Quale anestesia per l’obeso


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Anesthesia choice in the obese patient

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Quale anestesia per l’obeso

  1. 1. Quale anestesia per l’obeso? C.Melloni Libero professionista
  2. 2. • „Let me have men about me that are fat“ (Caesar in „The Tragedy of Julius Caesar“, Act 1, Scene II, A Public Place. Von William Shakespeare, 1564–1616)
  3. 3. Ringraziamenti Grazie a Mario Tedesco (Casa di cura accreditata SSn San Michele ,Maddaloni (CE) e Peppe che mi hanno consentito di mostrare le loro immagini delle tecniche loco regionali .Raccomando a tutti di visitare il loro sito e di andare a incontrarli di persona!
  4. 4. An Update on Best Practice Guidelines for Specialized Facilities and Resources Necessary for Weight Loss Surgical Programs David B. Lautz, Michael E. Jiser, John J. Kelly, Scott A. Shikora, Sheila K. Partridge,John R. Romanelli, Robert J. Cella and John P. Ryan. Obesity (2009) 17, 911–917. doi:10.1038/oby.2008.581. • The objective of this study is to update evidence-based best practice guidelines for specialized facilities and resources for weight loss surgery (WLS). We performed systematic search of English-language literature on WLS and facilities, equipment, and resources published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. Evidence-based best practice recommendations from the most recent literature on specialized facilities and resources for WLS were developed. We identified 1,647 papers in our literature search; the 46 most relevant were reviewed in detail. Regular updates of evidencebased recommendations for best practices in facilities and resources for WLS are required to address technology advances and growing recognition of the need for adequate equipment and specially built nursing units. Key factors in patient safety include availability of trained personnel and specialized equipment for the care of extremely obese WLS patients.
  5. 5. Personnel • • • • • • Physician director of weight loss surgery program • Weight loss surgery program coordinator • Multidisciplinary team, including available medical subspecialists • Nutritionists with experience with bariatric surgical patients • Critical care coverage 24 h a day/7 days a week • All staff credentialed as specified in recommendations from the Surgical Care, Anesthesia Perioperative Care, Behavioral and Psychological • Care, and Nursing Perioperative Care task groups • • Mandatory sensitivity training for all clinical and nonclinical staff who interact with weight loss surgery patients
  6. 6. Equipment • • • • • • • • • • • • • • In-patient units (floor, ICU, PACU) ○ Wide beds ○ Standard to 440 lb ○ Automated/adjustable to full sitting position ○ Low air-loss mattress • Lifting/transferring equipment • Wide commodes • Wide wheelchairs, stretchers, walkers • Monitoring devices • Wide blood pressure cuffs • Biphasic defibrillators • Sequential compression devices • Emergency airway equipment
  7. 7. ROOMS: • Ambulatory facility • • Wide examination tables, bolted to floor • • Appropriately sized scales • • Wide waiting room chairs of appropriate weight tolerance • Operating room • • • • • • • • • Automated wide operating table ○ Appropriate weight capacity • Lifting/transferring equipment • Mechanical venous compression devices appropriate for the extremely obese • Instruments ○ Extra-long abdominal instrument sets ○ Appropriately sized retractors ○ 43–46 cm laparoscopes
  8. 8. • Radiology • • • • Automated wide tables with appropriate weight capacity • CT, MRI, and interventional capability within 60 min ○ 400 lb capacity • Physical Plant • • • • • • Dedicated floor for weight loss surgery patients • Weight-appropriate facilities in PACU and ICU • Wide entrance doors to rooms and bathrooms • Floor-mounted or reinforced toilets • Elevators with wide doors and adequate weight capacity • Patient safety • • • • • • Personnel ○ Physician director of bariatric program ○ Designated hospital administrator ○ Critical care coverage 24 h a day/7 days a week • Executive walkrounds
  9. 9. • Staff Safety • • • • • • Size-appropriate portable transfer equipment ○ Readily available ○ Familiar to staff • Established plans for transferring of the extremely obese patient ○ Staff educated on plans and methods of avoiding injury • Medication error reduction • • • • • • Follow 2004 JCAHO medication management standards • Sentinel event reporting system • Pharmacy and Therapeutics Committee to establish dosing guidelines • Computerized order entry • Automated medication administration system • Systems improvements • • • • • • Critical pathways • Weight loss surgery database, tracking patient outcomes Credentialing requirements • See Surgical Care, Anesthesia, and Nursing task group reports • Establish criteria for credentialing in emerging technology (see Endoscopic Interventions Task Group report)
  10. 10. Table 2: Optional recommendations • • • • • • • • • • • • • • • • • • • Equipment • Wide beds. Available to 880 lb • Ceiling-mounted transferring equipment • Wireless monitoring system • Selective cardiac and apnea telemetry Ambulatory facility • Wide automated examination tables Operating room • Designated operating room • Ceiling-mounted lifting/transferring equipment Radiology • High-weight capacity (600 lb) CT and MRI scanners Physical plant • Follow American Institute of Architects’ guidelines for design of any new health-care facility accommodating weight loss surgery patients Staff safety • Dedicated on-call lift team Medication error • Adopt barcode technology for medication administration
  11. 11. • • • • • • • • • • • • • • • • • • Operating room • Specially equipped operating room and ancillary equipment, including. • An automated extra-wide operating table with appropriate weight capacity. • Extra-long abdominal instrument sets. • Appropriately sized retractor. • 43–46 cm laparoscopes. Radiology equipment • Special diagnostic and interventional equipment. Such equipment should include • CT scanners with 400 lb weight capacity. • MRI magnet with 400 lb weight capacity. • Fluoroscopic equipment with 300 lb capacity that can study patients in a standing position with high-beam voltages. • Interventional facilities available 24 h a day, 7 days a week.
  12. 12. • The American Institute of Architects has established guidelines for planning and designing WLS health-care facilities (16). • These specify a barrier-free environment that avoids stairs and provides ramp access when possible. They set minimal clearances for rooms that will accommodate WLS patients, including operating rooms, and address appropriate-sized in-patient rooms, postanesthesia care units, and morgues. The guidelines set clearance for a floor-mounted toilet at 5 ft, and weight ratings for toilets and sinks at 700 lb and 300 lb, respectively. They also address increased storage requirements for WLS-related equipment
  13. 13. Generale o regionale? AG • controllo vie aeree e ventilazione:difficoltà? • dosaggi • Miorisoluzione? • Urgenza • All afine però: – Respirazione spontanea:TOFR>0.90 – Antagonismo – Analgesia postop?Multimodale Regionale • Risparmio delle vie aeree • • • Reperi difficili Possibile spostamento ago,catetere Possibile conversione in AG!!! • Possibile estensione nel postop
  14. 14. Top tips per anest regionale • Non fare promesse avventate • Tieni sempre in serbo un piano di riserva • Non forzare la vendita della anestesia regionale sostenendo che la generale è “terribile”:cosa dirai in caso di fallimento? • Tieni sempre pronto tutto per AG e vie aeree • Precarico liquidi?vasopressori ? • Circondati di spazio • Il Tuohy potrebbe essere un valido introduttore per l’ago spinale
  15. 15. Difficile???...trovate i repere ossei….
  16. 16. Vantaggi della combinata CSE: • Onset rapido • Dosaggi minori di AL • Possibilità titolazione(dopo inserimento del catetere) • Prolungamento analgesia • Oppioidi non necessari
  17. 17. Ossigenazione e capnometria
  18. 18. Ricorda alcuni punti nella MO: • • reperi: difficili da palpare ;US? • • piccoli errori direzionali incrementati dalla lunghezza dell’ago • Catetere almeno 5 cm nello spazio epid.
  19. 19. Problemi • • • • • • elevata incidenza di fallimenti – epid fallita Blocco unilat Più tentativi Comfort/discomfort del paziente ;ampia infiltrazione (con adr).
  20. 20. Opzioni • • iniezione liquorale;intenzionale –“ “ ;non intenzionale: – Spinale continua? – Anestetico locale diluito & oppioide per analgesia nel parto? – • 2ml/hr of 0.1%-0.125 % bupivacaine with fentanyl 2mcg/cc(catet 23 g) • – LA + concentrato per CS • • 1-1.5 ml 0.5% bupivacaine iperb+ fent 20mcg • • attenzione alla PDPH
  21. 21. Additional Points to Remember:  problemi tecnici:manicotto pressione da obeso ,ma ;cateterizzazione diretta arteria radiale forse meglio .titolazione AL Tratatmento dolore postop Protocolli profilassi DVT ;adeguamento dei dosaggi
  22. 22. Spinale •  elevata incid.ipotens: – Blocco autonomico alto e variabile • Deviazione pelvica:pericolo di danno al cone medullare • Possibile ipossiemia • Nella puntura singola:svantaggi nella chirurgia prolungata – Adiuvanti – Cateterizzazione liquorale?
