyphase.Nevertheless,literaturesupportsitsroleinimproving topresentsuchaconsensusandtoprovidegradedrecommendationsforelementsinanevidence-based‘‘enhanced’’
perioperativeoutcomescomparedwithconventionalcareinthisscenario.Evidence-basedprotocols, perioperativeprotocol.
multidisciplinaryteamworkandmeticulousauditseemtobethekeyfactorsforsuccessinERAS Methods TheEnglish-languageliteraturebetweenJanuary1966andJanuary2015wassearched,withparticular
methodology. attentionpaidtometa-analyses,randomisedcontrolledtrialsandlargeprospectivecohortstudies.Selectedstudies
Keywords were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a
enhancedrecoveryaftersurgery,enhancedrecoveryaftersurgerybariatricsurgery,obesitysurgeryenhanced consensusrecommendation.
recoveryaftersurgery Results Althoughforsomeelements,recommendationsareextrapolatedfromnon-bariatricsettings(mainlycol-
orectal),mostrecommendationsarebasedongood-qualitytrialsormeta-analysesofgood-qualitytrials.
Conclusions A comprehensive evidence-based consensus was reached and is presented in this review by the
enhancedrecoveryaftersurgery(ERAS)Society.TheguidelineswereendorsedbytheInternationalAssociationfor
MIEoNnrbThiRadnOocbDeedUsirtCeycTaoInvOdeNrsyleaefptearpsnueragery(ERAS)isaprotocol yseeqauresnatviencgosnoomf inceabrelyne4fi0ts00a0re0ldikoelllayrst.oTbheeesvuebn- SeluermgiecnatlsMofettahbeomlisumltimanoddaNluptreirtiioopne(rIaAtiSveMcEaNre)paantdhwbaasyedfoornpathtieenetvsiduenndceergaovianiglabbaleriaintritchesulirtgeerraytu.reforeachofthe
guided, multimodal, multidisciplinary evidence- higherasthecostofERASestablishmentwouldbe
based interventional perioperative approach to incurredprimarilyinthefirstyear.Interestingly,for
majorsurgery.Itsaimistoenhanceperioperative bariatric surgery, Proczko et al. [2&] demonstrated
physiol•o Agvyotidh pursemperdoimcatoiotnin (ngoa snedoaptiotinm) izationoffunc- thatERASprotocolsnotonlyreducedpostoperative
tional recovery. ERAS has consistently shown a recoverytimes,butalsosignificantlyshortenedthe
reductio• Anvionid lperonlgonthgedo ffassttianygandcomplicationsina anesthesia initiation and the surgical procedure
vvaensttivoanr•ia Ienltity‘iafatoesf tthsrutorrmagcbikocpainrlogpp’hryotlahcxeaisdtusrpeas.nUsnplriikmePatrrheiolepyecraottihvneee- dbyupraatsiso.nExftorarpboolathtiosnleoefvethgeiarsftirnecdtionmgsysuagngdesgtsasptorisc- & [email protected] 6 DLaeupsaarntmnee,nStwofitVzeirslcaenrdalSurgery,UniversityHospitalCHUV,
postope• rDaiteitv-meordeicfioedv wereyighfot rredaunctaiocncelerateddischarge, sibilities of rapid operating room turnover saving 1 KarolinskaInstitutet,DepartmentofClinicalSciences, 7 De´partementd’anesthe´siereanimationServicedechirurgie
EtiRvAe,Sinatc•r tPausoaypclhleyorlaoetgniivcceaol ammnopdtiavpastsoioesnstoapnereaxttivenedpehdasperfeoocpuesread- potentiallythe‘exp•• eSMnhinsoiirmvt-aealc’lytoi ninpgve aarsnaievtseit nshuegrtigcresoryomtime. DHaonspdietrayl,ds11H6o9sp1itSatlo&ckhDoelpma,rtSmweendteonfSurgery,Ersta dCilgeermstiovnet,FCeHrrUaneds,taFirnagnc1e,placeLucieetRaymondAubrac,
primarilyonthequalityofrecovery.Thisimprove- • Nonopioid analgesia 2 DepartmentofSurgery,UniversityofAuckland,Auckland, 8 DepartmentofAnesthesia,HospitalItalianodeBuenosAires,
