AANA Journal/February 2003/Vol. 71, No.

1 45
T
h e eti o lo gy o f o b esi ty i s m u lti facto ri al,
i n clu d i n g gen eti c, m etaboli c, p sych ologi c,
an d soci oecon om i c factors.
1 ,2
Several stu d -
i es su ggest th at an aston i sh i n g 25% to 45%
of th e ad u lt p op u lati on i n th e U n i ted States
i s obese.
3-6
B od y m ass i n d ex B M I ) , d efi n ed as wei gh t
i n k i logram s d i vi d ed by h ei gh t i n m eters squ ared
k g/m
2
) , i s a bod y m easu re th at i d en ti fi es p ati en ts
k n own to be at i n creased ri sk of d i rect wei gh t-related
m orbi d i ty an d p rem atu re d eath .
4,6,7
M orbi d obesi ty i s
d efi n ed as a B M I of m ore th an 35.
2,6
P ati en ts wi th m orbi d obesi ty u n d ergoi n g bari atri c
su rgery op erati on s d esi gn ed to i n d u ce wei gh t loss
p resen t m an y u n i qu e ch allen ges to th e an esth esi a
team . O berg an d P ou lsen
4
classi fi ed p ati en ts wi th B M I
between 30 an d 35 to be at m od erate ri sk , 35 to 45 at
h i gh ri sk , an d m ore th an 45 at very h i gh ri sk of an es-
th eti c-related m orbi d i ty; a B M I of m ore th an 35 h ad a
ri sk of p ostop erati ve atelectasi s as h i gh as 45% an d a
su bsequ en t h i gh er ri sk of p n eu m on i a an d oth er p ost-
op erati ve p u lm on ary com p li cati on s. T h e p oor p h ysi o-
logi c con d i ti on of th ese m ark ed ly obese p ati en ts an d
associ ated com orbi d con d i ti on s led to a p rop en si ty for
ad verse p ostop erati ve ou tcom es.
8
R esp i ratory com p li -
cati on s occu rri n g after m ajor abd om i n al su rgery are
beli eved to be i n creased by extrem e obesi ty an d are of
co n cern to p ati en ts, su rgeo n s, an d an esth esi a
p rovi d ers.
9
T h e seri ou s m ed i cal con d i ti on s related to
severe obesi ty an d th e tech n i cal d em an d s of bari atri c
Morbid obesity is associated with multiple metabolic and
mechanical abnormalities that increase morbidity and
mortality after major abdominal surgery. It is unclear
whether patients undergoing bariatric surgery have
increased pulmonary complications postoperatively. We
performed a retrospective chart review of 207 patients
who underwent elective gastric bypass surgery during a
recent 2-year period. Body mass index (BMI = kg/m
2
) of
more than 35 was used to define morbid obesity. The pur-
pose of this study was to determine the frequency of res-
piratory failure, defined as intubation for 24 hours or more
and/or reintubation, in these patients. We also evaluated
differences in the frequency of respiratory failure between
patients with a BMI of 43 or less and those with a BMI of
more than 43. Patients with morbid obesity undergoing
elective weight loss surgery had few respiratory or other
perioperative complications with our experienced team.
The rates of respiratory failure and total postoperative
complications were 8% in the group with a BMI of 43 or
less and 14% in the group with a BMI of more than 43.
Skillful anesthetic care allows patients with significant
comorbid conditions to benefit from bariatric surgery with
reasonable risk in terms of postoperative complications.
Key words: Gastric bypass, obesity, respiratory failure.
The frequency of respiratory failure in patients
with morbid obesity undergoing gastric bypass
Eleanor L. Blouw, CRNA, MNA
Anne D. Rudolph, CRNA, MNA
Bradley J. Narr, MD
Michael G. Sarr, MD
Rochester, Minnesota
p roced u res lead on e to exp ect th at th e ri sk of com p li -
cati on s wou ld be i n creased .
T h e p u rp ose of th i s stu d y was to d eterm i n e th e fre-
qu en cy of resp i ratory com p li cati on s an d , m ore sp eci f-
i cally, resp i rato ry fai lu re i n p ati en ts u n d ergo i n g
R ou x-en -Y gastri c byp ass for m orbi d obesi ty i n a ter-
ti ary referral cen ter wi th a d ed i cated m u lti d i sci p li n ary
an esth eti c team wi th exp eri en ce i n electi ve bari atri c
su rgery. O u r h yp oth esi s was th at cu rren t ad van ces i n
an esth eti c care, ou r better u n d erstan d i n g of p u l-
m on ary p ath op h ysi ology, an d a d ed i cated , exp eri -
en ced , m u lti d i sci p li n ary su rgi cal an d an esth esi a team
h ave led to a lower i n ci d en ce of p ostop erati ve resp i ra-
tory com p li cati on s i n th i s h i gh -ri sk p ati en t p op u la-
ti on th an h ave been rep orted i n th e li teratu re. B ecau se
of th ese p red i cted i m p rovem en ts, bari atri c su rgery
sh ou ld rem ai n a vi able op ti on for m orbi d ly obese
p ati en ts.
