Bariatric surgery articles...
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vibha naik
Feb 3, 2010, 3:37:21 AM2/3/10
to isan...@googlegroups.com
Hi,
Came across some good articles published in CACC Jan issue about managing patients for bariatric surgery. Hope you find them useful too.
It would be nice if any one of us reads an article and presents a summary to be retrieved later while managing such patients. Just like notes :) Here is my summary of Bariatric Airway article -
1. Our misconception that all obese patients are a difficult airway. Most studies suggest that difficult intubation, if defined by difficult laryngoscopy alone, does not appear to be more common in the obese. However, identifying the individual factors that appear to be more closely associated with difficult intubation is paramount.
2. Our misconception that 180kg is more difficult to intubate than 120kg is not true. Several studies show that the super obese (BMI >50 kg/m2) are no more difficult to intubate than the obese or morbidly obese.
3. So then what is important? Remember the basics. Mallampatti score of 3 or 4 and Patils TM distance less than 6cm is a strong predictor of difficult airway. Presence of cervical pad of fat leading to difficulty in neck extension?
4. We need to pull out tailor's measuring tapes - neck circumference more than 40cm is a predictor of difficult intubation
5. Send your patients for OSA study. The presence of Obstructive sleep apnea remains underdiagnosed in many obese patients and is an important indicator of airway problems during induction as well as recovery. Preoperative CPAP treatment in OSA patients found helpful.
6. UK guidelines - 'Perioperative management of morbidly obese patient' - helpful - sent as attachment.
7. In premed - H2 blocker or proton pump inhibitor helpful and sedatives in pt with OSA to be avoided.
8. A towel or folded blankets under the shoulders and head helpful than the routine sniffing air intubation position. Described in different articles by different authors and different names (ex. HELP position, rammed or semisitting position) patient’s head, upper body and shoulders be significantly elevated above the chest with the head extended to optimise the view at laryngoscopy.
9. Preoxygenation in 30* headup for 3 min essential.
10. Rapid sequence intubation with cricoid pressure may not be necessary for all but definitely helpful for patients with symptomatic reflux disease or hiatus hernia.
11. Supraglottic airway(LMA, Proseal, ILMA, etc) should be kept standby in case of difficult mask ventilation.
12. Various videolaryngoscopes have been shown to facilitate intubation without having to align the oral, pharyngeal and laryngeal axes.
13. Routine awake/fiberoptic intubation of the morbidly obese patient has not been recommended.
14. Surgical airway (Tracheostomy) may be technically difficult and is associated with increased perioperative complications.
15. They have increased sensitivity to opioid induced respiratory depression and depression of the arousal to obstructed breathing. Hence multimodal analgesia to be planned including regional.
Pray well the night before. God will help you (Sorry this part was not in the article ;) )
Dr Vibhavari Naik, MD
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vib...@yahoo.co.in
Mobile: +91 9959189958
Came across some good articles published in CACC Jan issue about managing patients for bariatric surgery. Hope you find them useful too.
It would be nice if any one of us reads an article and presents a summary to be retrieved later while managing such patients. Just like notes :) Here is my summary of Bariatric Airway article -
1. Our misconception that all obese patients are a difficult airway. Most studies suggest that difficult intubation, if defined by difficult laryngoscopy alone, does not appear to be more common in the obese. However, identifying the individual factors that appear to be more closely associated with difficult intubation is paramount.
2. Our misconception that 180kg is more difficult to intubate than 120kg is not true. Several studies show that the super obese (BMI >50 kg/m2) are no more difficult to intubate than the obese or morbidly obese.
3. So then what is important? Remember the basics. Mallampatti score of 3 or 4 and Patils TM distance less than 6cm is a strong predictor of difficult airway. Presence of cervical pad of fat leading to difficulty in neck extension?
4. We need to pull out tailor's measuring tapes - neck circumference more than 40cm is a predictor of difficult intubation
5. Send your patients for OSA study. The presence of Obstructive sleep apnea remains underdiagnosed in many obese patients and is an important indicator of airway problems during induction as well as recovery. Preoperative CPAP treatment in OSA patients found helpful.
6. UK guidelines - 'Perioperative management of morbidly obese patient' - helpful - sent as attachment.
7. In premed - H2 blocker or proton pump inhibitor helpful and sedatives in pt with OSA to be avoided.
8. A towel or folded blankets under the shoulders and head helpful than the routine sniffing air intubation position. Described in different articles by different authors and different names (ex. HELP position, rammed or semisitting position) patient’s head, upper body and shoulders be significantly elevated above the chest with the head extended to optimise the view at laryngoscopy.
9. Preoxygenation in 30* headup for 3 min essential.
10. Rapid sequence intubation with cricoid pressure may not be necessary for all but definitely helpful for patients with symptomatic reflux disease or hiatus hernia.
11. Supraglottic airway(LMA, Proseal, ILMA, etc) should be kept standby in case of difficult mask ventilation.
12. Various videolaryngoscopes have been shown to facilitate intubation without having to align the oral, pharyngeal and laryngeal axes.
13. Routine awake/fiberoptic intubation of the morbidly obese patient has not been recommended.
14. Surgical airway (Tracheostomy) may be technically difficult and is associated with increased perioperative complications.
15. They have increased sensitivity to opioid induced respiratory depression and depression of the arousal to obstructed breathing. Hence multimodal analgesia to be planned including regional.
Pray well the night before. God will help you (Sorry this part was not in the article ;) )
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vib...@yahoo.co.in
Mobile: +91 9959189958
Your Mail works best with the New Yahoo Optimized IE8. Get it NOW!.
nilesh tatar
Feb 5, 2010, 3:46:19 PM2/5/10
to ISA NASHIK
Good article,
some good videos about how intubation is done in morbidly obese
pt.s(how towels are kept under shoulders) was shown in last years
Mumbai conference. He also has shown some funny videos of
anesthetising 900 pound person. To shift him to hospital from his home
entire wall of his house was broken, etc.
some good videos about how intubation is done in morbidly obese
pt.s(how towels are kept under shoulders) was shown in last years
Mumbai conference. He also has shown some funny videos of
anesthetising 900 pound person. To shift him to hospital from his home
entire wall of his house was broken, etc.
> E-mail: vibn...@yahoo.co.in
> Mobile: +91 9959189958
>
> The INTERNET now has a personality. YOURS! See your Yahoo! Homepage.http://in.yahoo.com/
>
> Perioperative management of morbidly obese patient.pdf
> 276KViewDownload
>
> Bariatric Airway CACC 2010.pdf
> 222KViewDownload
>
> Bariatric Anaesthesia CACC 2010.pdf
> 628KViewDownload
>
> Bariatric OSA CACC 2010.pdf
> 759KViewDownload
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