MANAGEMENT OF ANAESTHESIA IN AN OBESE PATIENT

MODERATOR DR.A. S.BHATTACHARYA ASST. PROFF. PRESENTER DR. NITA HAZARIKA P.G. STUDT. DEPT.OF ANAESTHESIOLOGY AND CRITICAL CARE, GMCH DATED : 08-11-08

INTRODUCTION
While undernutrition and malnutrition are problems of the developing country , obesity is the bane of the developed country.Modern lifestyles and better standards of living have in a way been contributory in making obesity a global health problem whose prevalance is increasing day by day. Data shows that in UK , 22.9% of men and 25.4% of women are obese.In US the prevalance ranges from 33 36%.India is

PATHOPHYSIOLOGY
In simple terms , obesity is a condition of excessive body fat.The term is derived from the Latin word obesus which means fattened by eating.

When the net energy intake is in excess of the net energy expenditure over a prolonged period of time , the excess energy gets laid down in various parts of the body as fat.

Our brain controls appetite by means of signals triggered by dietary breakdown products and by autonomic signals produced by disturbance of the stomach and the intestine.Multiple signals are generated and processed by interactions between neuronal networks and neurotransmitters ,most important being CCK8,which acts at gut and the brain.It induces satiation ,is released at the beginning of a meal and releases insulin .Insulin

DISTRIBUTION OF FAT AND OBESITY INDUCED MORBIDITY Fat in the various parts of the body has different metabolic effects and is associated with different morbidity.Fat distributed primarily on the buttocks and thighs (gynaecoid) is metabolically relatively inert and is not associated with excess morbidity.While fat in a primarily truncal distribution (android, with a waist : hip circumference ratio of 1 in men or 0.8 in women) is associated with a higher oxygen consumption and a higher incidence of morbidities.

AETIOLOGY OF OBESITY
Etiology of obesity is complex and multifactorial.The following have been implicated-

. Genetic predisposition- obesity is found

in Prader Willi syndrome,Laurence- Moon -Biedle syndrome,Ahlstron,Cohen and Carpenter syndrome . hypothyroidim,insulinoma,craniopharyngio ma

. Medical disorders cushing's synd ,

. Drugs corticosteroids , antidepressants , . Energy imbalance between intake and . Psychosocial factors . Ethnic influences Africans , Asians ,and . Socioeconomic factors obesity is seen
more in poor strata in developed world and in rich in developing world. Mexicans with central distribution of fat are at higher risk expenditure. antihistaminics etc.

and other disorders involving the hypothalamus.

SOME DEFINITIONS
OVERWEIGHT : Excess of total body weight including all components ( muscle,bone,water and fat ) OBESITY : Metabolic disease in which adipose tissue comprises a greater than normal proportion of body tissue and amount of fat tissue is increased beyond a point compatible with physical and mental health and normal life expectancy

METABOLIC SYNDROME : The triad of obesity , hypertension and type diabetes mallitus is known as metabolic syndrome

MEASUREMENT OF OBESITY
Accurate measurement of body fat content is difficult as it requires sophisticated techniques such as CT scan or MRI and electrical impedence studies etc. In our clinical practice ,the various approaches that we use to quantify obesity includes . Anthropometry ( skin fold thickness ) . Densiometry ( underwater weighing ) . Body Mass Index (BMI ) . Ideal body weight

IDEAL BODY WEIGHT Ideal body weight (in kg) = height in cm x where x = 100 for adult males and its 105 for adult females a person is said to be obese when his or her actual body weight exceeds ideal body weight by more than 20%

RELATIVE WEIGHT it is the ratio of the actual and ideal body weight

BODY MASS INDEX . Most commonly used index . Also known as Quetlet index BMI = Body wt (in kg)/height (m)

CLASSIFICATION OF OBESITY ON BMI BASIS BMI CAT. Normal 25 Overweight 30 Obese 35 Morbidly obese BMI 20 25 30 35

CLASSIFICATION OF OBESITY AND HEALTH RISK

BMI (kg/m) HEALTH RISK

Normal Average Overweight Increased Obesity class I Moderate Obesity class II

18.5 24.9 25.0 29.9 30.0 34.9 35.0 39.9

PHYSIOLOGICAL CHANGES ASSOCIATED WITH OBESITY A.CARDIOVASCULAR SYSTEM

The cardiac pathology arises from adaptation to excess body mass and increased metabolic demands along with fatty infiltration of the heart.

