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Case 1 of 20
31 year old cook
Morbidly obes BMI 45
Lap gastric banding
HPT/DM/hyperlipidemia
Case 1 of 20
Multidiscipline management
Surgical, anaes, dietician, endocrinologist
Premedication round ? OSA
-snorring
-HPT
-?apnea
-BMI
-neck circumference 47cm
-male
Case 1 of 20
?delays surgery
Benefit and risk
obesity
Obesity
BMI=Weight(kg) / height2 (m)
Definition
AHI
Improves O2 saturation
excessive daytime sleepiness
systemic hypertension
Improves right heart failure
Improves neurocognitive function.
Anaesthetic technique
GA with endotracheal intubation – RSI or awake FOB
Usual considerations for laparoscopic surgery – effects of pneumoperitoneum
on respiratory mechanics & CVS
Postoperative management
Consider HDU/ICU management especially if significant co-morbidities or h/o
OSA
Postoperative pain management
Complications
RYGB AGB
anastomotic leak band erosion
gastric pouch outlet erosive oesophagitis
obstruction herniation of the stomach
jejunostomy obstruction upward inside of the band
gastrointestinal (GI) band migration
bleeding disconnections at the
wound infection portal site between the
dumping syndrome
tube and reservoir
protein-calorie
malnutrition
More common after open
RYGB
summary
Perioperative concern for obese pt
Airway difficulty
H/o OSA
1o or 2o
End organ damage
Drug interaction eg amphetamine
Obesity
n=6336
Multivariate regression analyses
Obesity was not a risk factor for development of
postop complications
Dindo D et al. Lancet 2003; 361:2032-5
STOP BANG or ASA
Screening:
Obes, difficult airway
All patients
Risk and benefit of proceed
Periop risk
Severity of OSA
Invasiveness of procedure
Requirements of postop analgesia
PACU observation
Anaesthetic technique
GA with endotracheal intubation – RSI or awake FOB
Usual considerations for laparoscopic surgery – effects of pneumoperitoneum
on respiratory mechanics & CVS
Postoperative management
Consider HDU/ICU management especially if significant co-morbidities or h/o
OSA
Postoperative pain management
references
Sharmeen Lotia and Mark C. Bellamy, Anaesthesia and morbid
obesity Contin Educ Anaesth Crit Care Pain (2008) 8(5): 151-
156
Gerges FJ. Anesthesia for laparoscopy: a review. J Clin Anesth
2006; 18: 67-78
ASA task force Anesthesiology 2006; 104: 1081-93
Chung F et al. Anesthesiology 2008; 108:812-21