Anesthesia For The Obese Patient

14/1/2016
Anesthesia for the obese patient
Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Author
Roman Schumann, MD
Section Editor
Stephanie B Jones, MD
Deputy Editor
Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2015. | This topic last updated: Jan 08, 2016.
INTRODUCTION As the prevalence of obesity increases worldwide, an increasing number of obese surgical
patients will require anesthesia. Obesity is typically defined by body mass index (BMI), the ratio of weight (in
kilograms) to the square of height (in meters) (calculator 1). In adults, the World Health Organization and the
National Institute of Health define obesity as a BMI 30 kg/m2.
This topic reviews the changes in anatomy and physiology in obese patients that affect anesthetic
management, anesthetic drug dosing in obesity, and planning the anesthetic (type of anesthesia, equipment,
appropriate monitoring, and analgesic plan) as it differs from patients with normal BMI. Preoperative medical
evaluation of obese patients, the impact of obstructive sleep apnea on anesthetic management, and general
principles and techniques in anesthesia are discussed separately.
(See "Preanesthesia medical evaluation of the obese patient".)
(See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep
apnea".)
(See "Intraoperative management of adults with obstructive sleep apnea".)
(See "Postoperative management of adults with obstructive sleep apnea".)
(See "Overview of anesthesia and anesthetic choices".)
PHYSIOLOGIC CHANGES Increasing obesity leads to respiratory and cardiovascular changes that impact
the delivery of anesthesia and perioperative analgesia.
Alterations in airway anatomy caused by obesity are discussed separately. (See "Preanesthesia medical
evaluation of the obese patient", section on 'Airway assessment'.)
Respiratory physiology Obesity-related respiratory changes occur as a consequence of physical
impingement of lung volumes and chest movement as well as the increased metabolic requirements of excess
tissue; these in turn lead to increased work of breathing [1], increased oxygen (O2) consumption [2], and
disordered ventilation to perfusion matching [3].
As a consequence, respiratory rates are increased, and functional residual capacity (FRC) and expiratory
reserve volume (ERV) are decreased, even in mild obesity [4]. FRC may be sufficiently reduced such that small
airways and alveoli remain closed during spontaneous ventilation, leading to ventilation-perfusion mismatch and
right to left shunting [5]. Lung volumes and intrapulmonary shunt worsen with the induction of general
anesthesia in all patients, but to a much greater degree in obese patients [6,7]. Supine position and obstructive
sleep apnea (OSA) increase the magnitude of these effects [8,9].
Consequences of these changes of concern to anesthesiologists include:
Decreased time to desaturation during apnea [10]
Increased O2 requirements [2]
Hypoventilation with supine spontaneous ventilation [9]
A general discussion of respiratory changes in obesity is found separately. (See "Diseases of the chest wall",
section on 'Obesity'.)
Cardiovascular physiology Cardiovascular physiologic changes in obesity include:
Increased circulating blood volume, although it is a lower proportion of total weight (50 mL/kg as compared
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with 75 mL/kg) compared with patients with normal BMI [11].

