British Journal of Anaesthesia 103 (BJA/PGA Supplement): i23i30 (2009)

doi:10.1093/bja/aep294

Obesity, obstructive sleep apnoea, and diabetes mellitus: anaesthetic implications

K. Candiotti*, S. Sharma and R. Shankar
Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami, Miller School of Medicine, PO Box 016370 (R-370), Miami, FL 33136, USA
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*Corresponding author. E-mail: kcandiot@med.miami.edu

Obesity is an epidemic in much of the Western World. The extent of this problem, combined with the increasing preference for ambulatory surgical procedures, has produced a difcult situation for many anaesthesiologists. Even the simplest anaesthetic procedures can become very complicated and potentially difcult in this population. Although there are numerous complications associated with obesity, perhaps obstructive sleep apnoea (OSA) and diabetes mellitus are among the more signicant. Patients with OSA are often not ideal candidates for certain day-case procedures, but many outpatient procedures can be performed on patients with OSA as long as attention is paid to anaesthetic technique. Diabetic patients are prone to numerous complications in the perioperative period, including cardiac problems, but with careful management, they are able to undergo day-case surgical procedures safely. Br J Anaesth 2009; 103 (Suppl. 1): i23i30 Keywords: anaesthesia, day-case; complications, obesity; diabetes; sleep apnoea

Obesity
In the USA, more than one-third of the adult population suffers from obesity. There is a higher prevalence in certain ethnic populations, including African-, Asian-, and Mexican-Americans.2 20 While denitions vary, obesity is dened as a BMI of 30 kg m22 or greater and morbid obesity as a BMI .35 kg m22.2 53 Super morbid obesity is often categorized as patients with a BMI .50 kg m22 and ultra obese patients as those with a BMI .70 kg m22.14 Obese patients, especially those with a central distribution of fat, have an increased risk of various medical disorders such as cardiovascular disease, stroke, and diabetes.2 53 Obesity can be classied as primary obesity resulting from increased caloric intake and secondary obesity, which is often a result of medications (e.g. corticosteroids) or medical disorders such as Cushings disease or hypothyroidism.2 This review focuses on primary obesity, the associated diseases of diabetes and obstructive sleep apnoea (OSA), and their implications for anaesthetic management focusing on the ambulatory care setting. The secondary form of obesity is associated with numerous other complications beyond the scope of this review.

Pathophysiology
Obesity can present signicant problems for anaesthesiologists, including difcult airway management, intravascular access, pulmonary aspiration, monitoring, and choosing appropriate medications.2 Although numerous organ systems

are affected in obese patients, the burden placed on the cardiovascular and respiratory system is especially concerning to the anaesthesiologist. Because of the restrictive ventilatory effects of obesity, these patients often show a decreased functional residual capacity and a decreased expiratory reserve volume, all leading to an overall decrease in total lung capacity. These decreases lead to arterial hypoxaemia, ventilation perfusion mismatch, and right-to-left shunting. Obese patients require increased cardiac output to maintain pulmonary and systemic circulations. Since increased left ventricular blood volume and systemic hypertension are common in these patients, complications of chronic, increased afterload, which translates into increased cardiac work and increased oxygen demands, are often encountered.2 53 Apart from cardiovascular and pulmonary issues, morbidly obese patients suffer from higher perioperative complication rates including renal problems, atelectasis, pneumonia, wound infections, sleep apnoea-related problems, and thromboembolic events.2 3 Thromboembolic problems, such as deep vein thrombosis, most likely arise from polycythemia, high abdominal pressures, and reduced mobility, all leading to venous stasis.52 Prophylactic techniques can reduce the occurrence of deep vein thrombosis and include early ambulation, compression devices, and sometimes preoperative inferior vena cava lter placement.2 52

Anaesthetic considerations
Mask ventilation and intubation can pose a challenge in an obese patient as a result of the excessive fat and

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problematic chest and lung biomechanics. Predictors of difcult mask ventilation include: age .55 yr, BMI .26 kg m22, the presence of a beard, lack of teeth, and a history of snoring.37 Tracheal intubation and positive pressure ventilation are still considered the best options for securing the airway in obese patients, but at times can be difcult as well. Awake breoptic intubation has traditionally been the safest method of securing an airway in a morbidly obese patient but can be difcult in obtunded or uncooperative patients. A recent study comparing postoperative lung function and oxygen saturation in moderately obese patients concluded that a laryngeal mask airway (LMA) can easily replace an orotracheal intubation for patients posted for most peripheral surgeries. This observation was based on the fact that oxygen saturation decreased more in the intubated group at 30 min, 2, and 24 h after operation than in the LMA group. Even inspiratory and expiratory spirometric values were better in the LMA group up to 24 h after operation.58 Another recent report demonstrated the use of other devices to secure a difcult airway such as the Aintree intubation catheter. The Aintree stylet was placed over a breoptic bronchoscope and both were introduced through an LMA. A tracheal tube was then inserted over the stylet after removing the breoptic scope and LMA.22 Another study assessed the impact of obesity on emergency intubations in trauma patients. The study included 9980 patients, with 46% lean, 37% overweight, 15% obese, and 2% morbidly obese patients and concluded that emergency intubation of obese trauma patients was not different from non-obese trauma patients and can be safely and successfully performed at a high volume level 1 trauma centre.50 Even with successful intubation, ventilation can present difculties in morbidly obese patients. These difculties can be attributed to the restrictive nature of the chest wall and the altered pulmonary mechanics. A recent study compared pressure-control ventilation with volume-control ventilation in a group of 36 patients undergoing laparoscopic bariatric surgery. The study demonstrated a higher PaO2, SaO2, and 0 PaO2/FIO2 ratio along with a lower ECO2 PaCO2 gradient and a comparatively normal pH and PaCO2 with pressure-control ventilation compared with volume-control ventilation. The improved oxygenation with pressure-control was explained by a better ventilationperfusion ratio.17 Appropriate drug dosage and drug selection are critical in morbidly obese patients. In general, opioids and sedatives should be used judiciously for induction, maintenance of anaesthesia and for postoperative analgesia because of the risk of respiratory depression in morbidly obese patients. Obese patients require different dosing compared with average weight patients. For instance, Shibutani and colleagues concluded that fentanyl should be dosed based on pharmacokinetic mass, which has a non-linear relationship to total body weight (TBW), in order to avoid overdosing. With this approach, the relative dosing of fentanyl in mg kg21 decreased as TBW