Materials and methods
T h e i n sti tu ti o n al revi ew b o ard M ayo C li n i c,
R och ester, M i n n ) ap p roved th i s i n vesti gati on . T h e
su rgi cal d atabase at th e M ayo C li n i c con tai n s i n for-
m ati on for all p ati en ts u n d ergoi n g gastri c byp ass. T h e
sam p le con si sted of all con secu ti ve ad u lt p ati en ts wh o
u n d erwen t gastri c byp ass su rgery at th e M ayo C li n i c
between Jan u ary 1 , 1 997, an d D ecem ber 31 , 1 999.
C h art revi ews were p erform ed on ly on th ose wh o h ad
p rovi d ed con sen t for u se of th ei r m ed i cal record s
46 AANA Journal/February 2003/Vol. 71, No. 1
u n d er cu rren t i n sti tu ti on al revi ew board gu i d eli n es.
P ati en ts h avi n g th i s p roced u re p erform ed as a reop er-
ati on were exclu d ed from th e stu d y.
T h e p reop erati ve m ed i cal, su rgi cal, n u rsi n g, an d
an esth esi a record s for each su rgi cal ep i sod e were
revi ewed . I n ad d i ti on to p ostop erati ve p u lm on ary
com p li cati on s, p reop erati ve an d d em ograp h i c d ata
were abstracted . I n traop erati ve d ata i n clu d i n g ASA
p h ysi cal statu s I -V) , typ e an d d u rati on of an esth esi a,
an d th e n eed for vari ou s typ es of p ostop erati ve resp i -
rato ry th erap y also were reco rd ed . T h e m ed i cal
record s were evalu ated from d ate of ad m i ssi on u n ti l
d i sch arge. R esp i ratory ou tcom es of m ost i n terest were
d efi n ed as follows: p u lm on ary em boli con fi rm ed by
p osi ti ve rad i on u cli d e ven ti lati on -p erfu si on sci n ti gra-
p h y or p u lm on ary an gi ograp h y; atelectasi s an d /or
asp i rati on con fi rm ed by ch est rad i ograp h ; n eed for
rei n tu bati on ; an d n eed for p rolon ged i n tu bati on of
m ore th an 24 h ou rs.
1 0
E ven ts requ i ri n g stay i n th e
i n ten si ve care u n i t, read m i ssi on to th e i n ten si ve care
u n i t, m yocard i al i n farcti on , sep si s, an d d eath also
were obtai n ed .
T h e sam p le con si sted of 1 97 p ati en ts wh o were
d i vi d ed i n to 2 grou p s: 1 , B M I of 43 or less; an d 2, B M I
of m ore th an 43. We ch ose a B M I cu toff of 43 for th e
su bgrou p s, becau se oth ers h ave p revi ou sly rep orted
th at p ati en ts wi th a B M I greater th an 43 are at great-
est ri sk for m orbi d i ty.
4
D escri p ti ve stati sti cs were u sed to an alyze th e fre-
qu en cy of p eri op erati ve resp i ratory even ts. T h e m ean
an d SD or m ed i an an d ran ge were calcu lated for each
B M I su bgrou p as ap p rop ri ate for th e d i stri bu ti on of
th e d ata. To com p are p aram eters wi th i n th e 2 B M I cat-
egori es, th e F i sh er exact test an d th e n on p aram etri c
Wi lcoxon test were u sed wh en ever ap p rop ri ate.
Results
T able 1 su m m ari zes p ati en t d em ograp h i cs an d sh ows
th e m ed i an ages to be 49 an d 45 years for grou p s 1
an d 2, resp ecti vely. T h e p ercen tage of wom en i n th i s
Group 1 Group 2
BMI 43 (n = 42) BMI > 43 (n = 155)
Median age (range), y 49 (38-59) 45 (37-53)
Sex
Male 7 (17%) 57 (36.8%)
Female 35 (83%) 98 (63.2%)
Median (range) BMI (kg/m
2
) 39 (35-42) 52 (48-60)
<
Table 1. Patient demographics*
* Data are given as number (percentage) unless otherwise indicated. BMI (kg/m
2
) indicates body mass index.
d atabase was m u ch greater th an th at of m en i n both
su bgrou p s P < .05) . T h e m ed i an B M I for th e grou p s
1 an d 2 was 39 an d 52, resp ecti vely.