INCREASED BLOOD VOLUME :Each kilogram of fat contains 3000 meters of blood vessels.increased activity of the renin angiotensin system also plays a role in intravascular volume expansion

volume on weight basis is less than normal ( may reach 45ml/kg compared to 70ml/kg in normal adults ) LEFT VENTRICULAR LOAD : It is increased because of intravascular volume and excess adipose tissue and muscle tissue.This leads to an increase in stroke volume and cardiac work leading to further increase in left ventricular load,dilatation and compensatory left ventricular hypertrophy which in turn decreases left ventricular compliance and increases left ventricular filling pressure

RIGHT VENTRICULAR LOAD : Right ventricular filling pressure increases .Increase in pulmonary artery pressure due to left ventricular failure and pulmonary vasoconstriction may lead to right ventricular hypertrophy and dilatation. SYSTEMIC HYPERTENSION : Mild to moderate systemic hypertension is present in 50 60% of obese patients while severe hypertension is present in 5 10%.the causes are- increased intravascular volume - increased cardiac output

- hyperinsulinemia leading to activation of

sympathetic nervous system and causing sod.retention

PULMONARY HYPERTENTION : It is common in obese patients and is due to - pulmonary vasoconstriction caused by hypoxemia , hypercarbia or both - left ventricular myocardial dysfunction with increased left ventricular filling pressure - increased pulmonary blood volume

causing further increase in intravascular volume.

- polycythemia secondary to hypoxemia

ISCHAEMIC HEART DISEASE : obesity is an independent risk factor for the development of ischaemic heart disease and is more common in obese individuals with central distribution of fat .Other factors such as systemic hypertension ,diabetes mallitus and hypercholesterolemia which are common in obese individuals compound the likely development of ischaemic heart disease.

CARDIAC ARRYTHMIAS : Frequent in obese and can lead to sudden death.The causes are multifactorial . Myocardial hypertrophy and hypoxemia . Coronary artery disease . Increased plasma catecholamine concentration . Fatty infiltration of pacing and conduction system . Sleep apnoea syndrome . Hypokalemia due to diuretic use

Blood vol CO SV LV distention

Metabolic demand

Eccentric LVH LV systolic & diastolic dysfunction LVF

B.RESPIRATORY SYSTEM
LUNG VOLUMES : Obesity imposes a restrictive ventilation defect because of the weight added to the thoracic cage and the abdominal weight impeding motion of the diaphragm,specially with the assumption of the supine position.This results in decreased functional residual capacity (FRC ),expiratory reserve volume (ERV),vital capacity (VC) and total lung capacity (TLC) with the FRC declining exponentially with increasing BMI.

The FRC may decrease to the point that small airway closure occurs with resulting ventilation to perfusion mismatching,right to left shunting,and arterial hypoxemia. Anaesthesia accentuates these changes such that a 50% decrease in FRC occurs in obese anaesthetised patients as compared to a 20% decrease in non obese individuals.

This decrease in FRC impairs the ability of the obese patients to tolerate periods of apnoea such as during direct laryngoscopy and tracheal intubation.In fact the obese patients are likely to experience arterial oxygen desaturation following induction of anaesthesia inspite of pre-oxygenation reflecting decrease oxygen reservoir and an increased oxygen consumption. FRC in anaesthetised obese patients can be increased by- ventilation using tidal volumes of 1520ml/kg - large manually performed lung

GAS EXCHANGE Morbidly obese patients usually have a modest decrease in arterial oxygenation and increase in the alveolar to arterial oxygen difference due to ventilation to perfusion mismatching.But arterial oxygenation may deteriorate markedly on induction of anaesthesia and increased concentration of delivered oxygen is required to maintain an acceptable PaO2. But the