  23. 23. Pelvic tilt
  24. 24. Danno al conus medullaris
  25. 25. Analgesia postop • Analgesia peridurale continua – Consente di evitare oppioidi • Analgesia perineurale – Selettiva, – Minor coinvolgimento emodinamico e respiratorio • PCA – Dosaggi basati su IBW –Multimodale:
  27. 27. Ostetricia? • Halpern et al.Conversion of epidural labour analgesia to anesthesia for CS.Br.J.Anaesth dec 9 2008. • Technique: • epid only;bupi 0.08-0,125 % 10-20 ml • CSE:bupi 1.25-2.5+sufent 5 microgr • Both + + cont infus 5-10 ml/h bupi 0.08+fent 2 microgr/ml.PCA lockout 10 min,bolus 5 ml • For C/S:18 ml lidoc 2%+adr 1:200.000 • Conversion 4.1%:71% of them intraop • Factors for epid failure in theatre: – maternal height(not weight!!!) – more than one clinician top up; – almost P:multiple initial attempts,last cervical dilation before <,FHR abnoprmalities,duration of labour analgesia(shorter)
  28. 28. L’obesità è una epidemia con conseguenze allarmanti • Obesità presente nel 35% delle morti materne (UK CEMACH 2000-2002) • La prevalenza dell’obesità è raddoppiata nelle maternità UK • Quasi tutte le morti materne del CEMACH 2003-2005 hanno obesità come fattore contributorio
  29. 29. PLoS One. 2011;6(12):e29077. Epub 2011 Dec 28. Risk factors for progression from severe maternal morbidity to death: a national cohort study. Kayem G, Kurinczuk J, Lewis G, Golightly S, Brocklehurst P, Knight M. • national cohort analysis using data from two sources obtained between 2003 and 2009: the Centre for Maternal and Child Enquiries maternal deaths database and the United Kingdom Obstetric Surveillance System database. • Pazienti incluse: eclampsia, antenatal pulmonary embolism, amniotic fluid embolism, acute fatty liver of pregnancy , antenatal stroke. • 42% of direct maternal deaths over the study period. • 476 women who survived and 100 women who died • Maternal death was associated with . – older age (35+ years (OR 2.36, 95%CI 1.22-4.56), – black ethnicity (OR 2.38, 95%CI 1.15-4.92) – unemployed, routine or manual occupation (aOR 2.19, 95%CI 1.034.68). – An association was also observed with obesity (BMI≥30 kg/m(2) (OR 2.73, 95%CI 1.15-6.46).
  30. 30. Acta Obstet Gynecol Scand. 2011 Nov 29. doi: 10.1111/j.16000412.2011.01331.x. [Epub ahead of print] Mortality in infants of obese mothers: is risk modified by mode of delivery? Nohr EA, Villamor E, Vaeth M, Olsen J, Cnattingius S. and population. A total of • 1 199 183 singletons, including 3481 infant deaths, from the Swedish Birth Register 1992-2006. • Register-based cohort study. Setting • Infant mortality increased with : • increasing maternal fatness [adjusted hazard ratios 1.2 for overweight (1.1-1.3), 1.4 for obesity (1.2-1.6), 2.1 for extreme obesity (1.8-2.5) • When accounting for mode of delivery, • neonatal mortality was increased in infants of obese and extremely obese mothers after spontaneous births [adjusted hazard ratios 1.8 (1.4-2.4) and 2.6 (1.8-4.0), respectively, after term births, • 1.4 (1.1-1.9) and 2.2 (1.5-3.3), respectively, after preterm births].
  31. 31. Proc Nutr Soc. 2011 Nov;70(4):450-6. Epub 2011 Aug 31. The consequences of obesity and excess weight gain in pregnancy. Norman JE, Reynolds RM • . • • • • • • • obesity is associated with an increased risk of : maternal mortality, gestational diabetes mellitus, thromboembolism, pre-eclampsia postpartum haemorrhage. Obesity also complicates operative delivery; it makes operative delivery more difficult, increases complications and paradoxically increases the need for operative delivery. • Risk proportional to the weight increase • hyperglycaemia and insulin resistance
  32. 32. Hum Reprod. 2011 Jun;26(6):1501-11. Epub 2011 Apr 5. Maternal body mass index and the risk of fetal and infant death: a cohort study from the North of England. Tennant PW, Rankin J, Bell R • Early pregnancy obesity (body mass index, BMI, ≥ 30 kg/m(2)) and risk • of fetal and infant death in pregnancies not affected by congenital anomalies or pregestational diabetes. singleton pregnancies delivered during 2003-2005 at five hospitals were linked with data from three regional registers: the Northern Perinatal Mortality Survey, the Northern Diabetes in Pregnancy Survey and the Northern Congenital Abnormality Survey. • Obese women were at significantly increased risks of : • fetal death [aOR = 2.32 (95% confidence interval: 1.64-3.28), P< 0.001] • infant death [aOR = 1.97 (1.13-3.45), P= 0.02]. • Continuous analyses revealed a V-shaped relationship between BMI and the risk of fetal and infant death, with a minimum risk at 23 kg/m(2), and significantly increased risk thereafter for both fetal death [aOR, per unit = 1.07 (1.05-1.10), P< 0.001] and infant death [aOR, per unit = 1.06 (1.02-1.10), P= 0.007]. No significant excess risks, however, were identified for either maternal underweight [fetal death: aOR = 0.98 (0.42-2.25), P= 0.96; infant death: aOR = 1.89 (0.73-4.88), P= 0.19] or maternal overweight [fetal death: aOR = 1.34 (0.94-1.89), P= 0.10; infant death: aOR = 1.35 (0.79-2.32), P= 0.27] as categories. Except for higher rates of pre-eclampsia among stillbirths, no specific cause of death could explain the increased odds of fetal and infant death among the obese.
  33. 33. J Matern Fetal Neonatal Med. 2011 Sep;24(9):1088-94. Epub 2011 Jan 21. The impact of obesity on maternal morbidity and feto-infant outcomes among macrosomic infants. Salihu HM, Weldeselasse HE, Rao K, Marty PJ, Whiteman VE. • A population-based retrospective cohort design using State of Missouri maternally linked birth cohort files. • mothers of 116,976 singleton macrosomic live births as non-obese (BMI < 30) or • • • • • • • • • • • • obese (BMI ≥ 30). We used logistic regression models to generate adjusted odd ratios for pregnancy and neonatal complications. We also estimated the proportion of potentially preventable excess maternal and neonatal complications that could be eliminated among obese women with infant macrosomia at various levels of pre-pregnancy obesity reduction. RESULT: Obese mothers with macrosomic infants were at elevated risk for: chronic hypertension (odds ratio (OR) = 6.78 [95% confidence interval (CI): 5.82-7.88]), insulin-dependent diabetes mellitus, (OR = 2.60 [CI: 2.34-2.88]) other types of diabetes mellitus (OR = 2.83 [CI: 2.65-3.02]) preeclampsia (OR = 2.49 [CI: 2.33-2.67]). Macrosomic infants of obese mothers were at greater risk for: hyaline membrane disease (OR = 2.14 [CI: 1.73-2.66]), extended assisted ventilation (OR = 1.71 [CI: 1.44-2.04]), birth injury (OR = 1.58 [CI: 1.37-1.84]) meconium aspiration syndrome OR = 1.42 [CI: 1.09.87]). The proportion of preventable excess maternal morbidity was 60%, 45%, 30% and 15%, assuming an effective pre-conception intervention that could reduce obesity down to 0%, 25%, 50% and 75% of its current level, respectively. The corresponding proportion of preventable excess neonatal complications would be 40%, 30%, 20% and 10%, respectively.
  34. 34. For ICU I suggest: • Crit Care Clin. 2010 Oct;26(4):715-31. • Special populations critical care considerations of the morbidly obese pregnant patient. • Baldisseri MR, Larkins-Pettigrew MD. • • • • Source Department of Critical Care Medicine, University of Pittsburgh Medical Center, 613 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15238, USA. baldisserimr@ccm.upmc.edu Abstract The critically ill pregnant patient poses a unique challenge to the clinician, requiring a thorough understanding of normal and abnormal maternal and fetal physiology associated with pregnancy. The morbidly obese patient presents even greater challenges to the clinician, and morbidity and mortality are proportionately increased. Because increased numbers of obese pregnant women are now admitted to intensive care units, practitioners must be aware of the physiology associated with both pregnancy and obesity. A multidisciplinary approach is imperative to prevent both maternal and fetal morbidity and mortality for these very complex patients, especially when they are admitted to the ICU with critical illness.
  35. 35. Vantaggi dei blocchi periferici
  36. 36. Dove è il collo?????
  37. 37. Dove è il collo???
  38. 38. Però un po’ si vede lo SCM…
  39. 39. Supraclavicular Block in the Obese Population: An Analysis of 2020 Blocks Carlo D. Franco, Feodor J. Gloss, Gennadiy Voronov, Serge G. Tyler, Ljuba S. Stojiljkovic.Anesth Analg 2006;102:1252–4) • • Regional anesthesia in the obese patient can be challenging and possibly carries a greater failure rate as compared with that in the non-obese patient. We retrospectively reviewed our prospectively gathered peripheral block data to determine the influence of body weight on success rate of the supraclavicular block. Obesity was defined as body mass index>30. • The overall success rate was 97.3% in nonobese and 94.3% in obese patients (P 0.01). • • • Residents completed 80% of the blocks in nonobese patients and 73% in obese patients (P 0.01). No difference in acute complications was observed. Obesity is associated with a slight decrease in success rate of supraclavicular block and an increase in its relative difficulty without apparent effect on acute complications. (
  40. 40. • Less success in obese pts ( ref 4–8). • • • • • Nielsen K, Guller U, Steele S, et al. Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks. Anesthesiology 2005;102:181–7. Fisher A, Waterhouse TD, Adams AP. Obesity: its relation to anaesthesia. Anaesthesia 1975;24:208–16. Greengrass R, Steele S, Moretti G. Peripheral nerve blocks. In: Raj PP, ed. Textbook of regional anesthesia. New York: Churchill Livingstone, 2002:325–77. Vincent RD, Chestnut DH. Analgesia during labor and delivery.In: Brown DL, ed. Regional anesthesia and analgesia.Philadelphia: W.B. Saunders Company, 1996:587–608. Leith P, Sanborn R, Brock-Utne JG. Intraoperative epidural catheter malfunction in two obese patients. Acta Anaesthesiol Scand 1997;41:651–3. • every consecutive supraclavicular block used for anesthesia between February 1996 and April 2003. • Our database contains demographic and technical information entered contemporaneously with every case according to a preestablished protocol. • The type of response elicited with the nerve stimulator was added to the original protocol a few months after the database was started; thus, it was • present in 1732 of 2020 cases (86%), being the only data in the protocol not available in 100% of the cases. • No supraclavicular block performed for surgical anesthesia was excluded for
  41. 41. • • • • • • • • • • • • We graded our block results in the following manner: good sensory block of the upper extremity distal to the shoulder developed within 30 min from the injection or before surgical incision (if it took place earlier) and was the only anesthetic used for the surgical procedure; partial local anesthetic supplementation was required at some point, either by the surgeon or anesthesiologist; and failure general anesthesia was required. Responses were grouped into ‘fingers‘ (flexion or extension), ‘wrist‘ (flexion or extension), and ‘other.‘ This last group included supination and pronation.