increased.48 Reduced opioid-induced complications can also be achieved by multimodal analgesic therapy. A number of studies have shown reduced fentanyl-induced respiratory depression by using adjuvant drugs. One showed that the preinduction use of ketamine and clonidine in morbidly obese patients posted for bariatric surgery reduced total doses of intraoperative fentanyl and sevourane, time to extubation, postoperative tramadol use for analgesia, and visual analogue scale pain scores.52 Recently, the use of dexmedetomidine, a selective a2 adrenergic receptor agonist, has gained popularity in obese patients because of its sedative/hypnotic, anaestheticsparing, analgesic, and sympatholytic properties. The use of dexmedetomidine reduces opioid-induced respiratory depression in morbidly obese patients with OSA and pulmonary hypertension undergoing bariatric surgery.30 The drug has also proven advantageous in patients who are undergoing laparoscopic gastric bypass procedures by reducing the amount of opioids required, thus giving the added advantage of reduced emesis and decreased duration of post-anaesthesia care unit stay.30 51 Yet another study demonstrated the use of dexmedetomidine as the sole sedative agent for awake breoptic intubations in a series of obese patients.1 The altered physiology in an obese individual, when compared with a non-obese patient, affects the pharmacokinetics of many drugs including volatile anaesthetics. A study by Mantouvalou and colleagues41 showed that there was no signicant difference in the emergence and recovery characteristics of desurane or sevourane in obese patients. In contrast, another study conducted by La Colla and colleagues36 did show a signicant difference in the recovery proles between desurane and sevourane with desurane leading to signicantly faster wash-in and wash-out and a shorter recovery room stay compared with sevourane. The use of regional anaesthesia has been less explored for morbidly obese patients. Challenges in performing regional anaesthesia in obese patients often lie in nding correct landmarks, selecting the right equipment and positioning, all of which can be improved through obesespecic anaesthetic techniques.15 42 For example, uoroscopic or ultrasonographic guidance can be used to improve the success rate and ease of regional anaesthesia procedures in obese patients.42 While obese patients are increasingly being treated in ambulatory care centres with regional anaesthesia, they have a higher rate of block failures and complications. For example, phrenic nerve palsy after brachial plexus block in a morbidly obese patient led to unanticipated hospitalization as a result of dyspnoea, ank pain, chest discomfort, and anxiety.24 Overall, obese patients are 1.62 times more likely to have an unsuccessful block in an ambulatory setting. Despite these difculties, regional anaesthesia can still be an excellent option for obese patients in an outpatient setting, particularly in patients with OSA.42

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Ambulatory patients
Candidacy for surgery, clinical outcomes, and likelihood of being able to leave the hospital are factors often considered when assessing the obese patient for ambulatory and other procedures.48 Morbid obesity does not appear to be a signicant independent risk factor for unanticipated admissions after operation, and ambulatory surgeries should not be avoided solely on the basis of weight. However, morbidly obese patients have an increased likelihood of bronchospasm and need for supplemental oxygen after surgery.31 Obese patients with a mean BMI of 44.5 kg m22 undergoing gastric banding were successfully treated as outpatients with only nine of 343 patients having signicant complications, the most common being stoma occlusion.56 The study included ASA I and II patients; however, patients with severe sleep apnoea were also enrolled, provided they were treated with appropriately titrated CPAP and were compliant with their machines. In contrast to these ndings, other studies indicate that obese patients experience frequent perioperative complications including postoperative oxygen desaturation, even with supplemental oxygen, necessitating increased preventative measures for hypoxaemia.31 51 Even minor ambulatory procedures, such as dental surgeries, demonstrate obesity-related complications. In a closed-claim study based on ofce-based dental anaesthetic procedures, obesity was cited as one of the most frequent risk factors associated with increased morbidity and mortality.33