PULMONARY COMPLIANCE AND RESISTANCE Pulmonary compliance in morbidly obese patients may be decreased to 35% of the predicted value.This is due to- adiposity in and around the ribs,diaphragm and abdomen - smaller lung volumes - limited movements of the ribs caused by thoracic kyphosis and lumber hyperlordosis from excessive abdominal fat content. This decrease in pulmonary compliance and increase in resistance leads to rapid and shallow

breathing ,increased workload on the respiratory muscles and decreased efficiency of breathing. WORK OF BREATHING Increased metabolic activity in obese patients leads to increase in oxygen consumption and carbon dioxide production .So in order to maintain normocapnia there is increased minute ventilation which results in increased oxygen cost i.e.work of breathing.Obese patients typically breathe rapidly and

OBSTRUCTIVE SLEEP APNOEA Obstructive sleep apnoea is a disorder in which partial or complete obstruction of the airway during sleep causes loud snoring ,oxyhaemoglobin desaturation and frequent arousals.As a result affected persons have unrestful sleep and excessive day time sleepiness.The disorder is often associated with hypertension,impotence and emotional problems. 2% of women and 4% of men over the age of 50 yrs have symptomatic obstructive sleep

apnoea PATHOPHYSIOLOGY There is peripharyngeal infiltration of fat and /or increased size of the uvula or the soft palate or the tongue in obese patients.Some patients may have a diminutive or receding jaw that results in an insufficient room for the tongue. These anatomic abnormalities decreases the cross sectional area of the upper airways.Decreased airway muscle tone during sleep and the pull of gravity in supine position further decreases airway size thereby impeding

airflow during respiraton. Initially partial obstruction leads to snoring. As tissues collapse further,the airway may become completely obstructed,patient struggles to breathe and is aroused from sleep. With each arousal event ,the muscle tone of the tongue and the airway tissues increase.This alleviates the obstruction and terminate the apnoeic episode.Soon the patient falls asleep again and the

MANIFESTATIONS . Frequent episodes of obstructive apnoea( 10 secs or longer occuring five times or more per hour during sleep )or hypopnoea (50% decrease in airflow or a decrease sufficient to lower arterial oxygen saturation by 4%) . Snoring . Daytime somnolence most likely reflecting sleep fragmentation at night (memory and concentration deficits,motor vehicle accidents)

PHYSIOLOGIC CHANGES . Arterial hypoxemia . Polycythemia . Hypercarbia . Systemic hypertension (IHD,CVA) . Pulmonary hypertension (RVF) RISK FACTORS . Male gender . Middle age . Obesity (BMI >30)

. Alcohol (evening ingestion) . Drug induced sleep

DIAGNOSIS It is done by Nocturnal polysomnography in sleep laboratories. ANAESTHETIC IMPLICATIONS . These patients are exquisitely sensitive to all the CNS depressant drugs. . Difficult tracheal intubation . Post operative pain management may be difficult in these patients

Nasal CPAP may allow the use of systemic analgesics and reduce the haemodynamic changes.it acts as a Pneumatic splint to hold the upper airways open during sleep.

OBESITY HYPOVENTILATION SYNDROME It is the long term consequence of obstructive sleep apnoea. There is alterations in the control of breathing leading to central apnoeic events (apnoea without respiratory effort).This leads to progressive desensitisation of respiratory centers to nocturnal hypercapnia eventually leading to type 2 respiratory failure,with increasing reliance on hypoxic drive for ventilation.At its extreme,it culminates in the pickwickian syndrome ,which is characterised by

obesity,daytime hypersomnolence,arterial hypoxemia,polycythemia,hypercarbia,resp iratory acidosis,pulmonary hypertension and right ventricular failure.

ENDOCRINOLOGICAL CHANGES

. It is an independent risk factor type 2 diabetes. . Increased cortisol production and metabolism is found in obesity. . Incidence of hypothyroidism and infertility is more

GASTROINTESTINAL SYSTEM . Higher risk of aspiration of gastric

contents and development of pneumonia due to- raised intra abdominal pressure - high volume(>25ml) and low pH (<2.5)of gastric contents - delayed gastric emptying - high incidence of hiatus hernia and gastro esophageal reflux disease . Fatty infiltration of the liver and gall stone incidence increases

such as rectal,prostate,endometrial,gall bladder and breast.

