Key note lecture: The importance of synergy between surgery

London 28 nov 2014
Key note lecture:
Factors for successful surgery:
The importance of synergy between surgery &
anesthesiology in bariatric surgery.
Should there be a subspecialty?
Prof. Jan Paul Mulier
Departement of Anesthesiology
AZ Sint – Jan AV Brugge Belgium
London Mulier 2014
Should there be a subspecialty?
•  A:Sub-speciality
or B:Sub-society?
•  A:Anesthesia of the obese patient
or B:Anesthesia for bariatric and metabolic surgery?
•  A:Achieving credits by extra training in a certified center
and/or examinations before qualification
or B:Scientific meetings and/or live training?
•  A:Part of the basic anaesthesia training
or B:Post specialisation training?
London Mulier 2014
1. We need a sub society for
Anaesthesia of the obese patient
Anaesthesia of an obese patient requires special anaesthetic knowledge,
skils and equipment.
To improve this we need to:
•  Stimulate Research, by bringing interested researchers in this area
together, by giving a forum to exchange ideas and by stimulation of
publications together.
•  Improve the Skills of anaesthesiologists and the supporting team by
training, by congresses and by providing clinical visits and clinical
training.
•  Adapt our equipment by the stimulation of inventions (in the industry)
•  Discuss with surgeons what we need and what they need to improve
together the patient outcome.
•  By understanding each other problems we
London Mulier 2014
Mission of ISPCOP ESPCOP SOBA
The Mission of both Societies for the Perioperative Care of the Obese Patient
is to promote
Excellence in Clinical management, Education and Research
regarding the care of the morbidly obese patient
during the perioperative period.
London Mulier 2014
Function of Society ESPCOP ISPCOP SOBA
•  The societies deal with a disease, a medical problem being obesity with
its different components like
•  Metabolic syndrome
•  Diabetes
•  Hypertension
•  Central obesity
•  OSAS
•  Hypoventilation syndrome and pulmonary hypertension
•  The society is not fixed to one work environment but combines
anaesthesiologists, intensivists and emergency care physicians who all
deals with these problems peri operative.
•  The anaesthesia is including all surgery types from bariatric surgery to
orthopaedics, including also sedation for diagnostic procedures.
London Mulier 2014
01:50:55
ESPCOP [[email protected]] namens ESPCOP [[email protected]]
Verzonden:zaterdag 24 mei 2014 18:54
To:
dr. Jan Mulier
26
Anesthetic Aspects of Bariatric Surgery
Newsletters
Bariatric Times • May 2013
ESPCOP Newsletter
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ANESTHETIC
ASPECTS of Bariatric Surgery
Column Editor: Stephanie B. Jones, MD
Dr. Jones is Associate Professor, Harvard Medical
School and Vice Chair for Education, Department of
Anesthesia, Critical Care and Pain Medicine, Beth Israel
Deaconess Medical Center, Boston, Massachusetts.
THIS MONTH:
Intraoperative Fluid
Assessment in Patients
with Obesity
by KONSTANTIN BALONOV, MD
Bariatric Times. 2013;10(5):26–27.
This ongoing column is authored by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient.
ABSTRACT
Intraoperative fluid management in morbidly obese patients remains a controversial and
under-researched topic. Minimizing the risk of the intraoperative complications requires
precise assessment of the patient’s volume status. This article reviews current scientific
views and concepts regarding fluid management in morbid obesity. Goal-directed therapy
appears to be the most accurate approach in guiding fluid management. Dynamic
parameters such as pulse pressure variation are considered to be the most reliable in
assessing volume status and fluid responsiveness of the patient.
KEYWORDS
bariatric surgery, fluids, intravascular volume
INTRODUCTION
Estimation of intravascular volume is
one of the most important clinical skills
of the anesthesiologist. Management of
the fluid balance in patients with
morbid obesity remains controversial,
which, to great extent, can be
attributed to the lack of randomized
controlled studies. Current paradigms
for fluid management in this patient
population are based on studies that
mostly compared liberal to restrictive
approaches in a nonobese population.
FLUID MANAGEMENT APPROCHES:
BENEFITS AND RISKS
Liberal fluid management can
produce a positive fluid balance, weight
gain, and congestive heart failure while
a more restrictive approach may
increase the risk of acute tubular
necrosis and rhabdomyolysis. The
benefits of the liberal approach as
demonstrated in studies by Ettinger et
al,1 Schuster et al,2 and Oggunnaike et
al3 include the prevention of
rhabdomyolysis and a decrease in
postoperative nausea and vomiting.
Patients with more liberal fluid
management (40mL/kg vs. 15mL/kg
totak body weight [TBW]) also
produced significantly higher urine
output in the operating room, in the
post-anesthesia care unit (PACU), and
on Postoperative Days 0 and 1 as
demonstrated by Wool et al.4 However,
the same study failed to prove any
changes in the incidence of
rhabdomyolysis.4
On the other hand, a restrictive
approach to intra- and postoperative
fluid management has been advocated
by Brandstrup et al.5 Surgical patients
whose fluid balance was managed in the
more restrictive fashion demonstrated
faster recovery of gastrointestinal (GI)
function, better wound healing, and
improvement in pulmonary function
and tissue oxygenation. In the bariatric
setting, as proposed by McGlinch et al,6
limiting intravenous fluids reduced the
incidence of postoperative pulmonary
dysfunction and hypoxia, and
shortened hospital stay.