O bstru cti ve sleep ap n ea was d ocu m en ted p reop er-
ati vely i n 1 1 26% ) of 42 grou p 1 p ati en ts, wh ereas
67.8% of th ose i n grou p 2 n = 1 55) h ad sleep ap n ea
P < .05) . T h e frequ en cy of u se of con ti n u ou s p osi ti ve
ai rway p ressu re C PAP ) also was h i gh er P < .05) i n
grou p 2. T h e p ercen tage of com orbi d con d i ti on s su ch
as d i abetes m elli tu s i n creased fasti n g blood glu cose
level) an d ch ron i c obstru cti ve p u lm on ary d i sease
were si m i lar i n th e 2 grou p s, bu t th e p ercen tage of
p revi ou s m yocard i al i n farcti on or oth er card i ac d i s-
ease was greater P < .05) i n grou p 2 T able 2) .
T h e an esth eti c d ata are d escri b ed i n T ab le 3 . T h e
m ajo ri ty o f p ati en ts m et th e cri teri a fo r A SA p h ysi cal
statu s I I I ; o n ly 3 % o f th e p ati en ts were classi fi ed as
A SA p h ysi cal statu s I V. T h e m ajo ri ty o f p ati en ts
recei ved a co m b i n ed an esth eti c tech n i q u e gen eral
an esth esi a p lu s ep i d u ral) fo r th ei r an esth eti c, i n clu d -
i n g 3 7 8 8 % ) i n gro u p 1 an d 8 5 . 8 % i n gro u p 2 . A
tech n i cally easy i n tu b ati o n was ex p eri en ced m o st fre-
q u en tly 3 8 /3 9 [9 7 % ] an d 1 2 7 /1 3 2 [9 6 . 2 % ], resp ec-
ti vely) wi th rap i d -seq u en ce i n d u cti o n p erfo rm ed
6 9 % 2 9 /4 2 ) an d 5 0 . 3 % o f th e ti m e i n gro u p s 1 an d
2 , resp ecti vely. T h e u se o f fi b ero p ti c i n tu b ati o n was
less i n gro u p 1 3 /4 2 [7 % ] th an i n gro u p 2 1 3 . 5 % ) .
T h ere was n o d i fferen ce i n gro u p s 1 an d 2 i n th e
m ai n ten an ce o f en d o trach eal i n tu b ati o n at th e en d o f
th e o p erati o n 1 /4 2 [2 % ] vs 3 . 2 % , resp ecti vely) . Si m -
i larly, th ere was n o d i fferen ce i n th e gro u p s i n th e
ti m e sp en t i n th e reco very ro o m .
P o sto p erati ve d ata are revi ewed i n T ab le 4 .
Alth ou gh on ly 1 p ati en t 2% ) i n grou p 1 rem ai n ed
i n tu bated for m ore th an 24 h ou rs p ostop erati vely, 8
p ati en ts 5.2% ) i n grou p 2 requ i red p rolon ged i n tu ba-
ti on . T h e m ed i an d u rati on s of i n tu bati on of grou p 1
an d 2 p ati en ts wh o were n ot extu bated i n th e op erat-
i n g ro o m i m m ed i ately p o sto p erati vely o r wh o
requ i red rei n tu bati on were 23 h ou rs an d 41 h ou rs,
<
AANA Journal/February 2003/Vol. 71, No. 1 47
resp ecti vely; th ese d i fferen ces d i d n ot reach stati sti cal
d i fferen ce P = .81 ) . T h e resp i ratory i n terven ti on i n
wh i ch th e grou p s sh owed a si gn i fi can t d i fferen ce was
i n th e u se of C PAP p ostop erati vely. P ati en ts i n grou p
1 were treated wi th ad d i ti on al resp i ratory su p p ort
wi th C PAP on ly 1 0% of th e ti m e 4/42) , wh ereas
p ati en ts i n grou p 2 were treated wi th C PAP 39.4% of
th e ti m e P = .0002) . O f th e 61 p ati en ts i n grou p 2
wh o u sed C PAP p ostop erati vely, 49 h ad u sed C PAP
p reop erati vely as well.
Ad verse p u lm on ary ou tcom es are revi ewed i n T able
5. Wh i le th e total com p li cati on rate seem ed greater i n
grou p 2 1 0% [4/42] vs 1 2.3% [1 9/1 55] , th e d i ffer-
en ces for th e i n d i vi d u al resp i ratory com p li cati on s,
i n clu d i n g p ostop erati ve p u lm on ary em boli , asp i rati on ,
atelectasi s, p rolon ged i n tu bati on , an d rei n tu bati on ,
were m i n i m al, an d n o stati sti cal d i fferen ces were
fou n d i n ei th er i n d i vi d u al or overall p u lm on ary com -
p li cati on s. N on e of th e p ati en ts i n ei th er grou p exp eri -
en ced a p eri op erati ve m yocard i al i n farcti on or sep si s.
