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Peri-operative management of obese patients undergoing bariatric surgery.ppt
- 2. Peri-operative management of obese surgical patients and bariatric surgery Dr Tanveer Alam Khan Department of Anesthesiology Shaukat Khanum Memorial Cancer Hospital & Research Centre 5th May 2017
- 3. Learning Objectives • Obesity: classification • Bariatric surgery • Peri-operative management - pre-operative - intra-operative - post-operative • Take home message • References Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 4. Obesity • Worldwide increase in obesity - 2013 (UK): - 24% of men and 25% of women obese Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 5. Obesity Pakistan ranked ninth most obese country in the world • World Health Organization (WHO): classification of obesity Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 6. Obesity: pathophysiology • Fat distribution: Peripheral deposited fat vs central/visceral/intra- • Respiratory system: - Decrease FRC - Easier airway closure wheezing - obstructive sleep apnoea syndrome (OSAS) -opioids induce respiratory depression( increase sensitivity) • Cardiovascular system: - hypertension - ischemic heart disease - ↑ cardiac output - heart failure /hypertrophy - arrhythmias (fat deposition) • Thrombosis: obesity is a prothrombotic state • Metabolic syndrome: central obesity is associated with increased insulin resistance • Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 7. Obesity: pharmacology • Drug dosing: fat soluble vs fat insoluble drugs Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 8. Bariatric surgery 1) Malabsorbtive: Jejuno-ilieal bypass ,ballio-pancreatic bypass 2)Restrictive approach Introduction Obesity Bariatric surgery Peri-operative management Take home message Roux-en-Y gastric bypass Adjustable gastric band
- 9. Bariatric surgery Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 10. Peri-operative management Pre-operative History and examination BMI Risk of aspiration Difficult ventilation Difficult intubation Difficult I/V line Stabilizing comorbidities Identifying OSA symptoms Previous surgeries and previous anesthetics NECK CIRCUMFERENCE difficult intubation 40 cm 5% risk (16 inches) 60 cm 35% risk ( 24 inches) BMI per se is not a predictor of a difficult airway Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 11. Peri-operative management Pre-operative Respiratory assessment: Assessment as per standard guidelines Spirometry Indicating resp disease: consider pre-operative arterial blood gas analysis - arterial saturation < 95% on air - forced vital capacity < 3 L or forced expiratory volume in 1 s < 1.5 L - respiratory wheeze at rest - serum HCO3 - > 27 mmol.L-1 Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 12. Peri-operative management Pre-operative Cardiovascular assessment: Routine assessment with METs if required can go for CPET /ECHO/ recumbent bikes Nutrional support: Liver shrinking diet Pre operative intensive dieting for 2 to 6 weeks Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 13. Peri-operative management Pre-operative General considration Routine lab tests Quit smoking stabilizing Pre-existing co-morbidities Avoid Sedatives Aspiration prophylaxis PPIs, H2 antagonists Thrombo-prophylaxis C-PAP machine Planning post-operative care Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 14. Peri-operative management Pre-operative Sleep disordered breathing (OSAS) Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 15. Peri-operative management Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 16. Peri-operative management Intra-operative 1) Preparation of patient Communication with staff positioning equipment 2) Regional anesthesia: preferred to general anesthesia - sedation: kept to minimum - equipment: extra long spinal/epidural needles - neuraxial anesthesia: standard dose of local anesthetic is sufficient for central neuraxial blockade Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 17. Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 18. Peri-operative management Intra-operative 3) General anesthesia: - preferable airway technique: tracheal intubation with controlled ventilation - positive end-expiratory pressure (PEEP) - care with neuromuscular blocking drugs: risk of apnoea 4) Maintenance of anesthesia: needs to be commenced promptly after induction of anesthesia Fat soluble agents are preferable - Propofol or volatile agents (Desflurane, Sevoflurane) Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 19. Peri-operative management Fourth National Audit Project (NAP4) Airway complications that are pertinent to the airway management of the obese patient • There was often a lack of recognition and planning for potential airway problems • As a result of the reduced safe apnoea time, when airway complications occurred, .. they did so rapidly and potentially catastrophically • There was evidence that rescue techniques such as supraglottic airway devices and emergency cricothyroidotomy had an increased failure rate • Adverse events occurred more frequently in obese patients when anaesthetised by inexperienced staff Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 20. Peri-operative management Intra-operative 5) Emergence of anesthesia - reversal of neuromuscular blockade, guided by a nerve stimulator - airway reflexed should be restored and patients should be breathing with good tidal volumes extubation in sitting position - in case of OSAS: insertion of nasopharyngeal airway - until patients wakes up Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 21. Peri-operative management Post-operative 1) Immediate post-anesthesia care: monitoring (respiration rate, apnoea) - oxygen therapy, CPAP prevent apnoea/hypnoea with oxygen desaturation 2) Analgesia - intramuscular route: not preferable - patient-controlled analgesia: not preferable (risk: respiratory depression) - epidural analgesia: not preferable (↓ post-operative mobility) - subarachnoid block with opioid adjunct: preferable Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 22. Peri-operative management Post-operative 3) Thrombo-prophylaxis - stimulate mobilization - anti-coagulants (Enoxaparin, Dalteparin, Tinzaparin) 4) Rhabdomyolysis: ‘post-operative’ deep tissue pain (mainly in the buttocks) - serum: ↑ creatinine kinase ( urinary alkalinization may be required to avoid acute renal failure)` Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 23. Take home message • Obesity: central obesity associated with a greater peri-operative risk lean/adjusted body weight to measure drug dosing • Bariatric surgery: leads to weight loss due to malabsorption and/or gastric restriction • Peri-operative management: – pre-operative: screening (co-morbidities), Obesity Surgery Mortality Risk Stratification – intra-operative: - airway: tracheal intubation with controlled ventilation - regional anesthesia preferred over general anesthesia - care with neuromuscular agents – post-operative: analgesia, thrombo-prophylaxis Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 24. References • C.E. Nightingale et al. Peri-operative management of the obese surgical patient Anesthesia 2015; 70, 859-876 • Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia • Bariatric surgery procedures https://asmbs.org/patients/bariatric-surgery- procedures Introduction Obesity Bariatric surgery Peri-operative management Take home message
- 25. Dank je wel
Editor's Notes
- According
- According
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. Exact lean body weight formula is quite complex but easy to remember ; 80% of total body weight of male 75% for female is LBW
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Obesity is associated with a 30% greater chance of difficult/failed intubation, although predictors for difficult laryngoscopy are the same as for the non-obese [50]. A large neck circumference is a useful additional indicator and when greater than 60 cm, is associated with a 35% probability of difficult laryngoscopy [51].
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.
- Patients with centrally distributed or ‘visceral’ fat are at greater peri-operative risk than those with peripherally distributed fat, and are far more likely to exhibit the metabolic syndrome, which consists of central obesity, hypertension, insulin resistance and hypercholesterolemia. OSA is associated with a greater than doubling of the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events and ICU admission. Obesity is strongly associated with increased insulin resistance [31]. Poor glycaemic control in the perioperative period is associated with increased morbidity, and good glycaemic control is recommended [32]. Gastric bypass surgery causes a unique neurohumeral response, resulting in a rapid, dramatic reduction in insulin requirement, starting immediately after surgery. In this cohort of patients, cautious postoperative reintroduction of diabetic medication and frequent blood sugar monitoring are essential.