OBESITY & ANAESTHESIA

Co-ordinator – Dr. Chavi Sethi(MD)

Speaker – Dr. Uday Pratap Singh
 OBESITY
LATIN WORD OBESUS, WHICH
MEANS FATTENED BY EATING

OBESITY: Metabolic disease in which adipose

tissue comprises a greater then 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.
Over wt.: excess of total body wt. including all components(muscle, bone, water and fat)

Ideal body wt. ( in Kg): also k/w as Broca,s index

Height in cm- 100 for males(105 for females)

Relative wt. : Ratio of actual and ideal wt.

Body mass index(BMI): also k/w as Quetelet index

Body wt.(in Kg)/ Height(met2)

Ponderal index
Ponderal index = height in cm divided by cube root of body weight in kg

Corpulence index: Actual wt/ desire wt.

normaly less then 1.2

Harpedence index: normally less then 40 in female and less then 50 in male.
CLASSIFICATION OF OBESITY

BMI STATUS
< 18.5 underweight
18.5–24.9 normal weight
25.0–29.9 overweight
30.0–34.9 class I obesity(Obese)
35.0–39.9 class II obesity (Morbidly obese)
≥ 40.0 class III obesity(Super morbidly
obese)
OBESITY & HEALTH RISKS

HEALTH RISKS
DEGREE OF OBESITY

ABDOMENAL FAT DISTRIBUTION

MALE WAIST ≥ 102cm

FEMALE WAIST ≥ 88cm

 CLINICAL MANIFESTATION

1.Pulmonary
2.C.V.S
3.G.I.T
4.Hepatic
5.Metabolic
 PULMONARY
MANIFESTATIONS

DEC. CHEST WALL • Lung compliance may normal

COMPLIANCE

RESTRICTIVE • Abdominal fat--cephalad shift of diaphragm

LUNG DISEASE

• Supine & Trendelenburg

DEC. FRC • anaesthesia

ALVEOLAR • If FRC < CC

• V/Q mismatch; R-L shunt; arterial hypoxemia and
ATELECTASIS hypercarbia.
 • Inc. metabolic rate– inc. Body wt.
INC. ALVEOLAR • Inc. O 2 demand
VENTILATION • Inc. CO 2 production

HYPOXIA & • Alert to impending complications

HYPERCARBIA

• Pickwickian synd.
OBESITY • Hypoxia & hypercapnia
HYPOVENTILATION • Polycythemia– cyanosis
SYND. • Rt. Sided heart failure
• somnolence
 OBSTRSUCTIVE SLEEP APNEA
SYNDROME

• Frequent episodes of apnea or hypopnea during sleep

Total cessation of airflow for = 10 sec.
Hypoapnea is 50% reduction in airflow
5 or more episode per hr. or 30 per night are counted as
clinically significant

• Day time somnolence associated with memory problem ,

impaired conc. and accident
• Throat muscles
become so relaxed
and floppy during
sleep that they
cause a narrowing
or complete
blockage of the
airway
Daytime sleepiness or fatigue
Dry mouth or sore throat upon awakening
Headaches in the morning
Trouble concentrating, forgetfulness,
depression, or irritability
Night sweats
Restlessness during sleep
Sexual dysfunction
Snoring
Sudden awakenings with a sensation
of gasping or choking
Difficulty getting up in the mornings
Hypertention Hypoxia

Myocardial
Arrhythmias
infarction

Pulmonary edema Stroke

Upper airway
Difficult intubation--
obstruction--
induction
recovery
 GASTROINTESTINAL
MANIFESTATIONS
HITUS HERNIA

GASTROESOPHAGEAL REFLUX

POOR GASTRIC EMPTYING

HYPERACIDIC GASTRIC FLUID

INC. RISK OF GASTRIC CANCER

 HEPATOBILIARY
MANIFESTATIONS
HEPATIC
• Fatty infiltration of liver
• Abnormal liver function
• Volatile anaesthetics defluorinated to
greater extent-halothane hepatitis

GALL STONES
• Abnormal cholesterol metabolism
 CARDIOVASCULAR
MANIFETATIONS
INC. BLOOD VOL