Recently, urine output as a guide for
perioperative fluid management has
been challenged. A study by Matot et al7
demonstrated low urine output in
bariatric patients regardless of relatively
high-volume fluid therapy. The authors
concluded that their results potentially
invalidate urine output as a reliable
indicator of the fluid status in the
patients with obesity and further
investigation is required.
Steep head-up (reverse
Trendelenburg) position in the
presence of pneumoperitoneum
represents another challenge for the
intraoperative assessment of fluid
balance. Under general anesthesia, this
position is associated with a gravity-
induced shift of blood volume to the
lower part of the body, which frequently
results in a significant decrease of
cardiac output and blood pressure.8,9
GUIDING PARAMETERS FOR
ADMINISTERING FLUIDS TO
PATIENTS WITH OBESITY
While administering fluids in patients
with morbid obesity undergoing
bariatric procedures or any other type
of surgeries, a promising technique is to
assess fluid responsiveness, and include
this parameter in the concept of goaldirected therapy (GDT), as proposed
by many authors.10,11 GDT encompasses
a technique involving intensive
monitoring and aggressive management
of intraoperative hemodynamics. It is
based on the achievement of certain
values rather than estimating fluid
status and calculating interventions.
Fluid responsiveness is defined as an
ability of the heart to increase stroke
volume in response to volume
expansion.
Dynamic parameters such as pulse
pressure variation (PPV) and stroke
volume variation (SVV), derived from
arterial waveform analysis, have been
suggested as the most reliable
indicators of fluid responsiveness in
mechanically ventilated patients as long
as sinus rhythm is maintained. A recent
study by Jain and Dutta12 demonstrated
the value of SVV in the bariatric
population. PPV or SVV values greater
than 13 percent indicate fluid
responsiveness, while patients with PPV
below nine percent should be
considered nonresponders.12 Twentyfive percent of the patients with PPV
value between 9 and 13 percent
represent the so called “gray zone,”
when fluid responsiveness cannot be
reliably predicted.13
Plethysmographic waveform
variation (PWV) obtained from the
pulse oximetry waveform is a
completely noninvasive dynamic
parameter that can also be used to
assess fluid responsiveness as described
by Pizov et al.14 Its noninvasive nature,
minimal additional cost, and practically
universal availability represents a major
benefit for its use. However, compared
to arterial waveform analysis, the
authors found some delay in detecting
hypovolemia. In other words, PWV may
be useful at levels of more profound
hypovolemia. There are other new
technologies for noninvasive
assessment of the cardiac output, PPV,
and SVV, such as the ccNexfin
(Edwards Lifesciences, Amsterdam,May ESPCOP Newsletter
Netherlands) that uses a finger cuff for
assessment of blood pressure and
interested in his work. Anaesthesia
derived variables. Based on a recent
Ed. Leafing through your research work, I was inspired from an
publication by Fischer et al,16 this
was working with monitoring that
technology was not sufficiently useful in
iterative topic “the ten golden
rules atofthat
obesity
a postoperative cardiac surgical
required
time aanaesthesia…”
lot of
population. On the other hand, early
Paraphrasing I shall continue
with” the
ten short
questions”
for the
results from intraoperative use in a
technical
expertise
besides
clinical
bariatric population suggest that
expertise. The ability to measure
ccNexfin may be comparable to
ESPCOP
President.
invasive PPV determination.17
the effect of your drugs and actions
The FloTrac (Edwards Lifesciences)
is a minimally invasive system that
directly, opened the world of
calculates vascular tone and cardiac
Professor Mulier , may we start with you giving us some brief
output by analyzing the waveform
physiology to me. Surgery at that
derived from the arterial line. Along
biographical information? How did you come into the profession?
with the SVV, it provides continuous CO
time seemed more manual work
and central venous oxygen saturation
And how long have you been
in obesity
(ScvO2) if connected to a central
andinterested
internal medicine
was topics?
venous line. The additional parameters
provided by the FloTrac can be used in
descriptive. At that time monitoring
bariatric patients with significant
cardiac comorbidities.
was airway pressure, manual blood pressure and an ECG if
Pulse-contour analysis-based
available,
butage
an explosion
in monitoring
technology
was aabout
to
techniques, such as PiCCO (Pulsion
JM. At the
of 18 when
I decided
to become
physician
and not
Medical Systems SE, Munich, Germany)
take place.
are a comprehensive modality for
an
engineer,
I
assisted
in
the
operating
room
for
my
father
who
is a
perioperative cardiovascular
assessment as they provide not only
surgeon
and
gynaecologist.
At
the
operating
table
in
1977
I
met
my
real-time measurement of PPV, SVV,
After several years of limited clinical experience I finally began my
and cardiac output, but also useful
uncle
Michel
Mulier,
who
worked
as
anaesthesiologist
and
I
got
newer parameters, such as Global Endtraining in anaesthesia and became more focused on research. In
Diastolic Index, intrathoracic blood
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Talking with…in this issue
ESPCOP President, Jan
Paul Mulier
London Mulier 2014
my second year the first endoscope-mounted echo probe became
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4.
5.
6.
7.
8.
b. Globesity
Challenge - Rome
News from Elsewhere
"Anaesthesia Excellence"
- Neil Hutcher , Surgical
Review Corporation
Special article
“Obesity Epidemic: The
Medical Profession Fights
Back” - Euan Shearer
Editor’s notes - Is sugar
1. Talking with… Jan Mulier
the most dangerous
the ESPCOP President
drug?
