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Title: Anesthetic Considerations for the Morbidly Obese


1
Anesthetic Considerations for the Morbidly Obese
  • Art Zwerling,
  • DNP, MS, MSN, CRNA, DAAPM
  • University of Pennsylvania College of Nursing
    Nurse Anesthesia Program
  • Fox Chase Cancer Center
  • a.to.z_at_comcast.net
  • MANA Spring 2009

2
Why We Are Here Oops Wrong Lecture.
3
Its always about the airway……
4
(No Transcript)
5
Society for Airway Management
  • 2009 SAM Meeting   September 25-27, 2009
  • The Venetian
  • Las Vegas, NV 
  • September 25-27, 2009
  • The Venetian
  • Las Vegas, NV 
  • http//sam.zorebo.com/index.php

6
Eritrea School of Nurse Anesthesia
  • Class of 2007

7
(No Transcript)
8
Friday , 3-31-06 after 2 weeks of Zwerling-Wilson
Brain Washing
9
Kessete Teweldebrhan, CRNA Program Director
Heather Wilson, CRNA, MS NAO Volunteer
10
Awet
11
Isack
12
Kissamet
13
Mekonen
14
Yemane
15
Yukunot
16
(No Transcript)
17
Upside to being a PD
  • Have to commit to an evidence based practice.
  • Vow of poverty.
  • Learn the negotiation skills of an UN mediator.
  • Learn to delegate as if theres anyone to
    delegate to.
  • Participate in clinical research

18
Applied Clinical Research 2004
19
Collate Outcome Data
20
AIRWAY JEOPARDY
  • SRNAs Only!!!!!!!!!!!
  • For 20.00 and the BRAINIAC Award
  • Topic Area Famous Experimental Subjects in
    Airway research.
  • Who was……………….?
  • The first SRNA to get the correct answer to me
    before I leave for Philly wins.

21
Take homes
  • Airway is the predominant clinical concern with
    morbidly obese patients.
  • Utilization of central alpha 2 agonists along
    with low solubility inhalational agents is an
    ideal approach to decrease residual airway
    compromise.
  • Dexmedatomidine is an easily titrateable central
    alpha two agonist with potent analgesic and MAC
    sparing properties.

22
FCCC Applications
  • Sedation for awake FOI
  • Cardioprotection
  • Narcotic sparing
  • MAC sparing
  • OSA patients /or compromised airway
  • Opioid tolerant
  • Avoidance of emergence delirium

23
How Did a Receptor Specificity Purest Get
Subverted?
  • They hid all his infusion pumps?
  • His chairman told him he can use all the propofol
    he wants if hes buying?
  • The surgeons were complaining about all those dn
    beeping pumps?
  • He developed a new appreciation for the
    titrability of inhalational agents?
  • The Sevo rep had fresher bagels than the propofol
    rep?

24
Inhaled Anesthetics and Immobility Mechanisms,
Mysteries, and Minimum Alveolar Anesthetic
Concentration
  • James M. Sonner, et. al.
  • Anesth Analg 200397718-740

25
Mechanisms of action of inhalational anesthetics
Neurotransmitter receptor candidates
  • Inhibitory Neurotransmitter Receptors
  • GABAA
  • Glycine
  • Excitatory
  • Transmitters
  •   NMDA
  •  AMPA
  •  Kainate
  •   Nicotinic
  •  5-HT3


Anesth Analg 200397718-740
26
The anatomical candidates
27
Morbid Obesity
28
Anyone who wants to ask what the ROI on obesity
treatment is must first tell me what the ROI is
for the treatment of Erectile Dysfunction ?
  • Attributable Deaths
  • per year in U.S.
  • Obesity 25-300K
  • Impotence 0

