Anaesthesia for Bariatic patients Mishelle Dehaini RN, CCRN, Grad.Cert HPE, Grad.Cert Periop,

CNE, Box Hill Hospital https://goo.gl/images/2TFipP

Definitions

“Overweight/Obesity is defined as abnormal or

excessive fat accumulation that may impair health” WHO

BMI = weight in kilograms/height in metres (kg/m2)

Obesity in Australia

▪ Adults

▪ 63% are overweight or obese

▪ >20% are obese – BMI>30

▪ >14% are severely obese – BMI>35

▪ >5% are morbidly obese – BMI>40

▪ Children

▪ 22%are overweight or obese

▪ 75% become morbidly obese adults

FROM DIABETES AUSTRALIA 2018https://goo.gl/images/gLJa6Z

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Optimal outcomes from surgery

Surgery – shows greater and sustained weight loss than non-surgical interventions

Sleeve Gastrectomy – show best outcomes

Resolution of co-morbidities well documented – ie. T2DM, IHD, Hyperlipidaemia, HT, OSA

Emotional needs

Negative attitudes from staff common

Respect and care for each patient individually

Interdisciplinary approach

Attention to detail – large gowns, specific equipment in wards now.

IV access

Can be difficult

Consider use of Ultrasound

Consider longer IV and arterial cannulae

Warm patient pre-operatively to vasodilate vessels

-consider bair huggers and warmed wet towels

Consider CVC access if unable to cannulate patient peripherally

-particularly if patient has any Cardiac dysfunction

IV Sizes and lengths

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Airway issues

BMV more difficult

Increased difficult intubation

Increased risk of aspiration

Neck circumference associated with difficult intubation

>40cms – 5% probability

>60 cms -35% probability

Reduced neck and mouth mobility

Decreased FRC, increased metabolic requirements

Earlier onset of hypoxia

Airway

Optimise patient positioning – use of pillows, RAMP

Use of stubby handle laryngoscope

Consider 2 handed BMV

Consider video laryngoscope

Awake Fibreoptic Intubation maybe an option

Video Laryngoscopes

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Optimise pre-oxygenation

Use of Nasal prongs or nasal catheters to increase inspiratory oxygenation

Use of Optiflow to maximum apneic oxygenation time

Pre-oxygenation

Optiflow

Photos courtesty Fischer and Paykel Healthcare

Optiflow

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Benefits of Optiflow

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RAMP pillows

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Optimal positioning for intubation

Operating tables for Bariatrics

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Positioning

Pt. in Reverse Trendlenberg 30 degrees

Most utilize lithotomy for legs- 1 surgeon stands between usually

Ensure good padding for all limbs – gels are optimal, foam is not as useful

Use of strapping to keep limbs on arm boards

Reverse Trendelberg benefits

Benefits include:

Reduction in compression of Inferior VC

Reduction in compression of diaphragm

Improves FRC

Blood flow as normalized as possible

Positioning on OR table

Ensure table can accommodate weight of the morbidly obese

High risk of pressure injuries, skin tears

Use of hover mats

Ensure multiple staff to help with positioning of pt.

Bariatric beds

SCDs, TEDS to reduce VTE- very high risk

Reverse Trendelenburg positioning

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Positioning

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Gels

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Warming the patient

Use of Forced Air warmers, mats

? Upper and Lower warming

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Warming the patient

Fluid warming

Temp monitoring - ? IDC

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Monitoring in the OR

NIBP – longer cuff, not bigger – often not well positioned

? Arterial line – necessary for patients with IHD/OSA

- allows ABG analysis and closer BP monitoring

ECG – ensure placement optimal –skin pendulous

- 5 leads for patients with IHD with V5-6 used

SpO2- probe may not fit fingers- consider disposable

Further monitoring

? Need for BSL monitoring intra-operatively

? Need for Actrapid infusion

?Need for ABGs regularly

Temperature monitoring

Monitoring urine output hourly if poor renal function

Surgical considerations

May need to proceed to open procedures instead of laparoscopic

Surgical procedures may take longer

This will mean longer anaesthesia time

Greater need for Analgesia and PONV medications post-operatively

Complications post surgery

Prolonged length of stay

Pressure ulcers

Wound infections

Respiratory complications- Atelectasis, Resp failure

Urinary complications, incontinence

VTE

Extubation

Optimise patient position – UPRIGHT

Increased risk of aspiration - ?need for NGT to reduce risk- discuss with Surgical team

Low tolerance for failure to extubate – re-intubate ASAP

Consider transfer of pt. directly to ICU/HDU

References

Carden, J, Perioperative Management of the Bariatric patient, ASPAAN lecture 2015

Duke, J, Anaesthetic secrets 4th Edition, Mosby Elsevier 2011

Nagelhout, J and Elisha, S, Nurse Anesthesia 6th Edition, Elsevier 2018

Rosewarne,F, Obesity & Anaesthesia – implications, considerations & management, Critical visions lecture 2013

Nicholson, P, Management of the Bariatric Patient, Deakin lecture 2015

AUSMED – Considering the Larger Patient in the Operating Theatre- What do you need to be aware of? https://www.ausmed.com/articles/larger-patient-in-the-operating/?utm_source accessed 24/5/2017