Anaesthetic consideration in obese patients during laparoscopic surgery

Anaesthetic consideration in obese patients during laparoscopic cholecystectomy

1. Case Presentation on Obesity Moderator : Dr Deepika Doneria Presenter : Dr Deepanshu Panchal

2. 59 year old female patient, weighing 120kg and height 166cm , primary school teacher by profesion visited to the outpatient department with pain in right upper abdomen since 2 months, associated with nausea and vomiting. there was no history of fever, jaundice, diarrhoea, constipation or difficulty in micturion . Patients had history of snoring, morning headache, multiple episodes of awakening during night since last one year. Patient was diagnosed type 2 Diabetes mellitus 1 year back and taking OHA (tab metformin 500 mg BD, tab glimipride 2 mg , tab pioglitazone 15mg OD), Random blood sugar was 202 mg/dl and HbA1c 8.2%. Pateint found hypertensive first time at the time of opd visit and her BP was 150/100mmg and started on medication (tab amlodipine 5mg OD) USG confirms the diagnosis of cholelithiasis and planned for lap cholecystectomy.

3. Shreedevi , 59y/F, housewife by occupation, resident of Firozabad, Weight-120kg, Height-166cm, BMI- 43.3 kg/m 2 (obese class III) Chief complaints: -Pain in right upper abdomen, radiating to back x 8 weeks -Burning sensation in epigastric region since 10 days

4. History of presenting illness H/O PAIN IN RIGHT HYPOCHONDRIUM x 8 WEEK -Sudden in onset -Severe in intensity -Colicky in nature -Increases after meals -Associated with nausea and vomiting -Pain radiating to back over right infra-scapular area during the same time H/O DYSPEPSIA x 10 DAYS -Increase after taking fatty meal.

5. H/O VOMITING - 2-3 episodes x 5 day -non projectile -vomitus: food particles, non bilious -associated with pain -No h/o yellow discolouration of eye and urine -No h/o weight loss -No h/o trauma -No h/o altered bladder and bowel habit -No h/o fever

6. Past history H/O pain in right upper quadrant on and off since past 5-6 months. - Patient is a k/c/o DM since 1 year . According to the patient’s reports available. which indicated that her blood sugar levels were higher with a combination of drugs (tab metformin 500 mg BD, tab glimipride 2 mg , tab pioglitazone 15mg OD). -No h/o HTN, TB, CAD, Asthma. -No previous history of chest pain or palpitation. -No h/o any known allergy/blood transfusion/surgery, decreased vision, UTI. FAMILY HISTORY Both the parents were obese. All the three children are obese. Her mother was diabetic (Type 2 DM)

7. → PERSONAL HISTORY Normal bowel and bladder habits Patient had abnormal sleep pattern since 1 year . Patient had history of snoring since 2 year . And patient has history of awakening during night, 5-6 times per night. Patient had sedentary life style (No exercise) No alcohol/ tobacco addiction → MENSTRUAL HISTORY - Menarche at 14 years - Menopause at 50 years of age → OBSTETRIC HISTORY - P3L3A0D0 → SOCIOECONOMIC STATUS - Lower middle class family

8. GENERAL PHYSICAL EXAMINATION Patient is examined in supine position with B/L flexed knees in a well lit room Patient is conscious, alert, cooperative and well oriented to time, place and person Weight: 120kg, height: 166cm, BMI: 43.3 kg/m2 STOP-BANG Score – 5(high risk of having OSA) Pallor –ve , Icterus –ve , Cyanosis –ve , Clubbing –ve , JVP Normal , Lymphadenopathy –ve , Pedal edema -ve

9. VITALS - Pulse: 90 bpm, right radial artery - good volume, - normal character, - normal condition of vessel wall, - all peripheral pulses are palpable HRV on Deep breathing was > 15 beats/min BP : 138/90 mmHg in right arm, sitting position SpO2 : 98% on RA RR: 14 breaths/min, regular, abdominothoracic, no use of accessory muscles of respiration, BHT= 24 Seconds , METS Score = 4 Temperature: Afebrile (98.5 degree F). RBS: 154 mg/dl taken with glucometer after meals. HbA1C: 8.2%

