Pr Philippe CUVILLON Pôle ARDU, CHU Nîmes
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1 Mortality and Morbidity in obese patients undergoing anesthesia and Preoperative preparation Pr Philippe CUVILLON Pôle ARDU, CHU Nîmes
2 Body Mass Index BMI= Weight (kg) /Height² (m²) Adiposity P / T 2 Adolphe Quetelet. Edinburgh Medical Journal 1817
3 Mortality and obese patients Assurance program : Moderate < 18,5 Very low 18,5 24,9 low 25 29,9 moderate 30 34,9 High Very high Super obese 35 39,9 40 > 50
4 Abdominal adiposity Cardiac All causes Cancer I II III IV Abdominal visceral fat Circulation 2016 Feb 16;133(7):
5 WHO (Worl Hearth Organization) 1997 Obesity is a «disease»
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7 Obesity and cancer
8 Male : 1,75 m Weight : 259 Kg Age = 23 years max : 296 kg Obesity BMI = 85kg/m² HTA Case n 1. Frequence = % OAS (Apnea) Frequence = % Heart failure Frequence = % Stroke Frequence = %
9 Preoperative evaluation Perioperative outcomes and surgery Surgery Non bariatric Bariatric Cardiac All causes Cancer I II III IV Abdominal visceral fat
10 Non bariatric surgery Dindo D et coll. 2003;361: consecutive patients 9% obese including, 4% with BMI > 35
11 General elective surgery
12 General elective surgery
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14 Obesity, diabetes and smoking are important determinants of resource utilization in liver resection: a multicenter analysis of 1029 patients. Gedaly R et al. Ann Surg 2009; 249:414-9.
15 23 studies (13 prospective, 10 retrospective): patients Admission : 15 of 2549 (0.59%) : pain, nausea, and dysphagia Readmission (30-days) : 0.55% (12 of 2181 pts) : dysphagia +++ Super obese (BMI> 50): more comorbidities, significantly longer operating times: 74 vs 81 min The predictors of increased mortality: BMI, ASA, type of procedure (i.e., Laparoscopic Roux-en-Y Gastric Bypass versus LAGB), operative time.
16 ICU and mortality: a troubling paradox Mortality is reduced compared to non obese patient
17 Bariatric surgery Mortality : 0.3 % Complications Death P. Emboli and DTV: 0.3 % 50 % Cardiac Failure: 0.4 % 15 % Anastomotic leak: 0.6 to 6 % % Hemorhage: 3% <low Parietal infection ans abscess: 1.6 % <low Respiratory AE, pneumonia: 4-5 % % Br J Anaesth. 1981, 53: , Obese Surg. 2016, May
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19 Surgery ,898 patients overal postdischarge complication: 3.2% - wound infection (49.4%) - reoperation (30.7%) - urinary tract infection (16.9%), - shock/sepsis (12.4%) - organ space surgical-site infection (11.0%) Open gastric bypass: greatest postdischarge complication 8.5%. The factors associated most strongly with increased odds of postdischarge complications: body mass index 50, use of steroids, procedure type, predischarge complication, prolonged duration of stay, and prolonged operative time.
20 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation: airway Surgery Non bariatric Bariatric
21 Operating room, difficult intubation : 8% vs 5% non obese
22 SCORE DE MALLAMPATI Classification Mallampati grade I grade II grade III grade IV Classification Cormack And Lehane (laryngoscopie) Facile Intubation Difficile
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24 Prediction of Difficult Tracheal IntubationTime for a Paradigm Change Anesthesiology 2002 Olivier Langeron, M.D., Ph.D.,* Philippe Cuvillon, M.D., Cristina Ibanez-Esteve, M.D., François Lenfant, M.D., Ph.D., Bruno Riou, M.D., Ph.D., Yannick Le Manach, M.D., Ph.D.#
25 Intubation and ventilation Modification of the air way Difficult intubation Difficult ventilation - Mallampati Score - Neck circumference > 40 cm - Mouth opening < 3,5 cm - Cervical motility. Never alone
26 Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: A prospective observational study Eur J Anaesth 2016 Riad, Waleed; Vaez, Mercedeh N.; Raveendran, Ravi; Tam, Amanda D.; Quereshy, Fayez A.; Chung, Frances; Wong, David T. PATIENTS: A total of 104 morbidly obese surgical patients (BMI 40 kg m 2 ) were included in the study. 88 patients were women and 16 were men. Exclusions were known difficult airway and emergency surgery. Male sex (P = 0.004) and BMI more than 50 kg m 2 (P = 0.031) were independent predictors of difficult mask ventilation.