Group 1 Group 2
BMI 43 (n = 42) BMI > 43 (n = 155)
Diabetes mellitus 15 (36) 73 (47.1)
Chronic obstructive pulmonary disease 0 (0) 4 (2.6)
Sleep apnea 11 (26) 105 (67.7)
CPAP use 5 (12) 77 (49.7)
Tobacco use
Past 9 (21) 39 (25.2)
Current 6 (14) 18 (11.6)
Hypertension 19 (45) 90 (58.1)
Coronary artery disease 7 (17) 9 (5.8)
Previous myocardial infarction 2 (5) 8 (5.2)
Other cardiac disease 4 (10) 11 (7.1)
<
Table 2. Preoperative comorbidity*
* Data are given as number (percentage) unless otherwise indicated. BMI (kg/m
2
) indicates body mass index; CPAP, continuous positive airway pressure.
Group 1 Group 2
BMI 43 (n = 42) BMI > 43 (n = 155)
ASA physical status
II 11 (26) 14 (9.0)
III 31 (74) 137 (88.4)
IV 0 (0) 4 (2.6)
Type of anesthesia
General 5 (12) 22 (14.2)
Combined (general and regional) 37 (88) 133 (85.8)
Intubation rating
Easy 38 (97) 127 (96.2)
Difficult 1 (3) 5 (3.8)
Rapid-sequence induction (yes) 29 (69) 78 (50.3)
Fiberoptic intubation (yes) 3 (7) 21 (13.5)
Left intubated at end of operation (no) 1 (2) 5 (3.2)
Median (range) length of stay in recovery room (min) 67 (60-90) 68 (51-90)
Use of CPAP in recovery room (yes) 1 (2) 18 (11.6)
<
Table 3. Anesthetic data*
* Data are given as number (percentage) unless otherwise indicated. BMI (kg/m
2
) indicates body mass index; CPAP, continuous positive airway pressure.
48 AANA Journal/February 2003/Vol. 71, No. 1
Discussion
B ari atri c su rgery i s a sp eci ali zed area of gen eral su r-
gery d ed i cated to th e treatm en t of severe obesi ty vi a
an atom i c m od i fi cati on s i n th e gastroi n testi n al tract
d esi gn ed to p rod u ce gastri c restri cti on , m alabsorp ti on
of n u tri en ts, or both .
1
T h e R ou x-en -Y gastri c byp ass
p roced u re h as p roven effecti ve i n obtai n i n g a d u rable
wei gh t loss for u p to 1 0 years. Wei gh t loss p rod u ces
an o verall i m p ro vem en t i n q u ali ty o f li fe an d
lon gevi ty. An oth er M ayo C li n i c stu d y sh owed th at
alm ost th ree fou rth s of bari atri c p ati en ts m ai n tai n ed a
p rolon ged wei gh t loss of at least 50% of th ei r excess
bod y wei gh t, an d m ost h ad d i sap p earan ce of i n su li n -
requ i ri n g d i abetes an d a d ecrease i n m ed i cati on -
d ep en d en t h yp erten si on .
1 1
Wi th th ese ben efi ci al lon g-
term o u tco m es, R o u x -en -Y gastri c b yp ass i s an
i n creasi n gly vi able op ti on for p ati en ts stru ggli n g wi th
m orbi d obesi ty. I n d eed a N ati on al I n sti tu tes of H ealth
con sen su s con feren ce i n 1 991 recogn i zed an d con -
d on ed bari atri c su rgery as an effecti ve, accep table
treatm en t for p ati en ts wi th m orbi d obesi ty.
1 2
T h e resu lts of th e 1 992 N ati on al B ari atri c Su rgery
R egi stry stu d y for obesi ty i d en ti fi ed resp i ratory com -
p li cati on s as th e m ost frequ en t p ostop erati ve com p li -
cati on occu rri n g i n abou t 5% of p ati en ts.
9
M an y stu d -
i es h ave sh o wn an i n crease i n p o sto p erati ve
p u lm on ary com p li cati on s i n obese p ati en ts. G ari bald i
et al
1 3
revi ewed 520 p ati en ts u n d ergoi n g i n tra-abd om -
i n al op erati on s an d fou n d th at p ati en ts wh o wei gh ed
m ore th an 250 p ou n d s were at an alm ost 40% greater
ri sk for d evelop i n g p n eu m on i a. I n an oth er stu d y,
H ood an d D ewan
1 4
followed u p 1 1 7 obese wom en
d u ri n g ch i ld bi rth an d fou n d lon ger h osp i tal stays an d
i n creased m ed i cal costs d u e to resp i ratory com p li ca-
ti on s. B rook s-B ru n n
1 5
also rep orted th at p ati en ts wi th
a B M I of 27 or m ore were at i n creased ri sk for p u l-
m on ary com p li cati on s, wi th si gn i fi can t p u lm on ary
com p li cati on s occu rri n g i n 29% of 1 81 obese p ati en ts.
