A series of 15 slides trying to share the challenges faced while administering general anaesthesia to the morbidly obese & the super obese. Issues like why obesity is an epidemic, the pre-anaesthetic (PAC) evaluation, the hardware required & drugs required are discussed.

1. Laparoscopy for major
surgeries – Anaesthetic
Challenges
Dr. Atul Dixit
Chief Anaesthesiologist,
Mohak Bariatrics & Robotics,
Indore

2. Obesityhas reached
epidemic
proportionsin India
in the 21st century,
withmorbidobesity
affecting5% of the
country'spopulation.
"India facing acute obesity
epidemic"
Source: The Hindu 2007-10-12

3. Obesity is the third biggest concern impacting
the global GDP

4. Source:YadavK,KrishnanA(September2008).
Changingpatternsofdiet,physicalactivityandobesityamongurban,ruralandslum
populationsinnorthIndia".ObesRev9(5):400–8.
Urbanization and modernization have been
associated with obesity
Urban Population
Rural Population
o In Northern India, obesity is most prevalent:
• Urban populations – Male 5.5%, Female 12.6%
• Urban slums – Male 1.9%, Female 7.2%
o Obesity rates lower in rural populations
• Male 1.6%, Female 3.8%

5. • Women of high socioeconomic class had rates of
10.4% as opposed to 0.9% in women of low
socioeconomic class.
• With people moving into urban centers and wealth
increasing, concerns about an obesity epidemic in
India are growing.
• Praveen Kumar Agarwal (2002-05-23) "Emerging
obesity in northern Indian states: a serious threat for
health" IUSSP Conference, Bankik
Socio-economic class contributes to the rate of
obesity

6. Success is a choice…
•PAC
•Hardware
•Drugs
1
2
3

7. PAC (1/2)
1. Airway
• Early airway closure
• Airway maintenance
2. Neck
• US visualization for IJV insertion
3. Peripheral veins; often tortuous
4. Conical arms; BP cuff ? A – line
5. High oxygen demand
• Desaturate fast
• Raised daiphragm
• Elevated carbon di oxide levels
6. Diabetes mellitus
• Autonomic instability, Sensitivity to drugs
• High or low BP, Compromised kidneys
• Careful positioning
1

8. PAC (2/2)1
7. Elevated PA pressures
• On tablet dytor + other
diuretics
• K imbalance; multi-
electrolyte fluids
• Acetated isotonic solutions
8. Hypothyroidism
9. Bronchospasm
10. Extubate carefully
• Only after responding to
commands, eye opening
tongue protrusion on
cardiac bed head up
11. Incentive spirometry
12. Liquid diet

9. Hardware
1. Special OT table
2. Design OT with white doors for cardiac bed
3. Monitor with E/R, S, N, AGM, BIS, 2P & urine output
4. Syringe drivers (upto 3)
5. Stiff ET tubes, cuff pressure monitoring
6. Bougie
7. Airway management kit
8. i-Gel, S.A.D.
9. Naso – pharyngeal airway
10. Q-site
11. Robotics
2

13. Drugs
1. IV Glycopyrrolate : 0.2-0.4 mg
2. IV Fentanyl
3. IV Ketamine (sub-anaesthetic dose)
4. IV Etomidate : 10 ml
5. IV Propofol – induction
6. IV Succinylcholine
7. IV Atracurium
8. IV Propofol – maintenance – TIVA
9. O2 + Air ventilator settings & CO2 management
10. Reversal
11. IV multi-electrolyte fluid – isotonic, acetated
12. IV Labetalol & IV Esmolol
13. IV Dexmed & IV Clonidine
14. IV NTG
15. IV Ephedrine & IV Phenylefrine
3

16. Thank you!