10. RESPIRATORY SYSTEM EXAMINATION INSPECTION: - Chest appears normal - Trachea appears to be in center. - No suprasternal or intercostal recession - No use of accessory muscles - B/L chest movements – symmetrical during respiration - No dilated veins/pulsation/swelling/scars over chest wall. PALPATION: - All findings of inspection are confirmed, trachea central in position. - Chest expansion b/l symmetrical - No tenderness or bony defect. - Tactile vocal fremitus – normal

11. PERCUSSION: - Resonant sound in all lung fields - Normal liver dullness in 5th,7th and 9th ICS at MCL ,anterior axillary lines respectively. AUSCULTATION: - B/L equal air entry present on both sides - Vocal resonance- equal - No added sounds - BHT – 24sec

12. CARDIOVASCULAR SYSTEM EXAMINATION INSPECTION : - Precordium normal in shape - Apical pulse not visible - No engorgement of superficial veins - Carotid pulsations not visible PALPATION: - Apex beat in 5th ICS, 1.2 cm medial to left MCL - No parasternal heave - No appreciable thrill or pulsation AUSCULTATION: - S1& S2 present - No murmur or added sounds heard METs score – 4

13. ABDOMEN EXAMINATION INSPECTION: - Excessive abdominal fat present - All quadrants move well with respiration - No dilated veins - Umbilicus appears normal, inverted PALPATION: - Abdomen is soft on palpation - Tenderness present in right hypochondrium - MURPHY’S sign positive - Guarding and rigidity absent - No mass, no organomegaly -Hernial orifices normal

14. ABDOMEN EXAMINATION PERCUSSION: tympanic note present, no shifting dullness/ fluid thrill. AUSCULTATION: bowel sounds present

15. CNS EXAMINATION - Patient conscious, oriented to time, place and person. - Higher mental function : normal - Cranial nerve examination – normal - Speech normal - No sensory motor deficit - tone – normal - power – B/L upper limb- 5/5 B/L lower limb – 5/5 - Reflexes – B/L UL and LL DTR – normal - Spine examination : normal curvature of spine, no deformity present, - intervertebral spaces were difficult to felt on palpation due to excessive fat over back.

16. AIRWAY EXAMINATION Sitting position No visible craniofacial deformity , excessive buccal fat present excessive fat present at nape of neck - Both nares look normal - Mouth opening- 5 cm/ 3 finger breadth , with large tongue. - Mallampati grading – grade III - No buck teeth, no loose , missing teeth or artificial dentures. - Thyromental distance - 5.5 cm - Sternomental distance -11.5 cm

17. AIRWAY EXAMINATION -Neck Range of motion – adequate, no stiffness of neck present. - Neck circumference – 43 cm at the level of thyroid cartilage - Upper lip bite test – grade 1 - TMJ mobility adequate on mouth opening. - Prayer sign- normal - Palm print test – grade 0

18. PREOP INVESTIGATION - Hb- 11.2 g/dl - TLC- 9300 cells/ mcL - Platelets – 2.03 Lakh/dl - Urine routine and microscopy : WNL - KFT- serum urea : 20mg/dl , s.creatinine : 0.7mg/dl - LFT: WNL - Lipid Profile - s cholesterol- 226 mg/dl - s triglycerides – 137 mg/dl - HDL – 41 mg/dl - LDL - 158 mg/dl - Fasting and postprandial blood sugar: 108mg/dl and 154 mg/dl - Glycosylated Hb : 8.2%

19. PREOP INVESTIGATION - TFT - WNL - Serum electrolytes: S Na+ : 136mg/dl S K+ : 4.1 S Ca+ : 1.20 meq /l - ECG : Low voltage QRS complex with LAD - 2D echo – Normal chamber size, LVEF- 60% , no significant valvular changes , No mass or PE seen. - CXR : WNL - ABG – Ph - 7.34 , Pco2- 43 , Po2- 90 , so2- 98 , Lactate – 0.6 , Hco3 - - 22 - Morning of surgery investigations: serum electrolytes, FBS, urine ketones.

20. PROVISIONAL DIAGNOSIS 59 years old obese female of ASA PS class III, k/c/o uncontrolled type 2 Diabetes mellitus on oral hypoglycemic agents (tab metformin 500 mg BD, tab glimipride 2 mg , tab pioglitazone 15mg OD) with newly diagnosed Hypertension controlled with (Tab amlodipine 5mg OD) complain of cholelithiasis planned for laparoscopic cholecystectomy.

21. THANK YOU