Decreased systemic vascular resistance [12].
Increased cardiac output by 20 to 30 mL per kilogram of excess body fat. Stroke index, cardiac index, and
heart rate remain normal; the increased cardiac output occurs by means of expanded stroke volume [13].
Left ventricular hypertrophy, related to the duration of obesity [14]. The increased cardiac output can lead
to either left ventricular failure (especially when associated with hypertension), or right heart failure
(especially when associated with the hypoxia and hypercapnia of OSA) (algorithm 1).
Hypertension and cardiovascular disease are also more prevalent in obese patients and when present may
produce additional changes (table 1). (See "Obesity, weight reduction, and cardiovascular disease", section on
'Obesity and cardiovascular disease' and "Preanesthesia medical evaluation of the obese patient", section on
'Screening for comorbidities'.)
DOSING ANESTHETIC DRUGS Drug dosing in obese patients may be based on total body weight (TBW),
lean body weight (LBW) (calculator 2) for females and (calculator 3) for males, or ideal body weight (IBW)
(calculator 4), depending upon the agent chosen [15,16]. Dosing methods for commonly used drugs are
presented in the table (table 2). When recommended dosing method for a specific drug is unknown, it is
reasonable to base doses on LBW, except for highly lipophilic drugs for which TBW should be used [17].
Modified drug dosing is required because of obesity-related increases in LBW, cardiac output, and blood
volume, as well as changes in regional blood flow; these can affect peak plasma concentration, clearance, and
elimination half-life of many drugs [17].
The volume of distribution (Vd) is the principal determinant of loading dose of drugs. The Vd of relatively
lipophilic drugs is increased by obesity; less lipophilic drugs have little to no change in Vd in obese
patients, as blood flow to fat tissue is lower than that to vessel-rich or lean tissue [18]. Vd is largely
dependent on the physiochemical attributes of a drug and varies with plasma protein binding and tissue
blood flow, but changes are not consistent for all drugs within a category, and in many cases have not
been determined [17].
Drug clearance is generally higher in obese individuals than non-obese individuals [17]. This is largely
controlled by hepatic and renal physiology. Obesity affects hepatic metabolic pathways in different ways,
with some only slightly and others significantly enhanced in obesity [18]. Renal elimination includes
glomerular filtration, tubular secretion, and tubular reabsorption; changes are observed in obesity, but vary
by drug and are not completely understood.
The elimination half-life (t1/2) impacts dosing interval and dosing of continuous infusions. The t1/2 of a drug
varies directly with Vd, and inversely on the clearance, both of which are altered in obesity.
While somewhat difficult to predict, pharmacodynamic changes also occur in severely obese individuals; for
example, therapeutic windows may be narrowed or side-effects exaggerated in some drugs.
PLANNING THE ANESTHETIC General anesthesia, regional anesthetic and sedation techniques have all
been employed safely in obese patients, and no technique has been found to be superior to another with
respect to important patient outcomes (eg, mortality, cardiopulmonary complications).
Due to the high prevalence of sleep apnea in obese patients, and consequent sensitivity to sedatives, the use of
long-acting respiratory depressants should be minimized in obese patients regardless of technique chosen.
Choice of anesthetic Avoidance of general anesthesia is often considered in obese patients (particularly
those with obstructive sleep apnea [OSA]) to avoid the potential for airway and respiratory problems, when other
anesthetic techniques are feasible [19-21].
Neuroaxial anesthesia and peripheral nerve blocks offer the advantages of improved postoperative pain control,
limited use of opioids for postoperative analgesia, and decreased potential for drug-induced respiratory
depression. Postoperative pain management with epidural infusions mitigates respiratory dysfunction in obese
individuals, compared with systemic opioids, although it has not been shown to result in clinically improved
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outcomes [22,23].
However, the following factors may lead to a choice of general anesthesia with assisted or controlled ventilation:
Surgical procedure Many surgical procedures can only be performed under general anesthesia (eg,
thoracotomy, laparoscopy, spine surgery).
Positioning Obese patients have decreased respiratory tolerance for supine or head-down positioning,
and may require ventilatory assistance or airway control in these positions. Obese patients may also be
uncomfortable in the prone position due to pressure on the abdomen, and may require more sedation to
tolerate this discomfort.
Relaxation Spontaneous breathing in patients with prominent abdominal obesity may interfere with an
immobile abdominal or pelvic surgical field; these patients may require controlled ventilation under general
anesthesia, with either an endotracheal tube (ETT) or supraglottic airway designed for controlled ventilation
(eg, Proseal LMA).
Anticipated difficult mask ventilation or intubation If airway difficulty is anticipated, it may be
prudent to intubate in a controlled manner at the beginning of the case, rather than after problems develop.
(See 'Intubation' below and "Preanesthesia medical evaluation of the obese patient", section on 'Airway
assessment'.)
Increased risk of hypoventilation/hypercapnia Hypercapnia may be especially problematic in
patients with pulmonary hypertension due to OSA or obesity hypoventilation syndrome.
Anxiety Anxious obese patients may not be good candidates to remain awake during procedures, as
anxiolytics and sedatives can lead to hypoventilation and/or airway compromise.
Redundant tissue This may lead to technical difficulty with placement of local, regional, or neuraxial
anesthesia, although this can usually be overcome with appropriate equipment (eg, long needles) and
ultrasound guidance [24-26].
Patient positioning The improperly positioned obese surgical patient can experience physiologic
impairment such as decreased ventilation, and even physical injury, including nerve injury and rhabdomyolysis.
Risks of developing rhabdomyolysis after bariatric surgery include male gender, elevated BMI, and prolonged
operating time [27].
Advantages and disadvantages of different positions include:
Supine or head-down (Trendelenburg) positions Decreased lung volumes and increased work of
breathing (caused by the weight of the intra-abdominal contents on the diaphragm), and increased venous
blood return (leading to increased cardiac output) occur when compared with the head-up (reverse
Trendelenburg) or sitting positions; this leads to more rapid oxygen desaturation during apneic periods,
increased pulmonary shunt, hypoventilation with spontaneous breathing, and edema of the head and neck
after lengthy periods [28].
Head-up position (reverse Trendelenburg, or semi-sitting/semi-Fowler) Patients with their heads
elevated are easier to mask ventilate, and there is a better view of the airway during direct laryngoscopy
compared with those in the supine position (figure 1). (See "Emergency airway management in the
morbidly obese patient", section on 'Positioning'.)
When supports are added to the bed to raise the upper trunk, it is important to provide sufficient support to
the arms in order to maintain the shoulders in a neutral position. When the entire bed is tilted, care must
be taken to prevent the patient sliding down the bed, especially if arms are secured to fixed arm supports;
use of a foot plate may be helpful.
Prone Obese patients who are properly positioned prone for procedures may have improved respiratory
function, with increased FRC, lung compliance, and oxygenation in anesthetized patients compared to
supine position [29]. (See "Prone ventilation".)
Patient supports should be placed under the chest and pelvis rather than the abdomen (which should be
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compression-free) to avoid increasing intra-abdominal pressure [30]. In selected cases, patients have been
intubated awake, and then allowed to comfortably position themselves prone, prior to the induction of
anesthesia; this eliminates the need for operating room personnel to turn and position the patient, and
allows identification of pressure points by the patient before injury occurs [31,32].
Lateral decubitus The lateral position removes the weight of the abdomen from the diaphragm, and
increases the diameter of the pharyngeal airway [33]. The lateral decubitus position combined with head
and upper body elevation may be helpful during recovery from general anesthesia, unless contraindicated
due to the nature of the surgery.
Axillary rolls used during lateral positioning may need to be larger than is standard. It can be challenging
to support the head in a neutral position, as the neck is often short and wide; extra pieces of foam and
rolled towels can be helpful. Standard bean-bags may be too narrow to support obese patients, so
alternatives should be sought to maintain the patient in lateral position. Use of gel-pads may prevent injury
to pressure points such as the hip.
Lithotomy position Lithotomy position decreases lung volumes by shifting abdominal contents towards
the diaphragm, which may contribute to hypoxia and hypoventilation. Correct positioning and adequate
padding of the legs is critical; neurologic injury or compartment syndrome may result from prolonged
pressure [34,35]. Specially designed leg holders may be necessary to accommodate the size and weight
of the legs.
Beds and equipment used to support obese patients must be constructed to support the additional weight and
must provide sufficient space to avoid pressure from side-rails. Carefully padding pressure points will help to
prevent pressure-related peripheral nerve injuries.
Positioning of the obese patient should be checked regularly during the maintenance phase of general
anesthesia, as large patients are prone to shift position when the operating table is tilted, and may need to be
repositioned. The use of Velcro to attach the mattress to the bed can help prevent slipping.
Special equipment needs The ability to safely anesthetize severely obese patients may require additional
