ANESTHESIA MANAGEMENT FOR OBESE PATIENT
AND BARIATRIC SURGERY
OBESITY
“Obesity is a medical condition characterized by excessive
accumulation of body fat that may impair health.”
It’s most commonly measured using the Body Mass Index (BMI).
Calculated by dividing a person's weight in kilograms by the
square of their height in meters (kg/m²).
According to the World Health Organization (WHO):
Normal weight: BMI of 18.5–24.9
Overweight: BMI of 25–29.9
Obesity: BMI of 30 or higher
PATHOPHYSIOLOGY
The pathophysiology of obesity involves a complex interplay of factors
leading to excess fat accumulation and various health complications
Metabolic and hormonal imbalances, along with genetic predispositions and environmental influences, contribute to the
development and maintenance of obesity
Key pathophysiological mechanisms:
Energy imbalance
Adipose tissue dysfunction
Inflammation
Insulin resistance
Hormonal imbalances
Hormonal influences:
Leptin resistance • Genetic predisposition
Ghrelin levels
• Environmental factor
PHYSIOLOGICAL CHANGES
Obese patients undergoing anesthesia are at an increased risk for various
complications, including respiratory problems, cardiovascular issues, and difficulties
with airway management.
Specific
complications:
Respiratory complications:
Hypoxemia and hypercapnia
Atelectasis
Obstructive sleep apnea (OSA)
PHYSIOLOGICAL CHANGES
Cardiovascular complications:
Hypertension and ischemic heart disease
Myocardial infarction
Airway management difficulties:
Difficult intubation
Difficult mask ventilation
Post-operative complications:
Deep vein thrombosis (DVT)
Wound infections
KEY CONSIDERATIONS
Obese patients undergoing bariatric surgery require careful preoperative
anesthesia management to minimize risks and ensure optimal outcomes.
Airway Management:
Obese patients are at higher risk for difficult airways, so careful assessment and planning are essential.
Cardiovascular Evaluation:
Obesity increases the risk of cardiovascular disease, so thorough cardiovascular evaluation is necessary.
Respiratory Function:
Obese patients may have reduced lung volumes and respiratory reserve, requiring careful respiratory
management.
Medication Dosing:
Anesthetic medication dosing may need to be adjusted based on the patient's weight and body
composition
PREOPERATIVE MANAGEMENT
Obese patients present unique challenges during anesthesia due to
physiological changes, comorbid conditions, and difficult airway management.
Anesthetic Management of Obesity
Preoperative Assessment:
Airway evaluation:
Higher risk of difficult mask ventilation and
intubation.
Features like short neck, large tongue,
limited neck mobility.
Use of Mallampati score, neck
circumference, BMI for risk prediction.
Cardiopulmonary assessment:
Evaluate for hypertension
obstructive sleep apnea (OSA)
heart disease.
Pulmonary function may be reduced due to decreased
lung volumes and increased work of breathing.
Comorbidities:
Diabetes, GERD, fatty liver, renal dysfunction, and venous
thromboembolism (VTE) risks.
Investigations (ECG, echocardiogram (if cardiac risk),
chest X-ray, blood glucose, electrolytes, liver and kidney
function tests
INTRAOPERATIVE MANAGEMENT
Induction:
Premedication:
Antacids (e.g., Ranitidine or pantoprazole)
Anticholinergics (e.g, Atropine).
Induction agents: rapid sequence induction
(RSI)
Propofol
Muscle relaxants: succinylcholine
If contraindicated, use rocuronium.
Consideration for difficult airway
Positioning
Ramp positioning:
Reverse Trendelenburg
(30–45 degrees)
MAINTENANCE
• Anesthesia maintenance:
sevoflurane or desflurane) or total
intravenous anesthesia (TIVA) with propofol
and remifentanil.
• Volatile anesthetics lower concentrations due to
the higher body fat content
• Opioid use:
Mechanical strategy
low tidal volume (6–8 mL/kg)
Inspiratory : Expiratory Of 1:2
PEEP (positive end-expiratory pressure), 5-8cmHg
Capnography: EtCO2 (32-37 mmHg)
FLUID MANAGEMENT
Crystalloid solution (Lactated Ringer's or
normal saline) is used for maintenance fluid.