. Increased incidence of the malignancies

MUSCULOSKELETAL SYSTEM
. Increased incidence of osteoarthritis of weight bearing joints and back pain . Significant increase in the incidence of wound infection

THROMBOEMBOLIC DISEASE . Two fold increase in the incidence of

venous thrombosis due to - reduced mobility leads to venous stasis - main circulating anticoagulant -antithrombin III is diminished in morbidly obese - decreased fibrinolytic activity in obese

INFLUENCE OF OBESITY ON DRUG HANDLING AND DOSING

Obesity alters the pharmacokinetic as well as the pharmacodynamic profile of a drug. VOLUME OF DISTRIBUTION : the distribution of drug changes during obesity and is due to- smaller than normal fraction of total body water - greater than normal adipose tissue content - increased lean body mass and

output - increased concentration of blood constituents such as free fatty acids,triglycrides, cholesterol ,a1 acid glycoprotein.

- increased blood volume and cardiac

PLASMA PROTEIN BINDING : No significant change is seen DRUG CLEARANCE : Renal clearance is increased due to increased renal blood flow ,increased GFR and tubular secretion. drug metabolism in liver may be decreased as obesity decreases hepatic blood flow .

As a general rule,the hydrophilic drugs have relatively similar absolute volume of distribution,elimination half life and metabolic clearance in the obese and the non obese,while the fat soluble drugs have an increased volume of distribution,more selective distribution to fat stores and a longer elimination half life and therefore prolonged effect in the obese compared to the non obese.

INHALATIONAL ANAESTHETICS . Obese patients metabolise all halogenated anaesthetics to a greater extent . Halothane and enflurane are metabolised more leading to increased levels of serum and urinary fluoride concentration . Sevoflurane produces slight increase in fluoride concentration after prolonged exposure . No change after isoflurane and desflurane anaesthesia.so they

because of high demand for oxygen.

. Nitrous oxide has limited usefulness

INTRAVENOUS INDUCTION AGENTS . Thiopentone is highly lipophilic and has increased volume of distribution and elimination half life but clearance remains unchanged.So larger absolute dose but smaller dose per unit weight is suggested. . Propofol is also highly lipophilic and the absolute dose should be increased.

NEUROMUSCULAR BLOCKING AGENTS . The absolute dose of succinyl choline should be high as there is increased plasma pseudo- cholinesterase level . Recovery time is prolonged in case of vecuronium due to impaired hepatic clearance . Obesity does not alter the elimination of atracurium.so atracurium in same dose per total body weight is the nm blocking agent of choice . Duration of action of rocuronium is

drug, so total dose per kg body weight is similar. OPIOIDS . Kinetics of fentanyl,alfentanyl and sufentanyl are quite unpredictable in obese patients . The pharmcokinetic of remifentanyl is similar in obese and lean patients.This characterstic of remifentanyl suggests it to be the analgesic of choice in obese patients LOCAL ANAESTHETICS . Intra venous lignocaine can be given

.pancuronium is a low lipid soluble

according to total body weight . The dose requirements of local anaesthetics for intrathecal and extradural anaesthesia in obese patients are reduced by 20 25% SEDATIVES/HYPNOTICS . Midazolam and diazepam shows increased volume of distribution and prolonged elimination half life,so increase in absolute dose requirement .Duration of action is prolonged specially after infusion

ANAESTHETIC IMPLICATIONS
Obese patients can undergo surgery for a variety of causes emergency/routine as well as surgeries for the treatment of obesity itself.the altered physiological state in these group of patients can make anaesthetising them a really challenging task. PRE-OPERATIVE ASSESMENT . A thorough clinical examination with excellent relevant history looking for hypertension,signs of

cardiac failure (increase in JVP,added sounds,pulmonary crackles,hepatojugular reflex and peripheral oedema) and IHD. . A through assessment of the respiratory system for OSA. . Special emphasis on respiratory and CV system along with renal ,GIT (h/o GERD )and hepatic systems . Reassurance to the patients while doing PAC as these group of patients often suffer from depression,hidden anxiety and fear

. Importance of early ambulation and physiotherapy should be emphasized on . Drug and treatment history should be thorough and in detail . Careful assesment of the intubating conditions should be made including Mallampatti grading,assesment of the mobility of the head ,neck and jaw,dental status and oropharyngeal inspection . If difficult intubation is anticipated ,awake intubation must