equipment that is not typically available. These include:
Special equipment for positioning, as discussed above.
Large beds and operating tables Designated weight limits may not remain valid if the patient is shifted on
the table, or the table is unlocked [36]. Additional arm supports to widen the table, or the use of two
operating tables, may be necessary.
Mechanical transfer mechanisms Various means of mechanically assisting the transfer of severely
obese patients between stretchers and beds have been developed. These may improve patient safety and
prevent injury to care personnel.
Additional personnel Assistance may be needed to transfer and position patients safely.
Extra-long needles Normal length epidural, spinal, and nerve block needles may be insufficient to access
structures in severely obese patients.
Ultrasound Ultrasound may be used to assist in vascular access, nerve block, and neuraxial procedures
[37,38]. (See "Overview of peripheral nerve blocks", section on 'Ultrasound guidance'.)
Blood pressure cuffs Appropriately-sized blood pressure cuffs for noninvasive blood pressure (NIBP)
result in accurate readings. The conical shape of the upper arm in many obese patients makes it difficult
to place a standard NIBP cuff, so alternative NIBP cuff locations (eg, forearm or lower leg) are commonly
used, although no studies confirm accuracy [16]. (See "Blood pressure measurement in the diagnosis and
management of hypertension in adults", section on 'Cuff size' and "Blood pressure measurement in the
diagnosis and management of hypertension in adults", section on 'Alternative sites for measurement'.)
MANAGEMENT OF PAIN AND ANXIETY A multimodal approach to analgesia to minimize the use of opioids
is reasonable to decrease the risk of respiratory complications. One approach is to use potent nonsteroidal
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antiinflammatory analgesics (NSAIDs) such as ketorolac, along with local anesthetic wound infiltration [16,3941]. The addition of acetaminophen to this regimen can be considered (an intravenous formulation is available in
many countries including the United States). This medication reduces postoperative opioid use and may have
an intrinsic antiemetic effect [42,43], but it has not been specifically investigated in the obese population.
Other agents that may be used to augment analgesia include ketamine, alpha-2 agonists (eg, clonidine and
dexmedetomidine), and antiepileptic drugs (pregabalin and gabapentin); these may reduce the need for
intraoperative and postoperative opioids, although the optimal regimen has not been determined in obese
patients [44,45]. In a few small trials, obese patients who received alpha-2 agonists (preoperative oral clonidine,
or intraoperative intravenous dexmedetomidine infusion) had lower opioid use than patients who did not, and in
some cases had decreased need for antiemetic drugs and shorter post-anesthesia care unit stays [46-49].
Perioperative pregabalin and gabapentin have been associated with decreased use of postoperative opioids and
decreased opioid-related side effects, but increased side effects related to the study drug [50-52]; however,
these have not been studied specifically in obese patients.
General considerations for the management of postoperative pain and aspects of analgesic management
specific to patients with OSA are discussed separately. (See "Management of acute perioperative pain" and
"Postoperative management of adults with obstructive sleep apnea", section on 'Pain control'.)
The increased risk and consequences of respiratory depression in obese patients indicate caution in the use of
opioids, sedatives (eg, propofol), and anxiolytic medications (eg, benzodiazepines). Incremental boluses, at
lower doses than typically used, allow titration to desired effect without excessive side-effects. When sedation
is offered to obese patients, they should understand that the sedation level may be light.
MANAGEMENT OF NEURAXIAL ANESTHESIA In general, neuraxial anesthetic techniques with local
anesthetic (ie, without opioids) minimally affect respiratory drive, and are safe and appropriate choices for obese
patients. Spinal and epidural anesthesia at higher dermatomal levels (ie, thoracic levels) may lead to respiratory
difficulty; in one study, the onset of spinal anesthesia decreased spirometric lung volumes, to a greater extent in
more severely obese patients [53]. Neuraxial medication should be given incrementally whenever possible, to
avoid excessively high blockade; the same dose of spinal and epidural local anesthetics can spread to higher
levels in obese compared with normal weight patients [54-56]. When planning a neuraxial technique at higher
levels, it is prudent to use a technique that allows control of the amount and interval of dosing, such as an
epidural or spinal catheter, rather than a single shot block.
Although landmarks tend to be more difficult to identify in obese patients and a greater number of attempts are
required to place spinal and epidural anesthetics, the success rate of placement in obese individuals is
equivalent to that in normal weight patients [24-26].
MANAGEMENT OF GENERAL ANESTHESIA Modifications of the approach to general anesthesia in obese
patients center largely on respiratory issues. Obese patients have a higher incidence of hypoxia and respiratory
events than patients with normal BMI [57,58]. Because these patients desaturate more quickly during apneic
periods, the anticipation and management of respiratory problems is critical.
Premedication of the obese patient should ideally allow anxiolysis without abolishing airway reflexes or
preventing patient cooperation prior to induction of general anesthesia. We agree with the practice guidelines of
the American Society of Anesthesiologists that do not recommend routine use of pharmacologic medication to
decrease aspiration risk in patients without an increased risk of aspiration [59]. Morbid obesity did not correlate
with gastroesophageal reflux in a study of 250 patients [60], and there is no evidence that aspiration risk is
increased in obesity. Obese patients who are at increased risk of aspiration are managed in the same manner
as non-obese patients.
Airway management Obese patients are more likely to require intubation rather than a supraglottic airway
(eg, laryngeal mask airway [LMA]). One reason is that obese patients are more likely to require controlled
ventilation to prevent hypoventilation during spontaneous respiration, and during positive-pressure ventilation, an
LMA may not maintain a seal at the higher airway pressures needed in obese patients. Obesity-specific criteria
for the use of a supraglottic airway have not been established. However, we consider factors including extent
and distribution of obesity, type of surgery, length of surgery, and patient position to determine when its use is
appropriate; in patients with BMI over 40, primarily abdominal obesity, abdominal/thoracic surgery, duration over
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two hours, and planned head-down positioning, we prefer to control ventilation with an endotracheal tube.
Obese patients are seldom managed with mask ventilation alone; face mask ventilation can be technically
challenging in the obese patient, and thus is generally restricted to extremely brief anesthetics (eg, an exam
under anesthesia, or knee manipulation).
Intubation may be more challenging in obese patients. Airway assessment is discussed in detail separately.
(See "Preanesthesia medical evaluation of the obese patient", section on 'Predictors of airway difficulty' and
"Airway management for induction of general anesthesia", section on 'Prediction of the difficult airway'.)
Awake intubation is prudent when there is concern for both difficult intubation (previous difficult intubation, BMI
>40, male gender [61]) and difficult mask ventilation (obesity, age >55 years, history of snoring, lack of teeth,
presence of a beard, BMI >40, abnormal mandibular protrusion test [62]). (See "Management of the difficult
airway for general anesthesia", section on 'Airway Approach Algorithm' and "Management of the difficult airway
for general anesthesia", section on 'Awake intubation'.)
There is less time to rescue the obese patient in a failed airway situation (cannot ventilate, cannot intubate) due
to rapid apneic desaturation, so devices for difficult intubation (a difficult intubation cart) (table 3), medications,
equipment to topically anesthetize the airway, and expert assistance should be readily available for any patient
having general anesthesia. (See "Management of the difficult airway for general anesthesia", section on
'Preparation for difficult airway management'.)
Preparation for induction Pre-oxygenation is ideally performed in the sitting or head-up (reverse
Trendelenburg) position to maintain oxygenation, as both the supine position and the induction of anesthesia
decrease lung volumes in the obese patient [63,64]. A head-up or ramped position also improves laryngoscopic
view [65,66]. The bed can be tilted (or a stack of blankets or pre-formed ramp can be used) to elevate the
patients upper body and head with the goal of horizontal alignment between the external auditory meatus and
the sternal notch (figure 1).
Preoxygenation should be performed via a tight-fitting facemask using 100 percent oxygen (O2) at a flow rate
high enough to prevent rebreathing (10 to 12 L/min), aiming for an end-tidal concentration of O2 greater than 90
percent in order to maximize safe apnea time. Patients should be preoxygenated with either three minutes of
tidal volume breathing or eight vital-capacity breaths over 60 seconds. These two techniques have been shown
to be equally effective at preventing desaturation and are more effective than four vital-capacity breaths over 30
seconds [67-69]
Pre-oxygenation with manually-applied positive end-expiratory pressure (PEEP), or the use of noninvasive
ventilation (NIV), will improve oxygenation in obese patients who will tolerate it. For example, in a trial of 30
patients with BMI >35 kg/m2, pre-oxygenation with PEEP of 10 cm H2O during induction increased the
nonhypoxic apneic period by 50 percent (from 127 to 188 seconds) [70]. In other trials, application of NIV with
PEEP prior to induction resulted in higher oxygen levels than spontaneous breathing of 100 percent oxygen
[71,72].
The use of nasal cannula for passive apneic oxygenation during laryngoscopy can prolong the time to