Range of estimates from CDC Excludes death
from embarrassment

But theres a new trend. Organizations that own
someone for life are starting to offer obesity
treatment.
29
How Does Obesity Cause Disease? Abnormal
production of hormones and inflammation in fat
Hypertension
á Lipoprotein Lipase
Type 2 DM
á Lactate
á Angiotensinogen
Inflammation
Dyslipidemia
á IL - 6
á Fat Stores
Arthritis
á Leptin
á FFA
á Insulin
Type 2 DM
á TNF- a
Asthma
áResistin
á Adipsin (Complement D)
Thrombosis
áEstrogen
á Plasminogen Activator Inhibitor 1 (PAI-1)
?Adiponectin
ASCVD
DMdiabetes mellitus FFAfree fatty acid
PAI-1plasminogen activator inhibitor-1
TNF?tumor necrosis factor alpha
IL-6interleukin 6. Slide After Dr. G Bray
30
Medical Complications of Obesity Almost every
organ system is affected
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Coronary heart disease
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Diabetes
Dyslipidemia
Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Skin
Phlebitis venous stasis
Gout
31
Conceptual Framework for the Metabolic Syndrome
  • Environmental causes are responsible for the
    epidemic of the metabolic syndrome (NCEP)
  • Treatment reduce obesity and increase
    activity
  • Insulin resistance is the underlying cause of the
    metabolic syndrome (WHO)
  • Treatment a) reduce obesity and increase
    activity b) insulin
    sensitizers
  • Inflammation is the underlying cause of the
    metabolic syndrome
  • Treatment a) reduce obesity and increase
    activity b) insulin
    sensitizers c) statins,
    ACE Inhibitors, ARBs

32
How does weight loss improve health? Reducing fat
cell mass reduces hormone production and
inflammation
Prevent these
Prevent these
Hypertension
Shrink This
á Lipoprotein Lipase
Type 2 DM
á Lactate
á Angiotensinogen
Inflammation
Dyslipidemia
á IL - 6
á Fat Stores
Arthritis
á Leptin
á FFA
á Insulin
Type 2 DM
á TNF- a
Asthma
áResistin
á Adipsin (Complement D)
Thrombosis
áEstrogen
á Plasminogen Activator Inhibitor 1 (PAI-1)
?Adiponectin
ASCVD
DMdiabetes mellitus FFAfree fatty acid
PAI-1plasminogen activator inhibitor-1
TNF?tumor necrosis factor alpha
IL-6interleukin 6. Slide After Dr. G Bray
33
Why is it so hard to lose weight? Weight is
controlled by a feedback system.
Hypothalamus, etc
Afferent
Efferent
Ghrelin PYY CCK
Autonomic Nervous System
External Factors food availability, palatability

Vagus Nerve
Food Intake
Gut and Liver
Meal Size
Pancreas
Insulin
Energy Balance and Adipose Stores
Energy Expenditure
Adipose Tissue
Leptin
Adrenal Cortex
Adrenal Steroids
Adiponectin
Aronne LJ. Adapted from Campfield LA, et al.
Science. 19982801383-1387 and Porte D, et al.
Diabetologia. 199841863-881.
34
Weight change at 1 year is consistent across all
trials The plateau is a physiological phenomenon!
Completers
Weight change (kg)
Weeks
35
Synergy of Leptin and Sibutramine in Treatment of
Dietary Obesity in Rats
4
-35
0
-19
CN Boozer, RJ Love, MC Cha, R Leibel, LJ Aronne.
Metabolism, 2001.
36
Central Weight Regulating Mechanisms
  • Food intake
  • energy expenditure
  • food intake
  • energy expenditure

Science, Feb 7, 2003, Vol 299 Illustration by
Katharine Sutliff
37
Central Weight Regulating Mechanisms and
Treatments Which Will Impact Them
  • Food intake
  • energy expenditure

IGS
Implantable Gastric Stimulator
PYY analog
  • food intake
  • energy expenditure

Pramlintide Exenatide
Pramlintide Rimonabant
Science, Feb 7, 2003, Vol 299 Illustration by
Katharine Sutliff
38
Alternative perspectives
  • The epidemic of morbid obesity is an issue for
    all providers.
  • The perspective that this is a chronic,
    progressive, ultimately fatal disease process is
    a reasonable start.

