OBESITY Interhospital case presentation ATA.pdf

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1. A WEIGHTY
OPERATION
Dr. ChristabelleIleana L. Toh
2
nd
year resident
Davao Doctors Hospital

2. OBJECTIVES

3. CASE
NAME J.B.
AGE 27 year old
SEX Male
ADDRESSEcolandSubdivision, Davao
City
RELIGIONRoman Catholic

4. CHIEF COMPLAINT
Right Upper Quadrant Pain

5. HISTORY OF PRESENT ILLNESS
INTERIM
•Tolerated Right
Upper quadrant
pain
4 MONTHS PTA
• Onset Epigastric pain
associated with
decreased appetite
•Consulted with AP
•Imaging reveal
Gallbladder stone and
polyp . Surgery was
advised for surgery but
they were still undecided
ADMISSION
• Increasing Right
quadrant pain not
relieved with
Buscopan, opted
for admission and
surgery

6. ADMITTING DIAGNOSIS
CHRONIC CALCULOUS CHOLECYSTITIS

7. PAST MEDICAL HISTORY
•AUTISM SPECTRUM DISORDER
•NON HYPERTENSIVE
•NON DIABETIC
•NON ASTHMATIC
•NO ALLERGIES
•NO PREVIOUS SURGERY

8. PERSONAL SOCIAL HISTORY
•Nonsmoker
•Non alcoholic beverage
drinker
•Homeschooled
•Able to perform activities of
Daily living independently

9. GENERAL APPEARANCE
AWAKE, ALERT
NOT IN RESPIRATORY DISTRESS
WEIGHT 138 kg
HEIGHT 168cm
BMI 49.2 (Obese 3)

Blood Pressure
130/90 mmhg
Heart rate
92 bpm
Respiratory Rate
21 cpm
Temperature
36.5 °C

10. GENERAL APPEARANCE
HEENT
ANICTERIC SCLERAE, PINK
PALPEBRAL CONJUNCTIVA
CHEST/LUNGS
EQUAL CHEST EXPANSION, CLEAR
BREATH SOUNDS, NO WHEEZING
HEART
ADYNAMIC PRECORDIUM,
DISTINCT HEART SOUNDS, NO
MURMUR
ABDOMEN
SOFT, GLOBULAR, RIGHT UPPER
QUADRANT TENDERNESS (deep
palpation)

11. GENERAL APPEARANCE
EXTREMITIES
ESSENTIALY NORMAL, STRONG
PULSES
(-) EDEMA, RASHES
NEURO-EXAM
GCS 15, ESSENTIALLY NORMAL, NO
MOTOR AND SENSORY DEFICITS

12. COURSE IN THE WARD

13. COURSE IN THE WARD
HOSPITAL DAY 1
DAY OF ADMISSION
ADMITTED DUE TO RIGHT UPPER QUADRANT PAIN
PATIENT WAS SEEN AND EXAMINED
ANESTHESIA PLAN EXPLAINED
PATIENT WAS PUT ON NPO 8 HOURS PRIOR TO PROCEDURE
HOSPITAL DAY 2 PATIENT UNDERWENT CONTEMPLATED SURGERY

14. PRE-OPERATIVE EVALUATION
LABORATORIES
HGB 104 L
HCT 32 L
PLT 243
WBC 5.9
CREA 85
CXRAY
- NEGATIVE CHEST
ECG
- NORMAL SINUS RHYTHM
COVID RTPCR
- NEGATIVE

15. PRE-OPERATIVE EVALUATION
SUBJECTIVE RIGHT UPPER QUADRANT PAIN 5-6/10
DECREASED APPETITE
OBJECTIVE 130/90 92 21 36.5
AWAKE, COMFORTABLE, NIRD
(+) RUQ TENDERNESS, SOFT GLOBULAR ABDOMEN
EQUAL CHEST EXPANSION, CLEAR BREATH SOUNDS
FULL PULSES
MALLAMPATI GRADE 2, GOOD MOUTH OPENING AND NECK
MOVEMENT, NO BEARD, NO LACKING TEETH
ASSESSMENT ASA 3- morbid obesity

16. PRE-OPERATIVE EVALUATION
ANESTHETIC
PLAN
GENERAL ANESTHESIA-
TOTAL INTRAVENOUS
ANESTHESIA UNDER
LARYNGEAL MASK AIRWAY
DEVICE

18. COURSE IN THE WARD
PACU NO SUBJECTIVE COMPLAINTS
120-130 mmhg
80s-90s bpm
98-99% o2 saturation (2lpm nasal cannula)
HOSPITAL DAY 3 TOLERABLE POST OP PAIN
NO NAUSEA/VOMITING
FLATUS + BM +
TOLERATES DIET
130/70 mmhg, 82bpm, 98% o2 saturation
DISCHARGED

19. DEFINITION

20. Pre-Operative Evaluation
Airway
Anatomic changes in Obese patients
➢Limitation of neck movement (short, thick neck, thick submental fat
pads; suprasternal, presternal, and posterior cervical fat)
➢Excessive pharyngeal fat
➢Large breasts – in females

21. Pre-Operative Evaluation of Obese Patients
Airway
Neck circumference > 40cm- difficult airway management
General
Fat Distribution
peripheral obesity deposition is predominantly in the lower body
central obesity= associated with increased oxygen consumption and
increased incidence of cardiovascular disease.

