dr hany fawzi senior specialist- anesthesia department rashid hospital & trauma center
DESCRIPTION
Dr Hany Fawzi Senior Specialist- Anesthesia Department Rashid Hospital & Trauma Center 7 March 2013. BARIATRIC SURGERY. USA bariatric surgeries /year: 16 200 (1992) 220 000 (2008). 344 000 worldwide (2008). Schumann R ,Best practice & Research Clinical Anaesthesiology 2010. - PowerPoint PPT PresentationTRANSCRIPT
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Dr Hany FawziSenior Specialist-
Anesthesia DepartmentRashid Hospital & Trauma Center
7 March 2013
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BARIATRIC SURGERYUSA bariatric surgeries /year:
16 200 (1992) 220 000 (2008).
344 000 worldwide (2008)
Schumann R ,Best practice & Research Clinical Anaesthesiology 2010
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DEFINITIONSBODY MASS INDEX BMI ( Quetelet’s Index): WEIGHT(kg)/HEIGHT (m2)
BMISEVERE OBESITY 35-39.9MORBID OBESITY > 40SUPER OBESITY > 50
WEIGHT FEMALE MALEIDEAL 19.1-25.8 20.7-26.4MARGINAL OVERWEIGHT
25.9-27.2 26.5-27.8
OVERWEIGHT 27.3-32.3 27.9-31.3OBESE 32.4-34.9 31.4-34.9
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IDEAL BODY WEIGHT Ideal Body Weight: IBW (Lorentz) :
IBW = X + 0,91 (height in cm - 152,4)Female : X = 45, 5Male : X = 50
More easy to rememberIBW (kg) = Height (cm) - 100 in MALE IBW (kg) = Height (cm) - 110 in FEMALE
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OBESE PATIENT = RISKS
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COMORBID DISEASE PREVALENCE IN 1,210 PATIENTS FOR BARIATRIC SURGERY
MUSCULOSKELETAL ARTHRITIS
47%
VENOUS STASIS DISEASE
3%
HYPERTENSION 43%
HERNIA 2%
SLEEP APNEA 36%
FLUID RETENTION
1%
DIABETES MELLITUS
21%
SUPRAVENTRICULAR TACHYCARDIA
< 1%
RESPIRATORY DISORDERS
16%
CHF < 1%
GERD 1 1%
LYMPHEDEMA < 1%
HYPERLIPIDEMIA 5% INCONTINENCE <1%
DEPRESSION 4%Benotti P.Surg Obes Relat Dis 2006
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COMORBID DISEASE BURDEN
PATIENTS %
NO COMORBIDITIES 137 14 1 COMORBID DISEASE 263 22
2 COMORBID DISEASE
454 38
3 COMORBID DISEASE 284 23 4 OR MORE COMORBID DISEASE
71 6
Benotti P.Surg Obes Relat Dis 2006
COMORBID DISEASE PREVALENCE IN 1,210 PATIENTS FOR BARIATRIC SURGERY
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• Hypertension• Diabetes• Venous stasis
disease• pseudotumor
cerebri• OSA and/ or OHS
no major comorbid disease
1 or +Jamal MK Surg Obes Relat Dis.2005
Comorbidities on mortality and complications after gastric bypass
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32 + 6 BMI 0.001 35 + 80.2% Mortality 0.0032 2.3%
1.2% Leak rate 0.0032 4.1%
1.4% Surgical Infection 0.0133 3.9%
68% Excess weight loss 0.001 62%
Jamal MK Surg Obes Relat Dis.2005
Comorbidities on mortality and complications after gastric bypass
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INDICATIONS/CONTRAINDICATIONS
1- Individuals with BMI > 40 Kg/m2 who have failed conventional weight-control programs.
2- Individuals with a BMI between 35 and 39.9 kg/m2 who have high risk health problems affecting lifestyle ( i.e, employment or mobility)
CONTRAINDICATIONS: 1- Severe mental illness resulting in psychosis.2- Substance abuse.3- Major organ failure.
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PREOPERATIVE ASSESSMENT=
Multidisciplinary
Benotti.P, Gastroenterology & Endoscopy news 2007
Special Bariatric SurgeonAnesthesiologist
MedicalCardiologyPulmonaryDiabetologyEndoscopistPsychiatryDietitianPlastic Surgeon
• PULMONARY- Restrictive lung disease-OSA-OHS
• CARDIAC -HTN/CAD/CHF-Dysrhythmias-cardiomyopathy
• DM/Thyroid/Adrenal• AIRWAY•Vascular assessment
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PULMONARY FUNCTION
Reduced compliance of lung and chest wall.
Reduced lung volume.
Increased respiratory resistance.
Increased work of breathing.
Koening SM.Am J Med Sci 2001
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RESPIRATORY SYSTEMDyspnea with exertion.Significant impairement of pulmonary
function , often with few symptoms.Reduction in lung volumes atelectasis,
airway closure hypoxia.Reduction of functional residual capacity
rapid desaturation during apnea at anesthesia induction.