desaturation in high-risk patients during airway management [73-75] We suggest the administration of oxygen
by nasal cannula at 10 L in addition to facemask oxygen in those patients who are at high risk for difficult
laryngoscopy and intubation.
When high concentration oxygen is used during induction of anesthesia, resorption atelectasis may occur,
particularly in obese patients [76-78]. Use of a recruitment maneuver and prompt application of positive end
expiratory pressure after intubation may prevent or reverse resorption atelectasis. (See 'Ventilation management'
below.)
Induction When using a neuromuscular blocking agent (NMB) for airway placement, it is reasonable to
choose a rapid acting one (eg, succinylcholine or rocuronium) to decrease the interval between induction and
intubation, during which the patient must either be mask ventilated or be apneic. Obesity increases difficulty
with mask ventilation and decreases the apneic period until desaturation occurs. (See "Preanesthesia medical
evaluation of the obese patient", section on 'Airway assessment' and 'Respiratory physiology' above.)
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LMA use The use and safety of supraglottic airway devices in this population has remained a matter of
debate. When chosen, however, second-generation devices designed for controlled ventilation, which allow for
higher seal pressures and provide a gastric vent, are frequently employed [79]. There are no specific technical
considerations due to obesity for the placement of these devices.
Intubation Unless rapid sequence intubation is being performed, patients should be mask ventilated
between induction and intubation. An LMA may be used to ventilate the patient prior to intubation, if mask
ventilation is difficult. Mask ventilation should be carried out expertly with optimal positioning, early use of an
oral airway, and a double-handed approach when needed.
Intubation technique in obese patients is discussed separately. (See "Management of the difficult airway for
general anesthesia".)
Extubation The head-up position is ideal at emergence, to improve oxygenation and decrease work of
breathing.
The obese patient should only be extubated in the operating room when fully awake and after any
neuromuscular blockade has been completely reversed, in addition to standard extubation criteria.
Neuromuscular blockade may be reversed using either sugammadex or neostigmine. Sugammadex is a slightly
lipophilic reversal agent for steroidal non-depolarizing neuromuscular blockers, used particularly with
rocuronium. In a trial of obese patients receiving sugammadex 2 mg/kg versus neostigmine 0.05 mg/kg, (both
given according to IBW + 40 percent), the sugammadex group had a significantly faster recovery from NMB (2.7
versus 9.6 minutes) and a significantly better train-of-four (TOF) ratio in the recovery room (110 versus 85
percent) [80]. Anecdotal evidence suggests that sugammadex may offer additional benefits over neostigmine in
certain clinical circumstances including fatty liver disease and recurarization of the obese [81,82].
There is limited information regarding dose adjustments of neostigmine for the obese. Although some authors
advocate sugammadex dosing based on TBW in the obese, in a dose finding study (100 obese patients at a
train-of-four [TOF] recovery between 1 and 2) sugammadex 2 mg/kg IBW resulted in adequate reversal, with no
residual neuromuscular blockade. However, reversal was achieved more quickly at a dose adjusted to IBW + 40
percent, slightly above LBW [83].
Ventilation management When patients are managed with spontaneous respiration (either with an LMA or
an endotracheal tube), minute ventilation and end-tidal CO2 should be closely monitored to assure adequate
ventilation. We use continuous positive airway pressure (CPAP) during spontaneous respiration to improve
oxygenation. When patients are unable to maintain sufficient volumes, ventilation should be assisted or
controlled. The addition of pressure support assistance to PEEP may result in adequate ventilation; otherwise,
ventilation should be controlled with either pressure or volume control.
When obese patients are managed with controlled ventilation, a protective ventilation strategy is reasonable to
maintain oxygenation and normocapnia, and to avoid lung damage, based on the available evidence and expert
opinion, including this author [84,85]. This consists of low tidal volumes (TV), low levels of oxygen (as tolerated),
positive end-expiratory pressure (PEEP), and recruitment maneuvers (RM) (see "Overview of mechanical
ventilation", section on 'Settings' and "Mechanical ventilation of adults in acute respiratory distress syndrome",
section on 'Recruitment maneuvers'):
Set tidal volume of 6 to 8 mL/kg IBW (calculator 4)
Adjust respiratory rate to maintain normocapnia (permissive hypercapnia is acceptable in patients without
pulmonary hypertension)
Keep FIO2 below 0.5 to 0.8, to prevent resorption atelectasis and oxygen toxicity
Use RMs repeatedly during anesthesia (6 to 20 seconds duration; plateau pressure 40 to 55 cm H2O)
Institute PEEP 10 to 15 cm H2O following RMs
Maintain head-up (reverse Trendelenburg) position, whenever feasible
Although there are no trials which include all the elements of this protective ventilation strategy in obese
patients, we recommend protective ventilation based on evidence in non-obese patients, and the effectiveness of
elements of this strategy in obese patients:
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In a trial of 400 non-obese adults having major abdominal surgery, patients were randomized to lung
protective ventilation (TV 6 to 8 mL/kg IBW, PEEP 6 to 8 cm H2O, RM after intubation and every 30 min)
or traditional ventilator settings (TV 10 to 12 mL/kg IBW, no PEEP, no RM); both groups had oxygen level
<50 percent, as tolerated [86]. Protective ventilation led to:
Decreased incidence of major pulmonary and extrapulmonary complications in the first week (10.5
versus 27.5 percent, relative risk [RR] 0.40 [95% CI 0.24-0.68])
Lower incidence of acute respiratory failure requiring noninvasive ventilation or intubation (5.0 versus
17.0 percent, RR 0.29 [95% CI 0.14-0.61])
Shorter median hospital stay (11 versus 13 days, between-group difference 2.45 days [95% CI 0.724.17 days])
In a 2012 meta-analysis of studies of ventilation strategies (pressure- or volume-controlled ventilation, tidal
volumes, PEEP or RMs) in obese patients (BMI >30 kg/m2), RMs added to PEEP improved intraoperative
oxygenation and compliance, compared with PEEP alone; there was no increase in adverse effects and no
difference between pressure-controlled and volume-controlled ventilation [87].
PEEP of 15 cm H2O is effective in maintaining functional residual capacity and improving oxygenation
during laparoscopic surgery in morbidly obese patients [88,89]. Higher levels of PEEP can induce
hypotension due to decreased venous return; increased fluid administration or vasopressors may be
needed to maintain blood pressure [88,90,91].
Recruitment maneuvers should not be performed unless patients are hemodynamically stable and euvolemic, as
they may lead to a transient decrease in preload.
Anesthetic agents The choice of anesthetic agent in obesity should be based on patient-specific clinical
factors, rather than the presence of obesity.
Induction agents Choice of induction agent is not different in obesity. However, it is reasonable to use a
neuromuscular blocking agent (NMB) with a rapid onset (eg, succinylcholine or rocuronium) to decrease the
interval between induction and intubation, during which the patient must either be mask ventilated or be apneic
and at risk for hypoxia. (See "Preanesthesia medical evaluation of the obese patient", section on 'Airway
assessment' and 'Respiratory physiology' above.)
Dosing of these agents may require modification in obese patients (table 2). (See 'Dosing anesthetic drugs'
above.)
Maintenance agents Anesthesia can be maintained with either an inhaled anesthetic agent (eg,
isoflurane, sevoflurane, desflurane, with or without nitrous oxide) or with an intravenous agent (most often
propofol). A limited number of studies have compared these agents in severely obese patients with inconsistent
results, and no clear clinical superiority of one over the other. Slightly more rapid emergence and recovery
occurred in patients with desflurane compared with sevoflurane, isoflurane or propofol in some trials [92-94], but
in other trials there were no differences in recovery or other outcomes [95-98]. In a study of morbidly obese adult
patients, the end-tidal sevoflurane concentration required to maintain 50 percent of patients at a bispectral index
(BIS) of <50 was 1.6 percent [99], higher than that reported in a separate study of non-obese adults (0.97
percent) [100].
While nitrous oxide (N2O) may be used to supplement a volatile agent or propofol, some obese patients with
underlying respiratory problems may not tolerate the decreased inspired oxygen concentration that
accompanies the use of N2O. Concern that rapid diffusion of N2O into the bowel obscures the view of the
surgical field was not confirmed in a study of obese patients undergoing laparoscopic bariatric surgery;
surgeons were unable to determine which patients had received N2O and which had not [101].
Fluid management There is very little evidence addressing perioperative fluid management specifically in
obese patients, and euvolemia in this population is poorly defined; consequently clinical judgment based upon
available measures of volume status and tissue perfusion remains the most important factor. (See
"Intraoperative fluid management".)
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The use of dynamic indices to guide intravascular fluid administration has not been studied in obese patients;
however, in a prospective study of 50 bariatric surgery patients with mean BMI over 50 kg/cm2, fluid therapy
guided by stroke volume variation (derived from arterial pressure waveform analysis) maintained all
hemodynamic parameters within 10 percent of baseline values [102]. (See "Intraoperative fluid management",
section on 'Monitoring volume status'.)
POST-ANESTHESIA CARE UNIT MANAGEMENT Issues specific to the obese patient in the postanesthesia care unit (PACU) are largely respiratory and ventilatory. General care in the PACU, issues specific
