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  1. Home
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  3. Morbid Obesity
  • Cited by 7
Publisher:
Cambridge University Press
Online publication date:
May 2010
Print publication year:
2010
Online ISBN:
9780511676307
DOI:
https://doi.org/10.1017/CBO9780511676307
Subjects:
Anesthesia, Intensive Care, Pain Management, Medicine, Surgery
Information

Book description

The world is experiencing an obesity epidemic. In both industrialized and emerging countries, the percentage of adults and children with obesity is increasing annually. It is no longer unusual to encounter a patient with extreme or morbid obesity in the operating room; these patients are routinely scheduled for every type of surgical procedure. Everyone involved in the peri-operative management of the surgical patient with morbid obesity – surgeons, anesthesiologists, internists, psychologists, nurses, nutritionists, respiratory therapists – must be aware of the special needs of these patients. Morbid Obesity: Peri-operative Management, 2nd edition considers the perioperative care of the morbidly obese patient, from preoperative preparation to intraoperative management and through to their postoperative course. Edited by leading experts in the management of the morbidly obese surgical patient, Morbid Obesity: Peri-operative Management, second edition, provides clear, practical clinical guidance on the management of the extremely obese surgical patient.

Reviews

Praise for the first edition:'Alvarez's lucid presentation of these complex and timely issues is an achievement in itself, but even more so is his production of a very readable book. This book is assured to inform and complement the busy clinician. I recommend it to every physician involved in the care of the morbidly obese patient.'

Source: Obesity Surgery

'I enjoyed reading this organized, appropriately illustrated, and well-references book. …Although this, by intention, is not a textbook of anaesthesia for obesity, it contains a wealth of anaesthetic-related information and I have no reservation in recommending it as essential reading for any anaesthetist involved in the care of patients suffering obesity. In my opinion, it will also appeal to surgeons, physicians, intensivists, theatre, recovery and ward nursing staff, psychologists, dieticians, and managers involved in the care of these complex and frequently challenging patients.

Source: British Journal of Anaesthesia

'… the text is well illustrated and … organised. The authors come from varied clinical backgrounds … Each chapter is well researched and appropriately referenced … an excellent resource for anaesthetists, surgeons and intensivists who wish to develop skills to recognise potential complications and provide quality peri-operative care to obese patients.'

Source: Critical Care (ccforum.com)

'… this book should be on the shelf of any provider who regularly cares for obese patients. [Its] easy-to-read chapters and efficiently indexed information make it a very useful tool for quick reference in the operating room or preoperative assessment setting. The text is filled with easy-to-read figures and tables, which only enhances its usefulness in clinical practice. The editors even provide a list of abbreviations in the front of the book. [They] have clearly achieved their goal of providing a comprehensive yet very accessible manual for the care of the morbidly obese patient.'

Source: Anesthesiology

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Contents

Page 2 of 2

Contents
  • 19 - Nursing considerations
  • View abstract

    Summary

    Intra-operative positioning considerations are more important for the obese patient. The supine position causes a marked increase in intra-abdominal pressure, which results in a splinting effect of abdominal contents on the diaphragm. Awake, spontaneously breathing obese patients should be in a head-up position. The Trendelenburg position can be used to engorge neck veins to facilitate central venous cannulation. Spontaneously breathing obese patients generally do not tolerate the Trendelenburg position. In mild to moderately obese patients, respiratory mechanics, lung volumes, and oxygenation all increase when changing from the supine to prone position. Due to the difficulties moving and positioning mobidly obese (MO) patients, procedures routinely performed prone are often done in the lateral decubitus position. In the lithotomy position the patient is on their back with their legs and thighs flexed at right angles. MO patients are at special risk for rhabdomyolysis (RML), a potentially fatal post-operative complication.
  • 21 - Anesthetic considerations for the post-bariatric surgery patient
  • View abstract

