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1. 42 BMI FEMALE POSTED FOR LAPAROSCOPIC CHOLECYSTECTOMY PRESENTER- D r . Charan MODER A T OR - Dr. Shahbaz Alam sir

2. PATIENT PARTICULARS Mrs . Sahana 4 7 yrs/female Ht. - 164 cm Wt. - 120 Kg Residence: Bijnor Occupation : Farmer C.R.No: 7072015244 Admitted on: 5 th June Date of surgery: 7 th june

3. CHIEF COMPLAINTS Pain in R ight Hypochondrium since -1month Indigestion & bloating - since 6 days Nausea, vomiting - since 6 days

4. HISTORY OF PRESENT ILLNESS: She was apparently well 1 month back, when she developed pain in r ight hypochondrium which markedly worsens after heavy meal . The pain was gradual in onset, dull aching in nature, no diurnal variation. The pain got subsided on taking medication. patient developed Nausea & vomiting 6 days back which was acute in onset, 2-3 times a day, associated with abdominal pain, vomitus consist of meal which patient has recently taken & yellowish in colour. No H/o weight loss, loss of appetite, headache, vertigo. No H/O burning micturition, low back pain, infertility,amenorrhea or dysmenorrhea, skin disease/rashes. No H/O Tuberculosis, Diabetes Mellitus, Hypertension, COPD, Asthma, Seizures, Thyroid disease. H/O weight gain present post Rt.tibia fracture 3 years ago d/t trauma No LOC after trauma.

5. PAST HISTORY : H/O loud snoring, disturbed sleep, daytime sleepiness, morning headaches, and difficulty concentrating present since 3-4 yrs PERSONAL HISTORY: Diet - mixed Bowel/bladder – regular Appetite – adequate Sleep – Inadequate Addiction - nil F AMI L Y HIS T O R Y : Nothin g significant MENSTRUAL HISTORY : Menarche at 17 yrs, Acheived menopause at 44 yrs of age

6. GENERAL PHYSICAL EXAMINATION Patient is conscious, oriented to time place and person, morbidly obese. Ht. - 164 cm Wt. - 120 Kg BMI - 42 Kg/m 2 Vitals :- Temperature - Afebrile (97.6 o F) Pulse rate - 86 bpm, regular in rhythm, normal in volume, character and no radio-femoral and radio-radial delay was found. All peripheral pulses was felt. Blood pressure - 126/80 mmHg in right arm supine position R espiratory rate – 1 8 /min, regular a nd Thoracoabdominal . Pallor - Absent Icterus - Absent Cyanosis - Absent Clubbing - Absent Lymphadenopathy - Absent Edema - Absent

7. AIRWAY EXAMINATIOIN :- - No deviated nasal septum. - Mouth opening - 3 finger - Neck circumference - 50 cm - Thyromental distance <6 cm - S terno-mental distance <12 cm . - Neck extension and flexion - In adequate - MP grading - 3 Spine :- Midline, Difficult to palpate interspinous space.

8. SYSTEMIC EXAMINATION :- • Respiratory: B/L air entry present, No added sounds. BHT : 18 seconds MET Score : < 4 H/o Snoring (+) H/o OSA (+) • CVS: Sl and S2 heard, no audible murmur. • CNS: conscious, oriented to time, place and person.

9. Abdomen examination: Inspection: Shape of abdomen normal, no distension present. No pulsatile swelling seen No discolouration of skin of abdomen. Palpation: Tenderness present below the tip of 9th coastal cartilage on lateral margin of right rectus muscle No distension present No abdominal lump palpated. Percussion: Shifting dullness and fluid thrill absent Auscultation: Peristaltic sound heard.