mentinqualitMyutlthisepnecpiarloitym inotetgersataedr eadppurcotaicohninrecov- aHoInstpraitoapleraIttiavleiano de B•u LeoncoosreAgiiroensa,l aBnuaelgnoessicAires, Argentina, NewZealand BuenosAiresUniversity,1179BuenosAires,Argentina
erytimes.Evidencesuggeststhatimplementationof SbDcehpoaorltmofenMteodficAinnee,sHthoesspio •i tslAaoulgvpyoopfiadltenh hmdeyeCpUnorntitt i+hivcee aNrrlsmSiCtyAiaaroIeDfSMPeendnicsiynlvea,nPiae,rePlmhialan- 3 DepartmentofSurgery,CountiesManukauHealth, 9 DepartmentofAnesthesia,AllIndiaInstituteofMedical
EbRutASalp•s oFroulhtlyoa acswoaalksedn/rieorvetecrotsneddl!eysebixrotauobbslaettsioipnmaptiaecnttosanticsofasctt/ipoenr-, Idnesltpithuitae,oPfeMnnesdyilcvaanliSac,iUenScA•e Psa,rnoNdteewccDtiDevpee alhvreit,mnInteidlnaitatioofnAnesthesia,AllIndia 4 AThueckElaanstd-,MNidelwanZdesaBlaanrdiatric&MetabolicInstitute,Derby 10 SGcaisetnrocienst,eNsteinwalDSeulrhgie1ry1,00N2a9t,ioInnadliaInstituteforHealth
fsohromwae••nd LNcutoenhngooa petfixoatpihdadnoess paihontenaiol agenlxeteshroicccfissaEerRse/AsstSreartpvergiocyegsr.amStomneefoetralol.w[1er] CAvoernreidsapoMneddernacneot3o•6 A4H,dFirgiiarshntefAlorlv oaprr,aeCtziA,eHBnoAts, pBsiatuaetlinsItoafsaliaAcnitroeiosdn1e1B7u9e,AnorgseAntirineas., THeoascphitianlg,DHeorsbpyitaDlsE2N2H3SNFEo,uUndKationTrust,RoyalDerby RReesseeaarrcchhNUontitti,nNghoattmingDhiagmestUivneivDerissietayseHsoBspioitmalesdaicnadl
gastro•i nPOteNsVti npraolphsyularxgiseries at a Quaternary MPosetdopiecraatlive Tel:[phone]•; eR-maapili:dta ptoattaiteunn@t gtumranil.coovmer 5 SchoolofClinicalSciences,UniversityofNottingham, UniversityofNottingham,Queen’sMedicalCentre,
Cente•r Eianrlyt hcaethUetSeAr/dlreaaind rsemtoovtahlereductionofhospital CurrOpinAnesth•e sHioela2lt0h17c,a3r0e: 1e3c3o–n1o39mic growth NottinghamNG72UH,UK NottinghamNG72UH,UK
stayby• E0a.r7ly– o2ra.l7 ndutariytisonth avaotidt rNaGn stulabteedintothenetfirst DOI:10.1097/ACO.•0 D00e0c0r0e0a0s0e00d0 c0o4m04plication rates
• Early ambulation
123
0952-7907Copyright!2017WoltersKluwerHealth,Inc.Allrightsreserved. www.co-anesthesiology2.co0m17 7
FIGURE 1. Figure dem Conosptraytrinigghtht e©e l2em0e1n7ts Wanodltceormsp oKnleunwtseorf Henehaanlcthed, Irnecco.v eAryll arifgtehrtssu rgreersyeprrvoetodco.l for bariatric
surgery.
Fromtheavailableevidence,wesuggestthatERAS goalsthatshouldbesetandmetduringthisphase
forbariatricsurgeryshouldhavethefollowinginte- are:
gralparts(Fig.1).
(1) Successfulmedicalmanagementofweight[5&&]
–preferablyaround5%ofweightlossnotonly
PREOPERATIVEPHASE confirms a motivated patient, but also makes
Thiscanberegardedasthepatientenrollmentphase surgerytechnicallyeasierbylivershrinking.
into the programme. Unlike most other surgeries (2) Maintenanceofreducedweightbycomplianceto
whereinthesurgeonisoftentheprimaryandthe dietcontrolthatshouldbearound1200–1500kcal.
only preoperative contact, in ERAS programmes, (3) Multivitamin and micronutrient supplement-
nursing staff, anesthesiologist, psychologist and ationasobesepatientsaremorelikelytohave
nutritionistalsoplayanoutstandingrole. deficienciesduetomalnutritionandpoorsun
ERAS-based preoperative phase can be further exposure(vitaminD)[24].
brokendownintodifferentphases. (4) Smokingcessation–ifapplicable.
