anaesthesia for bariatic patients · anaesthesia for bariatic patients mishelle dehaini rn, ccrn,...
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Anaesthesia for Bariatic patients Mishelle Dehaini RN, CCRN, Grad.Cert HPE, Grad.Cert Periop,
CNE, Box Hill Hospital https://goo.gl/images/2TFipP
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Definitions
“Overweight/Obesity is defined as abnormal or
excessive fat accumulation that may impair health” WHO
BMI = weight in kilograms/height in metres (kg/m2)
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Obesity in Australia
▪ Adults
▪ 63% are overweight or obese
▪ >20% are obese – BMI>30
▪ >14% are severely obese – BMI>35
▪ >5% are morbidly obese – BMI>40
▪ Children
▪ 22%are overweight or obese
▪ 75% become morbidly obese adults
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FROM DIABETES AUSTRALIA 2018https://goo.gl/images/gLJa6Z
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Optimal outcomes from surgery
Surgery – shows greater and sustained weight loss than non-surgical interventions
Sleeve Gastrectomy – show best outcomes
Resolution of co-morbidities well documented – ie. T2DM, IHD, Hyperlipidaemia, HT, OSA
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Emotional needs
Negative attitudes from staff common
Respect and care for each patient individually
Interdisciplinary approach
Attention to detail – large gowns, specific equipment in wards now.
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IV access
Can be difficult
Consider use of Ultrasound
Consider longer IV and arterial cannulae
Warm patient pre-operatively to vasodilate vessels
-consider bair huggers and warmed wet towels
Consider CVC access if unable to cannulate patient peripherally
-particularly if patient has any Cardiac dysfunction
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IV Sizes and lengths
https://goo.gl/images/urDiXi
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Airway issues
BMV more difficult
Increased difficult intubation
Increased risk of aspiration
Neck circumference associated with difficult intubation
>40cms – 5% probability
>60 cms -35% probability
Reduced neck and mouth mobility
Decreased FRC, increased metabolic requirements
Earlier onset of hypoxia
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Airway
Optimise patient positioning – use of pillows, RAMP
Use of stubby handle laryngoscope
Consider 2 handed BMV
Consider video laryngoscope
Awake Fibreoptic Intubation maybe an option
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Video Laryngoscopes
https://goo.gl/images/Ug8WBr https://goo.gl/images/Y1cbLN
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Optimise pre-oxygenation
Use of Nasal prongs or nasal catheters to increase inspiratory oxygenation
Use of Optiflow to maximum apneic oxygenation time
Pre-oxygenation
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Optiflow
Photos courtesty Fischer and Paykel Healthcare
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Optiflow
https://goo.gl/images/H9jU1J
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Benefits of Optiflow
https://goo.gl/images/C6omhH
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RAMP pillows
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Optimal positioning for intubation
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Operating tables for Bariatrics
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Positioning
Pt. in Reverse Trendlenberg 30 degrees
Most utilize lithotomy for legs- 1 surgeon stands between usually
Ensure good padding for all limbs – gels are optimal, foam is not as useful
Use of strapping to keep limbs on arm boards
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Reverse Trendelberg benefits
Benefits include:
Reduction in compression of Inferior VC
Reduction in compression of diaphragm
Improves FRC
Blood flow as normalized as possible
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Positioning on OR table
Ensure table can accommodate weight of the morbidly obese
High risk of pressure injuries, skin tears
Use of hover mats
Ensure multiple staff to help with positioning of pt.
Bariatric beds
SCDs, TEDS to reduce VTE- very high risk
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Reverse Trendelenburg positioning
https://images.app.goo.gl/mR1Pnpo3j7zp1iAk6
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Gels
https://images.app.goo.gl/AmBVMZSra3ovPu4W9https://images.app.goo.gl/Vw4ZEtDgS2jpnnNT6ttps://images.app.goo.gl/iLafoZmq9jzCwLsg8
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Warming the patient
Use of Forced Air warmers, mats
? Upper and Lower warming
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Warming the patient
Fluid warming
Temp monitoring - ? IDC
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Monitoring in the OR
NIBP – longer cuff, not bigger – often not well positioned
? Arterial line – necessary for patients with IHD/OSA
- allows ABG analysis and closer BP monitoring
ECG – ensure placement optimal –skin pendulous
- 5 leads for patients with IHD with V5-6 used
SpO2- probe may not fit fingers- consider disposable
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Further monitoring
? Need for BSL monitoring intra-operatively
? Need for Actrapid infusion
?Need for ABGs regularly
Temperature monitoring
Monitoring urine output hourly if poor renal function
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Surgical considerations
May need to proceed to open procedures instead of laparoscopic
Surgical procedures may take longer
This will mean longer anaesthesia time
Greater need for Analgesia and PONV medications post-operatively
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Complications post surgery
Prolonged length of stay
Pressure ulcers
Wound infections
Respiratory complications- Atelectasis, Resp failure
Urinary complications, incontinence
VTE
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Extubation
Optimise patient position – UPRIGHT
Increased risk of aspiration - ?need for NGT to reduce risk- discuss with Surgical team
Low tolerance for failure to extubate – re-intubate ASAP
Consider transfer of pt. directly to ICU/HDU
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References
Carden, J, Perioperative Management of the Bariatric patient, ASPAAN lecture 2015
Duke, J, Anaesthetic secrets 4th Edition, Mosby Elsevier 2011
Nagelhout, J and Elisha, S, Nurse Anesthesia 6th Edition, Elsevier 2018
Rosewarne,F, Obesity & Anaesthesia – implications, considerations & management, Critical visions lecture 2013
Nicholson, P, Management of the Bariatric Patient, Deakin lecture 2015
AUSMED – Considering the Larger Patient in the Operating Theatre- What do you need to be aware of? https://www.ausmed.com/articles/larger-patient-in-the-operating/?utm_source accessed 24/5/2017