  42. 42. AG • Posizionamento:ramped – Oltre alle precedenti:riduzione del rischio del reflusso gastroesofageo e aspirazione • Preossigenazione • CPAP • reclutamento
  43. 43. Do Patients with Obstructive Sleep Apnea have an Increased Risk of Desaturation During Induction of Anesthesia for Weight Loss Surgery?The Open Respiratory Medicine Journal, 2010, 4, 58-62.Matthias Eikermann, Jaime Garzon-Serrano, Jean Kwo,Martina Grosse-Sundrup, Ulrich Schmidt. Luca Bigatello • • • 100 morbidly obese (body mass index: 53±10) adult patients undergoing open bariatric surgery in a prospective study. At least 1 h before induction of anesthesia, peripheral oxygen saturation (SpO2) was measured by an oximetry finger probe in the sitting and supine positions, and Mallampati score was taken. Oxygen saturation was recorded also during induction of anesthesia, and nadir values were analyzed, and the STOP-BANG questionnaire was applied. • Results: 36 patients presented with clinical suspicion of OSA. Nadir oxygen saturation during induction of anesthesia was considerably higher in patients with clinical suspicion of OSA, a significant finding that persisted as a trend after correction for age, gender and BMI. Mallampati score was an independent predictor of OSA, even in morbidly obese patients scheduled for weight loss surgery. • Morbidly obese patients presenting for weight loss surgery have a significant risk to desaturate during induction of anesthesia. A history of OSA does not independently increase the risk of desaturation Conclusions: during induction of anesthesia, if the appropriate precautions are being taken.
  44. 44. Means and standard deviations of peripheral oxygen saturation (SpO2) before and during induction of anesthesia. In the sitting and supine positions, patients with history of OSA was significantly lower SpO2. Nadir SpO2 was remarkably lower in patients without history of OSA PreO2(fresh gas flow of 10L/min) until the end-tidal oxygen saturation was >90% or the end-tidal nitrogen concentration was <5% gradient between expiratory and inspiratory end-tidal O2 concentration was less than 5-10 mmHg. • patient in a stacking ramp with reverse Trendelenburg positioning of 25º propofol (adjusted dose formula (adjusted dose= ideal body weight (IBW) dose x [1+.007(total body weight – IBW)]), fentanyl, cisatracurium two-hand mask ventilation technique was performed when needed. Anesthesia maintained with isoflurane or desflurane, and remifentanil, and neuromuscular blockade was maintained with cisatracurium, and reversed with neostigmine. Intraoperatively, subjects received IV morphine sulfate or IV hydromorphone.
  45. 45. Fin qui parlare della forma delle airways? • Walsh JH; Leigh MS; Paduch A; Maddison KJ; Armstrong JJ; Sampson DD; Hillman DR; Eastwood PR. Effect of body posture on pharyngeal shape and size in adults with and without obstructive sleep apnea. SLEEP 2008;31(11):1543-1549.
  46. 46. Michael Beal, MD; Andrew Chesson, MD; Thomas Garcia, MD; Gloria Caldito, PhD;Fred Stucker, MD, FACS; Cherie-Ann Nathan, MD, FACS A Pilot Study of Quantitative Aspiration in Patients with Symptoms of Obstructive Sleep Apnea: Comparison to a Historic Control Group.Laryngoscope, 114:965–968, 2004 • • • • • Objective: It has been shown that many healthy people aspirate secretions at night. Patients with obstructive sleep apnea (OSA) have frequent episodes of gasping at night that may predispose them to aspiration. The purpose of this study was to determine whether patients with symptoms of OSA are predisposed to pharyngeal aspiration. Study Design: A prospective study in which patients with symptoms of OSA were compared with a historic group of normal controls by using the same methodology. Methods: The study was offered to patients with symptoms of OSA undergoing a sleep study. The radiotracer Technicium99 was infused through a plastic tube placed in the nasopharynx after the patient achieved stage II sleep. • • • • A chest radionuclide scan determined the amount of material aspirated. The Wilcoxon-rank sum test was us ed to compare the mean amount aspirated between the experimental and historic control groups. Results: Fourteen patients successfully completed the study. One normal volunteer in our study aspirated a quantity similar to the historic normal control group. The amount of aspirated material in the study group ranged from 0.152 to 3.648 mL, with a mean of 1.24 mL 0.905 (SD). the patients with symptoms of OSA aspirated significantly more radiotracer (P <.01). There was a lack of association between respiratory When compared with the historic normal control group, disturbance index and amount aspirated. • Conclusions: The results suggest there is an apparent risk of increased pharyngeal aspiration in patients with symptoms of OSA
  47. 47. Anaesthesist 2011 · 60:607–616.F.M. Konrad1 · K.M. Kramer2 · T.H. Schroeder3 · K. Stubbig4 Anästhesie bei bariatrischer Chirurgie • • • • Die notwendige Dauer der präoperativen Nüchternheit für extrem adipöse Patienten ist nicht geklärt [46]. Bergland et al. [9] untersuchten bei 158 Patienten die Menge (ml) und den pH-Wert des Magensafts extrem adipöser Patienten zu Beginn bariatrischer Operationen nach Narkoseeinleitung. Die Patienten hatten 12 bzw. 8 h vor der Operation keine feste resp. flüssige Nahrung zu sich genommen. Auf eine Gabe von Antacida wurde in der Studie verzichtet. Bei einem Patienten wurden mehr als 300 ml Magensaft gemessen. Sieben Patienten hatten zwischen 50 und 100 ml Magensaft. Der pH lag zwischen 1,5 und 2 [9]. Die Prävalenz von Hiatushernien und gastroösophagealem Reflux ist bei adipösen Patienten (BMI > 30 kg/m2) im Vergleich zu normalgewichtigen Patienten mehr als verdoppelt [6]. In einer weiteren aktuellen Untersuchung wurden bei fast 80% der extrem adipösen Patienten mithilfe einer präoperativen Gastroösophagoduodenoskopie pathologische Befunde erhoben, obwohl nur 20% der Patienten vorher symptomatische Beschwerden angegeben hatten [27]. Deshalb ist bei extrem adipösen Patienten von einer erhöhten Aspirationsgefahr auszugehen. Die Gabe von Antacida sollte präoperativ erwogen werden. Aufgrund des häufig bestehenden OSAS und der verlängerten Eliminationshalbwertszeit werden anxiolytische Medikamente präoperativ in reduzierter Dosierung empfohlen oder erst im OP-Bereich unter Monitoring appliziert [9]. 6. Aro P, Ronkainen J, Talley NJ et al (2005) Body mass index and chronic unexplained gastrointestinal symptoms: an adult endoscopic population based study. Gut 54:1377–1383 9. Bergland A, Gislason H, Raeder J (2008) Fast-track surgery for bariatric laparoscopic gastric bypass with focus on anaesthesia and peri-operative care. Experience with 500 cases. Acta Anaesthesiol Scand 52:1394–1399 27. Kuper MA, Kratt T, Kramer KM et al (2010) Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery. Surg Endosc 24:1996–2001
  48. 48. Ma mancano dati di outcome con monitoraggio invasivo pressione ,EEG ,monitoraggio funz neuromuscolare…. • 41. Schumann R, Jones SB, Cooper B et al (2009) Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004–2007. Obesity 17:889–894 • 42. Schumann R, Jones SB, Ortiz VE et al (2005) Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obes Res 13:254–266
  49. 49. Controllo vie aeree • • • • • Intubazione Presidi sopraglottici IRMA? Video assisted laryngoscopy:VAL.. Reclutamento intraop ma: • ATTENZIONE ALLA RIDUZIONE DELLA GC,specie in antitrendelemburg e chir.laparoscopica • Aumento fluidi intraop • Aumento supporto pressorio • Reclutamento alla fine op • Estubazione “protetta”
  50. 50. Monitoraggio Temperatura – diuresi – Loops respiratori – gas • NIBP;bracciali speciali • Bassa soglia per intraarterial /invasive blood pressure • Monitoraggio miorisoluzione;NMT • Monitoraggio EEG;BIS/entropiae,cc – Data la variabilità della farmacocinetica(vedi quanto detto prima:TBW?LBW?IBW? – Il problema è che manca un monitor di analgesia, a meno che………….sudorazione/analisi polso,ecc.