(5) Optimizationofassociatedmedicalconditions
–ifapplicable.
Preadmissionphase (6) EvaluationofOSAandinitiationofcontinuous
Thisphaseisnotonly‘educational’,butalso‘moti- positive pressure (CPAP) if needed – studies
vational’.Itspansaperiodof2–3weekspriortothe have shown multiple benefits of early CPAP
dayofadmission forsurgery.Uniquely,theprep- therapysuchasimprovementofmetabolicsyn-
aration for surgery should not be limited to the drome,hypertensioncontrol,lowered risks of
patient,butrathershouldinvolvethefamilyaswell. coronaryarterydiseaseandbetterbloodsugar
It should be kept in mind that an aware family control[25].
is likely to act as the monitor for possible post-
dischargecomplicationsandplaysastrongrolein Thesuccessofthisphaseisbothgovernedand
patient’s rehabilitation both mentally and physi- monitoredbyprescheduledpatientvisits.Frequent
cally.Manybariatricprogrammeshavesuccessfully verbalcommunicationassistedbyaudiovisualaids
incorporated the use of patient and family infor- may help to attain higher degree of success and
mationbrochuresforthispurpose[2&,8,23].Other betterpatientadherencetoERASprotocols.
136 www.co-anesthesiology.com Volume30 Number1 February2017
! !
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
WorldJSurg(2016)40:2065–2083 2067 2068 WorldJSurg(2016)40:2065–2083
Table1 ERASrecommendationsfor(a)preoperative,(b)intraoperativeand(c)postoperativecareinbariatricsurgery Table1continued
Element Recommendation Levelofevidence Recommendationgrade Element Recommendation Levelofevidence Recommendationgrade
(a) Standardised Thecurrentevidencedoesnotallowrecommendationof Low Weak
Preoperative Patientsshouldreceivepreoperativecounselling Moderate Strong anaesthetic specificanaestheticagentsortechniques
information, protocol
educationand Airwaymanagement Anaesthetistsshouldbeawareofthespecificdifficultiesin Moderate Strong
counselling managingbariatricairway
Prehabilitationand Althoughprehabilitationmayimprovefunctionalrecovery, Low Weak Trachealintubationremainsthereferenceforairway Moderate Strong
exercise thereareinsufficientdataintheliteraturetorecommend management
prehabilitationbeforebariatricsurgeryforthereduction
ofcomplicationsorlengthofstay Ventilationstrategies Lungprotectiveventilationshouldbeadoptedforelective Moderate Strong
bariatricsurgery
Smokingandalcohol Tobaccosmokingshouldbestoppedatleast4weeksbefore Smoking:High Strong
cessation sa2ubyrsgetiaenrreysn..cMFeoosrrhepooauvtleidern,bttesheswtrirtiihcstklayohfaidrsehtolearrypesdoeft(oaolrfcoonrheaowtlloaenbasusestte,in Alhcioghho-ql:uLaloitwy(RoCnlTy)one Paaatinbetsnie-tnopcroesboitefiaopcnnhienucghmiaonipraepnroitasoinnttieio-unTmirneginm,dppearleorntvibecusurlpagur,llflmyeoixnneadtrhyheip, Low Weak
patientswithoutearlierabuse)aftergastricbypassshould mechanicsandgasexchange
beacknowledged Neuromuscularblock Deepneuromuscularblockimprovessurgicalperformance Low Weak
Preoperativeweight Preoperativeweightlossshouldberecommendedpriorto Postoperative Strong Ensuringfullreversalofneuromuscularblockadeimproves Moderate Strong
loss bariatricsurgery Patientsonglucose-loweringdrugs complications:High patientrecovery
shouldbeawareoftheriskofhypoglycaemia Postoperativeweightloss: Objectivequalitativemonitoringofneuromuscularblockade Moderate Strong
Low(inconsistency,low improvespatientrecovery
quality) Monitoringof BISmonitoringofanaestheticdepthshouldbeconsidered High Strong
Glucocorticoids Eightmgdexamethasoneshouldbeadministeredi.v., Low(noRCTsinbariatric Strong anaestheticdepth whereETAGmonitoringisnotemployed
preferably90minpriortoinductionofanaesthesiafor surgery) Laparoscopy Laparoscopicsurgeryforbariatricsurgeryisrecommended High Strong