STAMPEDE2.study
Brit Cop - The SOBA
Upcoming events
way-Michael Margarson
Tell your Story!
3. News from around
Europe
a. 5th ESPCOP
meeting - Gent
BritCOP -b. Globesity
interested in his work. Anaesthesia
available. My orthopaedic surgeon uncle was performing many total
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Fibre-Optic Intubation in the Morbidly
Obese: A Pilot Survey of International
Opinions and Practices.
Research
John Cousins, Mike Margarson
Society for Obesity and Bariatric Anaesthesia
Depts. of Anaesthesia, Charing Cross Hospital London & St Richards Hospital, Chichester UK
Background
The management of the airway in the
morbidly obese patient is a source of
great concern to many anaesthetists, and
there is considerable variation in practice
between different countries. Awake fibreoptic intubation (FOI) is held the goldstandard in safe airway management, but
its precise role is much debated.
Objectives
Bariatric Anaesthetists have the most
extensive experience of managing
morbidly obese patients. We therefore
performed an international survey of
anaesthesia colleagues from major
bariatric surgical centres to better
understand the incidences and drivers
around decision making for FOI in the
obese.
www.ISPCOP.ORG
Methods
Thirty-nine members of the two major
societies for obesity anaesthesia
(ISPCOP & SOBA) with a known major
bariatric practice were personally
contacted by email.
Five questions were initially asked,
pertaining to experience in any morbidly
obese patient (BMI >40 kg.m-2) over the
last five years (see table 1 below).
To date, 28 bariatric specialists from 11
countries have responded (72% of those
approached). These reported a combined
experience of 21,145 general anaesthetic
procedures in Morbidly Obese (BMI >40)
patients over the past five years
A total of 278 FOIs were reported, an
overall incidence of 1:80. 155 of these
were performed for “classical indications”
i.e a past history of airway problems.
acute airway swelling, scarring etc. and
these are discounted in the subsequent
results.
Rate
Northern
Europe (14)
13930
31
0.22%
Southern
Europe (4)
2640
77
2.9%
North
America (7)
3225
15
0.47%
South
America (3)
1350
0
0%
Table 2: International comparison of FOI
incidence
Discussion
In 14 of the 27 centres, representing 53%
of the total number of MO patients, no
FOI was ever done for obesity alone.
This is a pilot survey and the numbers of
respondents are small, so extrapolation
of this data must be done with great
caution.
There were three episodes of transient
CICV described amongst the entire
cohort of cases, in none did the patient
come to harm.
Sixteen (41%) of respondents felt that
their incidence of FOI was reducing,
fifteen attributing this to the presence of
videolaryngoscopes, and one feeling
Intubating LMAs were responsible. Three
considered that cyclodextrans had
contributed.
Nineteen respondents provided free-text
comments, five of these mentioned the
role of training.
1. Please estimate how many Morbidly Obese patients (BMI >40) you have personally
anaesthetised in the past five years. (include those where you were present in the
operating theatre at induction, even if supervising a trainee)
2. Please estimate - or if you are sure of the number tell us - in how many of those
morbidly obese patients you performed an awake fibre-optic intubation (past 5 years)
3. Please estimate in what percentage of those fibre-optic intubations numbered above,
you chose the technique primarily because of predicted difficulties due to obesity alone
(and not because of a known and clear anatomical indication; e.g. Mandibular fracture,
head and neck scarring/radiotherapy, or other acute swelling)
4. Have you ever had a "can't intubate, can't ventilate" scenario
patient (BMI >40) that you have personally anaesthetised?
in a morbidly obese
5. Do you believe that because of the availability of Sugammadex and/or video
laryngoscopes, that you have performed significantly fewer awake Fibre-optic intubations
in recent years?
Any other comments or thoughts??? Please add below, I may refer to these, but they will
of course be anonymous.
Western Sussex Hospitals
FOI for
Obesity
123 (1:170) were performed primarily for
predicted difficult airway due to obesity.
The median incidence of FOI for this
indication was 0.1% (IQR 0-0.9%).
Table 1: Questions circulated to the members of ISPCOP and SOBA who were surveyed
London Mulier 2014
Total
Cases
Results
However, there appears to be a large
variation in the practice of FOI. Bigger
centres with greater experience use the
technique rarely, and northern European
centres use it least. Within the free text
responses, it appears that many of the
reported FOIs were performed
predominantly with training purposes in
mind.
The presence of two centres with
markedly higher incidences of fibre-optic
intubation skew the figures because of
the relatively small sample size, and thus
the overall figures (and particularly the
international figures) must be interpreted
with caution .
A larger and more detailed survey to
explore the drivers behind FOI practice
today is underway.
Conclusions
There is a huge variation in the practice
of FOI in the morbidly obese.
Larger centres with greater experience
use the technique rarely, and northern
European centres use it least. Many of
the reported FOIs were performed
predominantly with training purposes in
mind.
The impact of Videolaryngoscopy would
appear to be reducing the number of
awake fibre-optic intubations performed.