• To perfuse Additional body fat

INC. STROKE VOL

INC. CARDIAC OUT PUT

• 0.1 ml / min / kG body fat

ARTERIAL HTN

INC. CARDIAC WORKLOAD

LT VENTRICULAR HYPERTROPHY

PULMONARY HTN & COR

PULMONALE
• INC. Pulmonary blood flow
• Pulmonary vasoconstriction
• Persistent hypoxia
Cardiac manifestations of obesity

LVH

RVH
THROMBO-EMBOLIC DISEASE:

• Inc risk of DVT

• Inc. intra-abdominal pressure
• Polycythemia
• Inc. pressure in deep veins
• Immobilization-venous stasis
 METABOLIC DYSFUNCTIONS

TYPE-2 DM
• Inc resistance to insulin in periphery

HYPERTENTION

CORONARY ARTERY DISEASE

CHOLILITHIASIS
• Abnormal cholesterol metabolism

HYPERCHOLESTEROLEMIA

HYPERINSULINEMIA
• Inc. sympathetic activation
 Body Water
• Reduction in total body water to 40% of TBW.
• Relative dehydration may be present.
• Poor tolerance to fluid load.
 METABOLIC SYNDROME

OBESITY

METABOLIC
SYND
TYPE-2
HTN
DM
 Clinical Criteria for Diagnosing
Metabolic Syndrome *
Criteria Defining Value

Waist circumference >102 cm in men and

Abdominal obesity
>88 cm in women

Triglycerides ≥150 mg/dL

<40 mg/dL in men and <50 mg/dL in

High-density lipoprotein cholesterol
women

Blood pressure ≥130/85 mm Hg

≥110 mg/dL
Fasting glucose
*Three of five criteria must be met.
 OBESITY & DRUGS DOSES

LIPID SOLUBLE WATER SOLUBLE

1. Inc. vol of distribution 1. Limited vol of

distribution
2. Larger loading doses to
2. Doses not influenced by
produce same plasma fat stores
concentration but
maintenance doses less
frequent-slow clearance
3. Doses based on ideal
3. Doses based on actual body wt. – to avoid
body wt. overdosing.
• Commonly used anesthetic drugs can be dosed according to total-body weight (TBW) or
IBW based on lipid solubility.

• Lean body mass is a good weight approximation to use when dosing hydrophilic
medications. As expected, the volume of distribution is changed in obese patients with
regard to lipophilic drugs.

• Three exceptions to this rule are digoxin, procainamide, and remifentanil, highly lipophilic,
have no relationship between properties of the drug and their volume of distribution.

• Consequently, dosing of commonly used anesthetic drugs such as propofol, vecuronium,

rocuronium, and remifentanil is based on IBW.

• In contrast, thiopental, midazolam, succinylcholine, atracurium, cisatracurium, fentanyl,

and sufentanil should be dosed on the basis of TBW.

• maintenance doses of propofol should be based on TBW. Conversely, based on real body
weight, smaller amounts of propofol are needed to anesthetize the patient.
Halogenated anaesthetics:

• Morbidly obese pt. Metabolize halothane and enflurane more resulting in high
serum and urine level or fluoride.

• Isoflurane and desflurane are volatile agent of choice bc it produces lower

fluoride conc.

• Liver and body fat store inhalational anaesthatics long after completion of
surgery bt drug conc. In brain and lungs decrease rapidly.
 Pharmakinetics
• Alternation in drug binding, distribution, and elimination of
many anesthetic drugs.

• Dose calculation based on IBW rather than TBW.

• IBW calculated as :
Men = 49.9 Kg + 0.89 kg/cm above
152.4 cm
WoMen = 45.4 Kg + 0.89 kg/cm above
152.4 cm
 ANAESTHETIC
CONSIDERATIONS

PREOPERATIVE

INTRAOPERATIVE

POSTOPERATIVE
 PREOPERATIVE

HISTORY

• Duration of obesity & associated

problems
• Previous operation & anaesthesia
• Medication
INVESTIGATIONS
• Blood
• Urine
• LFTs
• RFTs
• ECG
• X-Ray chest
• Echocardiography
• ABGs
RISK FOR ASPIRATION PNEUMONIA
• Premedication:
• Anticholinergic agent
• H2-antagonist
• Metoclopramide
• Sodium citrate(oral antacid 30 ml of 0.3M)
• LMWH subcutaneous(DVT prophylaxis)