reductionofPONVaswellasinflammatoryresponse wheneverexpertiseisavailable
Preoperativefasting Obesepatientsmayhaveclearfluidsupto2handsolidsup Non-diabeticobese Strong Nasogastrictube Routineuseofnasogastrictubeisnotrecommended Low Strong
to6hpriortoinductionofanaesthesia.Furtherdataare patients:High postoperatively
necessaryindiabeticpatientswithautonomicneuropathy Diabeticpatientswithout Weak Abdominaldrainage Thereisinsufficientevidencetorecommendroutineuseof Low Weak
duetopotentialriskofaspiration Autonomicneuropathy: abdominaldrainage
Moderate
(c)
Diabeticpatientswith Weak
Postoperative Multimodalsystemicmedicationandlocalanaesthetic Multimodalintravenous Multimodalintravenous
autonomicneuropathy:
analgesia infiltrationtechniquesshouldbecombined.Thoracic medication,local medication,local
Low
epiduralanalgesiashouldbeconsideredinlaparotomy anaestheticinfiltration: anaestheticinfiltration:
Carbohydrateloading Whilepreoperativeoralcarbohydrateconditioningin Shortenedpreoperative Strong High Strong
patientsundergoingmajorabdominalelectivesurgeryhas fasting(Non-diabetic
Epiduralanalgesia:Very Epiduralanalgesia:Weak
beenassociatedwithmetabolicandclinicalbenefits, obesepatients):Low
low
furtherdataarerequiredinmorbidlyobesepatients. Diabeticpatientswithout
Similarly,furtherdataareneededonpreoperative autonomicneuropathy: Thromboprophylaxis Thromboprophylaxisshouldinvolvemechanicaland Mechanicalmeasuresin Strong
carbohydrateconditioninginpatientswithgastro- Moderate pharmacologicalmeasureswithLMWH.Dosageand combinationwith
oesophagealrefluxwhomaybeatincreasedriskof durationoftreatmentshouldbeindividualised LMWH:High
aspirationduringanaestheticinduction Diabeticpatientswith DosageofLMWH:Low Weak
autonomicneuropathy:
Low Earlypostoperative Proteinintakeshouldbemonitored.Iron,vitaminB12and Nutritional Strong
nutrition calciumsupplementationismandatory supplementation:
Preoperative
carbohydrateloadingin Postoperativeglycaemicandlipidcontrolhastobestrictin Moderate
obesepatients:Low patientswithdiabetes Glycaemiccontrol:High Strong
(b) Postoperative ObesepatientswithoutOSA,shouldbesupplementedwith Prophylacticoxygen Strong
oxygenation oxygenprophylacticallyinhead-elevatedorsemi-sitting supplementation:Low
Perioperativefluid Excessiveintraoperativefluidsarenotneededtoprevent Maintenanceasopposed Maintenancefluid
positionintheimmediatepostoperativeperiod (onlyretrospectivedata)
management rhabdomyolysisandmaintainurineoutput.Functional toliberalfluid regimens:Strong
parameters,suchasstrokevolumevariationfacilitate regimens:Moderate Positioninginthe Strong
goal-directedfluidtherapyandavoidintraoperative Reducestressresponse: postoperativeperiod:
hypotensionandexcessivefluidadministration. Moderate High
Postoperativefluidinfusionsshouldbediscontinuedas UncomplicatedpatientswithOSAshouldreceiveoxygen High(14RCTsand1 Strong
Opensurgery:High
soonaspracticablewithpreferencegiventouseofthe supplementationinasemi-sittingposition.Monitoringfor meta-analysis)
enteralroute Laparoscopicsurgery: possibleincreasingfrequencyofapnoeicepisodesshould
Moderate bediligent.Alowthresholdforinitiationofpositive
PONV AmultimodalapproachtoPONVprophylaxisshouldbe Low Strong pressuresupportmustbemaintainedinthepresenceof
adoptedinallpatients 2017 signsofrespiratorydistress 8
123 123
WorldJSurg(2016)40:2065–2083 2067 2068 WorldJSurg(2016)40:2065–2083
Table1 ERASrecommendationsfor(a)preoperative,(b)intraoperativeand(c)postoperativecareinbariatricsurgery Table1continued
Element Recommendation Levelofevidence Recommendationgrade Element Recommendation Levelofevidence Recommendationgrade
