BARIATRIC SURGERY
emergency surgical airway (eg: those obese patients in whom the cricothyroid membrane or trachea cannot be identified).
n If awake fibre optic intubation (AFOI) is chosen extreme care is required in titration of sedatives and monitoring, in order to avoid airway obstruction and periods of apnoea
n Failure of regional anaesthesia may necessitate general anaesthesia. Obese patients undergoing regional anaesthesia still require a strategy for airway management. Regional anaesthetic blocks should be thoroughly checked before surgery. All theatre staff must be aware of the hazards posed by intra-operative conversion from regional to general anaesthesia
n Pre-oxygenation, performed to high standards, should be used for all obese patients prior to general anaesthesia
n Organisations and individual anaesthetists should procure and use airway devices and techniques that meet the specific needs of obese patients. Safety should take priority in the decisions made
n The end of an anaesthetic in an obese patient should be planned. This includes pre-oxygenation before extubation and transfer to recovery. The possible need for re-intubation should be anticipated and planned for
n Anaesthetic training should emphasise the importance of obesity as a risk factor for complications of airway management.
Guidelines for anaesthesia in obese patients
A number of key guidelines have been published to guide practice in anaesthetising obese patients, to avert some of the risks identified by the audit. Among these include guidance from The Society for Obesity and Bariatric Anaesthesia (SOBA) and The Association of Anaesthetists of Great Britain and Ireland (AAGBI), titled: Peri-operative Management of
The Obese Surgical Patient (2015).2 This guideline outlined 16 key
recommendations: n Every hospital should nominate an anaesthetic lead for obesity
n Operating lists should include the patients’ weight and body mass index (BMI)
n Experienced anaesthetic and surgical staff should manage obese patients
n Additional specialised equipment is necessary
n Central obesity and metabolic syndrome should be identified as risk factors
n Sleep-disordered breathing and its consequences should always be considered in the obese
n Anaesthetising the patient in the operating theatre should be considered
n Regional anaesthesia is recommended as desirable but is often technically difficult and may be impossible to achieve
n A robust airway strategy must be planned and discussed, as desaturation occurs quickly in the obese patient and airway management can be difficult
n Use of the ramped or sitting position is recommended as an aid to induction and recovery
n Drug dosing should generally be based upon lean body weight and
Patients with centrally distributed fat (ie: ‘apple shaped’ as opposed to ‘pear shaped’) are at greater peri-operative risk than those with peripherally distributed fat.
titrated to effect, rather than dosed to total body weight
n Caution is required with the use of long-acting opioids and sedatives
n Neuromuscular monitoring should always be used whenever neuromuscular blocking drugs are used
n Depth of anaesthesia monitoring should be considered, especially when total intravenous anaesthesia is used in conjunction with neuromuscular blocking drugs
n Appropriate prophylaxis against venous thromboembolism (VTE) and early mobilisation are recommended since the incidence of venous thromboembolism is increased in the obese
n Postoperative intensive care support should be considered, but is determined more by co-morbidities and surgery than by obesity per se.
Other guidelines include the SOBA Single Sheet Guideline for patients with a BMI over 35, which is designed to be laminated, left in the anaesthetic room and used as an aide memoire when required. It is available on the SOBA website and updated every six months as new evidence becomes available (
www.sobauk.com). The guide offers recommendations on equipment that will be needed, anaesthetic technique, patient positioning, drug dosing and post-operative management. However, until recently there has been no published data on the impact of the guidelines, specifically on anaesthetic practices for obese patients in UK hospitals. Dr Rebecca Black, an
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