  51. 51. Rischio di DVT
  52. 52. Criteri di scelta generali • Anestetici a rapido on e offset: –Sevoflurane e desflurane –Remifentanil –Propofol –Miorilass steroidei perché sugammadex!anche se cisatrac…. –(midazolam)
  53. 53. Anest volatili • Favoriti quelli a bassa solubilità:desflurano=sevoflurano>isoflurano • • • • • Strum EM, Szenohradszki J, Kaufman WA et al. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: a prospective, randomized study. Anesthesia & Analgesia 2004; 99:1848–1853. Arain SR, Barth CD, Shankar H et al. Choice of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane.Journal of Clinical Anesthesia 2005; 17: 413–419. De Baerdemaeker LEC, Jacobs S, Den Blauwen NMM et al. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Obesity Surgery 2006; 16: 728–733. Vellejo MC, Sah N, Phelps AL et al. Desflurane versus sevoflurane for laparoscopic gastroplasty in morbidly obese patients. Journal of Clinical Anesthesia 2007; 19: 3–8. Leykin Y, Pellis T, Del Mestro E et al. Anesthetic management of morbidly obese and super-morbidly obese patients undergoing bariatric operations: hospital course and outcomes. Obesity Surgery 2006; 16: 1563–1569.
  54. 54. Kinetics of desflurane,isoflurane and halothane in humans. Anesthesiology 74:489-498, 1991 • Yasuda, Nobuhiko, M.D., Ph.D.*; Lockhart, Stephen H., Ph.D., M.D.†; Eger, Edmond I., II, M.D.‡; Weiskopf, Richard B., M.D.§; Johnson, Brynte H., M.S.¶; Freire, Beth A., B.S.**; Fassoulaki, Argyro, M.D.†† • • ABSTRACT: The low solubility of desflurane in blood and tissues suggests that the partial pressures of this agent in blood and tissues should approach the inspired partial pressure more rapidly than would the blood and tissue partial pressures of other potent inhaled anesthetics. We tested this prediction, comparing the pharmacokinetics of desflurane with those of isoflurane, halothane, and nitrous oxide in eight volunteers. We measured the rate at which the alveolar (end-tidal) (FA) concentration of nitrous oxide increased towards an inspired (FI) concentration of 65–70%, and then measured the concurrent increase in FA and mixed expired concentrations (FM) of desflurane, isoflurane, and halothane at respective FI values of 2.0%, 0.4%, 0.2%. Minute ventilation (E) was measured concurrently with the measurements of anesthetic concentrations. The potent vapors were administered for 30 min; administration of nitrous oxide continued throughout the period of anesthesia. For the potent agents, we also measured E, FA, and FM for 5–7 days of elimination. We used FA/FI and FA/FA0 (FA0 = the last FA during the administration of each anesthetic) to define the rate of increase of anesthetic in the lungs and the rate of elimination of anesthetic, respectively. FA/FI values at 30 min of administration were: (mean ± SD) nitrous oxide 0.99 ± 0.01, desflurane 0.90 ± 0.01, isoflurane 0.73 ± 0.03, and halothane 0.58 ± 0.04. FA/FA0 values after 5 min of elimination were: desflurane 0.14 ± 0.02, isoflurane 0.22 ± 0.02, and halothane 0.25 ± 0.02. Recovery (volume of anesthetic recovered during elimination per volume taken up) of desflurane (105 ± 25%) equalled recovery of isoflurane (102 ± 13%) and exceeded recovery of halothane (64 ± 9%). Time constants for a five-compartment mammillary model for halothane and isoflurane differed for the lungs, fat group, and hepatic metabolism, and exceeded those for desflurane for all compartments. In summary, we found that FA/FI of desflurane increases more rapidly and that FA/FA0 decreases more rapidly in humans than do these variables with other available potent anesthetics. We also found that desflurane resists biodegradation in humans and so may have little or no toxic potential.
  55. 55. Time constants
  56. 56. Clinical Characteristics of Desflurane in Surgical Patients: Minimum Alveolar Concentration Anesthesiology 74:429-433, 1991 • • • • • • AUTHOR(S): Rampil, Ira J., M.S.,M.D.*; Lockhart, Stephen H., Ph.D.,MD†; Zwass, Maurice S., M.D.*; Peterson, Natalie, BS‡; Yasuda, Nobuhiko, M.D.†; Eger II, Edmond I., M.D.§; Weiskopf, Richard B., M.D.¶; Damask, Michael C., M.D.** ABSTRACT: Desflurane (formerly I-653) is a new inhalational anesthetic with a promising pharmacokinetic profile that includes low solubility in blood and tissue, including fat. Since its lipid solubility is less than that of other volatile agents, it may have lower potency. Low solubility would be expected to increase the rate at which alveolar concentration approaches inspired concentration during induction as well as to increase the rate of elimination of desflurane from blood at emergence. We determined the minimum alveolar concentration (MAC) of desflurane in 44 unpremedicated ASA physical status 1 or 2 patients undergoing elective surgery. We prospectively studied four patient groups distinguished by age and anesthetic regimen: 18–30 versus 31–65 yr and desflurane in 60% N2O/40% O2 versus desflurane in O2. Anesthesia was induced with desflurane or desflurane in 60% N2O/40% O2. MAC was determined by a modification of Dixon's up-and-down method with increments of 0.5% desflurane. The MAC of desflurane in O2 was 7.25 ± 0.0 (mean ± SD) in the 18–30-yr age group, and 6.0 ± 0.29 in the 31–65-yr group; the addition of 60% N2O reduced the MAC to 4.0 ± 0.29 and 2.83 ± 0.58, respectively. The median time from discontinuation of desflurane to an appropriate response to commands was 5.25 min. Desflurane appears to be a mild airway irritant but was well tolerated by all patients.
  57. 57. age
  58. 58. Yasuda N, Lockhart S H.,Eger E, Weiskopf R B.,Liu J,Laster M,Taheri S,Peterson NA.Comparison of Kinetics of Sevoflurane and Isoflurane in Humans .Anesth Analg 1991; 72:316–24 • • • ABSTRACT: The low solubility of sevoflurane in blood suggests that this agent should enter and leave the body more rapidly than isoflurane. However, the closeness of sevoflurane and isoflurane tissue/blood partition coefficients suggests that the rates of equilibration with and elimination from tissues should be similar. We tested both predictions, comparing sevoflurane with isoflurane and nitrous oxide in seven volunteers. We measured the rate at which the alveolar (end-tidal) (FA) concentration of nitrous oxide increased toward an inspired (FI) concentration of 65%–70%, then measured the concurrent rise in FA and mixed expired concentrations (FM) of sevoflurane and isoflurane at respective FI values of 1.0% sevoflurane and 0.6% isoflurane for 30 min. Minute ventilation (E) was measured concurrently with the measurements of anesthetic concentrations. For the potent agents, we also measured E, FA, and FM for 6–7 days of elimination. FA/FI values at 30 min of administration were as follows: nitrous oxide, 0.986 ± 0.003 (mean ± SD); sevoflurane, 0.850 ± 0.018; and isoflurane, 0.733 ± 0.027. FA/FA0 (FA0 = the last FA during administration) values after 5 min of elimination were as follows: sevoflurane, 0.157 ± 0.020; isoflurane, 0.223 ± 0.024. Recovery (volume of anesthetic recovered during elimination/volume taken up) of sevoflurane (101% ± 7%) equaled recovery of isoflurane (101% ± 6%). Time constants for a five-compartment mammillary model for sevoflurane were smaller than those for isoflurane for the lungs but were not different from isoflurane for the other compartments. In summary, we found (a) that FA/FI of sevoflurane increases and FA/FA0 decreases more rapidly than do these variables with isoflurane in humans; but (b) that elimination from tissues did not differ between sevoflurane and isoflurane; and (c) that the metabolism of sevoflurane did not differ from that estimated for isoflurane.
  59. 59. Anesth Analg. 2008 Dec;107(6):1864-70. Obesity modestly affects inhaled anesthetic kinetics in humans. Lemmens HJ, Saidman LJ, Eger EI 2nd, Laster MJ. • • • • • • • • • • Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA. hlemmens@stanford.edu Abstract BACKGROUND: Few studies have determined the effect of obesity on inhaled anesthetic pharmacokinetics. We hypothesized that the solubility of potent inhaled anesthetics in fat and increased body mass index (BMI) in obese patients interact to increase anesthetic uptake and decrease the rate at which the delivered (FD) and inspired (FI) concentrations of an inhaled anesthetic approach a constantly maintained alveolar concentration (end-tidal or FA). This hypothesis implies that the effect of obesity would be greater with a more soluble anesthetic such as isoflurane versus desflurane. METHODS: In 107 ASA physical status I-III patients, anesthesia was induced with propofol, tracheal intubation facilitated with neuromuscular blockade, and ventilation controlled with 50% nitrous oxide in oxygen to maintain end-tidal carbon dioxide concentrations between 35 and 45 mm Hg. Isoflurane or desflurane was administered in a 1 L/min inflow rate at FD concentrations sufficient to maintain FA at 0.6 minimum alveolar anesthetic concentration (0.7% or 3.7%, respectively). FD, FI, and FA were measured 5, 10, 20, 40, 60, 90, 120,150, and 180 min after starting potent inhaled anesthetic delivery. RESULTS: Fifty-nine patients received isoflurane and 48 received desflurane. BMI ranged between 18 and 63 kg/m(2) and demographic variables did not differ between anesthetic groups. For isoflurane, FD/FA or FI/FA weakly (but significantly) correlated with BMI at 9/18 time points whereas for desflurane FD/FA or FI/FA correlated significantly with BMI at only one time point (P < 0.01). After dividing each group into nonobese (BMI < 30) and obese (BMI > or = 30) patients, with isoflurane, FD/FA or FI/FA was higher in obese patients at four time points whereas there was no difference between nonobese and obese patients for desflurane. Patients receiving isoflurane took longer to respond to command after discontinuing anesthesia but obesity did not increase or decrease awakening time for either isoflurane or desflurane. When BMI was used to normalize FI/FA and FD/FA the median values for isoflurane consistently exceeded the median value for desflurane by factors ranging from 3 to 5, values comparable to the ratios of their blood/gas (3.1), muscle/gas (4.6), and fat/gas (5.4) partition coefficients. CONCLUSION: BMI modestly affects FD/FA and FI/FA, and this effect is most apparent for an anesthetic having a greater solubility in all tissues. An increased BMI increases anesthetic uptake and, thus, the need for delivered anesthetic to sustain a constant alveolar anesthetic concentration, particularly with a more soluble anesthetic. However, the increase with an increased body mass is small.