39
Scope of the ProblemThe Metric
  • Men Women Risk Factor
  • less than 20.7 less than 19.1 Underweight. The
    lower the BMI the greater the risk
  • 20.7 to 26.4 19.1 to 25.8 Normal, very low risk
  • 26.5 to 27.8 25.9 to 27.3 Marginally overweight,
    some risk
  • 27.9 to 30 27.4 to 30 Overweight. Moderate risk
  • 30.1 to 34.9 30.1 to 34.9 Severely overweight,
    high risk

40
Scope of the ProblemThe Metric
  • 35 to 39.9 35 - 39.9 Obesity Class II - Candidate
    for surgery with comorbities.
  • Greater than 40 greater than 40 Obesity Class III
    -
  • Morbid obesity, very high risk
  • Candidate for surgery

41
Mortality Ratio
  • Morbid obesity is defined by a Body Mass Index
    (BMI) of greater than 40 or between 35 and 40
    where there are other major medical conditions
    such as high blood pressure and diabetes are
    present.
  • Look at the escalation in mortality at BMIgt32-35

42
I was thinking about how people seem to read the
Bible a whole lot more as they get older then it
dawned on me . . they're cramming for their final
exam.
  • George Carlin

43
The Epidemiology
  • The numbers are down right scary!!
  • From 1986 to 2000 the prevalence of Americans
    with a BMI of 40 or greater has quadrupled from
    1200 to 150
  • There are approximately 325,000 deaths/yr
    attributable to obesity
  • This approaches the 400,000 excess death/yr
    attributable to smoking
  • The nation spends approximately 75 billion/yr on
    obesity related morbidities.

44
Laws of Anesthesia The Essentials
  • Air goes in and out.
  • Blood goes round and round.
  • Numb is good.
  • Numb and hemodynamically stable is better.
  • Numb, hemodynamically stable and amnestic is
    best.
  • Numb, hemodynamically stable, amnestic and warm
    is better yet.
  • Dead meat dont beat.

45
Airway….airway……airway!
46
And Airway
47
The Challenge!
  • Airway…..Airway…….Airway Potentially difficult,
    decreased FRC, decreased compliance, increased
    airway resistance- just wait until we have a
    peritoneum full of CO2.
  • Higher incidence of CAD, HTN, DVP, PE and pump
    failure geez and how about venous and arterial
    access. Superb teaching for ultrasound
    guidance!!!
  • The joys of neuroaxial anesthesia without
    palpable landmarks. But what better population
    for epidural analgesia.

48
FRC….FRC…..FRC…..FRC…….FRC
  • Obesity in anaesthesia and intensive care
  • J. P. Adams and P. G. Murphy British Journal of
    Anaesthesia, 2000, Vol. 85, No. 1 91-108

49
Prevention of Atelectasis Formation During the
Induction of General Anesthesia in Morbidly Obese
Patients
  • Marta Coussa, MD, Stefania Proietti, MD , Pierre
    Schnyder, MD , Philippe Frascarolo, PhD, Michel
    Suter, MD PhD , Donat R. Spahn, MD, and Lennart
    Magnusson, MD PhD
  • Departments of Anesthesiology, Diagnostic
    Radiology, and General Surgery, University
    Hospital, Lausanne, Switzerland

Anesth Analg 2004981491-1495
50
IMPLICATIONS
  • Application of positive end-expiratory pressure
    during induction of general anesthesia in
    morbidly obese patients prevents atelectasis
    formation and improves oxygenation.
  • Therefore, this technique should be considered
    for anesthesia induction in morbidly obese
    patients.
  • After intubation with a fraction of inspired
    oxygen of 1.0, PaO2 was significantly higher in
    the PEEP group compared with the control group
    (457 130 mm Hg versus 315 100 mm Hg,
    respectively P 0.035)

51
Respiratory System Resistance Desflurane vs.
Sevoflurane and Thiopental
Goff et al, Anesthesiology  200093(2)404-408
52
Atheism is a non-prophet organization.
  • George Carlin

53
Work Release
54
Anesthesia for a patient with morbid obesity
using dexmedetomidine without narcotics
  • Roger E. Hofer, MD, Juraj Sprung, MD PhD,
    Michael G. Sarr, MD and Denise J. Wedel, MD
    From the Departments of Anesthesiology, and
    Surgery, Mayo Clinic College of Medicine, Mayo
    Clinic, Rochester, Minnesota, USA.

