Quale anestesia per l’obeso?
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)
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!
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.
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
• Care, and Nursing Perioperative Care task groups
• • Mandatory sensitivity training for all clinical and nonclinical staff
who interact with weight loss surgery patients
• 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
○ Physician director of bariatric program
○ Designated hospital administrator
○ Critical care coverage 24 h a day/7 days a week
• Executive walkrounds
• 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
• Critical pathways
• Weight loss surgery database, tracking patient outcomes
• See Surgical Care, Anesthesia, and Nursing task group reports
• Establish criteria for credentialing in emerging technology (see Endoscopic Interventions Task
Table 2: Optional recommendations
• Wide beds. Available to 880 lb
• Ceiling-mounted transferring equipment
• Wireless monitoring system
• Selective cardiac and apnea telemetry
• Wide automated examination tables
• Designated operating room
• Ceiling-mounted lifting/transferring equipment
• High-weight capacity (600 lb) CT and MRI scanners
• Follow American Institute of Architects’ guidelines for design of any
new health-care facility accommodating weight loss surgery patients
• Dedicated on-call lift team
• Adopt barcode technology for medication administration
• Specially equipped operating room and ancillary equipment,
• An automated extra-wide operating table with appropriate
• Extra-long abdominal instrument sets.
• Appropriately sized retractor.
• 43–46 cm laparoscopes.
• 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
• Interventional facilities available 24 h a day, 7 days a
• The American Institute of Architects has established
guidelines for planning and designing WLS health-care
• 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
Generale o regionale?
• controllo vie aeree e
• All afine però:
Risparmio delle vie aeree
Possibile spostamento ago,catetere
Possibile conversione in AG!!!
Possibile estensione nel postop
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
Ricorda alcuni punti nella MO:
• • reperi: difficili da palpare ;US?
• • piccoli errori direzionali incrementati dalla
• Catetere almeno 5 cm nello spazio epid.
• elevata incidenza di fallimenti
– epid fallita
Comfort/discomfort del paziente ;ampia
infiltrazione (con adr).
• • iniezione liquorale;intenzionale
“ ;non intenzionale:
– Spinale continua?
– Anestetico locale diluito & oppioide per analgesia nel
– • 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
Additional Points to Remember:
problemi tecnici:manicotto pressione da obeso ,ma
;cateterizzazione diretta arteria radiale forse meglio
Tratatmento dolore postop
Protocolli profilassi DVT ;adeguamento dei dosaggi
– Blocco autonomico alto e variabile
• Deviazione pelvica:pericolo di danno al cone
• Possibile ipossiemia
• Nella puntura singola:svantaggi nella chirurgia
– Cateterizzazione liquorale?
• Halpern et al.Conversion of epidural labour analgesia to
anesthesia for CS.Br.J.Anaesth dec 9 2008.
• 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)
L’obesità è una epidemia con
• Obesità presente nel 35% delle morti
materne (UK CEMACH 2000-2002)
• La prevalenza dell’obesità è raddoppiata nelle
• Quasi tutte le morti materne del CEMACH
2003-2005 hanno obesità come fattore
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).
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
• 1.4 (1.1-1.9) and 2.2 (1.5-3.3), respectively, after preterm births].
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 :
gestational diabetes mellitus,
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
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
• Obese women were at significantly increased risks of :
• fetal death [aOR = 2.32 (95% confidence interval: 1.64-3.28), P<
• 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.
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
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.
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.
Department of Critical Care Medicine, University of Pittsburgh Medical Center, 613 Scaife Hall, 3550
Terrace Street, Pittsburgh, PA 15238, USA. firstname.lastname@example.org
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.
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
• 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
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
• 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
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.
– Oltre alle precedenti:riduzione del rischio del
reflusso gastroesofageo e aspirazione
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
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
during induction of anesthesia, if the appropriate precautions are being taken.
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
positioning of 25º
propofol (adjusted dose formula (adjusted
dose= ideal body weight (IBW) dose
x [1+.007(total body weight – IBW)]), fentanyl,
two-hand mask ventilation technique was
performed when needed.
Anesthesia maintained with
isoflurane or desflurane, and remifentanil,
blockade was maintained with
reversed with neostigmine.
Intraoperatively, subjects received IV
morphine sulfate or IV
Fin qui parlare della forma delle
• 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
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
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 .
Bergland et al.  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 . Die Prävalenz von Hiatushernien und
gastroösophagealem Reflux ist bei adipösen Patienten (BMI > 30 kg/m2) im Vergleich zu normalgewichtigen
Patienten mehr als verdoppelt . 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 . 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 .
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
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.
