problems faced by the anaesthesiologists when a pregnant obese patient comes for surgery will be discussed

1. A SRIDHAR RAO
MD
GOVERNAMENT MEDICAL COLLEGE AND
HOSPITAL,NIZAMABAD

2.  MBBS From Kakatiya Medical College 1989
 MD (Anaesthesiology) from Kakatiya Medical College 1994
 Since 1994 practising as Consultant Anaesthesiologist and
finished 25 years of service by this August
 Served as president and secretary of Nizamabad ISA city
branch
 Presently working as senior faculty in Govt Medical College
and Hospital Nizamabad

3. OBESITY DEFINITION
Obesity is derived from the
latin word OBESUS
Means fattened by eating
WHO, ACOG Defines
obesity as Abnormal or
excessive fat
accumulation that
presents a risk to health

4. INCIDENCE
One third of the
American population are
obese
In India
10-15% of the population
are obese

6. NORMAL BODY FAT
15-18% males
20-25% females
>25% in males
>33% in females

9. BMI
5 ft 2 inches comes
with 60 kgs weight
BMI
24.6 kgs/sq mtrs
Same patient with
80 kgs weight
BMI
34.1 kgs/sq mtrs

10. PROBLEMS OF OBESITY

11. 1.CARDIOVA
SCULAR
CHANGES
Each kg
increase in fat,
20-25 ml of
cardiac output
increases
Each kg of fat
contains 3000
metres of blood
vessels

14. 2 RESPIRATORY CHANGES

16. OSA
 Diagnosis is by POLYSOMNOGRAPHY
 S snoring
 T tiredness feeling
 O observation of apnoea
 P pressures
 B BMI >30Kgs/Sq Mtr
 A age >50 yrs
 N neck circumference >40 cm
 G male gender
 YES ANSWER >3 HIGHRISK OF OSA

17. 3 GASTROINTESTINAL
 Increased incidence of GERD
 Decreased pressure of of LES tone
 Impaired oesophageal and gastric mobility due to
gastroparesis
 Increased incidence of Barrets
oesophagus,adenocarcinomas of gastric cardia
 Colon cancers ,pancreatic cancers
 Fatty liver,gall stones,hepato cellular carcinomas

18. 4 RENAL SYSTEM
 Because of increased COP GFR increases
 Increased fat produeces Renin,Angiotensin and
Aldosterone levels which causes sodium retention and
hypertension
 Angiotensin produces constiction of efferent arterioles
leading to proteinuria

19. 5 ENDOCRINAL SYSTEM
 Increased incidence of DM
 T3,T4,TSH levels are normal in obese
 PCOS (1)Menustrual irregularities,
 (2) Hyperandrogenism
 (3) Polycystic ovaries on US
 Increased levels of TG, and LDL
 Decreased levels of HDL

20. 6 HAEMOTOLOGICAL CHANGES

22. CHALLENGES
DIABETES
GASTRO
OESOPHAGEAL
REFLUX,FATTY
LIVER,CHOLILITH
IASIS,HIATUS
HERNIAS,COAGU
LOPATHIES
COLORECTAL
CANCERS
DEEPVEIN
THROMBOSIS

23. PREOP PREPARATION

24.  Appropriate sized gowns
 Adequate monitoring equipment
 Appropriate sized BP cuffs
 Adequate staff must be there
 Record weight,height and BMI
 Strapping should be done to prevent fall from table
 Two OT tables keep side by side if she weighs >150Kgs

26. • Walters Hendersonmaneuver
for shifting patient on and off
table.

27.  Call experienced senior anaesthesiologist
 Optimise co morbid conditions
 Two anaesthesiologists are better than one
 Central neuraxial block is safer than general
 For painless labor epidural catheter should be placed
in labor suite
 Take the help of USG in difficult cases to know the
depth of space

28. PRE OP PREPARATION
 Detailed history and examination should be done
 Assessment of airway and spine should be done
 Evaluate intubating conditions byMallampati grading
 Inspection of oropharynx for excessive palatal soft
tissues
 Neck circumference 40 cm 5% chance of difficult
intubation 60 cm 35% of difficult intubation
 Investigations : Complete hemogram,Coagulation
profile,FBS,RFT,LFT,Lipid profile,TFT,ECG,2D
Echo,Ultra sound abdomen

29. PREMEDICATION
1 NO SEDATIVES
2 OMEZ OR
RANITIDINE

30. IV CANNULATION
INFRA RED Vein finder

31. CHOICE OF ANAESTHESIA

32. Choice of anaesthesia
 Always prefer SPINAL ANAESTHESIA
EPIDURAL ANAESTHESIA
COMBINED SPINAL EPIDURAL

36. TAYLORS APPROACH

37. GENERAL ANAESTHESIA
 PATIENT REFUSAL
 COAGULATION ABNORMALITIES
 INFECTION AT THE SITE
 UN CORRECTED HYPOVOLEMIA
 ANAPHYLAXIS
 FIXED CARDIAC OUTPUT STATES
 NEUROLOGICAL ABNORMALITIES

38. MANAGEMENT
 Preoxygenate for 3 minutes
 Ramp position or HELP position

40. HELP

41. LARYNGOSCOPY AND INTUBATION

49. DEEP VEIN THROMBOSIS
 Most common complication after surgery
 Dynamic compression devices,stockings
 Early ambulation is recommended
 LMW Heparin s/c 40 mg given 12 hours prior to
surgery
 Next dose 12 hrs after surgery
 Continued for 5-6 days post operatively

51. POST OP ANALGESIA
►NO
SEDATIVES
►FOR LSCS
BILATERAL
T A P
BLOCK
PRODUCES
EXCELLENT
ANALGESIA
EPIDURALS

52. CHALLENGES FACED BY
ANAESTHESIOLOGISTS
 1 MULTI ORGAN AND SYSTEM ABNORMALITIES
 2 DIFFICULTY IN SECURING VEINS
 3 DIFFICUT SPINALS,EPIDURALS
 4 DIFFICULT AIRWAY AND INTUBATION
 5 POST OPERATIVE HYPOXIA
 6 DEEP VEIN THROMBOSIS

53. TAKE HOME MESSAGE
 OBESE PATIENTS HAVE MULTISYSTEM DISEASES
 SPECIAL PRECAUTIONS TAKEN IN SHIFTING, AND
POSITIONING
 REGIONAL ANAESTHESIA BETTER THAN
GENERAL
 USE RAMP POSITION FOR INTUBATION
 DVT PROPHYLAXIS
 NO SEDATIVES IN PRE OP AND POST OP
 TAP Block or Epidurals for post op pain relief