(a) Standardised Thecurrentevidencedoesnotallowrecommendationof Low Weak
Preoperative Patientsshouldreceivepreoperativecounselling Moderate Strong anaesthetic specificanaestheticagentsortechniques
information, protocol
educationand Airwaymanagement Anaesthetistsshouldbeawareofthespecificdifficultiesin Moderate Strong
counselling managingbariatricairway
Prehabilitationand Althoughprehabilitationmayimprovefunctionalrecovery, Low Weak Trachealintubationremainsthereferenceforairway Moderate Strong
exercise thereareinsufficientdataintheliteraturetorecommend management
prehabilitationbeforebariatricsurgeryforthereduction
ofcomplicationsorlengthofstay Ventilationstrategies Lungprotectiveventilationshouldbeadoptedforelective Moderate Strong
bariatricsurgery
Smokingandalcohol Tobaccosmokingshouldbestoppedatleast4weeksbefore Smoking:High Strong
cessation sa2ubyrsgetiaenrreysn..cMFeoosrrhepooauvtleidern,bttesheswtrirtiihcstklayohfaidrsehtolearrypesdoeft(oaolrfcoonrheaowtlloaenbasusestte,in Alhcioghho-ql:uLaloitwy(RoCnlTy)one Paaatinbetsnie-tnopcroesboitefiaopcnnhienucghmiaonipraepnroitasoinnttieio-unTmirneginm,dppearleorntvibecusurlpagur,llflmyeoixnneadtrhyheip, Low Weak
patientswithoutearlierabuse)aftergastricbypassshould mechanicsandgasexchange
beacknowledged Neuromuscularblock Deepneuromuscularblockimprovessurgicalperformance Low Weak
Preoperativeweight Preoperativeweightlossshouldberecommendedpriorto Postoperative Strong Ensuringfullreversalofneuromuscularblockadeimproves Moderate Strong
loss bariatricsurgery Patientsonglucose-loweringdrugs complications:High patientrecovery
shouldbeawareoftheriskofhypoglycaemia Postoperativeweightloss: Objectivequalitativemonitoringofneuromuscularblockade Moderate Strong
Low(inconsistency,low improvespatientrecovery
quality) Monitoringof BISmonitoringofanaestheticdepthshouldbeconsidered High Strong
Glucocorticoids Eightmgdexamethasoneshouldbeadministeredi.v., Low(noRCTsinbariatric Strong anaestheticdepth whereETAGmonitoringisnotemployed
preferably90minpriortoinductionofanaesthesiafor surgery) Laparoscopy Laparoscopicsurgeryforbariatricsurgeryisrecommended High Strong
reductionofPONVaswellasinflammatoryresponse wheneverexpertiseisavailable
Preoperativefasting Obesepatientsmayhaveclearfluidsupto2handsolidsup Non-diabeticobese Strong Nasogastrictube Routineuseofnasogastrictubeisnotrecommended Low Strong
to6hpriortoinductionofanaesthesia.Furtherdataare patients:High postoperatively
necessaryindiabPeticrpeatie notswpitheaurtonaomticivneuerop awthyeDiiagbethicpta tileontsswitsho:ut Weak Abdominaldrainage Thereisinsufficientevidencetorecommendroutineuseof Low Weak
duetopotentialriskofaspiration Autonomicneuropathy: abdominaldrainage
Moderate
(c)
Diabeticpatientswith Weak
Postoperative Multimodalsystemicmedicationandlocalanaesthetic Multimodalintravenous Multimodalintravenous
autonomicneuropathy:
Should be recommLowended prior to bariatric saunalgregsiaery. infiltrationtechniquesshouldbecombined.Thoracic medication,local medication,local
epiduralanalgesiashouldbeconsideredinlaparotomy anaestheticinfiltration: anaestheticinfiltration:
Carbohydrateloading Whilepreoperativeoralcarbohydrateconditioningin Shortenedpreoperative Strong High Strong
patientsundergoiDngmiaajorbabedomtienalsele:ct ivbeseurg erayhwas afraseting o(Nofn -dhiabyeticpoglycaemia risk
Epiduralanalgesia:Very Epiduralanalgesia:Weak
beenassociatedwithmetabolicandclinicalbenefits, obesepatients):Low
low
fSuirmthilearrldya,tfaurathreer redqautaireadreinnemeodrebdidolnyporbeeospeepraattiiveents. Daiaubtoetniocmpiactineenutsrowpiaththoyu:t Thromboprophylaxis Thromboprophylaxisshouldinvolvemechanicaland Mechanicalmeasuresin Strong