22. Pathophysiology in an Obese
Patient

23. Respiratory changes in Obesity
•Chest wall and lung compliance
• Decreased FRC, Vital Capacity and Total Lung Capacity
•Decreases in FRC and ERV are the most commonly reported abnormalities of
pulmonary function in obese
Oxygen Consumption, Work of breathing, Carbon Dioxide production

24. Cardiovascular changes in Obesity
•Blood volume, Cardiac Output, LV wall thickness
Increased Proinflammatory and prothrombotic mediators
•Total Blood Volume increase 50 mL/kg
•Increased cardiac output by 20 to 30 mL per kilogram of excess body fat.
•Left ventricular hypertrophy, related to the duration of obesity

25. GASTROINTESTINAL
•Risk of Regurgitation
•Higher gastric volume and lower Ph- increases risk of severe
pneumonitis
•Current Fasting Guidelines are acceptable
•Associated liver abnormalities : fatty infiltration, inflammation, focal
necrosis, and cirrhosis

26. Renal and Endocrine
•Impaired glucose tolerance – resistance of peripheral
adipose to insulin
•Glomerular Hyperfiltration - Increased Renal Blood Flow,
Glomerular Filtration Rate and renal tubular resorption

27. PHARMACOKINETIC PRINCIPLES
•Modified drug dosing because of obesity-related increases in lean body
weight (LBW), cardiac output, and blood volume
•Dosing is generally based on volume of distribution for bolus doses, and on
clearance for infusions or repeat boluses.
•V
dof relatively lipophilic drugs is increased by obesity
•Drug clearance is generally higher in individuals with obesity

28. FORMULA
IDEAL BODY WEIGHT (kg) = HEIGHT (cm) – X
X= 100 MALES; X= 105 FEMALES
LEAN BODY WEIGHT
Males 1.1 x TBW – 0.0128 X BMI X TBW
Females 1.07 x TBW – 0.0128 X BMI X TBW

68kg
65.4kg

29. FORMULA
PREDICTED BODY WEIGHT
•Males: PBW (kg) = 50 + 0.91 × (height (cm) − 152.4);
•Female PBW (kg) = 45.5 + 0.91 × (height (cm) − 152.4)
65.9 kg

31. Intra-operative Care Patient positioning
Supine or head-down (Trendelenburg) positions
-Decreased lung volumes and increased work of breathing
- increased venous blood return

32. Intra-operative Care Patient positioning
Head-up position (reverse Trendelenburg, or semi-
sitting/"semi-Fowler“
•improve respiratory function - reduce pressure on the chest
wall and diaphragm.
•improves both mask ventilation and the view at
laryngoscopy

33. Intra-operative Care Patient positioning
Prone
•increased functional residual capacity (FRC), lung
compliance, and oxygenation
•Patient supports should be placed
•abdomen should be compression-free

34. Intra-operative Care Patient positioning
Lateral decubitus
removes the weight of the abdomen from the diaphragm
Lithotomy position
decreases lung volumes by shifting abdominal contents
towards the diaphragm

35. Intra-operative Care General anesthesia
-higher incidence of hypoxia and respiratory events
- desaturate more quickly during apneic periods,

36. Intra-operative Care General anesthesia
Difficulty with airway management
•increased frequency of aspiration , complications with the use of
supraglottic airways, difficulty intubation, airway obstruction during
emergence
•risk factor for both difficult mask ventilation and difficult
laryngoscopy

37. Intra-operative Care General anesthesia
Difficulty with airway management
Risk factors for difficult mask ventilation:
●Age older than 55
●Body mass index (BMI) >26 or 30 kg/m
2
●presence of a beard
●Lack of teeth
●History of snoring/sleep apnea
●Abnormal neck anatomy
●Male sex
●Short thyromental distance (TMD) (<6 cm)
●Severely limited mandibular protrusion
●Mallampati class 3 or 4

38. Intra-operative Care General anesthesia
Difficulty with airway management
Difficult supraglottic airway device use
•Small mouth opening (<3 finger breadths)
•Neck radiation
•Tonsillar hypertrophy
•Fixed cervical spine flexion deformity
•Applied cricoid pressure
•Obesity
•Poor dentition or large incisors
•Male sex

39. Intra-operative Care General anesthesia
Difficulty with airway management
Difficult intubation
•Prior difficult intubation
•Small mouth opening (<3 finger breadths)
•Mallampati class 3 or 4
•Shortened TMD (<6 cm)
•Shortened sternomental distance (<12 cm)
•Limited neck mobility
•Limited mandibular protrusion or upper lip bite test (ULBT)
grade 3
•Thick neck (circumference >40 cm)

42. Intra-operative Care General anesthesia
Choice of airway device
•mask ventilation is generally restricted to brief anesthetics
-difficulty with mask fit and handling, or obstruction
•more likely to require controlled ventilation
•more likely to require intubation rather than a supraglottic airway
•SGA may not maintain a seal at the higher airway pressures
•second generation SGAs -allow higher seal pressures, and provide a
gastric vent.