Canadian Journal of Anesthesia 52176-180 (2005)
55
Clinical Features
  • Clinical features We describe a 433-kg morbidly
    obese patient with obstructive sleep apnea and
    pulmonary hypertension who underwent Roux-en-Y
    gastric bypass. Because of the concern that the
    use of narcotics might cause postoperative
    respiratory depression, we substituted their
    intraoperative use with a continuous infusion of
    dexmedetomidine (0.7 µgkg1hr1). The
    anesthesia course was uneventful, and the
    intraoperative use of dexmedetomidine was
    associated with low anesthetic requirements (0.5
    minimum alveolar concentration). After completion
    of the operation and after tracheal extubation,
    the dexmedetomidine infusion was continued
    uninterrupted throughout the end of the first
    postoperative day. The analgesic effects of
    dexmedetomidine extended narcotic-sparing effects
    into the postoperative period the patient had
    lower narcotic requirements during the first
    postoperative day 48 mg of morphine by
    patient-controlled analgesia (PCA) while still
    receiving dexmedetomidine, compared to the second
    postoperative day (morphine 148 mg by PCA) with
    similar pain scores.

Canadian Journal of Anesthesia 52176-180 (2005)
56
Choice of volatile anesthetic for the morbidly
obese patient sevoflurane or desflurane
  • Shahbaz R. Arain MD, Christofer D. Barth MD1,
    Hariharan Shankar MD,
  • Thomas J. Ebert MD, PhD

Journal of Clinical Anesthesia (2005) 17, 413419
57
Design
  • A randomized, prospective blinded study to
    determine the emergence profiles of desflurane
    and sevoflurane in MO patients when anesthetic
    drug titration is used.
  • Patients were induced with fentanyl, midazolam,
    and propofol and maintained with
  • desflurane or sevoflurane, mixed in air and
    oxygen. Intraoperative bispectral index (BIS) was
    targeted to 45 to 50 and to 60 in the last 15
    minutes of surgery

58
Main Results
  • Demographic data (age, 61 36-83 years body
    mass index, 38 35-47 kg/m2), surgical
    procedures, length of anesthesia (3.5 hours),
    adjuvant drugs, and intraoperative BIS, heart
    rate, and mean arterial pressure were not
    significantly different.
  • Hemodynamics, time to follow commands and to
    extubation, and results of Digit Symbol
    Substitution Test and Mini-Mental Status Test did
    not differ between anesthetic groups during
    recovery.

59
AIRWAY AIRWAY AIRWAY
  • Dexmedetomidine and low-dose ketamine provide
    adequate sedation for awake fibreoptic intubation
  • Corey S. Scher, MD and Melvin C. Gitlin, MD
    From the Department of Anesthesiology, Tulane
    Health Sciences Center, New Orleans, Louisiana,
    USA.
  • Address correspondence to Dr. Corey S.
    Scher, Department of Anesthesiology, Tulane
    Health Sciences Center, 1415 Tulane Ave. SL-4,
    New Orleans, LA 70112, USA. Phone 504-588-5903,
    Fax 504-584-1941 E-mail cscher_at_anes.tulane.edu
  • Canadian Journal of Anesthesia 50607-610 (2003)