. Assessment of veins for placing infusion . Assessment of signs of DVT

. Assessment of feet and back for sores and ulcers If the patients are visited well in advance then, . Advice weight loss by diet control and exercise . Cessation of smoking is advised and chest physiotherapy is initiated preoperatively

PRE-OPERATIVE INVESTIGATIONS . Hb%,BT,CT,Blood sugar (fasting and post prandial) . Liver and Renal function tests . X-rays of the neck and chest . ECG and Echocardiography(coronary angiography,scintigraphy studies if required) . ABG in sitting and supine position . PFT in sitting and supine position . Lipid profile . Thyroid function test and Adrenal

be ensured and checked.

An informed and written consent must

PRE-OPERATIVE INSTRUCTIONS AND PRE-MEDICATIONS . Weight to be recorded . Narcotics and sedatives are best avoided . Intramuscular and subcutaneous injections are best avoided because of unpredictable absorption . Antacid prophylaxis :H2 blockers given at night

and two hours before surgery and metoclopromide given 12hrs and 2hrs before surgery . To continue medications for hypertension and diabetes mallitus . Oral antacid may be given . DVT prophylaxis should be initiated . Prophylactic antibiotics . Patients with diagnosed OSA on treatment with CPAP should take their equipment to the OT for post operative use

. Early establishment of a peripheral venous access or a central venous line POSITIONING . Two operating tables may be joined and extra padding must be used.lateral wedge or tilt may be used. . Trendelenberg and prone positions should preferably be avoided . Appropriate man power to shift patients are necessary

MONITORING . Invasive blood pressure in all but most minor surgeries . ECG,Pulse oximetry, Capnography, Temperature probes . Neuromuscular monitoring is essential . Others based on indication and availability

GENERAL PRINCIPLES OF ANAESTHESIA IN OBESE

REGIONAL technique to be used whenever feasible. GENERAL ANAESTHESIA . Combined regional and GA is preferable to GA alone . Ideally two anaesthesiologists should be present

POTENTIAL PROBLEMS DURING GA . Maintenance of an adequate airway, . Risks of regurgitation and aspiration of gastric contents . Spontaneous respiration under GA leads to both hypoxia and hypercarbia . Limited range of head ,neck and jaw movements . Short ,fat neck

AIRWAY MANAGEMENT IN OBESE

. Other than for the briefest of GA in selected patients,endotracheal intubation should be used in all obese patients . Anterior displacement of the mandible is less helpful to relieve airway obstruction.Mask ventilation can be difficult and may require an assistant . There seems to be no correlation between BMI and difficult laryngoscopy . Patients may be pre oxygenated in 25 degree propped up position to achieve higher oxygen tensions

prepared with a full range of aids for tracheal intubation such as short handled laryngoscope,polio blade,McCoy laryngoscope , gum elastic bougies, standard and intubating laryngeal mask airway. . Equipment for emergency cricothyrotomy should be kept ready and a capnograph available to confirm correct placement of the endotracheal tube.

. The anaesthesiologist should be

. If no difficulty in intubating conditions is anticipated,then in majority of the patients a rapid sequence intravenous induction with thiopentone(4mg/kg,max. 500 mg) or propofol ; and succinylcholine (1mg/kg of IBW or even TBW ;120 -140 mg appear satisfactory) combined with cricoid pressure is a safe method of securing the airway. . In difficult cases the choice of technique and equipment is a personal one.An awake fibre optic approach for tracheal intubation

correct placement of the ETT. . Bullard laryngoscope is an alternative in trained hands. . The intubating LMA has been shown to be effective airway device. . The proseal LMA can also be used. After intubation the patient should be ventilated with 100% oxygen and tidal volume of 12-15ml/kg .