Group 1 Group 2
BMI 43 (n = 42) BMI > 43 (n = 155) P value
Prolonged postoperative intubation (> 24 hours) 1 (2) 8 (5.2) NS
Median (range) duration of postoperative intubation

(hours) 23 (16-151) 41 (34-48) NS

Admission to ICU 5 (12) 23 (14.8) NS
Median (range) ICU duration (hours) 36 (21-80) 40 (18-57) NS
Respiratory cause for intubation or prolonged intubation 2 (5) 12 (7.7) NS
Postoperative CPAP 4 (10) 61 (39.4) .0002
CPAP used preoperatively and postoperatively 2 (5) 49 (31.6) .0002
<
Table 4. Postoperative respiratory considerations*
* Data are given as number (percentage) unless otherwise indicated. ICU indicates intensive care unit; CPAP, continuous positive airway pressure; BMI (kg/m
2
), body
mass index; NS, not significant. P > .6.
If not extubated immediately postoperatively or if there was a need for reintubation.
Group 1 Group 2
BMI 43 (n = 42) BMI > 43 (n = 155) P value
Postoperative pulmonary embolus 0 (0) 2 (1.3) NS
Aspiration 0 (0) 1 (0.6) NS
Atelectasis 1 (2) 2 (1.3) NS
Reintubation 2 (5) 3 (1.9) NS
Other complications 1 (2) 11 (7.1) NS
Total complications 4 (10) 19 (12.3) NS
<
Table 5. Adverse pulmonary outcomes*
* Data are given as number (percentage) unless otherwise indicated. BMI (kg/m
2
) indicates body mass index; NS, not significant. For all values, P > .29.
AANA Journal/February 2003/Vol. 71, No. 1 49
B ased on th e d ata obtai n ed i n ou r stu d y, th e ri sk of
resp i ratory p roblem s after bari atri c su rgery i n th i s
p ati en t p op u lati on i s n ot as h i gh as m i gh t be an ti ci -
p ated from revi ew of th e li teratu re. We con clu d ed th at
p ati en ts wi th m orbi d obesi ty p lan n i n g to u n d ergo
electi ve R ou x-en -Y gastri c byp ass su rgery can be reas-
su red th at th ei r ri sk of si gn i fi can t p eri op erati ve resp i -
ratory com p li cati on s i s relati vely low 1 2.3% ) .
T h e resp i ratory system i s of m ajor con cern to an es-
th esi a p erson n el. R esp i ratory d i sord ers, both m ech an -
i cal an d d i sease-related , can m ak e p ati en t m an age-
m en t d i ffi cu lt. O besi ty creates a su bstan ti al i n crease
i n th e work of breath i n g attri bu table to th e i n crease i n
elasti c work an d th e d ecrease i n effi ci en cy of th e res-
p i ratory m u scles.
3,4,6
B ecau se of th e i n creased work ,
m etaboli c d em an d s are greater, p rod u ci n g m ore car-
bon d i oxi d e i n creasi n g ven ti lati on requ i rem en ts ,
an d requ i ri n g greater am ou n ts of oxygen to m eet th e
bod y n eed s.
1 ,4,6,7,1 6
I n ad d i ti on , fu n cti on al resi d u al
cap aci ty i s d ecreased com p ared wi th th at i n n on obese
cou n terp arts. Wh en th e p ati en t wi th m orbi d obesi ty
i s p laced i n th e su p i n e p osi ti on , th e d ecrease i n fu n c-
ti o n al resi d u al cap aci ty b eco m es p ro fo u n d .
1 , 4 , 1 7 -1 9
O n ce an esth eti zed , fu n cti o n al resi d u al cap aci ty
d ecreases even fu rth er, to m ore th an 50% below n or-
m al i n obese p ati en ts.
4,6,7,1 7
T h i s d ecrease lead s to
sm all ai rway closu re an d su bsequ en t abn orm ali ti es i n
ven ti lati on an d p erfu si on . I n ad d i ti on , fat accu m u la-
ti on arou n d th e ri bs, u n d er th e d i ap h ragm , an d i n tra-
abd om i n ally ad d s to th i s resp i ratory i n effi ci en cy by
red u ci n g ch est wall com p li an ce.