THE SOCIETY FOR OBESITY AND BARIATRIC ANAESTHESIA GUIDELINES
ANAESTHESIA FOR THE OBESE PATIENT: BMI>35KG/M2
Preoperative Evaluation
Instruction cards
Any of:
Central Obesity (waist > half height)
Difficult airway /Ventilation problems more likely
Greater risk of CVS disease, thrombosis
↑Risk of Metabolic syndrome:
Central Obesity plus Hypertension
Dyslipidaemia, Insulin resistance
Peripheral Obesity
(Fat outside body
cavity)
Less co-morbidity
Intra Operative Management
Suggested Equipment
Suitable bed/trolley & operating table
Gel padding, wide strapping, table
extensions/arm boards
Forearm cuff or large BP cuff
Ramping device, step for anaesthetist,
difficult airway equipment, ventilator
capable of PEEP and pressure modes.
Hover mattress or equivalent.
Long spinal, regional and vascular needles.
Ultrasound machine.
Depth of anaesthesia and neuromuscular
monitoring.
Enough staff to move patient.
www.SOBAUK.COM
Ramping
Ear level with sternum. Reduces
risk of difficult laryngoscopy,
improves ventilation.
Drug dosing- what weight to use?
Induction agents: titrate to cardiac output- this equates to lean
body weight in a fit patient.
Competitive muscle relaxants: use lean body weight.
Suxamethonium use adjusted body weight to a maximum of
200mg
Neostigmine: Increase dose
Opioids: Use Lean body weight. Care with obstructive apnoea!
TCI propofol: IBW plus 40% excess weight
If in doubt, titrate and monitor effect!
Lean Body Weight this exceeds Ideal body weight in the obese
and plateaus ≈90kg for a man, ≈70kg for a woman.
Ideal Body Weight in Kg - Broca formula
Men: height in cm minus 100 Women: height in cm minus 105
Anaesthetic Technique
Consider premed antacid & analgesia,
careful glucose control & DVT prophylaxis.
Self-position on operating table.
Preoxygenate & intubate in ramped position
+/- CPAP. Minimize induction to ventilation
interval to avoid desaturation. Commence
maintenance anaesthesia promptly.
Tracheal intubation is recommended.
Avoid spontaneous ventilation. Use PEEP.
Use short-acting agents e.g. desflurane or
propofol infusion. short-acting opioids,
multimodal analgesia. PONV prophylaxis.
Ensure full NMB reversal.
Extubate and recover in head up position.
Suggested dosing regimes for anaesthetic drugs
Lean Body Weight Adjusted Body Weight
Males 90Kg Females 70Kg
Ideal plus 40% excess
Propofol induction
Thiopentone
Fentanyl
Rocuronium
Atracurium
Vecuronium
Morphine
Paracetamol
Bupivacaine
Propofol Infusion
Suxamethonium (Max 200mg)
Alfentanil
Lidocaine
Neostigmine (5mg)
Sugammadex (see package insert)
Antibiotics
Low Molecular weight Heparin
Post Operative Management
PACU discharge: Usual discharge criteria should be met. In addition, SpO2 should be maintained at pre-op levels with
minimal O2 therapy, without evidence of hypoventilation.
OSA or Obesity Hypoventilation Syndrome: Sit up. Avoid sedatives and post-op opioids. Reinstate CPAP if using it pre-op.
Additional time in recovery is recommended, only discharge to the ward if free of apnoeas without stimulation.
Patients untreated or intolerant of CPAP who require postoperative opioids are at risk of hypoventilation and require
continuous oxygen saturation monitoring. Level 2 care is recommended. Effective CPAP reduces this risk to near normal.
Ward care: Escalation to Level 1, 2 or 3 care may be required based on patient co-morbidity, the type of surgery undertaken
and issues with hypoventilation discussed above. General ward care includes: multimodal analgesia, caution with longacting opioids and sedatives, early mobilisation and extended thromboprophylaxis.
London Mulier 2014
See www.SOBAuk.com for references
Guidelines
The European Society for Perioperative Care of the Obese Patient
Key points to remember in anaesthesia
for the morbidly obese patient.
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight
(TBW) on operating list. If central obesity (weight >half
height), look for metabolic syndrome.
• Metabolic syndrome = visceral obesity plus diabetes,
dyslipidaemia, hypertension. These are the high risk patients.
• Atrial fibrillation, long QT, heart failure, pulmonary
hypertension or a cardiomyopathy?
• 10% pre operative body weight reduction is important
if visceral obesity. Improves respiratory function and
laparoscopic surgical access.
• “STOP BANG ”questionnaire ≥ 5 or Obesity
Hypoventilation Syndrome (OHS) (paCO2 >45mmHg)
-> regional or opioid free anaesthesia or postoperative
CPAP.
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or
bag under thorax.
• Pre-oxygenation and 10 cmH2O CPAP until the
intubation.
• Know the correct dosing scalars for induction agents and
muscular relaxants.
www.ESPCOP.ORG
• Mallampati and large neck circumference = difficult
laryngoscopy /intubation.
• Facemask ventilation is frequently problematic –needs
two hands ventilation and airways.
• Avoid laryngeal and supraglottic devices, endotracheal
tubes should be the default airway.
3. Key points in anaesthesia maintenance.
• Lung recruitment maneuvers after intubation followed by
sufficient PEEP even when oxygen saturation is normal.
• Lung protective ventilation and beach chair position
when possible.
• Prefer water-soluble short acting drugs that are easy to
dose and to monitor.
• Prefer loco regional anaesthesia. Avoid long working
sedatives and opioids.