to patients with obstructive sleep apnea (OSA), and postoperative care of the critically ill obese patient are
discussed elsewhere. (See "Overview of complications occurring in the post-anesthesia care unit" and
"Postoperative management of adults with obstructive sleep apnea" and "Bariatric surgery: Intensive care unit
management of the complicated postoperative patient".)
Extubation Some obese patients may be slow to emerge from anesthesia and should remain intubated until
they are awake and meet standard extubation criteria. Avoiding premature extubation is particularly important in
the obese patient, as swelling and edema can further complicate an already challenging intubation. Emergency
airway equipment (table 3) and personnel to assist in airway management must be available to manage
potential difficulties. (See "Management of the difficult airway for general anesthesia", section on 'Extubation'.)
Monitoring Patients should have continuous pulse oximetry in the PACU until they have demonstrated that
they can maintain adequate oxygenation when left unstimulated. If patients do not meet this standard when
otherwise ready to be discharged from the PACU, pulse oximetry monitoring should continue when transferred
to the hospital ward. Patients who cannot maintain adequate oxygenation when left undisturbed should not be
discharged from the hospital.
An arterial blood gas measurement is the best assessment for suspected hypoventilation, such as in patients
who are unable to maintain acceptable oxygen saturation despite supplementation, possibly with a sustained
decrease in level of consciousness. (See "Arterial blood gases".)
Oxygenation Postoperative obese patients have relative hypoxia compared with non-obese patients due to
changes in physiology. (See 'Respiratory physiology' above.)
Following extubation the following measures are used to maintain adequate oxygenation:
Administration of oxygen, titrated to keep O2 at >90 percent (by face mask or nasal cannula)
Positioning patient in head-up (sitting or semi-sitting) or lateral position (if surgically acceptable)
Use of incentive spirometry or chest physiotherapy
The postoperative use of incentive spirometry or chest physiotherapy improves pulmonary function and
decreases complications. For example, in a trial of obese patients (BMI 30 to 40 kg/cm2) having minor
surgery under general anesthesia, decreased postoperative complications resulted from either incentive
spirometry (OR 0.44 [95% CI 0.18-0.99]) or coughing every 10 to 15 minutes for the first two hours after
extubation (OR 0.43 [95% CI 0.27-0.63]), compared with no breathing exercises [103].
Administration of continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) in patients
with preoperative use, or with hypoxia unresponsive to incentive spirometry
The use of NIV following abdominal surgery in normal weight patients, compared with standard oxygen
therapy, reduces the incidence of reintubation and severe complications [104]; it is reasonable to think
that obese patients benefit as well. In a trial of morbidly obese patients with OSA, immediate application of
NIV after extubation, compared with CPAP 30 minutes later, significantly improved forced vital capacity at
the first postoperative day [105]. The use of NIV is feasible in patients with no previous experience with
NIV, when applied by a trained respiratory therapist [106].
Despite concern that aspiration of air during CPAP treatment might cause disruption of fresh anastomotic
suture lines following intestinal surgery, studies of gastric bypass patients receiving CPAP in the postanesthesia care unit have not shown an increased risk for anastomotic leak [107,108]. Following
gastrointestinal surgery such as gastric bypass, we prefer early joint decision between anesthesiologist,
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surgeon, respiratory technician, and nurse to determine CPAP use in selected patients, emphasizing the
team concept for the perioperative care of these patients [16].
Ventilation Although adequacy of ventilation is not routinely measured in the PACU, a high level of
suspicion for hypoventilation should be maintained in patients who remain sedated or become hypoxic despite
administration of oxygen. Hypoventilation due to sedative medication should be ruled out; pharmacologic
reversal of benzodiazepines or opioids may be used as clinically indicated. Often simply arousing a drowsy
patient with a reminder to breath deeply is sufficient; but this may need to be repeated frequently. When upper
airway obstruction is present, an oropharyngeal airway (if the patient is sedated), a nasopharyngeal airway, or
both, may open the airway and permit adequate ventilation.
When these maneuvers are insufficient, it is reasonable to assist these patients with NIV, which may keep them
from requiring re-intubation. (See "Noninvasive positive pressure ventilation in acute respiratory failure in adults".)
Discharge criteria There is very little objective evidence in the literature to guide clinical decision-making
regarding duration of postoperative monitoring in morbidly obese patients. We agree with following standard
considerations for the discharge of surgical patients, such as those published by the American Society of
Anesthesiologists (ASA) [109]. Prior to transfer of the patient to an unmonitored setting, oxygen saturation on
room air should return to preoperative baseline, and when left undisturbed the patient should not develop clinical
hypoxemia or airway obstruction [110]. We extend use of these recommendations to all severely obese
patients, with a low threshold for prolonged recovery room monitoring based upon the individual patients course.
The decision to discharge obese patients with diagnosed or likely OSA should take into account the ability to
use CPAP, the need for opioid medication, and comorbid medical conditions [111]. Postoperative management
of OSA is discussed elsewhere. (See "Postoperative management of adults with obstructive sleep apnea".)
SUMMARY AND RECOMMENDATIONS
Respiratory physiologic changes in obese patients include an increase in oxygen consumption and a
decreased functional residual capacity, leading to a rapid decrease in oxygen saturation during apneic
periods.
Increased blood volume, decreased systemic vascular resistance, and increased cardiac output may lead
to either left or right heart failure or both. (See 'Physiologic changes' above.)
Drug doses in obese patients depend on the pharmacokinetic and pharmacodynamic parameters of the
specific drug (table 2); when specific recommendations are not available, it is reasonable to base drug
doses on lean body weight, (calculator 2) for females and (calculator 3) for males. (See 'Dosing anesthetic
drugs' above.)
Although no anesthetic technique has been found to be superior to another with respect to important
patient outcomes (eg, mortality, cardiopulmonary complications), when suitable to the clinical setting,
general anesthesia is often avoided to minimize airway and drug-related respiratory problems. However,
general anesthesia may be necessary for certain surgical procedures, when relaxation is required or when
hypoventilation is a concern. No specific induction or maintenance agent has been shown to result in
improved clinical outcomes when compared with others. (See 'Choice of anesthetic' above and 'Anesthetic
agents' above.)
Regardless of anesthetic technique, opioid administration should be minimized to decrease the risk of
respiratory depression, particularly in patients with obstructive sleep apnea. In severely obese patients,
pain control with opioid-sparing multimodal analgesia may reduce the risk of respiratory depression and
other opioid-related side effects. This may include the use of local or regional anesthesia, nonsteroidal
antiinflammatory drugs, alpha-2 agonists, and other medications. (See 'Management of pain and anxiety'
above.)
When general anesthesia is used in obese patients, we recommend adequate pre-oxygenation (with
continuous positive airway pressure [CPAP] if tolerated) and induction in a head-up (reversed
Trendelenburg) position to improve oxygenation and tolerance for apneic periods without desaturation
(Grade 1B). Mask ventilation is more difficult and intubation may be more challenging in obese patients.
http://www.uptodate.com/contents/anesthesia-for-the-obese-patient?topicKey=ANEST%2F14932&elapsedTimeMs=1&source=search_result&searchTer
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When difficulty with both is anticipated, it may be prudent to perform awake intubation. Equipment and
skilled personnel to assist with a difficult or failed airway should be readily available. (See 'Airway
management' above.)
When obese patients are managed with controlled ventilation, we suggest using a protective ventilation
strategy to maintain oxygenation and normocapnia (Grade 2C) (see 'Ventilation management' above):
Set tidal volume of 6 to 8 mL/kg ideal body weight (calculator 4)
Adjust respiratory rate to maintain normocapnia (permissive hypercapnia is acceptable in patients
without pulmonary hypertension)
Keep FIO2 below 0.5 to 0.8, to prevent resorption atelectasis and oxygen toxicity
Use recruitment maneuvers repeatedly during anesthesia (6 to 20 second duration; plateau pressure
40 to 55 cm H2O)
Institute positive end-expiratory pressure (PEEP) 10 to 15 cm H2O following recruitment maneuvers
(RMs)
Maintain head-up (reverse Trendelenburg) position, whenever feasible
Postoperative oxygenation should be monitored until patients can maintain adequate oxygenation when
left unstimulated. A reasonable approach to hypoxia and hypoventilation is to maintain a head-up position
with oxygen by face mask and encouragement to breathe deeply, followed by a trial of CPAP or
noninvasive ventilation (NIV), with reintubation for the refractory patient.
Prior to transfer to an unmonitored setting, oxygen saturation on room air should return to preoperative
baseline, and when left undisturbed, the patient should not develop clinical hypoxemia or airway
obstruction. (See 'Discharge criteria' above.)
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111. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on
preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery.
Anesth Analg 2012; 115:1060.
Topic 14932 Version 24.0
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GRAPHICS
Cardiovascular physiologic changes in obesity
Pathogenesis of c ongestive heart failure in morbidly obese individuals