60
AIRWAY AIRWAY AIRWAY
  • The patient received a bolus of dexmedetomidine 1
    µgkg-1 (Precedex-Abbott Laboratories, North
    Chicago, IL, USA) over ten minutes. After the
    bolus, the infusion was set at 0.7 µgkg-1hr-1.
    Neither hypotension or bradycardia were noted
    during dexmedetomidine administration. The
    patient reported comfort and sedation at the
    termination of the loading dose. The patient was
    rousable at all times, but when left
    unstimulated, tended to sleep. No changes in
    oxygen saturation and respiration were noted
    during the bolus or maintenance infusion. Upon
    completion of the dexmedetomidine bolus, 15 mg of
    ketamine were administered as a bolus and an
    infusion of 20 mghr-1 was initiated. After the
    ketamine bolus, and during the infusion, the
    patient reported that he was calm, comfortable,
    sedated and stated that he was ready for the
    fibreoptic intubation. This low dose of ketamine
    did not result in adverse changes in mental
    status. There continued to be no change in oxygen
    saturation and respiratory status. He did
    complain of dry mouth.
  • During the continuous drug infusion, blocks of
    the recurrent laryngeal nerve and internal branch
    of the superior laryngeal nerve bilaterally were
    performed in the usual manner.1 The tongue and
    hypopharynx were sprayed with benzocaine. The
    patient remained both sedated and cooperative
    during these blocks. A Macintosh laryngoscope (4
    blade) was inserted and the patient remained very
    cooperative although the epiglottis and vocal
    cords were not visualized.
  • Canadian Journal of Anesthesia 50607-610 (2003)

61
AIRWAY AIRWAY
  • An endoscopic oral airway was placed in the mouth
    and fibreoptic intubation was performed. The
    endoscopist noted excellent conditions including
    a secretion free airway. The patient was able to
    respond to requests to take slow, large deep
    breaths. The epiglottis and vocal cords were
    visualized and intubation proceeded without
    difficulty. General anesthesia was then induced
    and the drug infusions were discontinued. After
    an uncomplicated surgery, the trachea was
    extubated after the patient met criteria for
    extubation. The patient had no recall of the
    nerve blocks, direct laryngoscopy, or fibreoptic
    intubation.
  • Canadian Journal of Anesthesia 50607-610 (2003)

62
Anesthesia for a patient with morbid obesity
using dexmedetomidine without narcotics
  • Roger E. Hofer, Juraj Sprung, Michael G. Sarr,
    and Denise J. Wedel

Canadian Journal of Anesthesia 52176-180 (2005)
63
Description
  • We describe a 433-kg morbidly obese patient with
    obstructive sleep apnea and pulmonary
    hypertension who underwent Roux-en-Y gastric
    bypass.
  • Because of the concern that the use of narcotics
    might cause postoperative respiratory depression,
    we substituted their intraoperative use with a
    continuous infusion of dexmedetomidine (0.7
    µgkg1hr1).
  • The anesthesia course was uneventful, and the
    intraoperative use of dexmedetomidine was
    associated with low anesthetic requirements (0.5
    minimum alveolar concentration).
  • After completion of the operation and
    aftertracheal extubation, the dexmedetomidine
    infusion was continued uninterrupted throughout
    the end of the first postoperative day.
  • The analgesic effects of dexmedetomidine extended
    narcotic-sparing effects into the postoperative
    period the patient had lower narcoticrequirements
    during the first postoperative day 48 mg of
    morphine by patient-controlled analgesia (PCA)
    while still receiving dexmedetomidine, compared
    to the second postoperative day(morphine 148 mg
    by PCA) with similar pain scores

64
Conclusions
  • Dexmedetomidine may be a useful anesthetic
    adjunct for patients who are susceptible to
    narcotic-induced respiratory depression.
  • In this morbidly obese patient the
    narcotic-sparing effects of dexmedetomidine were
    evident both intraoperatively and postoperatively.

65
Dexmedetomidine infusion during laparoscopic
bariatric surgery the effect on recovery outcome
variables.
  • Burcu Tufanogullari, et. al.

Anesth Analg 2008 1061741-1748
66
CONCLUSIONS
  • Adjunctive use of an intraoperative Dex infusion
    (0.20.8 µg kg1 h1) decreased fentanyl use,
    antiemetic therapy, and the length of stay in the
    PACU. However, it failed to facilitate late
    recovery (e.g., bowel function) or improve the
    patients overall quality of recovery. When used
    during bariatric surgery, a Dex infusion rate of
    0.2 µg kg1 h1 is recommended to minimize
    the risk of adverse cardiovascular side effects.