• Monitor the neuromuscular blockade (TOF and PTC ) to
provide sufficient depth if use neuromuscular blocking agents.
• Monitoring anaesthesia depth limits the anaesthetic load
and avoids awareness.
4. Key points in anaesthesia emergence.
• Use Pressure Support Ventilation and evaluate breathing
frequency.
• Be sure to have full neuromuscular blockade reversal.
• Empty stomach and avoid suctioning endotracheal tube
(if needed follow with recruitment).
• Extubation under CPAP in beach chair position when
fully awake.
• Avoid sedation and use the lowest level of opioids.
5. Key points in postoperative care.
• Continue with CPAP mask if used before surgery.
• Beach chair position or better sitting up to 60°.
• Sufficient pain and PONV treatment.
• Promote early mobilization and provide
tromboprophylaxis.
• Look for SpO2 desaturations and hypercarbia.
• Be aware of rhabdomyolysis when prolonged surgery in
the sitting position.
Key points to remember in anaesthesia for the morbidly obese patient © www.Espcop.org
London Mulier
2014 Michael Margarson, Paolo Pelosi, Thomas Gazynski, Luc de Baerdemaeker, Jan Mulier
Claire Nightingale,
The European Society for Perioperative Care of the Obese Patient
Key points to remember in anaesthesia
for the morbidly obese patient.
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight
(TBW) on operating list. If central obesity (weight >half
height), look for metabolic syndrome.
• Metabolic syndrome = visceral obesity plus diabetes,
dyslipidaemia, hypertension. These are the high risk patients.
• Atrial fibrillation, long QT, heart failure, pulmonary
hypertension or a cardiomyopathy?
• 10% pre operative body weight reduction is important
if visceral obesity. Improves respiratory function and
laparoscopic surgical access.
• “STOP BANG ”questionnaire ≥ 5 or Obesity
Hypoventilation Syndrome (OHS) (paCO2 >45mmHg)
-> regional or opioid free anaesthesia or postoperative
CPAP.
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or
• Mallampati and large neck circumference = difficult
London
Mulier
2014
bag under thorax.
laryngoscopy /intubation.
• Pre-oxygenation and 10 cmH2O CPAP until the
• Facemask ventilation is frequently problematic –needs
Am J Clin Nutr 2006;84:304 –11
Liver size reduction occurs in the first
2 weeks.
Reduction in visceral adipose tissue
(VAT) is faster than body weight, both
occurs over 12 weeks.
Massive hepatomegaly patients lose
more liver volume.
London Mulier 2014
Key points to remember in anaesthesia
for the morbidly obese patient.
The European Society for Perioperative Care of the Obese Patient
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight
(TBW) on operating list. If central obesity (weight >half
height), look for metabolic syndrome.
• Metabolic syndrome = visceral obesity plus diabetes,
dyslipidaemia, hypertension. These are the high risk patients.
• Atrial fibrillation, long QT, heart failure, pulmonary
hypertension or a cardiomyopathy?
• 10% pre operative body weight reduction is important
if visceral obesity. Improves respiratory function and
laparoscopic surgical access.
• “STOP BANG ”questionnaire ≥ 5 or Obesity
Hypoventilation Syndrome (OHS) (paCO2 >45mmHg)
-> regional or opioid free anaesthesia or postoperative
CPAP.
Key points to remember in anaesthesia
for the morbidly obese patient.
2.
induction.
1. Key
Key points
points in
in anaesthesia
pre operative
planning:
•• HELP:30
degree
upBMI
position,
add ramping
device or
Record body
masshead
index
and total
body weight
bag
under
(TBW)
on thorax.
operating list. If central obesity (weight >half
• Pre-oxygenation
and 10 cmH2O
CPAP until the
height), look for metabolic
syndrome.
intubation.
• Metabolic syndrome = visceral obesity plus diabetes,
• dyslipidaemia,
Know the correct
dosing scalars
agents
and
hypertension.
Thesefor
areinduction
the high risk
patients.
muscular
relaxants.
• Atrial
fibrillation,
long QT, heart failure, pulmonary
hypertension or a cardiomyopathy?
•• Mallampati
and large
neck
circumference
= difficult
10% pre operative
body
weight
reduction is
important
laryngoscopy
/intubation.
if visceral obesity. Improves respiratory function and
• Facemask
ventilation
is frequently problematic –needs
laparoscopic
surgical access.
two
hands
ventilation
and airways.
• “STOP BANG ”questionnaire
≥ 5 or Obesity
• Avoid
laryngeal
and
supraglottic
devices,
Hypoventilation Syndrome (OHS)
(paCO2endotracheal
>45mmHg)
tubes
shouldorbeopioid
the default
airway. or postoperative
-> regional
free anaesthesia
CPAP.
3. Key points in anaesthesia maintenance.
• Lung recruitment maneuvers after intubation followed by
• Prefer loco regional anaesthesia. Avoid long working
sedatives and opioids.
•• Lung
protective
and beach
position
•• Monitor
the neuromuscular
blockade
(TOF and=PTC
) to
HELP:30
degreeventilation
head up position,
addchair
ramping
device or
Mallampati
and large neck
circumference
difficult
when
possible.
provide
sufficient
depth
if
use
neuromuscular
blocking
agents.
bag under thorax.
laryngoscopy /intubation.
