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Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of Beirut Medical Center Beirut-Lebanon 2014

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Page 1: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Anesthesia for Bariatric Surgery:What the occasional anesthesiologist should know

Prof Samar Jabbour-KHOURY, MDDayane DAOU, MD

American University of Beirut Medical CenterBeirut-Lebanon

2014

Page 2: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Who am I?

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Page 3: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Unfortunately…

…he died at age 37 due to his obesity!

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Page 4: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Introduction

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Page 5: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Bariatric GREEK word : baros = weight and iatrics = medical treatment

• Greatest health challenge in western countries

• UK: 23% men, 25 % women *

• USA: 200 million people are overweight**

*Rennie KL, Jebb SA. Prevalence of obesity in Great Britain. Obes Rev 2005; 6: 11-2** Baskin MI et al: Prevalence of obesity in the United States. Obes Rev 6:5-7, 2005

Page 6: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Definition • Excess of body fat

• Intake > Expenditure

• Genetic, behavioral, cultural and socioeconomic factors

• Reduces quality of life and life expectancy

• Increased healthcare services demands (> 100 billion dollars)

Page 7: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
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Page 8: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
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Page 9: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Limitations of BMI

• Not a direct measure of adiposity• No account of fat distribution• No account of duration of obesity• Inaccurate at extremes of height• Inaccurate with extremes of lean body mass

(athletes, elderly)

Page 10: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 11: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 12: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Some definitions…• IBW = Ideal Body Weight (kg) = height (cm) – XWhere X = 100 in males and 105 in females

• PBW = predictive body weight (kg):Males PBW = 50 + 0.91(height in cm -152.4)Females PBW = 45.5 + 0.91(height – 152.4)

• LBW = Lean Body Weight = TBW (Total Body Weight) – adipose tissue

Males = 80% of TBWFemales = 75% of TBW

Page 13: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Associated co-morbidities

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Page 14: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Hypertension• Coronary Artery Disease and Stroke• Sudden death (cardiac)• Restrictive lung disease• Obstructive Sleep Apnea, Hypoventilation• Diabetes Mellitus, Insulin Resistance• Cancer (breast, gynecological, gastrointestinal)• Osteoarthritis • Socioeconomical and psychosocial impairment

Page 15: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 16: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Studies : weight loss of 5-10% can improve glucose intolerance, DM2, HTN and DLP!!

Obesity is second only to smoking as a preventable cause of death!!

Page 17: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Treatment

MEDICAL SURGICAL

Sibutramine Restrictive SurgeryOrlistat MalabsorptiveRimonabant Combined

Page 18: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

There are many types of bariatric surgeries…

Page 19: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Vertical Banded Gastroplasty

Page 20: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Adjustable Gastric Band

Page 21: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Sleeve Gastrectomy

Page 22: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Roux-en-Y Gastric Bypass

Page 23: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Sleeve Gastrectomy with duodenal switch

Page 24: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Indications for Surgery

BMI > 40 or between 35 – 40 + comorbidities

Failed non-surgical treatment (6 months)

METABOLIC SYNDROME!

Needing intensive specialist management

Fit for anesthesia and surgery

Committed to the need of long term follow-up

Page 25: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Contraindications

• Unstable CAD• Uncontrolled severe OSA• Uncontrolled psychiatric disorder• Mental retardation (IQ<60)• Inability to understand the surgery• Perceived inability to adhere to postoperative

restrictions• Continued drug abuse• Malignancy with a poor 5-year prognosis

Page 26: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Health benefits of bariatric surgery

Improvement of Comorbidities

Page 27: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Anesthetic management for bariatricsurgery

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Page 28: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

What the anesthesiologist should know preoperatively?

Page 29: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

The pathophysiological changes associated with

obesity

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Page 30: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Respiratory system

• Decreased chest wall compliance• Decreased lung compliance• Decreased FRC decreased ERV

decreased safe apnea time rapid desaturation

CC > FRC• Decreased VC

Page 31: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 32: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Respiratory system (cont’d)

• Increased (A-a) O2 gradient• Increased O2 consumption and CO2

production high energy turnover• Increased V/Q mismatch!!• OSA do polysomnography

preoperatively need for CPAP?

Page 33: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Cardiovascular system

• Increased blood volume fat!• Atherosclerosis and hypercoagulability!• Increased Cardiac Output 20-30 ml/kg• LV wall stress dilatation and hypertrophy

obesity cardiomyopathy• Sympathetic activation HTN• Arrythmias fatty infiltration of conductive

system

Page 34: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 35: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 36: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Gastrointestinal system

• Increased gastric volume (> 25 mL)• Increased acidity (pH< 2.5)• Increased risk of regurgitation and aspiration!!• DM type 2• Metabolic syndrome• Fatty infiltration of liver• Hiatal hernia and GERD!