carbohydrateconditioninginpatientswithgastro- Moderate pharmacologicalmeasureswithLMWH.Dosageand combinationwith
oesophagealrefluHxwihgomhay beimatinpcreaasecdrtis kaofnd strong recommendation durationoftreatmentshouldbeindividualised LMWH:High
aspirationduringanaestheticinduction Diabeticpatientswith DosageofLMWH:Low Weak
autonomicneuropathy:
Low Earlypostoperative Proteinintakeshouldbemonitored.Iron,vitaminB12and Nutritional Strong
nutrition calciumsupplementationismandatory supplementation:
Preoperative
carbohydrateloadingin Postoperativeglycaemicandlipidcontrolhastobestrictin Moderate
obesepatients:Low patientswithdiabetes Glycaemiccontrol:High Strong
(b) Postoperative ObesepatientswithoutOSA,shouldbesupplementedwith Prophylacticoxygen Strong
oxygenation oxygenprophylacticallyinhead-elevatedorsemi-sitting supplementation:Low
Perioperativefluid Excessiveintraoperativefluidsarenotneededtoprevent Maintenanceasopposed Maintenancefluid
positionintheimmediatepostoperativeperiod (onlyretrospectivedata)
management rhabdomyolysisandmaintainurineoutput.Functional toliberalfluid regimens:Strong
parameters,suchasstrokevolumevariationfacilitate regimens:Moderate Positioninginthe Strong
goal-directedfluidtherapyandavoidintraoperative Reducestressresponse: postoperativeperiod:
hypotensionandexcessivefluidadministration. Moderate High
Postoperativefluidinfusionsshouldbediscontinuedas UncomplicatedpatientswithOSAshouldreceiveoxygen High(14RCTsand1 Strong
Opensurgery:High
soonaspracticablewithpreferencegiventouseofthe supplementationinasemi-sittingposition.Monitoringfor meta-analysis)
enteralroute Laparoscopicsurgery: possibleincreasingfrequencyofapnoeicepisodesshould
Moderate bediligent.Alowthresholdforinitiationofpositive
PONV AmultimodalapproachtoPONVprophylaxisshouldbe Low Strong pressuresupportmustbemaintainedinthepresenceof
adoptedinallpatients 2017 signsofrespiratorydistress 9
123 123
ERAbS
The European Society for Perioperative Care of the Obese Patient
Key points to remember in anaesthesia
for the morbidly obese patient.
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight • 10% pre operative body weight reduction is important
(TBW) on operating list. If central obesity (weight >half if visceral obesity. Improves respiratory function and
height), look for metabolic syndrome. laparoscopic surgical access.
• Metabolic syndrome = visceral obesity plus diabetes, • “STOP BANG ”questionnaire ≥ 5 or Obesity
dyslipidaemia, hypertension. These are the high risk patients. Hypoventilation Syndrome (OHS) (paCO2 >45mmHg)
• Atrial fibrillation, long QT, heart failure, pulmonary -> regional or opioid free anaesthesia or postoperative
hypertension or a cardiomyopathy? CPAP.
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or • Mallampati and large neck circumference = difficult
bag under thorax. 2017 laryngoscopy /intubation. 10
• Pre-oxygenation and 10 cmH2O CPAP until the • Facemask ventilation is frequently problematic –needs
intubation. two hands ventilation and airways.
• Know the correct dosing scalars for induction agents and • Avoid laryngeal and supraglottic devices, endotracheal
muscular relaxants. tubes should be the default airway.
The European Society for Perioperative Care of the Obese Patient
T3h.e K Eeuyro ppoeiannt sS ionc iaetnya feosrt Pheersiioap emraatiinvete Cnaarnec oef. the Obese Patient
• Lung recruitment maneuvers after intubation followed by • Prefer loco regional anaesthesia. Avoid long working
Key points to remember in anaesthesia
sufficient PEEP even when oxygen saturation is normal. sedatives and opioids.