intra-airway pressure that can narrow the collapsible segments of the pharynx as a result of the lack of bony support. In REM sleep, the tone of the upper airway muscles decreases, increasing upper airway resistance. Any further diaphragmatic contraction during inspiration produces additional negative pharyngeal pressure, collapsing the pharynx even more.13 The relationship between OSA and obesity is emphasized by the observations that obesity has an inverse relationship with pharyngeal area, and the patency of the collapsible pharynx is determined by the difference between the extraluminal and the intraluminal pressures and by wall compliance, both of which are adversely affected by the fat mass in obese people. The effect of obesity on OSA is simply demonstrated by the fact that dietary and surgical weight reduction strategies reduce its severity.13 The systemic effects of OSA are primarily the result of hypoxaemia and hypercapnia occurring during apnoeic episodes. These changes can not only cause arousal and disturbed sleep but also lead to cardiac arrhythmias and ischaemia, pulmonary hypertension and right ventricular hypertrophy, and systemic hypertension and left ventricular hypertrophy.13 Fat distribution is not uniform in obese patients, and recent studies indicate that abdominal circumference is a better predictor of OSA than neck circumference or BMI.49 Leptin, an adipose tissue-derived hormone, regulates caloric intake, body weight, and fat distribution. Leptin resistance, causing increased serum leptin levels, is a contributing cause of obesity. Interestingly, OSA patients on continuous positive airway pressure (CPAP) demonstrate a decrease in serum leptin levels, suggesting a possible association with OSA.49

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Obstructive sleep apnoea

OSA can be a problem with serious implications for anaesthetic management. It is a syndrome characterized by some form of upper airway obstruction during sleep, often leading to respiratory interruptions and excessive daytime somnolence.9 Two separate entities have been documented: OSA, a complete cessation of airow for more than 10 s (apnoea), and obstructive sleep hypopnoea (OSH) characterized by an airow reduction of more than 50%, despite continuing breathing efforts resulting in hypoxaemia and hypercapnia.13 The accepted minimal clinical diagnostic criteria for OSA is an apnoea hypopnoea index (AHI) of 10 plus symptoms of excessive daytime somnolence; AHI is the number of episodes of apnoea or hypopnoea per hour during sleep.20 Overt OSA has been reported in 2% of women and 4% of men; however, these numbers are expected to increase as the population grows older and more obese.9

Anaesthetic considerations
Polysomnography (an overnight sleep study) is the best method for diagnosis of sleep apnoea; however, it is expensive, time-consuming, and clearly unsuitable for general screening purposes. Therefore, questionnaire-based tools have been developed to identify symptoms of OSA.19 The ASA has published a set of guidelines that help diagnose OSA based on elevated BMI, neck circumference, craniofacial alterations that obstruct the airway, snoring, airway exam anomalies, and hypersomnolence.9 The ASA has also developed a scoring system to assess the perioperative risk of complications from OSA (Table 1).13 37 The Berlin questionnaire is another aid to diagnose OSA before operation and uses three categories: (i) snoring, (ii) sleep and fatigue, and (iii) arterial pressure, weight, and height. A patient is at increased risk of OSA if signicant symptoms are present in two out of the three categories.19 Recently, Chung and colleagues20 formulated an excellent tool for the screening of OSA. The STOP questionnaire includes four questions with yes/no answers: Snoring, Tiredness during daytime, Observed apnoea, and high arterial Pressure. To further improve its sensitivity,

Pathophysiology
The pathophysiology of OSA depends on pharyngeal anatomy and the stage of sleep. Normally during inspiration, the contraction of the diaphragm creates a negative

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Table 1 OSA scoring system Points A Severity of sleep apnoea based on sleep study (or clinical indicators if sleep study not available) None Mild Moderate Severe Invasiveness of surgery and anaesthesia Supercial under local or peripheral nerve block without sedation Supercial with moderate sedation and general anaesthesia Peripheral with spinal or epidural anaesthesia and moderate or greater sedation Peripheral with general anaesthesia Airway surgery with moderate sedation Major surgery with general anaesthesia Airway surgery with general anaesthesia Postoperative opioids None Low dose oral High dose oral, parenteral, neuraxial Estimation of perioperative risk is calculated by adding A to either B or C whichever is greater. The greater the score, the greater the risk of perioperative complications

0 1 2 3 0 1 1 2 2 3 3 0 1 3 (0 6)

they incorporated questions concerning: BMI, Age, Neck circumference, and Gender to make the STOP-BANG questionnaire. Clinical prediction formulas can help evaluate an obese patients risk for OSA which is often underdiagnosed. Sleep apnoea scoring systems, similar to that developed by the ASA, have been published which help predict the likelihood of OSA. For example, in one scoring system, patients with a score of 15 or higher have an 81% chance of having OSA.25 This category of patients can also experience increased adverse events in the postanaesthesia care unit (PACU) and increased frequency of unplanned intensive care unit (ICU) admissions. Patients with high scores experience notably fewer adverse PACU events, if regional anaesthesia is used.25 Since a diagnosis of OSA in an obese patient affects anaesthetic care, the presence of a history consistent with OSA (i.e. hypertension, a neck circumference .40 42 cm, and snoring) is valuable. The ASA practice guidelines recommend a sleep study in patients with a probability of sleep apnoea in order to assess severity.9 Despite advances in the pathophysiology of OSA and the release of practice guidelines by the ASA, no standard anaesthetic management strategy has been validated. Bolden and colleagues,14 in a limited study, concluded that developing and following a perioperative anaesthesia protocol is the best way to avoid an adverse outcome in patients suffering from OSA. Preoperative preparation is an important part in the management of OSA patients and is intended to optimize their physical status. The ASA recommends (i) CPAP, or non-intermittent positive-pressure ventilation (NIPPV) or bilevel positive airway pressure, (ii) preoperative weight loss, (iii) preoperative medication, and (iv) preoperative use of mandibular advancement or oral appliances.9 Patients using CPAP should be instructed