Anesth Analg 2008 1061741-1748
67
Cardiovascular Considerations
Consider an Arterial Line
  • Obesity in anaesthesia and intensive care
  • J. P. Adams and P. G. Murphy British Journal of
    Anaesthesia, 2000, Vol. 85, No. 1 91-108

68
Cardiovascular Effects Human Volunteers Under
Anesthesia
MAC
plt0.05
Ebert et al, Anesth Analg 199581S11-22
69
Sevoflurane Does Not Activate Sympathetic Nervous
System


Sympathetic Nerve Activity (bursts/100 heartbeats)
Adapted from Ebert et al, Anesth Analg
199581S11-22
plt0.05 vs. baseline
70
The Challenge
  • Predisposition to hemodynamic instability due to
    often increased basal increase in SVR and SVO2.
  • What better patient population to test all of our
    clinical skills?
  • Lets look at some of the options

71
Whom
72
Bariatric Surgery and the Prevention of
Postoperative Respiratory Complications
  • Meg A. Rosenblatt, MD, David L. Reich, MD, and
    Ram Roth, MD Department of Anesthesiology, Mount
    Sinai School of Medicine, New York, NY

Anesth Analg 2004981810-1811
73
Consider
  • Airway team both anesthesia providers agree on
    airway approach.
  • 2 attendings and difficult airway cart available
    for all non FOB intubations.
  • Thoracic Epidural Analgesia for RNY
  • 5minutes of High Humidity NRB 100 with SAO2
    monitoring before transfer to PACU

74
Difficult Tracheal Intubation Is More Common in
Obese Than in Lean Patients
  • Philippe Juvin, MD PhD, Elisabeth Lavaut, MD,
    Hervé Dupont, MD, Pascale Lefevre, MD, Monique
    Demetriou, MD, Jean-Louis Dumoulin, MD, and
    Jean-Marie Desmonts, MD

Anesth Analg 200397595-600
75
IMPLICATIONS
  • We report a difficult intubation rate of 15.5 in
    obese patients and 2.2 in lean patients.
  • None of the risk factors for difficult
    intubation described in the lean population was
    satisfactory in the obese patients.
  • We also report a high risk of desaturation in
    obese patients with difficult intubation.

76
The neurosciences evidence
  • Compelling evidence for the primacy of genetic
    influences.
  • There is exciting evolving investigations that
    implicate dysregulation of leptin and ghrelin
    production in the etiology of morbid obesity.

77
Insulin resistance, leptin and TNF-alpha system
in morbidly obese women after gastric bypass.
  • Molina A, Vendrell J, Gutierrez C, Simon I,
    Masdevall C, Soler J, Gomez JM. Obes Surg. 2003
    Aug13(4)615-21

78
The results
  • Leptin and the TNF-alpha system could be involved
    in the pathogenesis of obesity and insulin
    resistance.
  • We conducted a study after GBP to analyze the
    pattern of variation of anthropometric and body
    composition variables, leptin and sTNFR1 and 2.

79
The results
  • METHODS 29 morbidly obese women were studied, at
    baseline and throughout 6 months after gastric
    bypass.
  • RESULTS At baseline, the BMI was 49 /- 6
    kg/m(2) and patients showed a higher fasting
    insulin resistance index (FIRI), leptin,
    leptin/fat mass and sTNFR1 and 2 than did
    controls.
  • CONCLUSIONS Morbidly obese women after GBP
    became less insulin resistant with lower leptin
    concentrations, but showed an initial increase of
    sTNFR1 and 2.