    Summary

    This chapter focuses on the peri-operative monitoring of the heart, circulation, respiratory system and brain function in the morbid obesity (MO) surgical patient. Intra-arterial blood pressure (BP) monitoring is the gold standard, but is not necessary in the otherwise healthy MO patient undergoing a simple surgical procedure. Transcutaneous oxygen tension monitoring has been used for many years in neonatal critical care as a surrogate for arterial oxygen tension. Body temperature should be measured in patients undergoing general or neuraxial anesthesia procedures exceeding 30 min duration. Neuromuscular activity should be monitored during surgery by train-of-four (TOF). Electroencephalogram (EEG)-based brain function monitors have been introduced to optimize the dose of anesthetic agents by monitoring electrical equivalents of levels of awareness. The decision to use bispectral index (BIS) monitoring in MO patients undergoing general anesthesia, and especially total intravenous anesthesia, is still a matter of choice.
  • 22 - Bariatric outcomes
  • View abstract

    Summary

    This chapter reviews several factors that affect pharmacokinetics (PK) and pharmacodynamics (PD) of anesthetic agents in the obese population and specifies certain dosing scalars. It presents the current knowledge of obesity's effects on the clinical pharmacology of specific drugs that produce or reverse anesthesia. In a PK study in which patients received thiopental to induce anesthesia, absolute total body clearance was significantly larger in the obese than in normal weight patients. In hemodynamically unstable morbid obesity (MO) patients or patients with obesity cardiomyopathy, anesthesic induction with etomidate may be a better choice than either thiopental or propofol. Opioids effectively block somatic and autonomic responses during surgery. Target-controlled infusion (TCI), an anesthetic dosing technique developed during the last decades, allows interactive drug dosing on the basis of common PK-PD models. Sugammadex can reverse profound neuromuscular blockade.
  • Section 5 - Special topics
  • View abstract

    Summary

    Reports of anesthesia-related deaths in obstetric practice point to difficulties with airway management in morbid obesity (MO) parturients as the primary cause. A large proportion of patients recruited for airway studies in MO are recruited from bariatric surgical populations, which typically exhibit a large preponderance of female patients. Numerous anatomic factors contribute to difficult airway management in the MO patient. This chapter presents options for airways management in an order that reflects their application in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm. Awake intubation maintains airway patency and spontaneous respiration, but is not without hazard in this difficult patient group. Flexible fiberoptic laryngoscopy is the most common technique chosen for awake intubation, but visualization may be difficult when excess fat deposition results in airway narrowing and redundant folds of tissue. Equal care and equipment should be available for extubation as well as intubation.
  • 24 - Bariatric surgery in adolescents
  • View abstract

    Summary

    This chapter discusses respiratory system mechanics and gas exchange during anesthesia of morbidly obese (MO) patients. It describes ventilatory strategies that can improve oxygenation while protecting the lungs from ventilator-induced mechanical stress. After induction of anesthesia, deterioration of partial pressure of arterial oxygen (PaO2) occurs in MO patients. For normal weight and obese patients, prolonged mechanical ventilation with high pressure can induce mechanical stress and acute ventilator-associated lung injury (VALI). PaCO2 is correlated with effective ventilation, and an acute decrease in PaCO2 after recruitment indicates improvement (decrease) of physiologic dead space. The chapter summarizes various peri-operative strategies that provide open-lung ventilation and protect against ventilator-induced lung injury. High tidal volume (VT) without positive end-expiratory pressure (PEEP) during mechanical ventilation may cause subclinical lung injury. For MO patients, a protective ventilatory strategy incorporates prevention of atelectasis and lung overexpansion while using lower end-inspiratory pressure (PEI).
  • 25 - Management of the obese parturient
  • View abstract

    Summary

    This chapter reviews the use of regional anesthesia techniques in obese patients. The most extensive experience with regional anesthetic techniques in obese patients is with neuraxial anesthesia. Obese patients require less local anesthetic than their normal counterparts to achieve a similar sensory level. For a lumbar approach for either an epidural or spinal anesthetic, a cooperative patient can be asked to identify the "midpoint of your body". The incidence of complications with epidural anesthesia increases with increasing weight. As with epidural anesthesia, obesity is an important factor influencing spinal anesthesia. Neuraxial anesthesia is often used in combination with general anesthesia during surgery to reduce the amount of inhalational and intravenous agents. All peripheral nerve blocks were performed using a nerve stimulator technique. Overweight and obese patients should not be excluded from undergoing regional anesthesia in the ambulatory setting.

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