  60. 60. Inhaled anesthetics and obese patients • • • • • • • • • • • • Several studies in obese patients have compared some kinetic aspects for inhaled anesthetics with variable results, perhaps because of different experimental conditions.9–14 For example, Strum et al.9 De Baerdemaeker et al.,10 and La Colla et al.13 showed that morbidly obese patients emerge from anesthesia more rapidly after desflurane than after sevoflurane anesthesia. However, Arain et al.11 and Vallejo et al.12 did not find a difference in time to awakening between patients receiving desflurane or sevoflurane. Finally, sevoflurane seems to provide a slightly more rapid washin and washout of anesthetic in morbidly obese patients than does isoflurane.15
  61. 61. • Eger EI II, Saidman LJ. Illustrations of inhaled anesthetic uptake, including intertissue diffusion to and from fat. Anesth Analg 2005;100:1020–33 • • • • • • • • • • • • • • • • • • • • • • • • • • 9. Strum EM, Szenohradszki J, Kaufman WA, Anthone GJ, Manz IL, Lumb PD. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: a prospective, randomized study. Anesth Analg 2004;99:1848–53; table of contents 10. De Baerdemaeker LE, Struys MM, Jacobs S, Den Blauwen NM, Bossuyt GR, Pattyn P, Mortier EP. Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an ‘inhalation bolus’ technique. Br J Anaesth 2003;91:638–50 11. Arain SR, Barth CD, Shankar H, Ebert TJ. Choice of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane. J Clin Anesth 2005;17:413–9 12. Vallejo MC, Sah N, Phelps AL, O’Donnell J, Romeo RC. Desflurane versus sevoflurane for laparoscopic gastroplasty in morbidly obese patients. J Clin Anesth 2007;19:3–8 13. La Colla L, Albertin A, La Colla G, Mangano A. Faster wash-out and recovery for desflurane vs sevoflurane in morbidly obese patients when no premedication is used. Br J Anaesth 2007;99:353–8 14. Casati A, Marchetti C, Spreafico E, Mamo D. Effects of obesity on wash-in and wash-out kinetics of sevoflurane. Eur J Anaesthesiol 2004;21:243–5 15. Torri G, Casati A, Comotti L, Bignami E, Santorsola R, Scarioni M. Wash-in and wash-out curves of sevoflurane and isoflurane in morbidly obese patients. Minerva Anestesiol 2002;68:523–7 16. Cleveland WS. Robust locally weighted regression and smoothing
  62. 62. • • • • • • • • • • • • • • • • Eur J Anaesthesiol. 2011 Nov;28(11):781-7. Volatile rapid sequence induction in morbidly obese patients. Pösö T, Kesek D, Winsö O, Andersson S. Source Department of Health Science, Luleå University of Technology, Luleå, Sweden. Tomi.Poso@nll.se Abstract BACKGROUND AND OBJECTIVE: The interest in bariatric surgery is growing. Morbidly obese patients have an increased risk of hypoxia and decreased blood pressure during rapid sequence induction (RSI). Alternate RSI methods that provide cardiovascular and respiratory stability are required. With this in mind, we evaluated a method for volatile RSI in morbidly obese patients. DESIGN: Observational study. METHODS: Thirty-four patients with mean BMI 42.4 kg m undergoing bariatric surgery (morbidly obese group) and 22 patients with mean BMI 25.6 kg m as a control group were included in the study. Anaesthesia was induced with sevoflurane, propofol, suxamethonium and alfentanil, designed to avoid respiratory and haemodynamic adverse events and to minimise depressing effect on the brain respiratory centre under ongoing RSI. Peripheral oxygen saturation (SpO2) and mean arterial blood pressure were registered before and after endotracheal intubation. In addition, two time periods were measured during RSI: spontaneous breathing time (SBT) and apnoea time. RESULTS: We found no significant differences between the groups. No periods of desaturation were detected. SpO2 was 100% before and after endotracheal intubation in all patients. Mean arterial pressure was maintained at a stable level in both groups. Mean SBT and apnoea time were 65.6 and 45.8 s in the morbidly obese group, and 70.7 and 47.7 s in the control group, respectively. CONCLUSION: A combination of sevoflurane, propofol, suxamethonium and alfentanil is a suitable method for RSI which maintains cardiovascular and respiratory stability in both morbidly obese and lean patients.
  63. 63. • • • • • • • • • • • • • • • Rev Esp Anestesiol Reanim. 2011 Apr;58(4):211-7. [Perioperative anesthetic management of 300 morbidly obese patients undergoing laparoscopic bariatric surgery and a brief review of relevant pathophysiology]. [Article in Spanish] Navarro Martínez MJ, Pindado Martínez ML, Paz Martín D, Caro Cascante M, Mariscal Flores M, Ruiz de Adana JC. Source Unidad de Anestesiologfa, Reanimación y Terapéutica del Dolor, Hospital Infanta Cristina, Madrid. majosenavarro@hotmail.com Abstract OBJECTIVES: Laparoscopic bariatric surgery is a challenge for anesthesiologists because morbidly obese patients are at high risk and laparoscopy may complicate respiratory and hemodynamic management. The aim of this study was to analyze the perioperative anesthetic management of morbidly obese patents undergoing laparoscopic bariatric surgery. MATERIAL AND METHODS: Prospective study of 300 consecutive patients diagnosed with morbid obesity and scheduled for laparoscopic bariatric surgery. Patients were positioned with a wedge cushion under the head and shoulders. A rapid sequence induction of anesthesia was carried out. A short-handled, articulated-blade McCoy laryngoscope was used for intubation; an intubation laryngeal mask airway (Fastrach) was on hand as a rescue device. Propofol and remifentanil were used for maintenance of anesthesia and morphine was administered at the end of surgery. Incentive spirometry was initiated in the postanesthetic recovery unit. RESULTS: Eighty percent of the patients were women with a mean (SD) body mass index (kg/m2) of 46 (5). The first choice of direct laryngoscopic intubation was successful in 98.6% of cases. All patients were successfully intubated. Only 5 patients required intensive care. Postoperative complications (mainly respiratory problems, bleeding, and infections) were observed in 17%. No patient died. CONCLUSIONS: Perianesthetic management of morbidly obese patients who undergo laparoscopic surgery is safe. To minimize pulmonary complications, preoxygenation and rapid sequence induction should be performed correctly and incentive spirometry should be initiated in the immediate postoperative period. The McCoy laryngoscope ensures intubation in most cases.
  64. 64. • • • • • • • • • • • • • • Anesthesiology. 2011 Jun;114(6):1313-9. Inspiratory oxygen fraction and postoperative complications in obese patients: a subgroup analysis of the PROXI trial. Staehr AK, Meyhoff CS, Rasmussen LS; PROXI Trial Group. Source Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. akstaehr1@hotmail.com Abstract BACKGROUND: Obese patients are at a high risk of postoperative complication, including surgical site infection (SSI). Our aim was to evaluate the effect of a high inspiratory oxygen fraction (80%) on SSI and pulmonary complications in obese patients undergoing laparotomy. METHODS: This study was a planned analysis of the obese patients (body mass index ≥ 30 kg/m²) recruited in the Danish multicenter, patient- and observerblinded, PROXI Trial of 1,400 patients undergoing acute or elective laparotomy. Patients were randomized to receive either 80% or 30% oxygen during and for 2 h after surgery. The primary outcome was SSI within 14 days. Secondary outcomes were atelectasis, pneumonia, and respiratory failure. RESULTS: Two hundred thirteen patients had a body mass index ≥ 30 kg/m². The median (5-95% range) body mass index was 34 kg/m² (30-44) and 33 kg/m² (30-41) in patients allocated to the 80% and 30% oxygen group. SSI occurred in 32 of 102 (31%) versus 29 of 111 (26%) patients given 80% and 30% oxygen, respectively (odds ratio, 1.29; 95% CI, 0.71-2.34; P = 0.40). In addition, the incidence of pulmonary complications was not significantly different, with atelectasis occurring in 9% versus 6%, pneumonia in 6% versus 5%, and respiratory failure in 8% versus 5% in patients given 80% and 30% oxygen, respectively. CONCLUSION: Administration of 80% oxygen, compared with 30% oxygen, did not reduce the frequency of SSI in obese patients. Moreover, no significant association was found between oxygen fraction and the risk of pulmonary complications.
