Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2011
ReviewPostoperative pain management of the obese patient.
In the obese patient, the goal of postoperative pain management is provision of comfort, early mobilisation and improved respiratory function without causing inadequate sedation and respiratory compromise. The pathophysiology of obesity, typical co-morbidities and the high prevalence of obstructive sleep apnoea (OSA) amongst obese patients make safe analgesic management difficult. ⋯ Advice on general management includes multimodal analgesic therapy, preference for regional techniques, avoidance of sedatives, non-invasive ventilation with supplemental oxygen, early mobilisation and elevation of the head of bed to 30 degrees. Finally, with regard to monitoring, sedation scoring is most relevant, but there should be a low threshold for continuous pulse oxymetry, arterial blood pressure measurement and placement in a high-dependency area for the postoperative period.
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Best Pract Res Clin Anaesthesiol · Mar 2011
ReviewAnaesthesia for adults undergoing non-bariatric surgery.
Obesity is a worldwide epidemic with increasing importance in both industrialised and developing countries. Anaesthesiologists will be increasingly challenged by the care for morbidly and super-obese patients. ⋯ Careful preoxygenation, special positioning, adequate monitoring and adapted intra-operative ventilation are key issues for a successful perioperative care. While co-morbidities are frequent in the obese, overall morbidity and mortality up to a body mass index (BMI) < or = 40 kg m(-2) are not significantly increased compared with lean patients.
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Best Pract Res Clin Anaesthesiol · Mar 2011
ReviewThe epidemiology and aetiology of obesity: a global challenge.
Positive energy imbalance Energy imbalance leads to obesity. A majority of the US population is overweight, a third obese and nearly 5% morbidly obese. In the developing world, this problem continues to evolve in an rapid manner, creating challenges for already burdened health systems. ⋯ Factors ranging from the availability of calorie-dense foods, decreased time spent in physical activities, technologically assisted household chores to time spent watching television, all have some contribution to the problem. Much more needs to be done to control this obesity epidemic, both from a public health as well as a communal-expense perspective. Forced misuse of economic resources and wasted potential lives should drive a better coordinated effort to control what could possibly be the biggest health challenge of the 21st century.
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Nearly 20% of all patients admitted to an intensive-care unit are obese. Their excess weight puts them at risk for several problems and complications during their intensive-care unit stay. Especially, pulmonary problems need particular attention, and comprehensive knowledge of the specific pathophysiologic changes of the respiratory system is important. ⋯ Careful positioning of the obese is essential to optimise ventilation and facilitate weaning from mechanical ventilation. Optimal hypocaloric nutrition with a high proportion of proteins is advised to control hyperglycaemia. Because mortality in obese patients is similar to or lower than in non-obese ones, it is conceivable that obesity has a protective effect in the critically ill.
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Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The 'ramped' upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. ⋯ Local anaesthetic wound infiltration and non-steroidal anti-inflammatory drugs should be part of multimodal opioid-sparing postoperative analgesia. Implementation of bariatric clinical-care pathways seems beneficial. Considering the prevalence of sleep apnoea in these patients, outpatient bariatric surgery remains controversial, but is probably safe for certain procedures, provided there is strict adherence to preoperative eligibility and home-care protocols.