•• Prefer
water-soluble
acting CPAP
drugs that
•• Monitoring
anaesthesia
limitsproblematic
the anaesthetic
load
Pre-oxygenation
andshort
10 cmH2O
untilare
theeasy to
Facemask ventilation
is depth
frequently
–needs
London
Mulier
2014
dose
and to monitor.
and
awareness.and airways.
intubation.
two avoids
hands ventilation
• Know the correct dosing scalars for induction agents and
• Avoid laryngeal and supraglottic devices, endotracheal
2. Key
points
anaesthesia
induction.
sufficient
PEEPin
even
when oxygen saturation
is normal.
Sterno mental distance without safety bird
Sterno mental distance
Normal position
Use of inflatable pillow
• Mulier J.P., Dillemans B. Intubation time with and without inflatable intubation device
London Mulier 2014
Eur J Anesthesia 2007 Suppl
• Mulier J.P., Dillemans B. CT analysis of the safety bird in
mobid obese patients
sterno mandibular cm
Inflatable pillow under thorax elongates sterno
mandibular distance
24
22
20
18
SM on
16
14
SM off
12
10
8
25
35
45
55
65
75
bmi
London Mulier 2014
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or
bag under thorax.
• Pre-oxygenation and 10 cmH2O CPAP until the
intubation.
The•European
Society
for
Perioperative
of the
Know the correct
dosing
scalars
for induction Care
agents and
muscular relaxants.
• Mallampati and large neck circumference = difficult
laryngoscopy /intubation.
• Facemask ventilation is frequently problematic –needs
two hands ventilation and airways.
Obese
Patientand supraglottic devices, endotracheal
• Avoid laryngeal
tubes should be the default airway.
3. Key points in anaesthesia maintenance.
Key points to remember in anaesthesia
for the morbidly obese patient.
• Lung recruitment maneuvers after intubation followed by
sufficient PEEP even when oxygen saturation is normal.
• Lung protective ventilation and beach chair position
when possible.
• Prefer water-soluble short acting drugs that are easy to
dose and to monitor.
1. Key points in pre operative planning:
4. Key
points in anaesthesia emergence.
• Record body mass index BMI and total body weight
• Use
Pressure
Supportlist.
Ventilation
evaluate
breathing
(TBW)
on operating
If centraland
obesity
(weight
>half
frequency.
height), look for metabolic syndrome.
• Be
sure to syndrome
have full neuromuscular
blockade
reversal.
Metabolic
= visceral obesity
plus diabetes,
• Empty
stomachhypertension.
and avoid suctioning
tube
dyslipidaemia,
These are endotracheal
the high risk patients.
• Atrial fibrillation, long QT, heart failure, pulmonary
hypertension or a cardiomyopathy?
5. Key points in postoperative care.
• Prefer loco regional anaesthesia. Avoid long working
sedatives and opioids.
• Monitor the neuromuscular blockade (TOF and PTC ) to
provide sufficient depth if use neuromuscular blocking agents.
• Monitoring anaesthesia depth limits the anaesthetic load
and avoids awareness.
• 10% pre operative body weight reduction is important
(if
needed obesity.
follow with
recruitment).
if visceral
Improves
respiratory function and
• Extubation
under
CPAP
in
beach
chair position when
laparoscopic surgical access.
awake.
• fully
“STOP
BANG ”questionnaire ≥ 5 or Obesity
• Avoid
sedation and
use the lowest
of opioids.
Hypoventilation
Syndrome
(OHS)level
(paCO2
>45mmHg)
-> regional or opioid free anaesthesia or postoperative
CPAP.
• Continue with CPAP mask if used before surgery.
tromboprophylaxis.
• Beach chair position or better sitting up to 60°.
• Look for SpO2 desaturations and hypercarbia.
2. Key
points in anaesthesia induction.
• Sufficient pain and PONV treatment.
• Be aware of rhabdomyolysis when prolonged surgery in
HELP:30early
degree
head up position,
add ramping device or
• Mallampati
and large neck circumference = difficult
• Promote
mobilization
and provide
the sitting position.
bag under thorax.
laryngoscopy /intubation.
• Pre-oxygenation and 10 cmH2O CPAP until the
• Facemask ventilation is frequently problematic –needs
Key points
to remember in anaesthesia for the morbidly
obese Mulier
patient 2014
© www.Espcop.org
London
intubation.
two
hands ventilation and airways.
Claire
Nightingale,
Michael
Margarson,
Paolo
Pelosi,
Thomas
Gazynski,
Luc de
Baerdemaeker,
Jan Mulier
• Know the correct dosing scalars for induction agents and
• Avoid laryngeal
and
supraglottic devices,
endotracheal
60°
90°
30°
45°
30° -> 0°
London Mulier 2014
London Mulier 2014
2. We need a subspeciality in
Anaesthesia for the surgery of Obesity and Metabolic
Disorders
•  A sub speciality focus on giving better patient care
•  By having a dedicated group of anaesthesiologists
•  Who work frequent in an area.
•  Who develop local guidelines for those less involved
•  The work area is not patients who are obese as these patients are not
grouped but are bound to the different surgeries.
•  The work area for an anaesthesiologist in the OR can be a certain
surgical discipline like cardiac surgery, thoracic surgery, orthopaedic
surgery or obesity and metabolic surgery.
•  In most centres this is combined with upper abdominal or thoracic
surgery when the bariatric volume is limited or when the surgical team
performs also other abdominal procedures.