with and without sleep apnea/obesity hypoventilation syndrome.
LV: left ventricle; RV: right ventricle.
Reproduced with permission from: Alpert MA, Hashimi MW. Obesity and the
heart. Am J Med Sci 1993; 306:117. www.lww.com. Copyright 1993
Southern Society for Clinical Investigation. Unauthorized reproduction of this
material is prohibited.
Graphic 90114 Version 1.0
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Comparison of cardiac structural and hemodynamic alterations in

patients with morbid obesity and hypertension
Obesity
alone
Hypertension
alone
Obesity and
hypertension
Variable
Heart rate
Normal
Normal
Normal
Blood pressure
Normal
Increased
Increased
Stroke volume
Increased
Normal
Increased
Cardiac output
Increased
Normal
Increased
Systemic vascular
resistance
Decreased
Increased
Normal or increased
LV volume
Increased
Normal
Increased
LV wall stress
Normal or
increased
Normal or
increased
Increased
LV hypertrophy
Eccentric
Concentric
Hybrid
LV diastolic
dysfunction
Usually present
Usually present
Usually present
LV systolic
dysfunction
Occasionally
present
Usually absent
Occasionally present
LV failure
Occasionally
present
Occasionally
present
Commonly present
RV hypertrophy
Occasionally
present
Usually absent
RV enlargement
Occasionally
present
Usually absent
RV failure
Occasionally
present
Usually absent
LV: left ventricular; RV: right ventricular.