Koening SM.Am J Med Sci 2001
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PRE OPERATIVE PULMONARY EVALUATIONPreoperative pulmonary function tests are
indicated for patients with1- documented pulmonary problems.2- limited performance status because of
dyspnea.3- BMI > 60 kg/m2.
Arterial blood gas hypoventilation in severely obese patients.
Identify risk for postoperative hypoxia.Facilitate postoperative respiratory care.
Koening SM.Am J Med Sci 2001Benotti P.Surg Obes Relat Dis 2006
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PULMONARY EVALUATIONForced vital capacity varies inversely with BMI.Patients with very high BMI , even when
asymptomatic will have major reductions in lung function*.
Patients with preoperative pulmonary impairement Significant risk for hypoxia during the immediate postoperative period Bi-level positive airway pressure in recovery room preserve oxygenation**.
No evidence of gastric pouch problems related to its use***.
•Santana AN , et al .Respir Med 2006** Ebeo CT, et al. Respir Med 2002 & Joris JL et al.Chest 1997*** Huerta S , et al J Gastrointest Surg 2002
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OBSTRUCTIVE SLEEP APNEA ( OSA)75 % of PATIENTS
The prevalence increases with BMI.*
OSA is an independent risk factor for metabolic syndrome ( impaired glucose tolerance-insulin
resistance and dyslipidaemia)**for all-cause mortality***
*Hallowell PT, et al .American Journal of Surgery 2007**Chung SA , et al.Anesthesiology 2008*** Marshall NS et al.Sleep 2008.
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OBSTRUCTIVE SLEEP APNEA ( OSA)Detailed clinical history is mandatory.Symptoms: - Heavy snoring - Witnessed apnea. - Excessive daytime somnolence. - Lack of restful sleep. Questionnaire: STOP, Berlin, ASA Check list. Patients with suspected OSA preoperative sleep study
(Polysomnography)& titration of CPAP.Consequence of OSA can be reversed by CPAP or BiPAP
Benumof JL Journal of Clinical Anesthesia , 2001
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STOP QUESTIONNAIRESTOP Questionnaire is concise and easy –to use screening tool
for OSA.1-Do you snore loudly?2- Do you often feel tired , fatigued or sleepy during day time?3- Do you have or are you being treated for high blood pressure?4- Has any one observed you stop breathing during sleep?
Combined with BMI age neck size & gender,
STOP = high sensitivity especially for patientswith moderate to severe OSA
Chung F. Anesthesiology 2008 18
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Validation of the Berlin Questionnaire and American Society of Anesthesiologists Checklist as screening tools for obstructive sleep apnea in surgical patients
The Berlin questionnaire and ASA checklist demonstrated a moderately high level of sensitivity for OSA screening.
STOP Questionnaire and the ASA checklist were able to indentify the patients who were likely to develop postoperative complications.
Chung F , Anesthesiology 2008
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OBSTRUCTIVE SLEEP APNEA ( OSA) & POLYSOMNOGRAPHY
Routine preoperative PSGcost effective lacking improved outcome => not part of ASA practice guidelines for the
perioperative management of patients with OSA. ASA practice guidelines for the perioperative
management of patients with obstructive sleep apnea. Anesthesiology 2006.
A referral for PSG study should be individualized.
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POTENTIALLY LIFE –THREATENING SLEEP APNEA IS UNRECOGNIZED WITHOUT AGGRESSIVE EVALUATION.
Hallowell P.American J of Surgery 2007
Era 1= OSA evaluation based on clinical parameters.Era2= Mandatory OSA evaluation for all patients
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POTENTIALLY LIFE –THREATENING SLEEP APNEA IS UNRECOGNIZED WITHOUT AGGRESSIVE EVALUATION.
OSA is grossly underdiagnosed.Clinical evaluation misses a % of patients with OSA.Mandatory testing with Polysomnography
Hallowell P.American J of Surgery, 2007
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CPAP or BiPAP DURATION EFFECT STUDY2 weeks correct abnormal
ventilatory drive in obese hypercapneic patients
Cartagena R. Anesthesiology clinics of North America 2005
3 weeks improves left ventricular ejection function in patients with CHF
Tkacova et al .Circulation 1998.
4 weeks reduce HR, BP & 35% increase in EF in patients with CHF.
Golbin JM ,et al.Proceedings of the American Thoracic Society.2008
4- 6 weeks reduce tongue volume & increase pharyngeal space
Ryan CT , et al .American Review of Respiratory Disease.1991
8 weeks improved morning hypertension
Dorkova Z,et al .Chest 2008.
3-6 months reduced pulmonary hypertension
Golbin JM ,et al.Proceedings of the American Thoracic Society.2008
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PREOPERATIVE SMOKING HABITS AND POSTOPERATIVE PULMONARY COMPLICATIONS
Smoking is a proven risk factor for postoperative pulmonary complications.
The risk declines with cessation of smoking for 8 weeks before surgery.
Most bariatric programs insist on abstinence from smoking before-hand.