4,7,20
All of th ese p eri -
op erati ve resp i ratory factors sh ou ld be tak en i n to con -
si d erati on wh en p lan n i n g th e best an esth eti c for i n d i -
vi d u al p ati en ts.
P ostop erati ve resp i ratory care i s com p li cated fu r-
th er by th e observati on th at u p to 30% of p ati en ts
wi th m orbi d obesi ty wi ll h ave obesi ty h yp oven ti lati on
syn d rom e m an i festi n g as ep i sod i c som n olen ce, sleep
ap n ea, an d loss of h yp oxi c d ri ve.
7
E xtrem e m an i festa-
ti on s of obesi ty h yp oven ti lati on syn d rom e i n clu d e
p olycyth em i a, alveolar h yp oven ti lati on wi th h yp ox-
em i a, h yp oven ti lati on , p u lm on ary h yp erten si on , an d
b i ven tri cu lar h eart fai lu re.
6 , 7 , 1 6 , 1 9 , 2 0
T h ese p ati en ts
seem to be at an even h i gh er ri sk for p ostop erati ve
resp i ratory com p li cati on s.
P reop erati ve assessm en t of p ati en ts wi th m orbi d
obesi ty p erm i ts m od i fi cati on of th e an esth eti c p lan to
m eet i n d i vi d u al p ati en t n eed s regard i n g si gn i fi can t
com orbi d i ty an d th e ri sk for p oten ti al an esth eti c d i ffi -
cu lti es. B en efi ts of ad d i ti on al research m i gh t i n clu d e
i n si gh t as to th e frequ en cy of resp i ratory fai lu re i n
p ati en ts wi th greater B M I s an d d eterm i n ati on of a ri sk
factor p rofi le. R esu lts of su ch stu d i es also m i gh t be
h elp fu l i n allowi n g m ore com p reh en si ve p reop erati ve
d i scu ssi on wi th p ati en ts con cern i n g th e ri sk s of com -
p li cati on s.
M an y ap p roach es to an esth esi a h ave been ap p li ed
to th i s p ati en t p o p u lati o n . T h e m ajo ri ty o f th e
p ati en ts i n th i s revi ew recei ved a com bi n ed tech n i qu e
of regi on al an d gen eral an esth esi a wi th excellen t ou t-
com es. T h e u se of p reem p ti ve an d p ostop erati ve
ep i d u ral an algesi a m axi m i zes resp i ratory fu n cti on by
better con trolli n g p ostop erati ve p ai n . T h i s level of
p ai n con trol allows rap i d p ati en t m obi li zati on an d
am b u lati o n . B ecau se o f th e p revi o u sly i d en ti fi ed
com orbi d con d i ti on s, p ati en ts u n d ergoi n g bari atri c
su rgery requ i re m eti cu lou s assessm en t an d sp eci fi c
an esth eti c p rep arati on to ach i eve op ti m al con d i ti on s
for a su ccessfu l an esth eti c.
T h e k n owled ge, sk i ll, an d foresi gh t of th e an esth esi a
p rovi d ers are k ey i n p red i cti n g an d p reven ti n g p oten -
ti ally seri ou s com p li cati on s. Sp eci fi c equ i p m en t m ay be
n ecessary for tran sp orti n g th e p ati en t wi th m orbi d obe-
si ty an d an op erati n g room bed equ i p p ed to h an d le
excessi ve wei gh t i s n eed ed .
21
An ai r m attress tran sfer
d evi ce H overM att Tran sfer Solu ti on , Allen town , P a)
m ay h elp k eep th e p ati en t an d op erati n g room staff safe
from i n ju ry wh en p h ysi cally tran sferri n g a m ark ed ly
obese i m m obi le p ati en t from bed to table or table to
stretch er; th ese d evi ces u se an ai r p u m p to i n flate a
d eflated ai r m attress p laced u n d er th e p ati en t p reop er-
ati vely; th en staff can easi ly sli d e th e p ati en t from th e
op erati n g room table to th e stretch er.
P rep arati on s for a d i ffi cu lt ai rway, i n clu d i n g th e
abi li ty for fi berop ti c i n tu bati on , laryn geal m ask ai r-
way, an d i n tu bati n g stylet sh ou ld be rou ti n e i n th e
setu p . Ad d i ti on al exp eri en ced assi stan ce i s i m p ortan t
d u ri n g i n d u cti on of an d em ergen ce from an esth esi a. I f
d ecreased n eck m obi li ty an d d i ffi cu lt ai rway vi su ali -
zati on are evi d en t, an awak e, fi berop ti c-assi sted i n tu -
bati on i s th e safest tech n i qu e. T ak i n g th e ti m e to
p rop erly p osi ti on th e p ati en t for m axi m al vi su ali za-
ti on of th e laryn x i n creases su ccess of i n tu bati on .