43. Intra-operative Care General anesthesia
Choice of airway device
Clinically important features of SGA use:
•Easily placed blindly
•Less hemodynamic response to placement than
laryngoscopy and ETT placement
•Lower risk of bronchospasm
•Does not protect against laryngospasm
Clinically important features of ETT use:
•May be difficult to place
•Requires deeper level of anesthesia for
placement than SGA
•Stimulus for bronchospasm
•High peak pressures possible
•Protects against aspiration

44. Intra-operative Care General anesthesia

45. Mechanical Ventilation
•Larger tidal volumes offer no added advantages during ventilation of
anesthetized morbidly obese patients.
•Further increasing tidal volumes offers no benefit.
•No specific ventilatory mode (volume vs. pressure control ventilation
[PCV]) has been found significantly better

46. Intra-operative Care General anesthesia
Ventilation management
•Set TV of 6 to 8 mL/kg predicted body weight (PBW)
•Adjust respiratory rate to maintain normocapnia
•Limit FiO
2to the level required to maintain peripheral
arterial oxygen saturation (SpO
2)
•individualized PEEP to optimize lung compliance
•Maintain head-up (reverse Trendelenburg) position,
whenever feasible.

47. Mechanical Ventilation
•Positive PEEP is the only ventilatory parameter that has consistently
been shown to improve respiratory function in obese subjects
•series of three short (6 seconds) inflations of large tidal volume
reaching an inspiratory pressure of 40 to 55 cmH2O.
•aims to open and maintain the patency of small airway units,
therefore improving ventilation–perfusion matching and oxygenation.

48. Laparoscopic Procedures
in Obese Patients

49. Effects of CO2 pneumoperitoneum in obese patients
•Primary (due to CO2 absorption) and secondary (due to increased intra-
abdominal pressure)
•Hypercarbia: stimulation of autonomic nervous system, cardiac arrhythmias,
tachycardia and vasoconstriction in the pulmonary vessels.
•Pulmonary: cephalad shift of the diaphragm, decreased frc, increased physiologic
dead space, increases airway pressures
•Acidosis has depressant effect on myocardial contractility
•Adjustments in ventilation are necessary to maintain normocapnia

50. Effects of increased intraabdominal pressure during
pneumoperitoneum:
•Obese patients better tolerate pneumoperitoneum
•Intra abdominal pressure 5 mmHg in non-obese; chronically elevated to 9-10
mm Hg in obese persons
•Cephalad direction of diaphragm resulting in increased pleural pressure
•Effects: decrease venous return, decreases preload, increases after load and
reduction in cardiac flow

51. Effects of pneumoperitoneum on respiratory mechanics
•Decrease respiratory compliance
•Increase airway pressure
•Increase respiratory rate
•Increase minute ventilation
•Reduce tidal volume

52. INTRAOPERATIVE VENTILATION STRATEGIES
•There is no difference between PCV and VCV in terms of better clinical outcome
•PCV- guarantees ensure minimal tidal volume at lower peak inspiratory pressure
•Tidal volume should be adjusted accordingly
•Studies have shown that recruitment maneuver (RM) and PEEP application in obese patients imporove
oxygenation and pulmonary mechanics
Recommendations for ventilation of obese :
•6-8 ml/kg
•VCV/ PCV MODE
• titration of respiratory rate according to normocapnia
•optimal PEEP,
•PIP or Ppl< 30 cm H2O

53. LARYNGEAL MASK AIRWAY
Uses:
- Temporary method to maintain an open airway
-Immediate life-saving device
-be used asan alternative to intubation
-effective method of ventilation
•Designed to beinserted blindly through the mouth and into the hypopharynx to seal around the
glottic opening allowing for ventilation
R RESTRICTION
O OBSTRUCTION
D DISTORTION
S SPACE/ SPINE

55. LARYNGEAL MASK AIRWAY
Clinical signs of incorrect SAD position include the following:
1.resistance to SAD insertion in the hypopharynx;
2.SAD dislodgement during cuff insufflation;
3.bite block malaligned with incisors;
4.poor oropharyngeal airway seal (OPLP; intracuff pressure);
5.ineffective gas exchange
6.no drain tube patency;

56. LARYNGEAL MASK AIRWAY
Corrective maneuvers:
1.Jaw thrust to correct initial downfolding of the epiglottis;
2.Adjustment of the position of the distal esophageal cuff;
3.Changing the SAD to a device with a reinforced tip configuration if the cuff folds over
backwards persistently;
4.Using a different size, type, or brand
5.Using a larger size of SAD or reinflating the cuff to an intracuff pressure of 40–60 cm
H
2O if cuff hypoinflation is observed; and
6.Change to a silicone-cuffed SAD when folding in the cuff is causing an air leak.

57. THANK YOU