Carefully monitor for fluid shifts, as patients
with obesity are prone to edema and volume
overload.
INTRAOPERATIVE ANALGESIA
Use multimodal analgesia to minimize opioid use:
• Paracetamol/Acetaminophen and NSAIDs
• Regional techniques (e.g., epidural analgesia,
transversus abdominis plane (TAP) block)
• Ketamine (low doses) and gabapentin can be
added to the regimen for further opioid-sparing
effects.
POSTOPERATIVE ANESTHESIA MANAGEMENT
The challenges include obesity-related respiratory issues,
opioid sensitivity, and risk of thromboembolism.
Postoperative Respiratory Management:
Airway monitoring
Obstructive sleep apnea (OSA) is common in
bariatric patients,
CPAP or BiPAP may be required postoperatively,
Ventilatory support:
If there is a risk of postoperative hypoventilation, it may
be necessary to provide supplemental oxygen,
especially if the patient is still under the effects of
residual anesthesia or opioids.
PAIN MANAGEMENT
NSAIDs (if appropriate) and acetaminophen
are often used.
Consider multimodal analgesia with local
anesthetic blocks (e.g., TAP block or
epidural analgesia) for effective pain control
while reducing opioid consumption.
Avoiding excessive sedation: Over-sedation
increases the risk of respiratory depression,
particularly in patients with OSA, so careful
titration of sedatives is necessary.
COMPLICATION OF BARIATRIC
SURGERY FOR A OBESE PATIENT
Anesthesia-Related Complications:
Difficult Airway Management
Postoperative Nausea and Vomiting (PONV)
Arterial Hypotension and Hypertension:
Adverse Drug Reactions
Pulmonary Complications:
Atelectasis (collapsed lung)
Aspiration
Hypoventilation.
Surgical Complications (directly related to the
surgery):
Anastomotic Leaks
Thromboembolism (Deep Vein Thrombosis and Pulmonary
Embolism)
Bleeding
Infection
Perforation
Other Potential Complications:
Dumping Syndrome
Nutritional Deficiencies
Gallstones
Psychiatric Complications
PREOPERATIVE ASSESSMENT
Comprehensive Medical History
Physical Examination:
Assessing the patient's airway
Cardiovascular
respiratory systems
Laboratory Tests
Conducting relevant laboratory tests, such as ECG, chest X-ray,
and pulmonary function tests.
Anesthetic Plan
Regional Anesthesia: Regional anesthesia may be considered to
reduce the risks associated with general anesthesia.
General Anesthesia: If general anesthesia is necessary, careful
planning and execution are crucial to ensure optimal outcomes.
INTRAOPERATIVE MANAGEMENT
Preoxygenation:
Optimal oxygenation
CPAP or high-flow nasal cannula
Airway management techniques:
Direct laryngoscopy (DL)
Video laryngoscopy (VL)
Supraglottic airway devices (sads)
VENTILATION STRATEGY:
Pressure-Controlled Ventilation (PCV):
Low Tidal Volumes:
Positive End-Expiratory Pressure (PEEP):
End-tidal CO2
Recruitment Maneuvers:
MULTIMODAL ANALGESIA
Combining different pain-relieving medications and techniques is crucial. This includes:
Non-opioid analgesics: NSAIDs like ibuprofen,
naproxen, or celecoxib can help reduce inflammation
and pain.
Opioids: Used strategically, often in lower doses than
in non-obese patients, and in conjunction with other
analgesics.
Local anesthetics
Ketamine
Dexmedetomidine
Regional Anesthesia
Epidural analgesia
Peripheral nerve block
POSTOPERATIVE ANESTHESIA MANAGEMENT
Monitoring:
Continuous Pulse Oximetry
Capnography: Especially in patients with OSA (obstructive sleep apnea) or high BMI.
Hemodynamic Monitoring:
Obese patients may have hypertension, OSA, and cardiac conditions requiring close cardiovascular
observation.
Positioning and Mobilization
Proper Positioning: Reduces risk of thromboembolism and promotes pulmonary function.
Thromboembolism Prophylaxis
High Risk for DVT/PE: Due to immobility, venous stasis.
Prophylaxis: Use of LMWH, compression stockings, and early mobilization.
Glycemic Control
Obese Patients Often Have Diabetes/Insulin Resistance