• Lung protective ventilation and beach chair position • Monitor the neuromuscular blockade (TOF and PTC ) to
Kwheen yposs ibple.oints to remembeprorvid e isunffici enat denpth iaf uese nseurtomhusceulars bliocaking agents.
for the morbidly obese patient.
• Prefer water-soluble short acting drugs that are easy to • Monitoring anaesthesia depth limits the anaesthetic load
dose and to monitor. and avoids awareness.
for the morbidly obese patient.
4. Key points in anaesthesia emergence.
1. Key points in pre operative planning:
• Use Pressure Support Ventilation and evaluate breathing (if needed follow with recruitment).
• f Rreeqcouredn cbyo.dy mass index BMI and total body weight •• E 10x%tu bparteio onp uernadteivr eC bPoAdPy iwn ebiegahct hr ecdhuacirti opno siist iiomnp wohrteann t
1. Key points in pre operative planning:
• B(TeB sWure) oton hoapveer aftuinllg n leisutr.o Imf cuesncutrlaalr obbloesciktyad (ew reeivgehrts >alh. alf fifu lvlyis caewraalk eo.besity. Improves respiratory function and
•• E Rhemeicgpohtrytd) ,s btlooomodkya cfmohar a smns dei ntaadvbeooxil diBc s MsuycInt iadonrndoi mntoget .aeln bdoodtrya cwheeiagl httu be •• A 1la0vp%oaird op ssrceeo dopapitecior sanut iarvgneidc b auols daeyc t chweese slio.g whte rset dleuvcetilo onf ios pimiopidosr.tant
• M(TeBtaWbo) loicn s oypnedrraotmineg = l ivsits. cIef rcael notbreasl iotyb pesluitsy d (iwabeeitgehst, >half • “ifS vTiOscPe rBalA oNbGes i”tyq.u Iemstpioronvneasir ere ≥sp 5ir oatro Oryb efusintcyt ion and
dhyesiglihpti)d,a leomokia ,f ohry pmeertteanbsoiloinc. sTyhnedsreo amree .the high risk patients. Hlaypparoovsecnotpiliact isounr gSicyanld aroccmees s(.O HS) (paCO2 >45mmHg)
5. Key points in postoperative care.
•• A Mtertiaabl ofilbicr islylantdioronm, leo n=g v QiscTe, rhael aorbte fsaitiylu prelu, sp duilamboetneasr, y • “->S TreOgPio BnaAl NorG o ”pqiouieds tfiroenen aaniraee s≥t h5e osira O obr epsoitsyto perative
• hdCyyospnleitpritniedunaese imwoniiat h,o hrC yaPp AcearPtre dmnisoaimoskny .o iTfp huaestsheedy ?abreef tohree hsiugrhg reirsyk. patients. tCHroPymApoPbv.oepnrtoiplahtyiolanx Sisy.n drome (OHS) (paCO2 >45mmHg)
•• ABteraicahl ficbhraiilrl aptioosnit,i olonn ogr Q bTet,t here asrittt finaigl uurpe ,t op u6l0m°o.nary • L->o orekg fioorn aSlp oOr 2o pdieosiadt ufrraetei oannsa easntdh ehsyiap eorrc aprobsitao.perative
• hSyupffierctieennsti opnai onr a an dc aPrdOiNomVy torepaattmhye?nt. • BCeP AawP.are of rhabdomyolysis when prolonged surgery in
• Promote early mobilization and provide the sitting position.
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or • Mallampati and large neck circumference = difficult
K2e.y Kpoeinyts ptoo rienmtesm bienr ian nanaaeesstthheseias ifaor itnhed muocrbtiidolyn o.bese patient © www.Espcop.org
bag under thorax. laryngoscopy /intubation.
Claire Nightingale, Michael Margarson, Paolo Pelosi, Thomas Gazynski, Luc de Baerdemaeker, Jan Mulier
•• P HrEe-LoPx:y3g0e dneagtiroene ahneda d1 0u pc mpoHsi2tOio nC, PaAddP ruanmtipl itnhge device or •• F Maaclelmamaspka tvi eanntdil alatirogne inse fcrke qcuirecnutmlyf eprreonbcleem =a dtiicffi –cnuelet ds
ibnatgu buantdioenr .thorax. tlwaroy nhgaonsdcso vpeyn /tiinlatutiboant iaonnd. airways.