  65. 65. • • • • • • • • • • • • • • Anesthesiology. 2011 Jun;114(6):1354-63. Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: a randomized controlled study. Futier E, Constantin JM, Pelosi P, Chanques G, Massone A, Petit A, Kwiatkowski F, Bazin JE, Jaber S. Source Department of Anesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France. efutier@chu-clermontferrand.fr Abstract BACKGROUND: Morbid obesity predisposes patients to lung collapse and hypoxemia during induction of anesthesia. The aim of this prospective study was to determine whether noninvasive positive pressure ventilation (NPPV) improves arterial oxygenation and end-expiratory lung volume (EELV) compared with conventional preoxygenation, and whether NPPV followed by early recruitment maneuver (RM) after endotracheal intubation (ETI) further improves oxygenation and respiratory function compared with NPPV alone. METHODS: Sixty-six consecutive patients (body mass index, 46 ± 6 kg/m²) were randomized to receive 5 min of either conventional preoxygenation with spontaneous breathing of 100% O₂ (CON), NPPV (pressure support and positive end-expiratory pressure), or NPPV followed by RM (NPPV+RM). Gas exchange was measured in awake patients, at the end of preoxygenation, immediately after ETI, and 5 min after the onset of mechanical ventilation. EELV was measured immediately after ETI and 5 min after mechanical ventilation. The primary endpoint was arterial oxygenation 5 min after the onset of mechanical ventilation. Results are presented as mean ± SD. RESULTS: At the end of preoxygenation, Pao₂ was higher in the NPPV and NPPV+RM groups (382 ± 87 mmHg and 375 ± 82 mmHg, respectively; both P < 0.001) compared with the CON group (306 ± 51 mmHg) and remained higher after ETI (225 ± 104 mmHg and 221 ± 110 mmHg, in the NPPV and NPPV+RM groups, respectively; both P < 0.01 compared with the CON group [150 ± 50 mmHg]). After the onset of mechanical ventilation, Pao₂ was 93 ± 25 mmHg in the CON group, 128 ± 54 mmHg in the NPPV group (P = 0.035 vs. CON group), and 234 ± 73 mmHg in the NPPV+RM group (P < 0.0001 vs. NPPV group). After ETI, EELV was higher in the NPPV group compared with the CON group (P < 0.001). Compared with NPPV alone, RM further improved gas exchange and EELV (all P < 0.05). A significant correlation was found between Pao2 obtained 5 min after mechanical ventilation and EELV (R = 0.41, P < 0.001). CONCLUSION: NPPV improves oxygenation and EELV in morbidly obese patients compared with conventional preoxygenation. NPPV combined with early RM is more effective than NPPV alone at improving respiratory function after ETI
  66. 66. • • • • • • • Br J Anaesth. 2010 Dec;105 Suppl 1:i16-23. Dose adjustment of anaesthetics in the morbidly obese. Ingrande J, Lemmens HJ. Source Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Room H3576, Stanford, CA 94305, USA. Abstract Anaesthesiologists must be prepared to deal with pharmacokinetic and pharmacodynamic (PD) differences in morbidly obese individuals. As drug administration based on total body weight can result in overdose, weight-based dosing scalars must be considered. Conversely, administration of drugs based on ideal body weight can result in a sub-therapeutic dose. Changes in cardiac output and alterations in body composition affect the distribution of numerous anaesthetic drugs. With the exception of neuromuscular antagonists, lean body weight is the optimal dosing scalar for most drugs used in anaesthesia including opioids and anaesthetic induction agents. The increased incidence of obstructive sleep apnoea and fat deposition in the pharynx and chest wall places the morbidly obese at increased risk for adverse respiratory events secondary to anaesthetic agents, thus altering the PD properties of these drugs. Awareness of the pharmacology of the commonly used anaesthetic agents including induction agents, opioids, inhalation agents and neuromuscular blockers is necessary for safe and effective care of morbidly obese patients
  67. 67. • • • • • • • • • • • • • • Obes Surg. 2010 Jul;20(7):885-94. Supplemental postoperative oxygen and tissue oxygen tension in morbidly obese patients. Kabon B, Rozum R, Marschalek C, Prager G, Fleischmann E, Chiari A, Kurz A. Source Department of Anesthesiology and General Intensive Care, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria. barbara.kabon@meduniwien.ac.at Abstract BACKGROUND: Subcutaneous tissue oxygen tension (PsqO(2)) is a major predictor for wound healing and the occurrence of wound infections. Perioperative subcutaneous wound and tissue oxygen tension is significantly reduced in morbidly obese patients. Even during intraoperative supplemental oxygen administration, PsqO(2) remains low. Tissue hypoxia is pronounced during surgery and might explain the substantial increase in infection risk in obese patients. It remains unknown whether long-term supplemental postoperative oxygen augments tissue oxygen tension. Consequently, we tested the hypothesis that 80% inspired oxygen administration during 12-18 postoperative hours significantly increases PsqO(2) compared to 30% inspired oxygen fraction. METHODS: After IRB approval and informed consent, 42 patients undergoing laparoscopic bariatric surgery were randomly assigned to receive either 80% inspired oxygen via a PULMANEX Hi-Ox Mask (Viasys MedSystems, Wheeling, IL) (10 L/min) or 30% oxygen via nasal cannula (2 L/min) after surgery until the next morning. PsqO(2) was measured with a temperature-corrected Clark-type electrode in the subcutaneous tissue of the upper arm and adjacent to the wound. RESULTS: Postoperative subcutaneous tissue oxygen tension was significantly increased in the Hi-Ox group: 58 (47.7, 74.1) mmHg vs. 43 (38.7, 55.2) mmHg, P = 0.002. Also, wound tissue oxygen tension was improved during supplemental oxygen administration: 75.2 (69.8, 95.5) mmHg vs. 52.4 (46.3, 66.1) mmHg, P < 0.001. CONCLUSION: Subcutaneous tissue oxygen tension was significantly increased by supplemental postoperative oxygen administration. Whether there is an effect on the incidence of wound infection in morbidly obese patients is matter of further research.
  68. 68. • • • • • • • Obes Surg. 2011 Jul;21(7):850-7. Effects of A-line Autoregression Index (AAI) monitoring on recovery after sevoflurane anesthesia for bariatric surgery. Freo U, Carron M, Innocente F, Foletto M, Nitti D, Ori C. Source Dipartimento di Farmacologia e Anestesiologia, Università di Padova, Via C. Battisti, 267, 35121, Padova, Italy. ulderico.freo@unipd.it Abstract Monitoring depth of anesthesia may improve anesthetic dosing and postanesthetic recovery in obese patients. Sixty morbidly obese patients undergoing laparoscopic adjustable gastric bandage (LAGB) were randomly assigned to receive anesthesia with sevoflurane titrated by either standard clinical parameters (SCP) (target = baseline hemodynamic parameters ± 20%) or by A-line ARX index (AAI) (target = 20 ± 5). Heart rate, arterial blood pressure, inspiratory and expiratory gas concentrations, and AAI were recorded in all patients at 5-min intervals, but AAI was made available only to the anesthesiologist assigned to AAI-monitored patients. Emergence times in surgery room and recovery times in postanesthesia care unit (PACU) were recorded at 1- and 30-min intervals. Mean intraoperative values of AAI were higher in AAI-monitored than in SCP-monitored patients (22.5 vs 15.0, p = 0.001). Compared to SCP monitoring, AAI monitoring reduced consumption of sevoflurane by 20% (p = 0.014), times to eye opening by 2.4 min (p = 0.001) and to extubation by 2.5 min (p = 0.009) and to achieve SpO(2) 92% in room air by 17 min (p = 0.001). Aldrete scores were higher in AAI- than in SCP-monitored patients at arrival in PACU (p = 0.035), but Aldrete scores ≥ 9 were attained in similar times. AAI monitoring can improve titration of and recovery from sevoflurane for LAGB.
  69. 69. • • • • • • • • • • • • • • Br J Anaesth. 2010 Feb;104(2):175-82. Epub 2009 Dec 26. Effect of increased body mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane. McKay RE, Malhotra A, Cakmakkaya OS, Hall KT, McKay WR, Apfel CC. Source Department of Anaesthesia and Perioperative Care, C-450, University of California San Francisco, San Francisco, CA 94143-0648, USA. eshimar@anesthesia.ucsf.edu Abstract BACKGROUND: Increased BMI may increase the body's capacity to store potent inhaled anaesthetics, more so with more soluble agents. Accordingly, we asked whether increased BMI and longer anaesthesia prolonged airway reflex recovery. METHODS: We measured time from anaesthetic discontinuation until first response to command (T1); from response to command until ability to swallow (T2); and from anaesthetic discontinuation to recovery of ability to swallow (T3) in 120 patients within three BMI ranges (18-24, 25-29, and >or=30 kg m(2)). All received sevoflurane or desflurane, delivered via an LMA. RESULTS: T1 and T3 after sevoflurane exceeded T1 and T3 after desflurane: 6.6 (sd 4.2) vs 4.0 (1.9) min (P<0.001), and 14.1 (sd 8.3) vs 6.1 (2.0) min (P<0.0001). T3 correlated more strongly with BMI after sevoflurane (28 s per kg m(-2), P=0.02) than desflurane (7 s per kg m(-2), P=0.03). Regarding T2, patients receiving sevoflurane with BMI >or=30 kg m(-2) were less often able to swallow 2 min after response to command than were those with BMI 18-24 or 25-29 kg m(-2) (3/20 vs 10/20 or 9/20, P<0.05). Each sevoflurane MAC-hour delayed T3 by 4.5 min (268 s) (R=0.46, P<0.001) whereas each desflurane MAC-hour delayed T3 by 0.2 min (16 s) (R=0.10, P=0.44). CONCLUSIONS: Prolonged sevoflurane administration and greater BMI delay airway reflex recovery. The contribution of BMI to this delay is more pronounced after sevoflurane than desflurane.