Adapted from: Alpert MA, Hashimi MW. Obesity and the heart. Am J Med Sci 1993; 306:117.
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Anesthetic drug dosing in obesity

Drug
Weight for
dosing
Notes
Sedative/hypnotics
Propofol bolus
doses
LBW
The dose required for loss of consciousness in

obese patients (BMI >40 kg/m2) [1].
Propofol
maintenance
LBW
Due to substantial interindividual variability,

continuous infusions should be titrated to a
infusions
clinical endpoint. A reasonable initial dose is

based on LBW and titrated to achieve the desired
clinical result. Several different dose calculation
models have been used for target controlled
infusion systems (not available in the United
States) [2].
Etomidate
LBW
Pharmacokinetic studies have not been done in

obesity [3].
Thiopental
LBW
Recommendation is based on computer models of

plasma concentrations. Doses should be adjusted
for high or low cardiac output, and rapid
redistribution may result in more rapid awakening
after a single bolus dose than in lean patients [4].
Midazolam (and
other
benzodiazepines)
bolus doses
TBW
As a sedative, usually dosed in small increments

(eg, midazolam 1 mg IV) that are repeated until
the clinical endpoint is reached. Caution should
be exercised as patients with OSA may have
increased central sensitivity to the sedative and
respiratory effects of benzodiazepines. TBW is
used for bolus dosing (eg, to induce general
anesthesia) due to the significant increase in V d
in these highly lipophilic drugs [5].
Midazolam (and
other
benzodiazepines)
continuous
LBW
Although clearance is not substantially different

from that in non-obese individuals [6], there is
substantial interindividual variability, so
continuous infusions should be titrated to a
infusions
clinical endpoint. A reasonable initial dose is

based on LBW and titrated to achieve the desired
clinical result.
Dexmedetomidine
There are no specific dosing recommendations

available in the obese, but as with other
infusions, doses should be titrated to a clinical
endpoint. The drug is highly lipophilic. Bolus (0.5
to 1 mcg/kg) and infusion dosing (0.2 to 0.8
mcg/kg) based on TBW (without a scalar) have
been used in several studies [7-10]. This is within
the manufacturer-suggested dose range. Dose
adjustments may be required for other
comorbidities or other sedative or anesthetic
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drugs used concomitantly.