•• K Prneo-owx ythgee n caotirorenc at nddo s1i0n gc mscHal2aOrs CfoPrA inPd uuncttiilo tnh ea gents and •• A Favcoeidm laasrky nvgeenatill aatniodn s uisp rfaregqloutetnict ldye pvriocbesle, menadtioct r–anceheedasl
minutusbcautliaorn r.elaxants. ttuwboe sh asnhdosu lvde bneti ltahteio dne faanudl ta airiwrwaayys..
• Know the correct dosing scalars for induction agents and • Avoid laryngeal and supraglottic devices, endotracheal
muscular relaxants. tubes should be the default airway.
3. Key points in anaesthesia maintenance.
• Lung recruitment maneuvers after intubation followed by • Prefer loco regional anaesthesia. Avoid long working
3. Key points in anaesthesia maintenance.
sufficient PEEP even when oxygen saturation is normal. sedatives and opioids.
•• L Luunngg prercortueicttmiveen vt emnatinlaetuivoenr as nadft bere aincthu cbhaatiior np ofosliltoiowne d by •• M Proenfeitro rl othceo nreeugrioomnauls caunlaare sbtlhoecskiaad.e A (vToOiFd alonndg P TwCo r)k tion g
wsuhfefinc ipeonst sPibElEe.P even when oxygen saturation is normal. psreodvaitdiev esus fafincdie notp dioepidths .i f use neuromuscular blocking agents.
•• P Lruenfger p wroatteecrt-isvoel uvbelnet islhaotirot na catnindg b dearucghs c thhaaitr aproes eitaiosyn to •• M Moonniitotor rtihneg n aenuaroemstuhsecsuiala rd belpotchk laidme i(tTs OthFe a annda PeTstCh e)t tioc load
dwohseen a pnods tsoib mleo.nitor. parnodv iadveo siudfsfi caiwenatr deenpetshs .if use neuromuscular blocking agents.
• Prefer water-soluble short acting drugs that are easy to • Monitoring anaesthesia depth limits the anaesthetic load
dose and to monitor. and avoids awareness.
4. Key points in anaesthesia emergence.
• Use Pressure Support Ventilation and evaluate breathing (if needed follow with recruitment).
4. Key points in anaesthesia emergence.
frequency. • Extubation under CPAP in beach chair position when
•• B Ues es uPrree stsou hrea vSeu fpuplol rnte Vueronmtiluasticounl aarn bdl oecvkaaludaet ere bvreerastahli.n g f(uifl lnye eadweadk efo.llow with recruitment).
• Efrmeqputeyn sctyo.mach and avoid suctioning endotracheal tube •• A Evxotuidb asteiodna tuionnd earn dC PuAseP t hine bloewacehs tc lheavier lp oofs iotpioioni wdsh.en
• Be sure to have full neuromuscular blockade reversal. fully awake.
• Empty stomach and avoid suctioning endotracheal tube • Avoid sedation and use the lowest level of opioids.
5. Key points in postoperative care.
• Continue with CPAP mask if used before surgery. tromboprophylaxis.
5. Key points in postoperative care.
• Beach chair position or better sitting up to 60°. • Look for SpO2 desaturations and hypercarbia.
•• SCuofnfitcinieunet wpaitihn CanPdA PP OmNasVk tirfe uatsmede nbte. fore surgery. • Btroe mawboaprero opfh ryhlaabxdiso.m yolysis when prolonged surgery in
•• PBreoamcho tceh eaairr lpyo msitoiboinl iozar tbioentt earn sdi tptirnogv iudpe to 60°. • Lthoeo ski tftoinrg S ppoOs2it idoens.aturations and hypercarbia.
• Sufficient pain and PONV treatment. • Be aware of rhabdomyolysis when prolonged surgery in
• Promote early mobilization and provide the sitting position.
Key points to remember in anaesthesia for the morbidly obese patient © www.Espcop.org
Claire Nightingale, Michael Margarson, Paolo Pelosi, Thomas Gazynski, Luc de Baerdemaeker, Jan Mulier
Key points to remember in anaesthesia for the morbidly obese patient © www.Espcop.org
Claire Nightingale, Michael Margarson, Paolo Pelosi, Thomas Gazynski, Luc de Baerdemaeker, Jan Mulier