  70. 70. • • • • • • • • • • • • • • Anesth Analg. 2011 Jul;113(1):63-9. Epub 2010 Oct 21. A comparison of desflurane versus propofol: the effects on early postoperative lung function in overweight patients. Zoremba M, Dette F, Hunecke T, Eberhart L, Braunecker S, Wulf H. Source Department of Anaesthesia and Intensive Care, University of Marburg, Baldingerstraße, Marburg, Germany. zoremba@med.uni-marburg.d Abstract BACKGROUND: In this study, we evaluated the influence of propofol versus desflurane anesthesia in overweight patients on postoperative lung function and pulse oximetry values. METHODS: We prospectively studied 134 patients with body mass indices of 25 to 35 kg/m(2) undergoing minor peripheral surgery lasting 40 to 120 minutes. Patients were randomly assigned to receive propofol (total IV anesthesia) or desflurane anesthesia via a tracheal tube targeting bispectral index values of 40 to 60. Premedication, adjuvant drug usage, and ventilation were standardized. We measured oxyhemoglobin saturation and lung function preoperatively (baseline), and at 10 minutes, 0.5 hour, 2 hours, and 24 hours after tracheal extubation. All values were measured with the patient supine, in a 30° head-up position. Changes from preoperative baseline values were first analyzed for the impact of body mass index and type of anesthesia using univariate methods, followed by linear regression and multivariate analysis of variance. RESULTS: Within the first 2 hours after surgery, the propofol group displayed lower oxyhemoglobin saturation (at 2 hours, mean ± SD, 93.8% ± 2.0% vs 94.6% ± 2.1%; P < 0.007) and lung function (forced vital capacity, forced expiratory volume exhaled in 1 second [FEV(1)], peak expiratory flow, midexpiratory flow [MEF], forced inspiratory vital capacity, and peak inspiratory flow; between 11% and 20% larger reduction from baseline in the propofol group, all P < 0.001) compared with the desflurane group. Even 24 hours after surgery, FEV(1), peak expiratory flow, MEF, forced inspiratory vital capacity, and peak inspiratory flow were reduced more in the propofol group (all P < 0.01). At 2 hours after extubation, increasing obesity was associated with decreasing FEV(1) and MEF in patients anesthetized with propofol but not desflurane (P < 0.01). CONCLUSION: We conclude that, for superficial surgical procedures of up to 120 minutes, maintenance of anesthesia with propofol impairs early postoperative lung function and pulse oximetry values more than with desflurane. Furthermore, increasing obesity decreases pulmonary function at 2 hours after propofol anesthesia but not after desflurane anesthesia.
  71. 71. • • • • • • • • • • • • • • • Obes Surg. 2009 Dec;19(12):1624-30. LMA supreme versus facemask ventilation performed by novices: a comparative study in morbidly obese patients showing difficult ventilation predictors. Abdi W, Dhonneur G, Amathieu R, Adhoum A, Kamoun W, Slavov V, Barrat C, Combes X. Source Anesthesia Department and Airway Management (Paris 13), University Diploma Group, Paris 13 School of Medicine, 93000 Bobigny, France. Abstract BACKGROUND: We designed a study to compare ventilation characteristics performed in morbidly obese patients by medical students via the facemask to that via the LMA Supreme. METHODS: This prospective, randomized, crossover study included 31 ASA I-III morbidly patients showing difficult mask ventilation predictors. After induction of anesthesia, ten medical students with no previous clinical experience in airway management, clinically educated to facemask ventilation maneuvers, and theoretically educated to laryngeal mask use were supervised by a senior anesthesiologist during performance of 60 s facemask and LMA Supreme ventilation in a randomly assigned order. Ventilation quality and difficulty were measured using an original score calculated as the sum of seven indicators (0=no ventilation and complications, 12=optimal and safe ventilation) and a visual analog scale (VAS; 0=no difficult-100=impossible), respectively. Values are presented as means (standard deviation) or medians [extremes]. RESULTS: Mean age and body mass index of the patients were 39 years (12 years) and 44 kg m(-2) (7 kg m(-2)), respectively. One patient was excluded because of ventilation difficulty experienced by the senior anesthesiologist. Medical students successfully established ventilation with the LMA Supreme in all the 30 patients after a delay of 21 s (9 s) compared to 34 s (14 s) with the facemask (P<0.05). Failure of ventilation occurred in four patients with the facemask. Ventilation quality score was superior and ventilation difficulty (VAS 0-100) was inferior with the LMA Supreme than with the facemask (11 [10-12] and 9 [0-45] versus 5 [1-12] and 50 [5-100]); both P<0.05, respectively. CONCLUSIONS: We showed that the LMA Supreme placed in novice hands systematically promoted easier ventilation of better quality than the facemask in morbidly obese patients showing difficult mask ventilation predictors. Our data suggest that the LMA Supreme could be considered as a standard airway management tool for both elective and rescue airway management of morbidly obese patients. PMID: 19730959 [PubMed - indexed for MEDLINE]
  72. 72. • • • • • • • • • • • • • • Middle East J Anesthesiol. 2009 Jun;20(2):207-11. Effects of sevoflurane on postoperative liver functions in morbidly obese as compared to the non-obese patients. Al-Ghanem SM, Massad IM, Al-Barazangi B, Al-Mustafa M, Daoud FS, Abu-Ali H. Source Dept. of Anesthesia & Intensive Care, Faculty of Medicine, Univ. of Jordan, Amman, Jordan. alghanem@ju.edu.jo Abstract OBJECTIVE: To assess the effect of sevoflurane anesthesia on hepatic function in morbidly obese versus non-obese patients undergoing abdominal surgeries. METHODS: We prospectively evaluated the levels of the serum concentration of liver enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and total bilirubin (TBil), in 42 morbidly obese and 40 non obese patients who were scheduled for elective abdominal surgery under sevoflurane anesthesia at the Jordan University Hospital, Amman, Jordan. Measurement of liver enzymes was done in the recovery room, and on the first, 3 and 7 days after sevoflurane anesthesia, and the results were compared between the morbidly obese and non obese patients. RESULTS: ALT, AST, GGT and LDH increased significantly in the morbidly obese than they did in non obese patients. In morbidly obese patients TBil increased gradually peaking 7 days after anesthesia, LDH increased in the recovery room, AST and ALT increased in the recovery room and first day, while GGT increased 7th day after anesthesia. In non obese patients, AST, LDH increased in the recovery. ALP did not change in both groups. CONCLUSION: Sevoflurane induces elevation of the serum liver enzymes in morbidly obese patients with variable onsets.
  73. 73. • • • • • • • J Neurosurg Anesthesiol. 2009 Jul;21(3):207-13. Early postoperative cognitive recovery and gas exchange patterns after balanced anesthesia with sevoflurane or desflurane in overweight and obese patients undergoing craniotomy: a prospective randomized trial. Bilotta F, Doronzio A, Cuzzone V, Caramia R, Rosa G; PINOCCHIO Study Group. Source Department of Anesthesiology, Critical Care and Pain Medicine, University of Rome La Sapienza, Rome, Italy. bilotta@tiscali.it Abstract Overweight and obese patients are at especially high risk for delayed awakening after general surgery. Whether this risk also applies to cerebral neurosurgical procedures remains unclear. This study evaluated early postoperative cognitive recovery and gas exchange patterns, after balanced anesthesia with sevoflurane or desflurane, in overweight and obese patients undergoing craniotomy for supratentorial expanding lesions. Fifty-six patients were consecutively enrolled, and randomly assigned to 1 of 2 study groups to receive balanced anesthesia with sevoflurane or desflurane. Cognitive function was evaluated with the Short Orientation Memory Concentration Test and the Rancho Los Amigos Scale and gas exchange patterns (pH, PaO2, and PaCO2) were recorded in all patients at 5 time-points: preoperatively and postoperatively, after patients reached an Aldrete score >or=9, at 15, 30, 45, and 60 minutes. Preoperative cognitive status was similar in the 2 treatment groups. Early postoperative cognitive recovery was more delayed and Short Orientation Memory Concentration Test scores at 15 and 30 minutes postanesthesia were lower in patients receiving sevoflurane-based anesthesia than in those receiving desflurane-based anesthesia (21.5+/-3.5 vs. 14.9+/-3.5) (P<0.005) and (26.9+/-0.7 vs. 21.5+/-1.4) (P<0.005), and the postoperative Rancho Los Amigos Scalegrade 8 showed a similar trend (25/28 patients 89% vs. 8/28 patients 28% (P<0.005) and 28/28 patients (100% vs. 13/28 patients 46%) (P<0.005). Similarly, gas-exchange analysis showed higher PaCO2 at 15 and 30 minutes and lower pH up to 45 minutes postextubation in patients receiving sevoflurane-based anesthesia. In overweight and obese patients undergoing craniotomy desfluranebased anesthesia allows earlier postoperative cognitive recovery and reversal to normocapnia and normal pH.