London Mulier 2014
The Anesthesia for the surgery of Obesity and
Metabolic Disorders
Giving anesthesia for
Gastric banding
Gastric bypass
Sleeve gastrectomy
Biliopancreatic diversion
Giving anesthesia for revision procedures in patients
with acute post operative Bleeding
with acute or chronic Leak
with insufficient weight loss or weight regain
with excessive weight loss till cachexia
in acute or chronic obstruction
Ex of a common surgical anaesthesia interaction where we need
to understand each other
and2014
need to help each other.
London Mulier
Can we do something to improve the
situation?
Intraabdominal pressure ?
Intraabdominal volume?
Workspace?
20
• 
Surgeon: The abdomen is flat, I have no space to
operate, I think the patient is pressing!
• 
Anesthesiologist: I don’t measure any change, your
problem? The patient is asleep and stable,
everything fine at my side.
• 
Surgeon: Look at the video screen. How do you
want me to operate in so little space? And the
pressure is already 18 mmHg.
• 
Anesthesiologist: The patient will not tolerate
higher pneumoperitoneum pressures. An
experienced surgeon can handle this.
• 
Surgeon: Do you want me to change to a
laparotomy? When was the last time you gave a
musclerelaxant, and by the way why do I always
have to ask that?
• 
Anesthesiologist: The patient has only one TOF
response in the AP. Last time this was enough.
What’s happening today with you?
• 
Surgeon: I don’t know what “one TOF response”
means. What I said is I can´t work with you. Call
your supervisor!
London Mulier 2014
From the most sensitive to the most resistant muscle for NMB
Tongue, throat muscles
Peripheral mucles, adductor pollicis
Orbicularis oculi
Corrugator supercilii
Abdominal mucles,
Vocal cords
Clinical definition of deep block:
TOF = 0 and PTC < 5
London Mulier 2014
Diaphragm
Laparoscopic view at 12 mmHg IAP
More space between stomach and anterior wall at deep NMB
Is ideal IAP for surgeon in this patient if deep NMB is applied
Moderate NMB
TOF = 2 PTC = /
IAP = 12 mmHg
E=2
PV0 = 8 ?
Calculated vol at 12 = 2 liter
London Mulier 2014
Deep NMB
TOF = 0 PTC = 6
IAP = 12 mmHg
E=2
PV0 = 6
Calculated vol at 12 = 3 liter
23
Can we change the OR scenario into...
• 
• 
• 
• 
• 
• 
• 
Surgeon: Now I can work and I have
enough space.
Anesthesiologist: the patient is OK.
Surgeon: Look at the screen. The
patient is relaxed and the IAP is low.
Anesthesiologist: the patient is now
on a deep neuromuscular block.
Surgeon: how many PTCs has the
patient in the adductor pollicis?
Anesthesiologist: only 3 PTCs, I will
keep him on a deep NMB until the end
and give Bridion to reverse after the
last stitch.
Surgeon: thanks, then we will end in
time and we can have a drink
together.
London Mulier 2014
Laparoscopic space (IAV) predicted
or measured at insufflation
IAV > 4 L
Large Abdomen
IAV 2 – 4 L
Medium Abd
Moderate or
no NMB
IAP 15 mmHg,
high opioids,
or low BIS
Deep NMB
IAP 12 mmHg,
less opioids,
and BIS 40- 60
Deep NMB
IAP 15 mmHg,
less opioids,
and BIS 40- 60
Laparotomy or
cancel case
IAV < 2 L
Small Abdomen
Deep NMB
IAP 18 mmHg,
and surgical
problems
London Mulier 2014
Weight
reduction pre
operative?
Abdominal
recruitment at
high IAP
Should there be a
subspecialty?
Hope is not enough to turn to change
•  YES: Sub-speciality for Anaesthesia for bariatric and
metabolic surgery
•  YES: Sub-society for Anaesthesia of the obese patient
•  YES: extra training in a certified centre
•  YES: Scientific meetings and live training?
•  YES: Part of the basic anaesthesia training and Post
specialisation training?
•  We deserve a dedicated surgeon who understand our
questions…
•  YOU deserve a dedicated anaesthesiologist who shares
your spirit: make him/her part of your team…
London Mulier 2014
London Mulier 2014
But what needs the surgeon?
Surgeon needs high IAP and
space/distance to put trocar
at the start
Surgeon needs space to
work during laparoscopy
Low pressure vs high
London Mulier 2014
Low volume vs high
Difference between active contraction
and relaxation
1.  No muscle relaxation
2.  Active contraction against ventilator
3.  Full muscle relaxation
30
1
25
2
3
2
40
1,5
30
1
20
15
0,5
10
IAP mmHg
35
IAP mmhg
PV loops with fit
2,5
IAP
IAV
40
IAV liter
45
IAP
2
20
1
3
10
0
5
no relaxation
0
0
500
valsalva contract
relaxation
1000
2000
1500
0
2500
-0,5
3000
-0,5
London Mulier 2014
0
0,5
1
IAV liter
1,5
2
2,5
Why surgeons are frequently the first
once to notice NMB recovery?
•  The diaphragm is more resistant than
the adductor pollicis to rocuronium.
Only deep NMB at
the adductor pollicis
ensures abdominal
muscle relaxation.
•  Cantineau JP Anesthesiology. 1994;81:585
•  Monitoring of the peripheral muscles
often overestimates the degree of
diaphragmatic relaxation, but is a safe
predictor of recovery.