to bring the machine with them if admitted to the hospital for any reason. As a result of the propensity for airway collapse and the aforementioned pharyngeal pathophysiology, OSA predisposes to the respiratory depressant effects of sedatives, opioids, and inhaled anaesthetics. These drugs should be used judiciously in patients with a history of OSA.9 20 Short-acting drugs, such as remifentanil, and agents with limited respiratory depression, such as dexmedetomidine, should be favoured.20 Patients with OSA have an increased incidence of difcult intubation. If a difcult airway is suspected, the patient should be managed conservatively, with an awake breoptic intubation considered optimal.9 If induction before intubation is considered appropriate, a rapid sequence induction is advisable as the risk of aspiration in obese and OSA patients is high as a result of poor lower oesophageal sphincter tone.49 51 Because of these airway issues, complete recovery from neuromuscular block and awake extubation are considered appropriate. A semi-upright or lateral position for extubation has also been suggested to be of benet irrespective of the patient position during surgery.9 In patients with OSA, regional anaesthesia appears to carry signicant benets over general anaesthesia.9 20 If sedation for these patients is considered, it is appropriate to utilize continuous capnography. CPAP can also prove benecial.32 The use of CPAP in moderate sedation might allow more liberal use of sedatives to improve patient comfort and prevent airway collapse.32 For simple peripheral procedures, local anaesthesia should be the preferred choice.9 Postoperative complications for patients with OSA include respiratory problems such as oxygen desaturation, apnoea, respiratory arrest, and cardiovascular problems such as hypertension, arrhythmias, and cardiac arrest.20 In order to minimize such complications, the ASA guidelines recommend supplemental oxygen until the patient is able to maintain a baseline saturation on room air. CPAP or NIPPV has been advised in patients who were receiving treatment before operation but remains controversial in those patients who were not. If frequent or severe obstruction or hypoxaemia occurs during postoperative monitoring, initiation of nasal CPAP or NIPPV should be considered.9 Either a semi-upright or lateral position can prove benecial. Continuous oximetry monitoring in a step-down unit, until room air oxygen saturation remains above 90% during sleep, has been advised to reduce the risk of respiratory complications. Additionally, the use of regional anaesthesia and non-steroidal anti-inammatory drugs to minimize the use of opioids for postoperative analgesia can also be benecial.9 OSA was not an independent risk factor for postoperative hypoxaemia in the rst 24 h after laparoscopic bariatric surgery. However, all obese patients with or without OSA experienced frequent desaturations, despite supplemental oxygen.4 In view of these ndings, it has been suggested that perioperative

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management of bariatric surgeries should include strategies to detect and prevent postoperative hypoxaemia, but additional measures in OSA patients might not be required.4

Table 2 The American Diabetic Association diagnostic criteria for diabetes 1 Symptoms of diabetes (polydypsia, polyuria, and unexplained weight loss) plus a casual (non-fasting) glucose concentration of 200 mg dl21, or A fasting (.8 h) glucose concentration 126 mg dl21 (normal ,100 mg dl21), or A glucose concentration 200 mg dl21 2 h after ingestion of 75 g of glucose (normal ,140 mg dl21)

Ambulatory patients
A number of factors must be considered before posting a patient with OSA for an ambulatory (day-case) procedure. These include sleep apnoea status, anatomical and physiological abnormalities, coexisting diseases, type of surgery, type of anaesthesia, need for postoperative opioids, age, adequacy of postoperative observation, and the capabilities of the out-patient facility.9 There is general agreement that supercial surgeries using local or regional anaesthesia, minor orthopaedics procedures with local or regional anaesthesia, and lithotripsy can be performed in outpatient settings.9 20 The ASA guidelines do not recommend performance of airway procedures, including tonsillectomies, in patients with OSA in an ambulatory setting. They do recommend ambulatory facilities for patients with OSA have emergency difcult airway equipment, CPAP capabilities, nebulizer and ventilator equipment, a radiology facility, clinical laboratory access, and a transfer arrangement to a nearby in-patient facility. Furthermore, monitoring for at least 3 h more than non-OSA patients and for at least 7 h after the last episode of apnoea or airway obstruction has been recommended for all ambulatory OSA patients.9