Page 37: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Musculo-skeletal and other systems

• Oestheoarthritis• Compression fractures• Urinary incontinence• Skin infections (candidiasis) wound• Varicose veins• Lymphoedema• Hypothyroidism

Page 38: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Airway Changes

• Limitation of movement of atlantoaxial joint and

cervical spine upper thoracic and low cervical fat

pads

• Excessive tissue folds in the mouth and pharynx

• Suprasternal, presternal and posterior cervical fat

• Short thick neck

• Very thick submental fat pad

• OSA excessive tissue in lateral pharyngeal walls

Page 39: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 40: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

How does this affect drug dosing??

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Page 41: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Effects on drug distribution

• Reduced total body water• Increased total body fat• Increased lean body mass• Altered protein binding• Increased blood volume• Increased cardiac output

Page 42: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Loading Dose Volume of DistributionMaintenance Dose Clearance

• Increased redistribution increased T1/2• Increased alpha-1-glycoprotein decreased

free drug concentration

Page 43: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Effects on drug elimination

• Hepatic clearance only phase II affected

• Renal clearance increased increased RBF increased GFR (ex: increased dosing of cimetidine and aminoglycosides antibiotics)

Page 44: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Highly lipophilic (BZD, BrB) increased VD dosed on TBW

• Less lipophilic (nondepolarizing muscle relaxants) no change dosed on LBW

• Increased blood volume increased plasma concentrations of rapidly injected IV drugs

• Repeated injections accumulation in fat increased duration of action

Exceptions: Digoxin, Procainamide and Remifentanil highly lipophilic but dosed on LBW

Page 45: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Preoperative assessmentWhat should we focus on??

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Page 46: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Stabilizing comorbidities• Identifying OSA symptoms• Previous surgeries and previous anesthetics• Difficult airway anticipationNECK CIRCUMFERENCE!!:*40 cm 5% risk60 cm 35% risk

BMI per se is not a predictor of a difficult airway!

*Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94:732-6

Page 47: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Routine and specific lab tests

• Glucose, lipid profile• Vitamin deficiencies• Liver function tests• ABG• Lung function tests• Polysomnography initiate CPAP periop• Echocardiography

Page 48: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Preoperative preparation

Avoid Sedatives!

Aspiration prophylaxis PPIs, H2 antagonists

Thromboembolism prophylaxis

Page 49: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Intraoperatively…

Page 50: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

We need:Special equipment

Trained personnel

Anesthetic expertise!!

Page 51: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Positioning

Page 52: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Special table with a bean bag

• Cushion gel pads pressure on gluteal

muscles may lead to rhabdomyolysis!

• Proper positioning:

Modified Lloyd – Davis position = steep

trendelenburg with legs spread apart and

both arms out on arm boards

Page 53: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
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Page 54: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of
Page 55: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

ALWAYS CHECK FOR THE CRITERIA OF A DIFFICULT AIRWAY MANAGEMENT

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Page 56: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Induction

• Head-up position (HELP)

• Stacking

• Good preoxygenation

• Tidal volumes < 13 ml/kg

• PEEP and recruitment maneuvers

AIRWAY

Page 57: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Induction Issues

Regurgitation*

Aspiration

Hypoxemia

* Koolwig J, et al. BMJ Case Rep 2013. doi:10. 1136/bcr-2013-201009

Page 58: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Maintenance • Sevoflurane and Desflurane lower lipid

solubility than Isoflurane• AVOID N2O• Fluids well balanced avoid ATN and volume

overload• Short- acting agents preferred• Consider Dexmedetomidine*

* Bakhamees HS, El-Halafawy YM, Ek-Kerdawy HM, Gouda NM, Altemyatt S. Effects of dexmedetomidine in morbidly obese patients undergoing laparoscopic gastric bypass. Middle East J Anesthesiol 2007; 19:537-51

Page 59: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Profound muscle relaxation needed Vecuronium, Rocuronium and Cisatracurium

• Pneumoperitoneum < 15 mmHg• Cephalad displacement of diaphragm

displace ETT to mainstem bronchus!

• Help with intragastric baloon placement and leak tests!

Page 60: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Emergence

• Semirecumbent and FULLY awake

• Prompt but SAFE

• Observe in OR before transfer

Page 61: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Recovery Room• SKILLED personnel

• Watch ventilation

• Initiate CPAP or BiPAP if needed

• Use multimodal analgesia

Page 62: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Postoperatively…

• Initiate thrombophylaxis• Continue analgesics• Continue CPAP if initiated• Antibioprophylaxis• PPIs and gastric protection• Fluid management

Page 63: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Complications of bariatric surgery

Page 64: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Risk factors for complications

Male Age > 65Open surgeryLong operative timeCardiac and respiratory comorbiditiesDiabetesLow case load