L i k ewi se, p laci n g th e p ati en t i n th e si tti n g p osi ti on
an d tap i n g red u n d an t ti ssu e away from th e m i d li n e
m ay h elp i d en ti fy i n tervertebral sp aces for ep i d u ral
p lacem en t. L on ger ep i d u ral n eed les to reach th e
ep i d u ral sp ace sh ou ld be avai lable.
Stan d ard p n eu m ati c blood p ressu re cu ffs are n ot
always accu rate i n p ati en ts wi th large arm s, an d an
arteri al li n e for m on i tori n g often i s n ecessary. Sp eci al
atten ti on m u st be gi ven to p ad d i n g an d p osi ti on i n g of
u p p er extrem i ti es to p reven t n erve d am age, an d often ,
arm s n eed to be left u n tu ck ed to m ai n tai n p rop er su p -
p ort. Sam p li n g an d tren d i n g arteri al blood gases wi ll
p rovi d e gu i d an ce abou t ven ti latory n eed s.
50 AANA Journal/February 2003/Vol. 71, No. 1
At th e en d of th e op erati on , tran sferri n g th e p ati en t
to th e cart an d p laci n g th e p ati en t i n th e sem i recu m -
ben t p osi ti on before extu bati on m ay faci li tate larger
ti d al volu m es. E xtu bati on sh ou ld n ot be p erform ed
u n ti l th e p ati en t i s awak e an d resp on si ve an d can
d em on strate i n tact laryn geal reflexes. Arran gi n g for
th e u se of C PAP i n th e recovery area m ay m axi m i ze
resp i ratory fu n cti on early on , an d i t m ay faci li tate
good p ai n con trol an d early m obi li zati on .
M u lti d i sci p li n ary team s, ran gi n g from th e su rgi cal
an d an esth esi a team s to n u rsi n g, n u tri ti on , an d bi o-
m ech an i cs, are n ecessary for th e care of th e p ati en t
wi th m orbi d obesi ty. C om m u n i cati on an d coop era-
ti on am on g all p ati en t care team s are essen ti al to
m ai n tai n p ati en t safety an d en su re a su ccessfu l su rgi -
cal exp eri en ce.
Alth ou gh ou r stu d y sh ows a very low rate of seri -
ou s resp i ratory com p li cati on s i n th i s h i gh -ri sk p op u -
lati on 1 2.3% ) , we ack n owled ge th e li m i tati on s of ou r
stu d y are i ts retrosp ecti ve d esi gn an d th e lack of a
si m i lar con trol grou p a n on obese grou p or a grou p
wi th m orbi d obesi ty u n d ergoi n g n on bari atri c su r-
gery) . Wi th ou t su ch con trol grou p s, we are u n able to
d raw absolu te con clu si on s regard i n g th i s p ati en t p op -
u lati on ; h owever, th e excellen t ou tcom es d ocu m en ted
are reassu ri n g.
We fou n d th at p ati en ts wi th m orbi d obesi ty h ave
fewer com p li cati on s th an wou ld be exp ected after
u n d ergoi n g R ou x-en -Y gastri c byp ass su rgery based
on p revi ou s rates rep orted i n th e li teratu re abou t su r-
gery i n th e obese p ati en t. We con clu d e th at cu rren t
an esth esi a care of th ese p ati en ts by a team th at u n d er-
stan d s p oten ti al com p li cati on s wi ll p rovi d e for a safe
p eri op erati ve cou rse.
REFERENCES
1 . O ri a H E , B roli n R E . P erform an ce stan d ard s i n bari atri c su rgery.
Eur J Gastroenterol Hepatol. 1 999;1 1 :77-84.
2. C owen G S, H i ler M L , B u ffi n gton C . C ri teri a for selecti on of p ati en ts
for bari atri c su rgery. Eur J Gastroenterol Hepatol. 1 999;1 1 : 69-74.
3. R ei sen E , F roli ch E D . O besi ty: card i ovascu lar an d resp i ratory
p ath op h ysi ology alterati on s. Arch Intern Med. 1 981 ;1 41 :431 -434.
4. O berg B , P ou lsen T D . O besi ty: an an esth eti c ch allen ge. Acta
Anaesthesiol Scand. 1 996;40:1 91 -200.
5. B i stri an B R . T h e m ed i cal treatm en t of obesi ty. Arch Intern Med.
1 981 ;1 41 :429-430.
6. B u ck ley F P. An esth esi a for th e m orbi d ly obese p ati en t. Can J
Anaesth. 1 994;41 :R 94-R 1 00.