•  Moerer O. Anasthesiol Intensivmed
Notfallmed Schmerzther. 2005;40:217
London Mulier 2014
Case of insufficient deep NMB
at PTC = 4
•  TOF = 0 PTC = 4
•  Rocuronium bolus 0,6 mg/kg at induction
•  No continous infusion
•  Patient started to breath against ventilator:
abdominal muscles active
London Mulier 2014
deep NMB (PTC=2) does not paralyze
diaphragm totally.
London Mulier 2014
Patient1 breaths against respirator,
disturbing the lap view
very dangerous during trocar closure at end surgery
Mulier 2014
32
Depth of NMB reveals TOF = 0 and PTC =
10
This is not deep enough to prevent patient from pressing and reduces the lap workspace
Mulier 2014
33
Why surgeons are frequently the first once
to notice NMB recovery?
Time difference between abdomen – adductor pollicis after bolus NMB is given.
Lateral abdominal
muscles blockade have a
faster onset and a
faster recovery than
adductor pollicis
Continuous infusion
avoids early abdominal
recovery not seen at the
adductor pollicis.
Kirov K et al. Ann Fr Anesth Reanim. 2000;19:734–738.
London Mulier 2014
Solution to Both Problems:
Deep NMB and Magnesium (prolongs NMB)
or Continuous NMB Infusion
Deep NMB till end if no space
Reduce earlier if sufficient space
Help us to get reversal agents (Bridion) that allows to stay deep till the end
London Mulier 2014
Should there be a
subspecialty?
Hope is not enough to turn to change
•  YES: Sub-speciality for Anaesthesia for bariatric and
metabolic surgery
•  YES: Sub-society for Anaesthesia of the obese patient
•  YES: extra training in a certified centre
•  YES: Scientific meetings and live training?
•  YES: Part of the basic anaesthesia training and Post
specialisation training?
•  We deserve a dedicated surgeon who understand our
questions…
•  YOU deserve a dedicated anaesthesiologist who shares
your spirit: make him/her part of your team…
London Mulier 2014
Patient info
Birth Date: 28 09 1971 35 years
Gender: female
Other: 25 Sept. 2014 lap RNBY after lap band in the past
172 kg
195 cm WHR 149/127 18 kg below max ever
stop bang 5/8
high risk for OSAS
WHR 147/129
Prediction score abd compliance:7/10 means medium abdomen
Calculated abd compliance: E 2 mmHg/l and PVO 6: sufficient work space possible, thanks to weight
reduction and previous laparoscopy. However central obesity with WHR > 1. use of deep NMB allows IAP
to be 12 mmHg
At end surgery spont recovery to TOF 4:
Lap view at moderate NMB (TOF4) are recorded and compared with lap view at deep NMB (PTC 6) after
Rocuronium 30 mg bolus with
Pictures taken at different IAP 15 12 8 7 mmHg with approval of patient before.
Easy reversal with 4 mg/kg Sugammadex at end surgery. TOF 100% Rapid
awakening.
London Mulier 2014
Predicted and calculated abd compliance pat
SR at start laparoscopy
large
Prediction: Medium
measurement: Large > 4L
London Mulier 2014
Moderate versus deep NMB
at end laparoscopy after leak test RNY
Spontaneous recovery at end surgery
Moderate NMB at 13:02
TOF = 3 (4 due to missing answer)
E=2
PV0 = increased to 8 ?
Calculated vol at 12 = 2 liter
Patient is not pressing or breathing
against ventilator, but is space reduced?
Bolus of 30 mg Rocuronium to deep block
Deep NMB at 13:10
TOF = 0 PTC = 6
E=2
PV0 = 6 as measured at start lap
Calculated vol at 12 = 3 liter
London Mulier 2014
Laparoscopic view at 7 mmHg IAP
Insufficient space in both, stomach touches anterior wall at moderate NMB
This IAP is always insufficient in this patient
Deep NMB
TOF = 0 PTC = 6
IAP = 7 mmHg
E=2
PV0 = 6
Calculated vol at 7 = 0,5 liter
Moderate NMB
TOF = 4 PTC = /
IAP = 7 mmHg
E=2
PV0 = 8 ?
Calculated vol at 7 = 0
London Mulier 2014
Laparoscopic view at 9 mmHg IAP
Stomach is lifted up with no view on fat behind
Air in stomach in both views blocks view more in moderate NMB
This IAP can work for this patient if deep NMB but not ideal for surgeon
Moderate NMB
TOF = 4 PTC = /
IAP = 9 mmHg
E=2
PV0 = 8 ?
Calculated vol at 8 = 0,5 liter
London Mulier 2014
Deep NMB
TOF = 0 PTC = 6
IAP = 9 mmHg
E=2
PV0 = 6
Calculated vol at 8 = 1,5 liter
Laparoscopic view at 15 mmHg IAP
Limited difference in visibility. Moderate NMB gives sufficient space
This IAP is required if no deep NMB is applied in this patient
Moderate NMB
TOF = 0 PTC = /
IAP = 15 mmHg
E=2
PV0 = 8 ?
Calculated vol at 15 = 3,5 liter
London Mulier 2014
Deep NMB
TOF = 0 PTC = 6
IAP = 15 mmHg
E=2
PV0 = 6
Calculated vol at 15 = 4,5 liter