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Obesity, OSA and bariatric surgery

Teoh Sc
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

BMI cut off for Asian BMI cut off


WHO classification
definition for action

Underweight <18.5 <18.5

Normal 18.5-24.9 18.5-22.9

Overweight 25-29.9 23-27.4

Obese class I 30-34.9 27.5-32.4

Obese class II 35-39.9 32.5-37.4

Obese class III ≥40 ≥37.5


(Morbid Obesity
Types
 Primary or secondary
 Central android
 waist/hip ratio > 0.9 in female & > 0.8 in male
 Peripheral gynaecoid
 Buttocks & thighs
Pharmacokinetics
 Vd
  blood volume
  CO
  lean body mass
 Protein binding normal
  Vd for lipophilic drugs
 Normal Vd for hydrophilic drugs
  GFR & renal clearance
 No change in liver clearance
Perioperative concern
 Airway difficulty
 H/o OSA
 1o or 2o
 End organ damage
 Drug interaction eg amphetamine
Difficult airway
 Desaturation- increase O2 demand, reduce FRC
 Difficult mask ventilation, difficult intubation
 Aspiration
 RSI with CP or awake fibreoptic
Predictors of difficult mask ventilation
 Overweight (BMI > 26)
 Beard
 Elderly (Age > 55 )
 Snoring
 Edentulous
 5% incidence
 2 factors predictive

O. Langeron et al Anesthesiology 2000;92:1229-36


Difficult intubation
Difficult intubation
OSA
STOP
 Validate OSA screening for surgical patients
 Concise, easy to use
 Moderate high sensitivity & NPV
 > sensitive to moderate & severe OSA
Chung F et al. Anesthesiology 2008; 108: 812-21
STOP
 Snoring
 Tiredness
 Observed apnea
 High BP
 ≥ 2 yes : high risk for OSA
STOP
STOP
STOP BANG
 BMI > 35
 Age > 50
 Neck circumference > 40
 Gender - male
 High risk if yes ≥ 3
STOP BANG
Polysomnography
 Monitor ECG, EEG, EMG, oximetry
 Oronasal airflow with thermistor or pressure
transducer
 Respiratory effort via inductance or impedance
pneumography and/or diaphragmatic EMG
 Body position
 LSAT
 Lowest SaO2 a/w abnormal respiratory event
Anaesthetic considerations
 Aspiration
 Polycythemia
 Pulmonary hypertension

Pashayan AG et al. Anesthesiology Clin N Am 2005; 23: 431-43


Difficult intubation
  difficult intubation in OSA
(16.7% vs 3.3%)
 AHI higher in difficult intubation
(67.4 vs 49.9) 27.6%
19.3%
3.3%

Kim JA et al. Can J Anesth 2006; 53: 393-7


Preop recommendations
 Pre procedure identification Of OSA status improves
outcome
 Preop CPAP
 Preop NIPPV, mandibular advancement, oral appliances
 Preop weight loss
OSA task force, Anesthesiology 2006; 104: 1081-93
Benefits of CPAP

  AHI
 Improves O2 saturation
  excessive daytime sleepiness
  systemic hypertension
 Improves right heart failure
 Improves neurocognitive function.

Roop K et al. Chest 2006; 129: 198-205

Ryan F et al Am Rev Respir Dis 1991; 144: 939-44

Jain SS et al. Curr Opin Pulm Med 2004; 10: 482-8


Intraops
 Avoid sedative premed
 Regional
 GA
 -RSI
 -awake fibreoptic intubation
Post op complications
 27% vs 9%
 Respiratory most common
 83% due to desaturation
 Incidence of post op complication
among patients with difficult airway
21%

Chung F et al. Anesth Analg 2008; 107: 915-20


Periop risk
 Severity of OSA
 Invasiveness of procedure
 Requirements of postop analgesia
 PACU observation

ASA task force. Anesthesiology 2006; 104: 1081-93


postops
 adverse respiratory event
 OSA, apnea, altered respiratory drive
 Rapid desaturation, difficult airway
monitoring
 -GICU
 -anaes male oncall room
 -anaes female oncall room
 -anaes specialist oncall room
postops
 O2 supplement, CPAP
 Opioid sparring, multimodal analgesia
 Pulmonary rehab
 DVT prophylaxis
Bariatric Surgery
Bariatric surgery
 Indications
 absolute BMI > 40 kg/m2 or
 BMI > 35 kg/m2 in combination with life-threatening
cardiopulmonary problems or severe diabetes mellitus

 Proven failed attempts after at least 6 months of


medically supervised weight loss (diet modification,
exercise, and medical therapy)
 loss of < 5%-10% excess body weight
 weight gain
 non-improvement in co-morbid conditions
Medical therapy

 Combination of phentermine and fenfluramine (Phen-Fen) –


associated with valvular heart disease and pulmonary
hypertension; no longer approved by FDA

 Sibutramine inhibits the reuptake of noradrenaline, serotonin,


and dopamine → increase satiety after the onset of eating

 Orlistat blocks digestion and absorption of dietary fat by binding


lipases in the GI tract
Types of surgery

Roux-en-Y gastric bypass. Adjustable gastric banding.


A, Proximal pouch. B, Adjustable
A, A 15- to 30-mL gastric pouch with
band. C, Needle access port
connected jejunal limb. B, Site of
through which saline is injected
jejuno-jejunostomy
or removed to vary the size of the
adjustable band.
Anaesthesia
 Considerations for obesity and its associated problems, in particular
 Airway considerations – airway options
 Reflux / regurgitation – acid aspiration prophylaxis

 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

ASA task force. Anesthesiology 2006; 104: 1081-93


Anaesthesia
 Considerations for obesity and its associated problems, in particular
 Airway considerations – airway options
 Reflux / regurgitation – acid aspiration prophylaxis

 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

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