Page 65: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

General complications

InfectionHemorrhageIncisionnal herniaBowel obstructionDeep Venous Thrombosis

Page 66: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Specific complications

Anastomotic leakAnastomotic strictureDumping syndromeNutritional deficiencies:Vitamin B12ThiamineProteinVitamin A

Page 67: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

All Surgeries Gastric Banding Roux-en-Y

Early BleedingInfectionDehydrationPeritonitisBowel obstructionPerforationPneumoniaDVT/PEDeath

Band slippageBand malfunctionInfection at band site

Leak from anastomotic site

Late CholelithiasisCholecystitisPouch dilationGERD/dysphagiaHerniation at the surgical siteNutrionnal issuesFat-soluble vitamin deficiencies (vit B12)

AnorexiaBand slippageBand malfunctionInfection at band site

Small bowel obstructionMarginal ulcersPancreatitisStricture

Page 68: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

In conclusion…

Page 69: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Health benefits

• Sustained loss of 65-80% of excess body weight• Resolution of:DiabetesHypertensionDyslipidemiasOSAGERDLow back pain and joint pain

Page 70: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Obesity and Heart-Rate Variability

What’s HRV?

• Variation in intervals between heartbeats

• Reflects cardiac autonomic modulation

• Influenced in a favorable way by increased

parasympathetic activity

Thayer JF et al. The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. International journal of Cardiology 141 (2010) 122-131

Page 71: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

• Obesity autonomic imbalance increased sympathetic and decreased parasympathetic activities increased workload and stress on the heart decreased HRV risk factor for heart diseases (MI, sudden death…)

• Weight loss restored autonomic balance increase HRV correlates with decreased heart diseases!!!

Nault I. et al. Impact of bariatric surgery-induced weight loss on heart rate variability. Metabolism Clinical and Experimental 56 (2007) 1425-1430

Page 72: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Increased self-esteem and participation in social activities!!

Page 73: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

To Conclude…

Page 74: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Obesity…Is a major healthcare problemIncreases co-morbidities and decreases the

quality of lifeIs a daily challenge for the anesthesiologistsNeeds extra care during the perioperative

period

Advancement in the anesthesia technology has made a dramatic improvement

Page 75: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Bariatric surgery is a beneficial and cost-effective healthcare intervention!

Page 76: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

References• Bucklin B, Anesthesia and Obesity, Chap 44 in Clinical Anesthesia, 7th

edition, LWW 2013 (Ed: Barash, PG)• Sinha AC and David ME, Anesthesia for Bariatric surgery, Miller’s

Anesthesia 7th edition, p.2089-2103• Raveendran et al., Perioperative management of the morbidly obese, IARS

2013 Review Course Lectures• Perioperative management of the morbidly obese patient, published by

The Association of Anaesthetists of Great Britain and Ireland, 21 Portland Place, London W1B 1PY

• Sabharwal A et al, Anesthesia for bariatric surgery, Continuing Education in Anesthesia, Critical Care & Pain, Vol 10 Numb 4. 2010

• Nishiyama T et al. Anesthesia for Bariatric Surgery, OBES SURG (2012) 22:2013-219

Page 77: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

References (cont’d)• Brodsky JB, Lemmens HJ. Brock-Utne JG, Vierra M, Saidman LJ. Morbid Obesity

and tracheal intubation. Anesth Analg 2002; 94:732-6• Karason K, Molgaart H, Wikstrand J, Sjostrom L. Heart rate variability in

obesity and the effect of weight loss. American Journal of Cardiology 1999; 83:1242-7

• Nault I. et al. Impact of bariatric surgery-induced weight loss on heart rate variability. Metabolism Clinical and Experimental 56 (2007) 1425-1430

• Trimer R. et al. Heart rate variability and Cardio-respiratory coupling during sleep in patients prior to Bariatric surgery. OBES SURG (2014) 23:471-477

• Mehta RK. Impacts of obesity and stress on neuromuscular fatigue development and associated heart rate variability. International Journal of Obesity (2014), 1-6

• Thayer JF et al. The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. International journal of Cardiology 141 (2010) 122-131

Page 78: Anesthesia for Bariatric Surgery: What the occasional anesthesiologist should know Prof Samar Jabbour-KHOURY, MD Dayane DAOU, MD American University of

Thank you!

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9th ANNUAL ACUTE · VIRTUAL MEETING. 14:05 - 15:40 SESSION 4 - ALL Chairs: Dr. Elias Jabbour, MD Anderson Cancer Center, Houston, USA Dr. Adolfo de la Fuente, MD Anderson Cancer Center

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Elias Jabbour, MD University of Texas – M. D. Anderson Cancer Center

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Accepted refereed manuscript of: Diana GC, Jabbour CJC ... · Accepted refereed manuscript of: Diana GC, Jabbour CJC, Jabbour ABSdL & Kannan D (2017) Putting environmental technologies