Diabetes mellitus
Diabetes mellitus is a chronic disease characterized by a decrease in insulin production (type 1) or impaired utilization of insulin as a result of peripheral insulin resistance (type 2) causing hyperglycaemia.57 The current diagnostic criteria for diabetes, as indicated by American Diabetic Association, are listed in Table 2.54 According to WHO statistics, 180 million people in the world suffer from diabetes at present and this number is likely to double by 2030. The reason for this dramatic increase in diabetes is thought to be the ageing of the population, increased prevalence of obesity, sedentary lifestyle, and dietary changes.54 The major risk factor for type 2 diabetes is obesity with 90% of these patients being overweight.16 Of note, it appears that the development of type 2 diabetes can be delayed or sometimes prevented from manifesting in individuals with obesity who are capable of losing sufcient weight.21

with insulin resistance and diabetes. In a study of the impact of intra-abdominal fat and age on insulin sensitivity, visceral fat was a strong determinant of insulin sensitivity and B-cell function.55 In a retrospective cohort study of patients undergoing coronary artery bypass surgery, obesity in non-diabetic patients was not independently associated with an increased risk of adverse postoperative outcomes. In contrast, obesity in diabetic patients was independently associated with a signicant increased risk of postoperative respiratory failure, ventricular tachycardia, atrial brillation, atrial utter, renal insufciency, and leg wound infections.43 Another study of the impact of bariatric surgery on type 2 diabetes concluded that clinical and laboratory (fasting glucose and HbA1c) parameters related to type 2 diabetes resolved or improved after bariatric surgery with 78% of the study group showing complete resolution of diabetes and 87% showing either resolution or improvement. The same study also demonstrated that weight loss and improvement of diabetes were related to the type of surgical procedure with a maximum impact associated with a biliopancreatic diversion.16 Diabetes is not only associated with obesity but also with OSA. A study of the association between OSA and impaired glucose metabolism in normal weight and obese individuals concluded that OSA is associated with occult diabetes, impaired fasting glucose, and impaired fasting glucose plus impaired glucose tolerance. The magnitude of this association was similar for obese and non-obese patients with OSA. Thus, OSA is an important risk factor for diabetes irrespective of weight.47

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Anaesthetic considerations
Diabetic patients suffer from an increased incidence of perioperative adverse cardiac events, including unexplained hypotension, arrhythmias, hypoxaemia, electrocardiographic changes, and myocardial infarction, which have a peak incidence at 48 72 h after surgery.8 More severe diabetics can suffer from autonomic dysfunction and these patients often do not experience pain with myocardial ischaemia. The presence of orthostasis (heart rate increase .15 beats min21, or systolic arterial pressure decrease .20 mm Hg 5 10 min after changing position from supine to upright) is a sign of autonomic neuropathy and indicates potential operative haemodynamic instability.7 Preoperative b-block has been shown to decrease the risk of myocardial infarction and had been advised in diabetic

Pathophysiology
The relationship between obesity and diabetes is emphasized by the fact that they both are important components of the metabolic syndrome,11 a syndrome characterized by central obesity, atherogenic dyslipidaemia, elevated arterial pressure, insulin resistance, and prothrombotic and proinammatory states.6 38 Obesity is strongly associated

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patients, despite previous concerns regarding the masking of symptoms of hypoglycaemia and worsening glucose intolerance.26 However, the use of b-blockers in all at-risk patients in the perioperative period was recently called into question by the Peri Operative Ischemic Evaluation (POISE) trial which showed an increased risk of death and stroke in patients started on b-blockers in the perioperative period.40 Although the exact handling of b-blockers is controversial, it is clear that patients who are currently taking these agents should have them continued in the perioperative period.54 Microvascular changes, secondary to diabetes, can make a diabetic patient more prone to cardiomyopathy with subsequent diastolic dysfunction. This dysfunction can respond well to b-blockers and calcium channel blockers that act by decreasing the heart rate and increasing diastolic relaxation.27 Reviewing the medication history of diabetic patients is an important part of the preoperative assessment. Poorly controlled diabetes is associated with worsening organ damage. For instance, long-term uncontrolled hyperglycaemia is an important risk factor for development of end-stage renal disease. Angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed for the prevention of renal complications in diabetic patients; however, patients with a creatinine concentration .3.0 mg dl21 or creatinine clearance of ,30 ml min21 should probably not receive ACE inhibitors because of an increased risk for deterioration of renal function.12 Biguanides, such as metformin, should also be discontinued in patients with compromised renal function or who will undergo large or extensive surgical procedures because of their propensity to cause lactic acidosis.7 Diabetic patients are at increased risk for various other perioperative complications.34 Hyperglycaemia decreases leucocyte chemotaxis and function. Increased susceptibility to delayed wound healing and wound infections, feared complications in diabetics, can be reduced by keeping blood glucose (BG) concentrations ,250 mg dl21. In addition to the tendency to diabetic ketoacidosis and non-ketotic hyperosmotic state, hyperglycaemia produces hyperosmolarity and hyperviscosity which can lead to thrombogenesis and increased perioperative complications.34 As a result of the frequent presence of microvascular disease, diabetic patients have an increased susceptibility to soft tissue ischaemia in addition to nerve injury, so pressure points must be well padded during positioning. For similar reasons, epinephrine should probably be avoided in diabetic patients when local anaesthetics are injected into areas of marginal blood supply.23 29 Diabetic patients are also at risk for pulmonary aspiration secondary to delayed gastric emptying. While not a rst-line drug for postoperative nausea and vomiting, metoclopramide can be effective for aspiration prophylaxis in patients with gastroparesis.21 35 While several other agents are effective for the prevention of postoperative nausea and vomiting in diabetics, dexamethasone should be used with caution due to its exaggerated effect on glucose in diabetics compared to non-diabetics.28