10. Routine Investigations Age Specific Disease Specific Hb: 1 1 . 2 g/dl TLC: 11 000 cells/mm3 Platelets: 1.50,000/mm3 Blood group: O +ve Chest Xray : Normal ECG: Normal RFT: Urea/Creat: 45mg/dl/1.0mg/dl Uric acid – 6.5 Sodium – 137 meq/l Potassium – 4.4 meq/l Chloride – 101 meq/l Lipid profile: Total Cholesterol - 219 mg/dl HDL - 32 mg/dl LDL - 110 mg/dl Triglycerides - 184 mg/dl VLDL - 42 mg/dl USG whole abdomen: Gall bladder: Shows multiple stones largest size 12mm. Grade II Fatty liver. LFT: SGOT/SGPT: 1 35/ 84 Total Billirubin:1.1 Direct Billirubin: 1.1 /0.4 Thyroid profile:
T3 - 0.8 ng/dl
T4 - 4.8 microgram/dl
TSH - 1.3 mIU/L RBS : 130 mg/dl
FBS : 90 mg/dl INR: 1.2
PT: 12 secs
Viral marker: negative

11. Diagnosis: 47 years old female with cholelithiasis with morbid obesity posted for laparoscopic cholecystectomy under ASA grade III.

12. Plan of Anaesthesia :- General anaesthesia with awake fiberoptic endotracheal intubation.

13. Preoperative Advice – Counselling informed written consent. NPO for 6 hrs. IV cannulation (18G) Kindly arrange 1 unit PRBC Remove jewelleries and nail paints

14. Pre op room checklist :- Patency of IV cannula Confirmation of NPO status Consent AST Inj. Pantoprazole 40 mg IV Inj. Metoclopramide 10 mg IV

15. P r ogr ess T ime PR b/m BP mmhg IVF IVD Urin e REMARK output S Pneumo peritoneum created Inj vec1mg Inj diclofenac 75 mg Inj vec 1mg Inj vec 1mg 9:30am 74 110/82 RL 1 9:45am 90 128/84 10:00am 98 140/90 10:15am 94 140/84 RL2 10:30am 100 142/94 10:45am 68 110/88 11:00am 96 138/84 11:15am 70 108/74 RL3 11:30am 100 142/90 Inj vec 1mg 1 1:45am 78 120/84 150ml

16. Post operative management :- PONV Oxygenation Multimodal analgesia Maintainance of IV fluids Post operative CPAP

17. P o s t O per a ti v e Vitals BP : 120/70 mm Hg HR : 80 /min. SpO2 : 99% @ 5L O 2 Post O p erative Advice : Nurse in lateral position NPO - 8 hours Moist O2 inhalation. Monitor vitals & inform SOS

18. Challenges in Anesthesia for a 120 kg Female: Airway management is challenging due to potential difficult intubation from a large neck circumference and excess soft tissue. Decreased lung volumes in obesity can lead to impaired oxygenation and increased risk of postoperative respiratory complications. Obesity is associated with cardiovascular conditions, increasing the risk of perioperative cardiac events. Pharmacokinetics are altered, requiring careful dosing of anesthetic drugs to account for increased adipose tissue. Proper positioning during surgery is difficult due to excess weight and limited mobility. Prone to perioperative hypothermia, necessitating careful temperature regulation. Risk of obstructive sleep apnea (OSA) complicates airway management and increases the risk of respiratory issues. Cardiovascular stability can be compromised due to limited cardiac reserve in obese individuals. Anesthesia depth monitoring may be challenging due to altered drug distribution and metabolism. Close monitoring for pressure injuries and musculoskeletal strain is essential during positioning.

19. Goals in Anesthesia for a 120 kg Female: Thorough preoperative evaluation of airway, cardiovascular, and respiratory status. Use of advanced airway techniques like video laryngoscopy for optimal airway management. Adequate preoxygenation to maximize oxygen reserves and reduce respiratory complications. Optimization of blood pressure and heart rate control for cardiovascular stability. Individualized drug dosing based on lean body weight to ensure optimal pharmacokinetics. Use of forced-air warming blankets and warmed IV fluids to prevent perioperative hypothermia. Consideration of awake intubation and alternative airway devices for difficult airways. Close monitoring of ventilation, oxygenation, and hemodynamics during surgery. Effective communication among the anesthesia team, surgeons, and nursing staff. Vigilant postoperative care with early mobilization and pain management to prevent complications.

20. RAMPING

21. THANK YOU