  74. 74. • • • • • • • • • • • • • • Anesthesiology. 2009 Mar;110(3):556-62. Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Maragakis LL, Cosgrove SE, Martinez EA, Tucker MG, Cohen DB, Perl TM. Source Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Lmaraga1@jhmi.edu Abstract BACKGROUND: Surgical site infections (SSI) after spinal surgery increase morbidity, mortality, length of hospital stay, and costs. Most previously identified risk factors for these infections, such as severity of illness and procedure duration, are not amenable to intervention. This study sought to identify modifiable risk factors associated with SSI after spinal surgery. METHODS: This is a case-control study including case identification and review of medical records. A total of 104 patients with SSI after spinal surgery were compared to 104 randomly selected control patients without SSI after spinal surgery in a 926-bed tertiary care hospital in Baltimore, Maryland, between April 1, 2001 and December 31, 2004. RESULTS: Multivariate analysis identified independent risk factors for SSI after spinal surgery including prolonged procedure duration (odds ratio [OR], 4.7; 95% confidence interval [95% CI], 1.6-14; P < 0.001), American Society of Anesthesiologists score of 3 or greater (OR, 9.7; 95% CI, 3.7-25; P < 0.001), lumbar-sacral operative level (OR, 2.9; 95% CI, 1.2-7.1; P = 0.02), posterior approach (OR, 3.5; 95% CI, 1.2-9.7; P = 0.02), instrumentation (OR, 2.5; 95% CI, 1.1-6.0; P = 0.03), obesity (OR, 4.0; 94% CI, 1.6-10; P < 0.01), razor shaving before surgery (OR, 3.6; 95% CI, 1.2-11; P = 0.02), and intraoperative administered fraction of inspired oxygen of less than 50% (OR, 12; 94% CI, 4.5-33; P < 0.001). CONCLUSIONS: In addition to previously reported risk factors, this study identified intraoperative administered fraction of inspired oxygen of less than 50% as an independent, modifiable risk factor for SSI after spinal surgery. Intraoperative administration of at least 50% fraction of inspired oxygen should be tested prospectively as an intervention to prevent SSI after spinal surgery.
  75. 75. inhaled anesthetics in obese patients ricerca su pubmed fin qui
  76. 76. Alpha 2 agonisti • Pawlik MT, Hansen E, Waldhauser D et al. Clonidine premedication in patients with sleep apnea syndrome:a randomized, double-blind, placebo-controlled study. Anesthesia & Analgesia 2005; 101: 1374–1380. • Feld JM, Hoffman WE, Stechert MM et al. Fentanyl or dexmedetomidine combined with desflurane for bariatric surgery.Journal of Clinical Anesthesia 2006; 18: 24–28. • Tufanogullari B, White PF, Peixoto MP et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesthesia & Analgesia 2008; 106: 1741–1748.
  77. 77. Analgesia Postop :NSAIDS • Strategia analgesica multimodale • NSAIDS(ketorolac) • Govindarajan R, Ghosh B, Sathyamoorthy MK et al. Efficacy of ketorolac in lieu of narcotics in the operative management of laparoscopic surgery for morbid obesity. Surgery for Obesity and Related Diseases 2005; 1: 530– 535. • Kamelgard JI, Kim KA & Atlas G. Combined preemptive and preventive analgesia in morbidly obese patients undergoing open gastric bypass: a pilot study. Surgery for Obesity and Related Diseases 2005; 1: 12–16. • Madan AK, Ternovits CA, Speck KE et al. Inpatient pain medication requirements after laparoscopic gastric bypass.Obesity Surgery 2005; 15: 778–781. • Schumann R, Shikora S, Weiss JM et al. A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery. Anesthesia & Analgesia 2003; 96: 469–474.
  78. 78. TIVA • TIVA TCI;ma gli algoritmi non sono stati cerati per BMI>30…..
  79. 79. Modulazione + accurata,con separazione sedazione/ipnosi/analgesia…
  80. 80. Analgesia postop:AL infiltrazione • Cottam DR, Fisher B, Atkinson J et al. A randomized trial of bupivacaine pain pumps to eliminate the need for patient controlled analgesia pumps in primary laparoscopic Rouxen-Y gastric bypass. Obesity Surgery 2007; 17: 595–600. • Feld JM, Laurito CE, Beckerman M et al. Nonopioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Canadian Journal of Anesthesia 2003; 50: 336– 341.
  81. 81. Altri approcci • Solazzi L, Modesto C, Vitale F et al. Preinductive use of clonidine and ketamine improves recovery and reduces postoperative pain after bariatric surgery. Surgery for obesity and Related Diseases 2009; 5: 67–71.
  82. 82. Epidurale toracica • Dopo chir addominale maggiore – Schumann R, Shikora S, Weiss JM et al. A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery. Anesthesia & Analgesia 2003; 96: 469–474. – von Ungern-Sternberg BS, Regli A, Reber A et al. Effect of obesity and thoracic epidural analgesia on perioperative spirometry. British Journal of Anaesthesia 2005; 94: 121–127. – Rigg JR, Jamrozik K, Myles PS et al. MASTER Anaesthesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–1282.
  83. 83. Outpatient anesthesia?? invasività tipo Paziente • laparoscopica vs open • Laparoscopic banding vs laparoscopic gastriic bypass • • • • Severità OSA comorbidità Età …..
  84. 84. • Ambulatory anesthesia for the obese patient • Fre´de´rique Servin
  85. 85. Qualche nota sulla chirurgia • Videoolaparoscopica vs open: • Menop stress chirurgico • Meno trauma tissutakle • • • • Ma Tempi più lunghi(in genere) Pneumoperitoneo Posizioni estreme
  86. 86. THE END
  87. 87. • • • • J Matern Fetal Neonatal Med. 2012 Mar;25(3):308-12. Epub 2011 May 26. Abnormal maternal body mass index and obstetric and neonatal outcome. Sebastián Manzanares G, Angel Santalla H, Irene Vico Z, López Criado MS, Alicia Pineda L, José Luis Gallo V. Source • Department of Obstetrics & Gynecology, Virgen de las Nieves University Hospital , Fuerzas Armadas Av 2, 18014, Granada , Spain. • • Abstract Objective. The objective of this study is to examine the effects of abnormal maternal body mass index (BMI), either underweight or severe or morbid obesity (BMI >35), on obstetrical and neonatal outcomes. Methods. 3 anni(2.007-2.009) observational retrospective study was carried out in Granada (Spain). Women were categorized by first ten weeks of pregnancy BMI, according to World Health Organization (WHO) into three groups: underweight (<18.5), normal (20-24.9), and severe or morbid obese (>35). Obstetrical and neonatal outcomes were evaluated using normal group as reference after suitable adjustments for confounding factors. Results. 3.016 patients out of 12.781 single births were included. Maternal BMI classified 168 women (5.5 %) as underweight, 2.597 (86.1%) as normal, and 251 (8.3%) as severe or morbidly obese. As compared to normal women, underweight women were younger, and class II or III obese showed higher parity and higher incidence of hypertension disorders and Diabetes Mellitus. After controlling for these confounders, underweight women showed increased adjusted risk of oligohydramnios and low birth weight babies, and severe or morbidly obese women had an increased adjusted risk of Streptococcus Group B colonization, induction of labour, elective and emergency cesarean section, fetal macrosomia, fetal acidosis at birth, and perinatal mortality. Conclusions. Severe or morbid obesity were associated with an increased risk of adverse perinatal outcome and mortality and should be managed as high-risk pregnancies. • •
  88. 88. • • • • • • • J Am Board Fam Med. 2011 Jan-Feb;24(1):75-85. Obesity and women's health: an evidence-based review. Kulie T, Slattengren A, Redmer J, Counts H, Eglash A, Schrager S. Source Department of Family Medicine, University of Wisconsin, Madison, WI 53715, USA. Abstract Obesity negatively impacts the health of women in many ways. Being overweight or obese increases the relative risk of diabetes and coronary artery disease in women. Women who are obese have a higher risk of low back pain and knee osteoarthritis. Obesity negatively affects both contraception and fertility as well. Maternal obesity is linked with higher rates of cesarean section as well as higher rates of high-risk obstetrical conditions such as diabetes and hypertension. Pregnancy outcomes are negatively affected by maternal obesity (increased risk of neonatal mortality and malformations). Maternal obesity is associated with a decreased intention to breastfeed, decreased initiation of breastfeeding, and decreased duration of breastfeeding. There seems to be an association between obesity and depression in women, though cultural factors may influence this association. Obese women are at higher risk for multiple cancers, including endometrial cancer, cervical cancer, breast cancer, and perhaps ovarian cancer.
  89. 89. • • • • • • • Postgrad Med J. 2010 Oct;86(1020):617-23. Obesity in pregnancy: a major healthcare issue. Tsoi E, Shaikh H, Robinson S, Teoh TG. Source Department of Metabolic Medicine, St Mary's Hospital, Imperial College London, London, UK. stephen.robinson@imperial.ac.uk Abstract The prevalence of maternal obesity is rising, up to 20% in some antenatal clinics, in line with the prevalence of obesity in the general population. Maternal obesity poses significant risks for all aspects of pregnancy. There are risks to the mother with increased maternal mortality, pre-eclampsia, diabetes and thromboembolic disorders. There is increased perinatal mortality, macrosomia and congenital malformation. The obstetric management, with increased operative delivery rate, and increased difficulty of anaesthesia, carry risk for the obese mother. Long term complications associated with maternal obesity include increased likelihood of maternal weight retention and exacerbation of obesity. This review aims to discuss these risks with a view to suggesting management to ensure the best outcome for both the mother and the offspring.
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