Opioids
Synthetic opioids
(fentanyl,
LBW
sufentanil,
alfentanil, and
remifentanil)
Morphine
On the basis of clinical pharmacokinetic studies in

lean patients, physiologic changes in obesity, and
supratherapeutic plasma levels with TBW
dosing [6].
IBW
Initial dosing should be based on IBW and

titrated to effect. This is a reasonable initial dose,
as postoperative opioid consumption was 30
percent less in obese versus normal weight
patients (on a morphine equivalent to kg basis)
[11].
Hydromorphone
IBW
As with morphine, initial dosing is based on IBW

and titrated to effect.
Neuromuscular blocking agents

Non-depolarizing
agents (eg,
vecuronium,
rocuronium)
IBW
Generally polar compounds [12]. The dosing scalar

will depend on the clinical circumstance. In
general, a higher (ie, closer to TBW) intubating
dose will result in faster onset and shorter time
to complete NMB, but a longer duration of action.
An IBW-based dosing will prolong the time to
ideal intubating conditions, but assure a faster
recovery from NMB [13].
Succinylcholine
TBW
This is based on superior intubating conditions

when succinylcholine 1 mg/kg TBW was compared
with dosing on the basis of IBW or LBW [14].
LBW: lean body weight; TBW: total body weight; IBW: ideal body weight; BMI: body mass
index; OSA: obstructive sleep apnea V d : volume of distribution; NMB: neuromuscular blockade.
References:
1. Ingrande J, Brodsky JB, Lemmens HJ. Lean body weight scalar for the anesthetic induction
dose of propofol in morbidly obese subjects. Anesth Analg 2011; 113:57.
2. Echevarria GC, Elgueta MF, Donosoto MT, et al. The effective effect-site propofol concentration
for induction and intubation with two pharmacokinetic models in morbidly obese patients
using total body weight. Anesth Analg 2012; 115:823.
3. Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics in the morbidly obese. Br J
Anaesth 2010; 105 Suppl 1:i16.
4. Wada DR, Bjrkman S, Ebling WF, et al. Computer simulation of the effects of alterations in
blood flows and body composition on thiopental pharmacokinetics in humans. Anesthesiology
1997; 87:884.
5. Greenblatt DJ, Abernethy DR, Locniskar A, et al. Effect of age, gender, and obesity on
midazolam kinetics. Anesthesiology 1984; 61:27.
6. Leykin Y, Miotto L, Pellis T. Pharmacokinetic considerations in the obese. Best Pract Res Clin
Anaesthesiol 2011; 25:27.
7. Feld J, Hoffman WE. Response entropy is more reactive than bispectral index during
laparoscopic gastric banding. J Clin Monit Comput 2006; 20:229.
8. Bakhamees HS, El-Halafawy YM, El-Kerdawy HM, et al. Effects of dexmedetomidine in morbidly
obese patients undergoing laparoscopic gastric bypass. Middle East J Anesthesiol 2007;
19:537.
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9. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine infusion during laparoscopic
bariatric surgery: the effect on recovery outcome variables. Anesth Analg 2008; 106:1741.
10. Ramsay MA. Bariatric surgery: The role of dexmedetomidine. Seminars in Anesthesia,
Perioperative Medicine and Pain 2006; 25:51.
11. Rand CS, Kuldau JM, Yost RL. Obesity and post-operative pain. J Psychosom Res 1985; 29:43.
12. Blouin RA, Warren GW. Pharmacokinetic considerations in obesity. J Pharm Sci 1999; 88:1.
13. Leykin Y, Pellis T, Lucca M, et al. The effects of cisatracurium on morbidly obese women.
Anesth Analg 2004; 99:1090.
14. Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006;
102:438.
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Ramp position illustration
In the ramp position, the patient's head and torso are elevated suc h that the
external auditory meatus and the sternal notc h are horizontally aligned (blac k
line). This position allows for a better view of the glottis in obese patients and
should be used unless there are c ontraindic ations (eg, possible c ervic al spine
injury).
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Suggested contents of difficult airway cart in the operating room

Rigid laryngoscope blades of alternate design and size from those routinely used; this may
include a rigid fiberoptic laryngoscope.
Videolaryngoscope.
Tracheal tubes of assorted sizes.
Tracheal tube guides. Examples include (but are not limited to) semirigid stylets,
ventilating tube-changer, light wands, and forceps designed to manipulate the distal
portion of the tracheal tube.
Supraglottic airways (eg, LMAs or ILMAs of assorted sizes for noninvasive airway
ventilation/intubation).
Flexible fiberoptic intubation equipment.
Equipment suitable for emergency invasive airway access.
An exhaled carbon dioxide detector.
The items listed in this table represent suggestions. The c ontents of the portable storage
unit should be c ustomized to meet the spec ific needs, preferenc es, and skills of the
prac titioner and healthc are fac ility.
LMA: laryngeal mask airway; ILMA: intubating LMA.
From: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult
airway: an updated report by the American Society of Anesthesiologists Task Force on Management
of the Difficult Airway. Anesthesiology. 2013; 118:251. DOI: 10.1097/ALN.0b013e31827773b2.
Reproduced with permission from Lippincott Williams & Wilkins. Copyright 2013 American Society
of Anesthesiologists. Unauthorized reproduction of this material is prohibited.
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Disclosures
Disclosures: Rom an Schum ann, MD Nothing to disclose. Stephanie B Jones, MD Consultant/Advisory Boards (Spouse): Allurion
Technologies [Obesity (Non-surgical w eight loss device)]. Marianna Crow ley, MD Nothing to disclose.
Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
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Anesthesia for the obese patient

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Anesthesia for the obese patient

Anesthesia for the obese patient

with 75 mL/kg) compared with patients with normal BMI [11].

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Anesthesia for the obese patient

Pathogenesis of c ongestive heart failure in morbidly obese individuals

Anesthesia for the obese patient

Comparison of cardiac structural and hemodynamic alterations in

LV: left ventricular; RV: right ventricular.

Anesthesia for the obese patient

Anesthetic drug dosing in obesity

The dose required for loss of consciousness in

Due to substantial interindividual variability,

clinical endpoint. A reasonable initial dose is

Pharmacokinetic studies have not been done in

Recommendation is based on computer models of

As a sedative, usually dosed in small increments

Although clearance is not substantially different

clinical endpoint. A reasonable initial dose is

There are no specific dosing recommendations

Anesthesia for the obese patient

drugs used concomitantly.

On the basis of clinical pharmacokinetic studies in

Initial dosing should be based on IBW and

As with morphine, initial dosing is based on IBW

Neuromuscular blocking agents

Generally polar compounds [12]. The dosing scalar

This is based on superior intubating conditions

Anesthesia for the obese patient

Anesthesia for the obese patient

Ramp position illustration

Anesthesia for the obese patient

Suggested contents of difficult airway cart in the operating room

Anesthesia for the obese patient

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