80
If a man is standing in the middle of the forest
speaking and there is no woman around to hear
him... is he still wrong?
  • George Carlin

81
Plasma Ghrelin Levels after Diet-Induced Weight
Loss or Gastric Bypass Surgery
  • David E. Cummings, M.D., David S. Weigle, M.D.,
    R. Scott Frayo, B.S., Patricia A. Breen, B.S.N.,
    Marina K. Ma, E. Patchen Dellinger, M.D., and
    Jonathan Q. Purnell, M.D.
  • NEJM Volume 3461623-1630 May 23, 2002 Number 21

82
Conclusions
  • Conclusions The increase in the plasma ghrelin
    level with diet-induced weight loss is consistent
    with the hypothesis that ghrelin has a role in
    the long-term regulation of body weight.
  • Gastric bypass is associated with markedly
    suppressed ghrelin levels, possibly contributing
    to the weight-reducing effect of the procedure.

83
Treatment options
  • Pharmacologic
  • Diet
  • Exercise
  • Surgery
  • Combinations

84
Gastric Banding
  • Decreases stomach surface area
  • No associated malabsorbtive syndromes
  • Now adjustable laparoscopic gastric banding
    available

85
Gastric Bypass
  • Decreases stomach surface area
  • Bypasses significant portion of duodenum
    jejunal digestive surface area
  • Malabsorptive syndromes common
  • Open vs laparoscopic

86
Sevoflurane Anesthesia in the Obese Surgical
Patient Overview
  • Numerous clinical studies document the
    suitability of sevoflurane anesthesia for the
    obese surgical patient
  • Sevoflurane has distinctive properties that are
    well-suited to these patients
  • Nonpungent and does not cause respiratory
    irritability
  • Rapid, predictable hemodynamic response to
    titration
  • Does not increase heart rate at concentrations
    below 2 MAC
  • Smooth emergence and rapid recovery from
    anesthesia

Torri et al. J Clin Anesth. 200113565 Torri et
al. Minerva Anestesiol. 200268523 Sollazzi et
al. Obes Surg. 200111623 Martinotti et al.
Obes Surg. 19999180 Roizen In Anesthesia.
5th ed. 2000903 Ultane (sevoflurane) complete
Prescribing Information, Abbott Laboratories.
87
Sevoflurane for Laparoscopic Gastric Banding
  • Randomized, blinded study of 30 ASA status II and
    III morbidly obese patients (BMI gt35)
  • Following standard IV induction, anesthesia was
    maintained with sevoflurane or isoflurane (1.4
    MAC-hr exposure per group)
  • Extubation, emergence, and response times were
    significantly shorter in the sevoflurane group
  • Median time to PACU discharge eligibility was 15
    min in the sevoflurane group vs 27 min in the
    isoflurane group
  • Overall, no between-group differences in
    hemodynamic effects
  • 20 of sevoflurane patients required therapy for
    minor hemodynamic side effects vs 46 of
    isoflurane patients

Torri et al. J Clin Anesth. 200113565.
88
Sevoflurane for Laparoscopic Gastric Banding
  • Randomized, blinded study of 30 ASA status II and
    III morbidly obese patients (BMI gt35)
  • Following standard IV induction, anesthesia was
    maintained with sevoflurane or isoflurane (1.4
    MAC-hr exposure per group)
  • Extubation, emergence, and response times were
    significantly shorter in the sevoflurane group
  • Median time to PACU discharge eligibility was 15
    min in the sevoflurane group vs 27 min in the
    isoflurane group
  • Overall, no between-group differences in
    hemodynamic effects
  • 20 of sevoflurane patients required therapy for
    minor hemodynamic side effects vs 46 of
    isoflurane patients

Torri et al. J Clin Anesth. 200113565.
89
Would a fly without wings be called a walk?
  • George Carlin

90
Sevoflurane for Gastric Bypass Procedures
Extubation
  • Times to Extubation

38 difference
Plt0.05 vs isoflurane.
Sollazzi et al. Obes Surg. 200111623.
91
Sevoflurane for Gastric Bypass Procedures
Recovery Scores
  • Aldrete Recovery Scores After Surgery

Plt0.05 vs isoflurane.
Sollazzi et al. Obes Surg. 200111623.
92
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