AVOID RESPIRATORY DEPRESSANT

• Pre-ops hypoxia & hypercapnia
• OSA

IM- Injections…Unreliable
 ASSESS CARDIOPULMONARY
RESERVE
• History
• Physical examination-(BP,Edema)
• X-Ray chest
• ECG
• ABGs

IV & IA ACCESS

• Technical difficulties
REGIONAL ANAESTHESIA-DIFFICULTIES
• Obscured landmarks
• Difficult positioning
• Extensive layers of adipose tissue
AIRWAY ASSESSMENT IN OBESE
• Difficulty in mask ventilation
• Difficult intubation--Consider FOB
• Temporomandibular joint-limited mobility
• Atlanto-ooccipital—limited mobility
• Narrow upper airway
• Distance b/w mandible & sternal fat pads-limited
• Large breasts
• Excessive palatal & Pharyngeal soft tissue.
• Short and thick neck(if circumference >14cm then difficult
intubation)
 INTRAOPERATIVE

GA
• PRE-OXYGENATION
• POSITIONING
• INDUCTION & INTUBATION
• MAINTAINACE

REGIONAL ANAESTHESIA
• Technical difficulties
• Doses of LA
• Complications
• Advantages
 PREOXYGENATION
SLIGHTLY HEAD UP POSITION

NECESSARY BECAUSE
• Dec FRC
• FRC Dec more on lying
• Supine
• After induction
• Obese rapidly desaturate
• Intubation may be difficult
 OBESITY & V/Q
MISMATCH

ATELACTASIS
• Chest obesity FRC < CC • Rt to Lt shunt
• Inc intra- • Supine position • Rapid hypoxia
abdominal • Induction
pressure
• Muscle
relaxation V/Q
DEC. FRC
MISMATCH
 POSITION IN INDUCTION &
INTUBATION

PRE-OXYGENAT & INTUBATE IN

SLIGHTLY HEAD UP POSITION

FOLDED BLANKETS PLACED UNDER

UPPER BODY,NECK & HEAD
• Sternal notch & external auditory meatus
are in line
 INDUCTION &
INTUBATION

DIFFICULT TO VENTILATE WITH MASK

RAPID SEQUENCE INTUBATION

• Risk for aspiration

VAREITY OF SCOPES
• Long blade & short handle

AWAKE INTUBATION-IF DIFFICULT

• FOB
 PEEP DURING
INDUCTION

Application of positive end-

expiratory pressure during the
induction of general anesthesia:
• prevents atelectasis formation.
• improves oxygenation and probably
increases the margin of safety before
intubation.
CONFIRMATION OF
INTUBATION

DIFFICULT TO CONFIRM
BY AUSCULTATION-
CLINICALLY

CONFIRMED BY END
TIDAL CO2
 MAINTAINACE OF
ANAESTHESIA

HIGH INSPIRED O2 CONCENTRATION

• LITHOTOMY,TRENDELENBURG & PRONE

CONTROLLED VENTILATION – HIGH TIDAL

VOLUMES

PEEP-WORSEN PULMONARY HTN IN

EXTREME OBESE
 POSTOPERATIVE
COSIDERATIONS

EXTUBATION
• Delayed until effects of NMBAs completely
reversed
• Fully awake
• Adequate airway maintenance
• Adequate tidal volume
• Supplemental oxygenation
• Modified sitting position
 POSTOPERATIVE COMPLICATIONS

RESPIRATORY FAILURE
• Major complication
• Inc risk-
• Pre-ops hypoxia
• Thoracic & upper abdominal Surgery

DEEP VENOUS THOROMBOSIS

PULMONARY EMBOLISM

WOUND INFECTION
THANK YOU
CPAP CIRCUIT
APPLICATION OF CPAP
DIFFICULT INTUBATION IN OBESE
ATELACTASIS IN OBESE
MONITORING
INVASSIVE
MONITORING—
HAEMODYNAMIC
INSTABILITY
• CVP
• INTRA-ARTERIL LINE
• PULMONARY ARTERY CATHETER