• 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
Controllo vie aeree
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”
– Loops respiratori
• NIBP;bracciali speciali
• Bassa soglia per intraarterial /invasive blood
• Monitoraggio miorisoluzione;NMT
• Monitoraggio EEG;BIS/entropiae,cc
– Data la variabilità della farmacocinetica(vedi quanto
– Il problema è che manca un monitor di analgesia, a meno
Criteri di scelta generali
• Anestetici a rapido on e offset:
–Sevoflurane e desflurane
–Miorilass steroidei perché
sugammadex!anche se cisatrac….
• Favoriti quelli a bassa
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.
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.¶;
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.
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.
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.
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. email@example.com
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.
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
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.
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.
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
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
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
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
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.
Department of Health Science, Luleå University of Technology, Luleå, Sweden. Tomi.Poso@nll.se
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.
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.
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.
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.
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
[Article in Spanish]
Navarro Martínez MJ, Pindado Martínez ML, Paz Martín D, Caro Cascante M, Mariscal Flores M, Ruiz de Adana JC.
Unidad de Anestesiologfa, Reanimación y Terapéutica del Dolor, Hospital Infanta Cristina, Madrid. firstname.lastname@example.org
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.
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.
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.
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.
Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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.
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
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.
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.
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.
Department of Anesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
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.
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.
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).
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
Br J Anaesth. 2010 Dec;105 Suppl 1:i16-23.
Dose adjustment of anaesthetics in the morbidly obese.
Ingrande J, Lemmens HJ.
Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Room
H3576, Stanford, CA 94305, USA.
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
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.
Department of Anesthesiology and General Intensive Care, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria.
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.
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.
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.
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.
Obes Surg. 2011 Jul;21(7):850-7.
Effects of A-line Autoregression Index (AAI) monitoring on recovery after sevoflurane anesthesia for bariatric
Freo U, Carron M, Innocente F, Foletto M, Nitti D, Ori C.
Dipartimento di Farmacologia e Anestesiologia, Università di Padova, Via C. Battisti, 267, 35121, Padova, Italy.
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.
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.
Department of Anaesthesia and Perioperative Care, C-450, University of California San Francisco, San Francisco, CA 94143-0648, USA.
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.
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.
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).
Prolonged sevoflurane administration and greater BMI delay airway reflex recovery. The contribution of BMI to this delay is more pronounced after
sevoflurane than desflurane.
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.
Department of Anaesthesia and Intensive Care, University of Marburg, Baldingerstraße, Marburg, Germany. email@example.com
In this study, we evaluated the influence of propofol versus desflurane anesthesia in overweight patients on postoperative lung function and pulse
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.
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).
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.
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
Abdi W, Dhonneur G, Amathieu R, Adhoum A, Kamoun W, Slavov V, Barrat C, Combes X.
Anesthesia Department and Airway Management (Paris 13), University Diploma Group, Paris 13 School of Medicine, 93000 Bobigny, France.
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.
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].
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.
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]
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
Al-Ghanem SM, Massad IM, Al-Barazangi B, Al-Mustafa M, Daoud FS, Abu-Ali H.
Dept. of Anesthesia & Intensive Care, Faculty of Medicine, Univ. of Jordan, Amman, Jordan. firstname.lastname@example.org
To assess the effect of sevoflurane anesthesia on hepatic function in morbidly obese versus non-obese patients
undergoing abdominal surgeries.
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.
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.
Sevoflurane induces elevation of the serum liver enzymes in morbidly obese patients with variable onsets.
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.
Department of Anesthesiology, Critical Care and Pain Medicine, University of Rome La Sapienza, Rome, Italy.
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.
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.
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Lmaraga1@jhmi.edu
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.
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.
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).
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.
inhaled anesthetics in obese patients
ricerca su pubmed fin qui
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.
Analgesia Postop :NSAIDS
• Strategia analgesica multimodale
• 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–
• 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:
• 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.
• TIVA TCI;ma gli algoritmi non sono stati cerati
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:
• 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–
• 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.
• 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.
• laparoscopica vs open
• Laparoscopic banding vs laparoscopic
• Ambulatory anesthesia for the obese patient
• Fre´de´rique Servin
Qualche nota sulla chirurgia
• Videoolaparoscopica vs open:
• Menop stress chirurgico
• Meno trauma tissutakle
Tempi più lunghi(in genere)
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.
Department of Obstetrics & Gynecology, Virgen de las Nieves University Hospital , Fuerzas Armadas Av
2, 18014, Granada , Spain.
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.
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.
Department of Family Medicine, University of Wisconsin, Madison, WI 53715, USA.
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.
Postgrad Med J. 2010 Oct;86(1020):617-23.
Obesity in pregnancy: a major healthcare issue.
Tsoi E, Shaikh H, Robinson S, Teoh TG.
Department of Metabolic Medicine, St Mary's Hospital, Imperial College London,
London, UK. email@example.com
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.