Anaesthesia and Morbid Obesity
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1 Anaesthesia and Morbid Obesity
2 Facts 20% adults Obese (1% Morbidly Obese) BMI >35 with comorbidity / BMI >40 without comorbidity = morbidly obese BMI > 55 = super-morbidly obese BMI > 30 rapid increase in morbidity and mortality Men higher risk of CVS problems
3 Apples and Pears BMI poor predictor of difficulty Fat distribution Android Gynaecoid
4 Causes of Obesity Multifactorial Genetic and Environmental Regulation of appetite and satiety (Hypothalamus) Leptin, Adiponectin long term (NB dieting) Insulin = short term (Hypothalamus) Ghrelin (Stomach Wall), Peptide YY 3-36 (Intestine)
5 Comorbidity
6 Facts Obesity associated with: Htn DM OA Liver Disease Asthma OSA Obesity Hypoventilation Syndrome Risk of cardio-resp comorbidity increases with duration NB severe comorbidity may be masked by sedentary lifestyle!
7 Respiratory System - OSA Apnoeic attacks due to collapse of pharynx whilst asleep Increases with obesity and age Fat in pharyngeal wall Features Snoring Frequent apnoeic spells whilst asleep (>10s) Daytime somnolescence Pathophysiological changes hypercapnia, polycythaemia, pulmonary htn and cor-pulmonale
8 Obesity Hypoventilation Syndrome Affects control of breathing CO 2 sensitivity and ventilatory drive partly leptin controlled Leptin insensitivity = reduced ventilatory response to CO 2. Depressant drugs accentuate Often combined with OSA
9 Respiratory Compromise Features Hypoxaemia at rest (worse supine + depressants) Rapid desaturation in apnoea Reduced lung compliance (increased pulm blood volume) Reduced chest wall compliance Small airways collapse + diaphragmatic splinting (Decreased FRC) Increased alveolar-arterial oxygen tension (worse on induction) Closing volume close to FRC airway closure and V/Q mismatch (shunting) Atelectasis NB Laparoscopy!! Postoperative period
10 Cardiovascular System Circulating Volume (renin-angiotensin. Polycythaemia). Ventricular Workload Redistributed to fat beds Cerebral/Renal flows unchanged Oxygen Consumption (Increased BMR) CO 2 production Systemic Htn (LV stress and LVH) Pulm Htn possible (Cor-Pulmonale) Increased metabolic demands of adipose
11 Cardiovascular System Arrythmias Why? Myocardial hypertrophy and hypoxaemia Hyperkalaemia (Htn Rx) CAD Increased circulating catecholamines OSA Fatty infiltration conducting system IHD DVT/PE Htn DM Cholesterol Sedentary Lifestyle
12 Other Sytems Microvesicular Fatty Liver Steatohepatitis +/- cirrhosis GORD and Hiatus Hernia (Aspiration) Insulin resistance and Type 2 DM
13 Preoperative Assessment
14 Planning Ahead Beware the Sedentary Patient Questioning Symptoms and signs of OSA/Heart Failure Comorbid disease Ability to tolerate supine position Full airway assessment Mouth opening, Mallampati, Neck movement, Collar circumference Any airway obstruction whilst awake
15 Pre-Op Investigations Individual basis FBC, U+Es, LFTs, Glucose ABG in suspected OSA/OHS ECG Echo LV/RV function, Pulm Htn CXR cardiac failure PFTs poor exercise tolerance
16 PreMed Antacids / PPI Prokinetics Sodium Citrate TEDs
17 Conduct of Anaesthesia
18 Pharmacokinetics Most drugs affected by adipose tissue lipophilic drugs How do you calculate doses?! Volume of central compartment similar (periph increased) Increased Volume of Distribution (Vd) Increased redistribution Increased elimination t1/2
19 Total weight/ideal weight Benzos/Barbiturates ideal body weight Relaxants Lean body mass (mass of organs, muscle, bone) Suxamethonium total body weight Propofol total body weight (esp TIVA) Local anaesthetics ideal body weight Epidurals Engorged veins and fat impinge on space Reduced volume of Epidural Space Reduce dose by 25%
20 Practical Aspects Theatre Table Enough staff to transfer Correct sized bp cuff Consider Position Could they be head-up? Sniffing position Pre-oxygenation The Difficult Airway Positioning Short-handle/Polio blade Desaturation Do they need awake fibreoptic? Temperature Control Calf Compression Beware Laparoscopy Ventilatory Issues PEEP Volatile choice Epidural?
21 Postoperative Considerations Extubation Risk of obstruction To CPAP? Location Post-Op Care Good analgesia Early mobilization, TEDS, Enoxaparin Close monitoring of BMs (Catabolism) Cardiovascular stability
22 Any Questions?
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