7. H u n ter JD , R ei d C , N oble D . An esth eti c m an agem en t of th e m or-
bi d ly obese p ati en t. Hosp Med. 1 998;59:481 -483.
8. P asu lk a P S, B i stri an B R , B en otti P N , B lack bu rn G L . T h e ri sk s of
su rgery i n obese p ati en ts. Ann Intern Med. 1 986;1 04:540-546.
9. M ason E E , R en qu i st K E , Ji an g D . P eri op erati ve ri sk s an d safety of
su rgery for severe obesi ty. AmJ Clin Nutr. 1 992;55 2 su p p l) :573S-
576S.
1 0. Warn er D O , Warn er M A, O fford K P, Sch roed er D R , M axson P,
Scan lon P D . Ai rway obstru cti on an d p eri op erati ve com p li cati on s
i n sm o k ers u n d ergo i n g ab d o m i n al su rgery. Anesthesiology.
1 999;90:372-378.
1 1 . B alsi ger B M , K en n ed y F P, Abu -L ebd eh H S, et al. P rosp ecti ve eval-
u ati on of R ou x-en -Y gastri c byp ass p ri m ary op erati on for m ed -
i cally com p li cated obesi ty. Mayo Clin Proc. 2000;75:673-680.
1 2. C on sen su s D evelop m en t C on feren ce P an el. N I H con feren ce. G as-
troi n testi n al su rgery for severe obesi ty. Ann Intern Med. 1 991 ;1 1 5:
956-961 .
1 3. G ari bald i R A, B ri tt M R , C olem an M L , et al. R i sk factors for p ost-
op erati ve p n eu m on i a. AmJ Med. 1 981 ;70:677-680.
1 4. H ood D D , D ewan D M . An esth eti c an d obstetri c ou tcom es i n m or-
bi d ly obese p artu ri en ts. Anesthesiology. 1 993;79:1 21 0-1 21 8.
1 5. B rook s-B ru n n J. P red i ctors of p ostop erati ve p u lm on ary com p li ca-
ti on s followi n g abd om i n al su rgery. Chest.1 997;1 1 1 :564-571 .
1 6. P i -Su n yer XF. M ed i cal h azard s of obesi ty. Ann Intern Med. 1 993;
1 1 9:655-660.
1 7. D am i a G , M asch eron i D , C orci M . P eri op erati ve ch an ges i n fu n c-
ti on al resi d u al cap aci ty i n m orbi d ly obese p ati en ts. Br J Anaesth.
1 998;60:574-578.
1 8. P au l D R , H oyt JL , B ou tros AR . C ard i ovascu lar an d resp i ratory
ch an ges i n resp on se to ch an ge of p ostu re i n th e very obese. Anes-
thesiology. 1 976;45:73-77.
1 9. N ak atsu k a M . P u lm on ary vascu lar resi stan ce an d ri gh t ven tri cu lar
fu n cti on i n m orbi d obesi ty i n relati on to gastri c byp ass su rgery. J
Clin Anesth. 1 996;8:205-209.
20. Stoll D A, Stei n L E . An esth eti c m an agem en t of th e m orbi d ly obese
p ati en t. AANA J. 1 984;52:436-444.
21 . Sarr M G , F elty C L , H i lm er D M , et al. Tech n i cal an d p racti cal con -
si d erati on s i n volved i n op erati on s on p ati en ts wei gh i n g m ore th an
270 k g. Arch Surg. 1 995;1 30:1 02-1 05.
AUTHORS
E lean or L . B lou w, C R N A, M N A, i s a staff an esth eti st at M ayo C li n i c,
R och ester, M i n n . Wh en th i s arti cle was wri tten , sh e was a stu d en t at
M ayo Sch ool of H ealth R elated Sci en ces, M aster of N u rse An esth esi a
P rogram , M ayo C li n i c, R och ester, M i n n .
An n e D . R u d olp h , C R N A, M N A, i s staff an esth eti st at Alban y An es-
th esi a, Alban y, O re. Wh en th i s arti cle was wri tten , sh e was a stu d en t at
M ayo Sch ool of H ealth R elated Sci en ces, M aster of N u rse An esth esi a
P rogram , M ayo C li n i c, R och ester, M i n n .
B rad ley J. N arr, M D , i s a con su ltan t i n An esth esi ology, M ayo C li n i c,
an d i s an assi stan t p rofessor of An esth esi ology, M ayo M ed i cal Sch ool,
R och ester, M i n n .
M i ch ael G . Sarr, M D , i s a con su ltan t i n su rgery, M ayo C li n i c, an d i s
p rofessor of Su rgery, M ayo M ed i cal Sch ool, R och ester, M i n n .