Overweight : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Jul 18, 2012

Flowchart summarising cardiovascular changes and aetiology of cardiomyopathy in obese patients from refl.in/ko

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Mar 12, 2012

Ideal body weight (IBW):
Male = (height in cm-100).
Female = (height in cm-105)
refl.in/4v

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Nov 14, 2012

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Associated conditions

Type II diabetes mellitus (NIDDM) is common in this population. Enquire about medication and complications of the disease, and consider withholding metformin for all but minor procedures. See NIDDM

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Sep 08, 2014

Periprocedural medication management

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Relevant procedures

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Disease management

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Preprocedure optimisation, Postponement

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Explanation, Patient Instructions

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Premedication

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IV access

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Monitoring

Unreliable non-invasive blood pressure (NIBP) with large arms, consider intra arterial line where applicable

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Sep 08, 2014

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Positioning, Protection

At elevated risk of pressure areas, (although not peripheral neuropraxias), so frequently check and reposition patient.

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Oct 09, 2011

Consider the risk of aortocaval compression in the hypotensive obese patient and place them in a >15 degree tilted position if required.

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Oct 11, 2011

Ensure table is correct size and rated to an adequate weight for the patient

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Oct 09, 2011

Analgesia, Anesthesia, Antiemesis

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Temperature

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LA doses to be reduced by 25% for subarachnoid & epidural blocks as engorged epidural veins/fat impinge on the epid space refl.in/4t

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May 18, 2011

Modified RSI technique for patients requiring intubation, & determined not to be at risk of full stomach. Goal is to reduce the consequences of a "can't intubate, can't ventilate" scenario. 25 degree head up to optimise preoxygenation (addit ~50secs of apneoic oxygenation), and "ramped" position (to optimise airway for laryngoscopy). Commence with min 3 mins good preoxygenation. Induce with propofol and suxamethonium to achieve anesthesia and profound muscle relaxation (and short acting opiate if required). If difficult laryngoscopy is encountered, the optimal positioning & adequate prolonged apnoeic preoxygenation means that there is more time available for use of alternative airway devices, and more time to wake the patient up in the "can't intubate, can't ventilate" scenario

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(1 comment)

Oct 10, 2011

The time to return of spontaneous ventilation following suxamethonium is 4.1-7.0 minutes. This means that despite best efforts, the apnoeic oxygenation is not guaranteed to outlast the suxamethonium.

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Obese patients are at high risk for obstructive sleep apnoea OSA. Consider the risk of post operative opioid respiratory depression and maximise the use of non-opioid analgesia. refl.in/ko

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Oct 09, 2011

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Airway, Ventilation

Difficult bag mask ventilation is common. Ensure adequate airway adjuncts are immediately available. High pressure mask ventilation may result in gastric insufflation, increasing the risk of gastric regurgitation as well as post-operative nausea and vomiting.

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Oct 12, 2011

If limited recovery staff, consider taking patient out in lateral position preemptively in case patient's airway obstructs & needs rolling

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May 18, 2011

Preoxygenation Is More Effective in the 25 degrees Head-up Position Than in the Supine Position in Severely Obese Patients. refl.in/35

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Sep 08, 2014

Consider the presence of a second anesthesiologist at induction as a second pair of hands in potentially difficult cases.

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Oct 10, 2011

Delivery of oxygen via a nasal cannula during difficult laryngoscopy in obese male patients in a head up position prolongs apneoic oxygenation time from 3.5min to 5.5min. refl.in/ks

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Oct 10, 2011

Every 1cm neck circumference above 40cm increases odd ratio of difficult laryngoscopy by 1.16 #ref

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Oct 09, 2011

Exaggerated reduction in FRC under general anesthesia. Reduction of 50% compared with 20% for non-obese patients. refl.in/ko

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Oct 09, 2011

Functional residual capacity (FRC) is more likey to fall below closing capacity (CC) resulting in ventilation perfusion mismatch. Patients will require higher peak expiratory pressures (PEEP) to avoid this. Image from refl.in/ko

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Mar 12, 2012

Some anesthetists regard obese patients to be at risk of gastroparesis/delayed gastric emptying, increasing the risk of pulmomary aspiration of gastric contents.

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(1 comment)

Sep 08, 2014

Evidence? refl.in/ar suggests otherwise

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Cardiovascular, Fluids

Patients with diastolic dysfunction have a fixed stroke volume, and are more reliant on heart rate for cardiac output.

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Sep 08, 2014