Approaches to managing of insulin dosing in the perioperative period vary by institution. In general, patients with type 1 diabetes and type 2 diabetes on chronic insulin therapy are treated similarly, with half of the usual long-acting insulin given the morning of surgery (basal insulin), supplemented by a regular insulin sliding scale titrated according to hourly glucose measurements. Alternatively, a regular insulin infusion of 0.5 2 U h21 can be used to meet basal metabolic needs. With either method, a slow glucose infusion will prevent hypoglycaemia while the patient is fasting. For type 2 diabetics undergoing short procedures, insulin is sometimes simply held the morning of surgery.5 46 No specic intraoperative recommendations regarding drug or uid administration exist for diabetics. However, decisionmaking should rely on regular intraoperative blood sugar monitoring. If an infusion is required for glucose control, regular insulin in 5% dextrose with or without potassium may be used to ensure a gradual decrease of the serum glucose level.46 While the hallmark of diabetes is hyperglycaemia, diabetic patients can also suffer from hypoglycaemia, dened as serum BG concentration ,50 mg dl21 in adults, usually related to treatment with medications such as insulin. Prolonged severe hypoglycaemia can cause seizures, focal neurological decits, coma, and death. Confusion, irritability, fatigue, headache, and somnolence are manifestations of hypoglycaemia. An adrenergic response can result in restlessness, diaphoresis, tachycardia, hypertension, arrhythmias, and angina. Anaesthetic drugs, analgesics, sedatives, and sympatholytic agents can interfere with symptom presentation. Administration of dextrose 50% (50 ml) is the initial therapy for signicant hypoglycaemia. Additional bolus doses might be necessary, and continuous evaluations of BG should be performed. Surgery and critical illness activate the metabolic response to stress, which includes alterations in both hormone and cytokine concentrations. These in turn lead to both increased glucose production and a state of insulin resistance that can be additive to the defects in carbohydrate metabolism already present in the diabetic patient.54 Preoperative glucose control can be achieved by oral hypoglycaemic drugs or insulin. The importance of preoperative glucose control was noted in a prospective study evaluating the impact of preinduction hyperglycaemia and BMI in the perioperative management of cardiac surgical patients. A preinduction glucose above 110 mg dl21 was associated with a higher perioperative insulin consumption than in patients with a preinduction BG of 110 mg dl21 or less. When the glucose was above 110 mg dl21, insulin requirements were not different between patients with or without a history of diabetes. Intraoperative insulin management was more difcult in patients with a higher preinduction glucose, requiring more adjustments in the rate of insulin infusion and more periods of BG levels below 80 mg dl21 or above 200 mg dl21.18

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Interventions other than medications have also been reported to be useful in controlling blood sugar levels. Studies have demonstrated the benecial effects of CPAP on hyperglycaemia in diabetic patients with OSA. After a mean treatment period of 83 days, 1 h postprandial glucose values and elevated levels of HbA1c were signicantly reduced in patients using CPAP. Additionally, patients who were noted to have elevated levels of HbA1c (.7%) had a signicant reduction in those levels as well.10 In support of these ndings, CPAP treatments increased insulin sensitivity signicantly in non-diabetic patients with OSA after two nights of treatment and benecial effects were preserved even after 3 months of CPAP therapy.45 CPAP when used regularly and with effective pressures improved insulin sensitivity over longer time periods (mean 2.9 yr).45 Despite the knowledge of the adverse effects of hyperglycaemia, the question remains as to how tightly glucose levels should be controlled in the perioperative period. In this past decade, studies had been conducted to support tight glucose control (TGC). In 2001, a landmark randomized controlled trial on 1500 surgical ICU patients showed that intense insulin therapy (IIT) (target BG, 80 110 mg dl21) reduced in-hospital mortality by 34% compared with standard therapy (target BG, 180 200 mg dl21) and signicantly decreased morbidity, including bloodstream infections, acute renal failure, red-cell transfusions, and critical-illness polyneuropathy.40 Recently, however, an evidence-based review on perioperative glucose control reported that the current criteria for TGC should be interpreted with care, since the major studies in favour of TGC were in surgical intensive care settings and might not apply to other settings. In general, careful and stepwise implementation of IIT protocols to maintain BG ,150 mg dl21 and reduce BG variability can be both safe and effective in reducing adverse events. There are subpopulations that might benet from TGC, but until those patients are identied IIT should be avoided in most surgical patients.39