Bluman LG, Chest 1998
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CARDIAC EVALUATIONCardiac abnormalities associated with morbid obesity
include: * - Systemic hypertension. - Ischemic heart disease - cardiac hypertrophy. - Cardiac arrhythmias - diastolic dysfunction - Deep vein thrombosis. - Frank systolic dysfunction with cardiomyopathy.** - Pulmonary hypertension*** - Pulmonary embolism - Congestive heart failure. - Poor exercise capacity - Increased incidence of sudden and unexplained
death**** *Poirier et al.Circulation 2009,**Thakur V,et al. Am J Med Sci 2001. ***Alpert MA. Am J Med Sci 2001.
****Drenick EJ.Am J Sur 1988.
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CARDIAC EVALUATIONCardiac evaluation can be difficult to ascertain.Clinical history limited mobility.Clinical examination muffled heart sounds. short thick neck conceal JVP SEDENTARY LIFE peripheral edema.Functional capacity 4 METS =climbing a flight
of stairs =moderate functional capacity.The Revised Cardiac risk is commonly used to
assess cardiac risk in patients undergoing non cardiac surgery
O ’ Neil T & Joanna A ,Best Practice & Research Clinical Anesthesiology 2010
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Derivation and prospective validation of a simple index for prediction of cardiac risk of major non cardiac surgery
1 High risk surgery2 IHD.3 CHF. 4 Cerebrovascular disease.5 IDDM 6 Renal insufficiency.
IF YES = 1 POINT/ITEM
Lee TH, et al , Circulation .1999
SCORE RISK0 0.4%1 0.9%2 6.6%3 11%
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Cardiovascular evaluation and management of severely obese patientsPaul Poirier ,et al .Circulation 2009
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CARDAIC EVALUATION Unknown or limited exercise tolerance or with any
significant co-morbidity Cardiopulmonary exercise testing( CPEX).
Unable to exercise cardiologist for alternative provocative cardiac testing.
O ’ Neil T & Joanna A ,Best Practice & Research Clinical Anesthesiology 2010
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CARDIORESPIRATORY FITNESS AND SHORT TERM COMPLICATIONS AFTER BARIATRIC SURGERY
31McCullough PA,et al.Chest 2006
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AIRWAY ASSESSMENTOBESE= PREDICTABLE DIFFICULT
INTUBATIONOSASHORT + FAT NECK
Airway claimsintubation = 37% obesityExtubation 67% - 28% OSA.
Peterson GN et al. Anesthesiology 2005
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Obstructive sleep apnea is not a risk factor for difficult intubation in 180 morbidly obese patients
Risk factors : Mallampati Score > 3 male gender
Neligan PJ , et al .Anesthesia& Analgesia 2009
AIRWAY ASSESSMENT
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AIRWAY MANAGEMENTOptimal positioning; - Ramped position by placing blankets under
the patient’s upper body. - 25-30 reversed Trendelenburg, head up or the
near sitting position Availability of different airway management options
ASA 2013
Schumann R .Best Practice & Research Clinical Anaesthesiology,2011
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Reverse Trendelenburg =
proclive
Courtesy from Pr Paolo PELOSI
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VASCULAR ACCESS
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ENDOCRINE FUNCTION15 -20% of morbidly obese patients have type 2
diabetes.Glucose control requires close preoperative attention.Hyperglycemia (> 220 mg/dl) inhibits many important
functions of polymorphonuclear leucocytes.Good preoperative glycemic control in terms of HbA1c
below 7% is associated with a reduced infection risk .Specialist consultation will be necessary.Thyroid function tests Adrenal function tests ( if Cushing’s Syndrome)
Golden SH, et al.Diabetes Care 1999. Van Den Berghe, et al.N Eng J Med,2001. Dronge AS, et al .Arch Surg.2005.
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Outcomes of preoperative weight loss in high –risk patients undergoing gastric bypass surgery.
> 10 % EXCESS BODY WEIGHT LOSS (N=425) 5%-10% EXCESS BODY WEIGHT LOSS (N=169) 0-5% EXCESS BODY WEIGHT LOSS (N= 137) 0-5% EXCESS BODY WEIGHT GAIN (N=86) > 5% EXCESS BODY WEIGHT GAIN (N=67)
Still CD et al, Arch Surg 2007
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SCORING SYSTEMSObesity Surgery Mortality Risk Score ( OS-MRS):Validated scoring system specific to obese
patients undergoing bariatric surgery ( 1 point for each)
1- BMI > 50 kg/m2. 2- Male gender. 3- Systemic hypertension. 4- Risk factors for pulmonary
embolism. 5- Age > 45
.
DeMaria EJ, Surg Obes Relat Dis 2007
SCORE RISK MORTALITY 0-1 LOW 0.31% 2-3
INTERMEDIATE 1.9%
4-5 HIGH 7.56%
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CLINICAL PATHWAY
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CLINICAL PATHWAY
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CLINICAL PATHWAY
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HOME MESSAGESExponential increase in Bariatric surgery
worldwide.
Comorbidities affect outcome.
Pre-operative evaluation is Multidisplinary.
Anesthetic evaluation & preparation.
Clinical pathway.43