27 Intubation and ventilation Modification of the air way Difficult intubation Difficult ventilation Inhalation and regurgitation - Gastric paresis (diabetic) - By pass surgery Never alone
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30 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation: Venous access Surgery Non bariatric Bariatric
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32 Venous access - Ultrasound - Jugular vein Head : neutral postion Femoral access Hind D, BMJ 2009
33 Venous access VJI ead : neutral position Fujiki M, Obes Surg 2008
34 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation: Labs Surgery Non bariatric Bariatric
35 Labs Chemistry, liver function, renal function Lipid Profile CBC Iron Profile- TIBC, total iron, saturation B-1, B-12 levels HbA1c H-Pylori Drug Screen (optional)
36 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation: cardiac evaluation Surgery Non bariatric Bariatric
37 Cardiac dysfunction and obesity
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39 Except for bariatric surgery, few data are available regarding the morbidity and mortality associated with severe obesity and specific surgical procedures.
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42 There are 6 known risk factors for perioperative cardiovascular morbidity in the general population according to the Revised Cardiac Risk Index These include: - high-risk surgery, such as emergency surgical procedures or major thoracic, abdominal, or vascular surgery - history of CHD - history of congestive heart failure - history of cerebrovascular disease - preoperative treatment with insulin - preoperative serum creatinine levels >2.0 mg/dl Risk Class/ complication rate Class I Zero 0.4% Class II One 0.9% Class III Two 6.6% Class IV Three 11.0%
43 Obese patients with no CHD risk factors who are referred for elective surgery may not require further testing. On the other hand, patients with 3 CHD risk factors or diagnosed CHD may require additional noninvasive testing if the results will change management. If significant coronary artery disease is found, surgery could be delayed to allow the institution and titration of appropriate medical therapy, such as statin or β-blocker therapy, or even coronary revascularization in appropriate patients with severe 3-vessel or left main disease
44 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation: cardiac evaluation Clinical evaluation Surgery Non bariatric Bariatric Dyspnea HTA ECG US echography
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50 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation: Pulmonary Function Obstructive Sleep Apnea (testing and treatment). Surgery Non bariatric Bariatric Asthma. Smokers.
51 Obstructive Sleep Apnea incidence IOSA-defined as an apnea/hypopnea index (AHI) 5.0 events/h Study 1: patients for bariatric surgery OSA was 74 % J Brazil Pneumol 2015 Study 2: 120 patients (Canada) Obes Surg 2015 BMI kg/m2 : 71 %. BMI kg/m2) : 74 % Superobese (BMI kg/m2): 77 % > BMI 60 kg/m2: 95 % Pulmonary complication after surgery : Chest 2016 Jan;149(1):84-91
52 Pulmonary evaluation Spirometry (effect of β2 agonist) NON Polysomnography showed an obstructive sleep apnea-hypopnea syndrome (OSAHS) 3 facteurs de risque STOP-BANG questionnaire NON Snoring (ronflemment) Tired (fatigue diurne) Observed (apnées observées) Blood Pressure (HTA) BMI > 35 Age > 50 Neck tour de cou > 40 cm Gender (homme) 6 weeks before surgery 3-4h / night
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55 Dose? Enoxaparine 2 x 3000 (n=19) vs 2 x4000 (n=33) BMI :50 kg/m² Mesure activité anti-xa: 1 and 3 dose Cible: 0,18-0,44UI/ml Bariatric surgery: banding + bypass Rowan et al, obes Surg 2008; 18: 162-6
56 Dose? Pic 3è dose Cible atteinte 42% pour 4000UI Mais chirurgie non homogène, Groupes successifs, 1è dose J-1 ou J0
57 Quelle thromboprophylaxie? Adaptation posologique Enoxaparine 2x4000(n=24) vs 2x6000(n=16) BMI 50 kg/m² Chirurgie bariatrique: banding ou bypass Cible: 0,18-0,44 Mesure anti-xa 1è et 3è dose Simone et al Surg Endosc 2008
58 Quelle thromboprophylaxie? Adaptation posologique 44% sous dosage pour 4000UI 57% surdosage pour 6000UI Mais étude groupes successifs Choix des valeurs limites?? Poso optimale: 5000UI?
59 Preoperative evaluation Perioperative outcomes and surgery Clinical Evaluation airway (intubation, ventilation) Labs Cardiac evaluation (physical status) Pulmonary evaluation (OSA and B2) Venous access DTV and EP
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