Conclusions
As the obese populations of many countries continue to grow so will the frequency of their presentation for surgery. With proper training and education, good care for these patients, while perhaps more complex, is obtainable. While many physicians in practice today see a large number of obese patients, they often do not fully recognize all the implications of obesity and its related disease states, OSA and diabetes. It is through this increased awareness that the care of obese patients can be improved.
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References
1 Abdelmalak B, Makary L, Hoban J, et al. Dexmedetomedine as a sole sedative for awake intubation in management of critical airway. J Clin Anesth 2006; 19: 370 37 2 Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth 2000; 85: 91 108 3 Ahlering TE, Eichel L, Edwards R, et al. Impact of obesity on clinical outcomes in robotic prostatectomy. Urology 2005; 65: 740 4 4 Ahmed S, Nagle A, McCarthy RJ. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg 2008; 107: 138 43 5 Ahmed Z, Lockhart CH, Weiner M, et al. Advances in diabetic management: implications for anesthesia. Anesth Analg 2005; 100: 6669 6 American Heart Association. Metabolic syndrome: Information for professionals [Internet]. Dallas, TX: American Heart Association Inc. [updated February 5, 2009; cited August 21, 2009]. Available from: http://www.americanheart.org/ 7 Angelini G, Ketzler JT, Coursin DB. Perioperative care of diabetic patients. American Society of Anesthesiologists Inc. 2001; 2: 1 10 8 Aronson D, Rayeld EJ, Chesbro JH. Mechanisms determining course and outcome of diabetic patients who have had acute myocardial infarction. Ann Intern Med 1997; 126: 296 306 9 ASA Task Force on Perioperative Management of Patients with OSA. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology 2006; 104: 1081 93 10 Babu AR, Herdegen J, Fogelfeld L, et al. Type 2 diabetes, glycemia control and continuous positive airway pressure in OSA. Arch Intern Med 2005; 165: 447 52 11 Bagry HS, Raghavendran S, Carli F. Metabolic syndrome and insulin resistanceperioperative considerations. Anesthesiology 2008; 108: 506 23 12 Bakris GL, Weir MR. Angiotensin-converting enzyme inhibitorassociated elevations in serum creatinine: is this a cause for concern? Arch Intern Med 2000; 160: 685 93 13 Benumof JL. Obesity, sleep apnea, the airway and anesthesia. Curr Opin Anaesthesiol 2004; 17: 21 30 14 Bolden N, Smith CE, Auckley D. Avoiding adverse outcomes in patient with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol. J Clin Anesth 2009; 21: 286 93 15 Brodsky JB, Lemmens HJM. Regional anesthesia and obesity. Obes Surg 2007; 17: 1146 9 16 Buchwald H, Estok R, Fahrbach K. Weight and type 2 diabetes after bariatric surgery: systemic review and meta-analysis. Am J Med 2009; 122: 248 56

Ambulatory patients
The pre- and perioperative anaesthetic considerations for diabetic patients in day-case surgery do not differ signicantly from inpatient procedures with the exception that in almost all ambulatory procedures, food intake is resumed fairly quickly after surgery. Importantly, this can allow for the timely resumption of routine diabetic medications. Medications should not, however, be resumed at normal levels until the patient has recovered sufciently to maintain good oral intake and, while typically true for any patient, special consideration for admission after surgery should be given to patients who suffer from severe diabetes and have difculty eating. In general, however, with the exception of patients who have signicant autonomic dysfunction and tend to manifest haemodynamic instability, outpatient surgery can be safely considered for most diabetics.44

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17 Cadli P, Guenoun T, Journois D, et al. Pressure-controlled ventilation improves oxygenation during laparoscopic obesity surgery compared with volume-controlled ventilation. Br J Anaesth 2008; 100: 70916 18 Cammu G, Lecomte P Casselman F. Preinductive glycemia and , body mass index are important predictors of perioperative insulin management in patients undergoing cardiac surgery. J Clin Anesth 2006; 19: 37 43 19 Chung F, Ward B, Ho J, et al. Perioperative identication of sleep apnea risk in elective surgical patients, using the Berlin questionnaire. J Clin Anesth 2006; 19: 130 4 20 Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg 2008; 107: 154363 21 Cummings S, Apovian CM, Khaodhiar L. Obesity surgeryevidence for diabetes prevention management. J Am Diet Assoc 2008; 108: 40 4 22 Doyle JD, Zura A, Ramachandran M, et al. Airway management in a 980-lb patient: use of Aintree intubation catheter. J Clin Anesth 2006; 19: 367 9 23 Emeking FK. Regional anesthesia in a patient with pre-existing neurologic decit. In: Atlee JL, ed. Complications in Anesthesia. Philadelphia: WB Saunders, 1999; 2425 24 Erickson JM, Louis DS, Naughton NN. Symptomatic phrenic nerve palsy after supraclavicular block in obese man. Orthopedics 2009; 32: 368 25 Gali B, Whalen FX, Gay PC, et al. Identication of patients at risk for postoperative respiratory complications using a preoperative OSA screening tool and postanesthesia care assessment. Anesthesiology 2009; 110: 86977 26 Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339: 489 97 27 Grossman E, Messerli HF. Diabetic and hypertensive heart disease. Ann Intern Med 1996; 125: 304 10 28 Hans P, Vanthuyne A, Dewendre PY, et al. Blood glucose concentration prole after 10 mg dexamethasone in a non diabetic and type 2 diabetic patients undergoing abdominal surgery. Br J Anaesth 2006; 97: 164 70 29 Hirch IB, McGill JB, Cryer PF. Perioperative management of surgical patients with diabetes mellitus. Anesthesiology 1991; 74: 34659 30 Hofer RE, Sprung J, Sarr MG, et al. Anesthesia for patients with morbid obesity using dexmedetomidine without narcotics. Can J Anaesth 2005; 52: 176 80 31 Hofer RE, Tetsuya K, Decker PA, et al. Obesity as a risk factor for unanticipated admissions after ambulatory surgery. Mayo Clin Proc 2008; 83: 908 13 32 Huncke T, Chan J, Doyle W, et al. The use of continuous positive airway pressure during an awake craniotomy in a patient with OSA. J Clin Anesth 2008; 20: 297 9 33 Jastak JT, Peskin RM. Major morbidity or mortality from ofce anesthetic proceduresa closed-claim analysis of 13 cases. Anesth Prog 1991; 38: 39 44 34 Joshi N, Caputo GM, Weitekamp MR, et al. Infections in patients with diabetes mellitus. N Engl J Med 1999; 341: 1906 12 35 Kaye AD, Kucera IJ. Intravascular uids and electrolyte physiology. In: Miller RD, Fleisher LA, Johns RA, et al., eds. Millers Anesthesia, 6th Edn, Vol. 2. Philadelphia: Churchill Livingstone Elsevier; 177681 36 La Colla L, Albertin A, La Colla G. Faster wash-out and recovery for desurane vs sevourane in morbidly obese patients when no sevourane is used. Br J Anaesth 2007; 99: 353 8

