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Abstract
The anaesthetist should be expect to be presented frequently with
obese patients in the operating theatre, intensive care unit or resuscitation
room. These patients may provide the anaesthetist with a considerable
challenge. A thorough understanding of the pathophysiology and specific
complications associated with the condition should allow more effective
and safer treatment for this unique group of patients.
Changes in pulmonary function include a decreased vital capacity,
maximum voluntary ventilation, total lung capacity, and functional
residual capacity (FRC).
Obesity is a dependent risk factor for cardiovascular disease.
Hyperlipidemia, hypertension, and diabetes all contribute to this risk.
From a gastrointestinal standpoint, obese patients are known to have
increased gastric volumes and increased gastric acidity when compared to
non-obese controls.
Postoperative management includes: Standard use of the 30° reverse
Trendelenburg (head up) position during preoxygenation, induction, and
emergence from anesthesia. Immediate availability of difficult airway
management devices, as well as an additional anesthesia clinician, the
circulating operating room nurse, and the surgeon during induction and
emergence. Prior to extubation, the patient should be fully awake and
complete reversal of neuromuscular blockade should be established in
addition to achieving standard extubation criteria.
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Respiratory function is deeply altered in the postoperative period.
Both upper abdominal and thoracic surgery result in a post-operative
pulmonary restrictive syndrome.
The obese pregnant patient presents particular difficulties, which
include: Increased risk of chronic hypertension, pre-eclampsia and
diabetes; Higher incidence of difficult labour with increased likelihood of
instrumental delivery and Caesarean section; Increased risk of
anaesthesia-related morbidity and mortality during Caesarean section and
in particular, increased risk of failed intubation and gastric aspiration
during procedures under general anaesthesia; Increased incidence of
multiple, failed attempts at epidural siting; Increased risk of fetal
morbidity and mortality, with some studies showing an increased
incidence of fetal distress; Supine and Trendelenburg positions further
reduce FRC, increasing the possibility of hypoxaemia.
It is a widely held belief that the outcome of trauma in obese patients
is poor, but data to support this are scarce. Care of the morbidly obese
trauma victim in the resuscitation room is likely to prove difficult.
It would seem prudent that obese children should be anaesthetized in
specialist centres that have experience of the condition.
Obese patients are more likely to be admitted to the intensive care
unit. Acute postoperative pulmonary events were twice as likely in the
obese as in the non-obese, and that hospitalized obese patients were at an
increased risk of developing respiratory complications.