. Capnography is essential to confirm the

alveolar recruitment is an effective means of improving intra operative oxygenation.the ventilatory strategy consists of- sustained lung insufflations - a high inspired oxygen fraction - large tidal volumes - positive end expiratory pressure - sustained inspiratory pressure of atleast 40 cm of water to fully reverse anaesthesia induced atelectesis

FLUID MANAGEMENT The total body water is reduced in obese patients from 65% to 40%.there is increased chance of fluid loss due to - increased sweating - enhanced bleeding - prolonged surgery But as most of these patients are in cardiac compromised state so preferably a CVP line or a Pulmonary artery catheter should be used to guide the replacement volumes.

EXTUBATION
Extubation should be done only when patients are fully awake with adequate cough reflex and have complete reversal of neuromuscular blockage. During post extubation period ,aspiration of gastric contents and post extubation pulmonary oedema may occur.

POST OPERATIVE CARE

. Post operatively the patients should be transferred to a PACU. . Transportation should be done in semi recumbent position . Supplemental oxygen should be provided and shivering avoided. . CPAP may be initiated post operatively in patients with OSA or after upper abdominal surgery . Post operative mechanical ventilation may be required in patients with coexisting cardiac

disease,hypercapnia,fever,infection,elderly , anxious and un cooperative patients. . Supplemental oxygen may be required for about 3 to 4 days post operatively. . Early ambulation,DVT prophylaxis,incentive spirometry and physiotherapy should be initiated. . Frequent change of position is important and patients should be nursed at a 30 to 45 degree propped up position

POST OPERATIVE ANALGESIA . Opioid induced ventilatory depression is a concern and the intra muscular route is best avoided because of unpredictable absorption. . It can be best provided with an indwelling catheter placed earlier for regional technique as it reduces the amount of opioid required. . Intravenous PCA is also effective in relieving pain and the dose should be based on IBW. . Analgesia can be supplemented

REGIONAL ANAESTHESIA
. Always a preferred option . The advantages are -airway intubation difficulties are avoided - risk of gastric aspiration is reduced - more cardio vascular stability - need for neuromuscular blockers and potential problems with their reversal are avoided - patients remain awake and can communicate

- lesser post operative respiratory complication - the incidence of PDPH is lower - early ambulation and lesser thrombo embolic complication DIFFICULTIES IN REGIONAL ANAESTHESIA - excess adipose tissues conceal bony landmarks - requirement of longer than usual spinal and epidural needles

puncture is 2-8 times higher

- incidence of inadverdant dural - local anaesthetic requirement is

reduced - high blocks are common - epidural anaesthetic drugs tend not to fix quickly in the obese with a tendency for continued cephalad spread

SPECIAL CIRCUMSTANCES A.PAEDIATRIC POPULATION

- Children heavier than 97th percentile weight have problems associated with their obesity - i.v. access is often a common problem - OSA is a frequent finding in them as in Prader-Willi syndrome

B.OBSTETRICS AND OBESITY

- all attending complications are

pregnancy increases the risk of late fetal death - regional anaesthesia is always a better choice - siting an epidural catheter during labour is a better option - extra long touhy needle or spinal needle may be needed for central neuraxial blocks - over all the sitting position is preferred for central neuraxial blocks - local anaesthetic requirement

- higher maternal weight before

C.BARIATRIC SURGERY
- Weight reductive surgeries - indications : BMI > 40kg/m BMI > 35kg/m with comorbidities dietary attempts have been ineffective - combination of thoracic epidural anaesthesia with general anaesthesia has been described as the ideal technique

D.OBESITY AND CRITICAL CARE

- Despite the widely held belief that outcome is poor for morbidly obese patients admitted into the ICU ,obesity is not included as a variable in the development of the APACHE II and III scoring systems - during ventilation ,tidal volume based on the IBW should be used initially and then adjusted according to inflation pressure and ABG analysis - nutritional support - weaning may be difficult due to:

. Increased work of breathing . Decreased lung volumes . v/q mismatch

.high oxygen requirement

CONCLUSION
Obese patients are not just bigger or heavier patients.Changes in body physiology set them apart from the non obese individuals.They pose tremendous challenges to the anaesthesiologists. But understanding the pathophysiology,anticipating the problems and preventing calamities by a systematic approach will certainly bring down the complication rate.

References :
. Miller's Anesthesia 6th ed . Wylie and Churchill 7th ed . Stoelting Anesthesia & Co-existing disease 4th ed

. Prys-Roberts