37 Langeron O, Masso E, Huraux C. Prediction of difcult mask ventilation. Anesthesiology 2000; 92: 1229 36 38 Levin PD, Weissman C. Obesity metabolic syndrome and the surgical patient. Med Clin N Am 2009; 93: 1049 63 39 Lipshutz AK, Gropper MA. Perioperative glycemic control. Anesthesiology 2009; 110: 204 6 40 London MJ. Quo vadis, perioperative beta blockade? Are you POISEdon the brink? Anesth Analg 2009; 106: 1025 30 41 Mantouvalou M, Fraggedakis G, Karabetian J, et al. Morbid obesity: sevourane or desurane is the volatile anesthetic of choice for maintenance of anesthesia? J Clin Anesth 2005; 17: 413 9 42 Nielsen KC, Guller U, Steele SM, et al. Inuence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9038 blocks. Anesthesiology 2005; 102: 181 7 43 Pan W, Hindler K, Lee VV, et al. Obesity in diabetic patients undergoing coronary artery bypass graft surgery is associated with increased postoperative morbidity. Anesthesiology 2006; 104: 441 7 44 Roizen MF, Fleisher LA. Anesthetic implications of concurrent diseases. In: Miller RD, Fleisher LA, Johns RA, et al., eds. Millers Anesthesia, 6th Edn, Vol. 1. Philadelphia: Churchill Livingstone Elsevier; 1019 27 45 Schahin SP, Nechanitzky T, Dittel C. Long-term improvement of insulin sensitivity during CPAP therapy in the obstructive sleep apnea syndrome. Med Sci Monit 2008; 14: CR117 21 46 Schwartz JJ, Rosenbaum SH. Anesthesia and the endocrine system. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical Anesthesia, 5th Edn. Philadelphia: Lippincott Williams and Wilkins; 1144 51 47 Seicean S, Kirchner HL, Gottlieb DJ, et al. Sleep disordered breathing and impaired glucose metabolism in normal weight and overweight/obese individuals. Diabetes Care 2008; 31: 1001 6 48 Shibutani K, Inchiosa MA, Sawada K, et al. Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients. Anesthesiology 2004; 101: 603 13 49 Isono S. Obstructive sleep apnea of obese adults. Anesthesiology 2009; 110: 908 21 50 Sifri ZC, Kim H, Lavery R, et al. The impact of obesity on the outcome of emergency intubation in trauma patients. J Trauma 2008; 65: 396 400 51 Sinha AC. Some anesthetic aspects of morbid obesity. Curr Opin Anaesthesiol 2009; 22: 442 6 52 Sollazzi L, Modesti C, Vitale F, et al. Preinductive use of clonidine and ketamine improves recovery and reduces postoperative pain after bariatric surgery. Surg Obes Relat Dis 2008; 5: 67 71 53 Tantawy H. Nutritional diseases and inborn errors of metabolism. In: Hines RL, Marschall KE, eds. Stoeltings Anesthesia and Co-existing Disease. Philadelphia, PA: Churchill Livingstone, 2008; 297 322 54 Tuttnauer A, Levin PD, Chir B. Diabetes mellitus and anesthesia. Anesthesiol Clin 2006; 24: 579 97 55 Utzschneider KM, Carr DB, Hull RL, et al. Impact of intra abdominal fat and age on insulin sensitivity and beta cell function. Diabetes 2004; 53: 2867 72 56 Watkins BM, Montgomery KF, Ahroni JH, et al. Adjustable gastric banding in an ambulatory surgery center. Obes Surg 2005; 15: 1045 9 57 World Health Organisation Fact Sheet on Diabetes. November 2008, No. 312 58 Zoremba M, Aust H, Eberhart L, et al. Comparison between intubation and the laryngeal mask airway in moderately obese adults. Acta Anaesthesiol Scand 2009; 53: 436 42

Downloaded from http://bja.oxfordjournals.org at Francis A Countway Library of Medicine on May 9, 2010

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