Anesthetic Considerations for the Obese and Morbidly Obese Oral and Maxillofacial Surgery Patient

Impact of Obesity on Complications and 30-Day Readmission Rates After Cranial Surgery: A Single-Institutional Study of 224 Consecutive Craniotomy/Craniectomy Procedures

BACKGROUND

The prevalence of obesity is increasing at a disparaging rate in the United States. Although previous studies have associated obesity with increased surgical complications and readmission rates, the impact of obesity on surgical outcomes after cranial surgery remains understudied. The aim of this study is to assess the effect of obesity on complication and 30-day readmission rates after cranial surgery.

METHODS

The medical records of 224 consecutive patients (nonobese, n = 164; obese, n = 60) undergoing either craniotomy or craniectomy at a major academic institution in 2011 were reviewed. Preoperative body mass index equal to or greater than 30 kg/m² was classified as obese. The primary outcome investigated in this study was the rate of intraoperative and postoperative complications and 30-day readmissions after craniectomy/craniotomy.

RESULTS

Baseline patient characteristics and comorbidities were similar between the cohorts. The mean body mass indexes for both cohorts were significantly different (nonobese, 22.8 ± 4.2 kg/m² vs. obese, 45.1 ± 15.9 kg/m²; P < 0.0001). Most patients underwent tumor excision in both cohorts (nonobese, 64.0% vs. obese, 66.7%; P = 0.75). Compared with the nonobese cohort, the obese cohort had significantly higher estimated blood loss (nonobese, 209.9 ± 201.3 mL vs. obese, 284.9 ± 250.0 mL; P = 0.04), but similar length of operation (nonobese, 187.3 ± 89.4 minutes vs. obese, 209.6 ± 100.5; P = 0.14). Length of hospital stay and rate of postoperative complications were similar between both cohorts. Obese patients had increased rate of 30-day readmission, but this was not statistically significant (nonobese, 3.1% vs. obese, 6.7%; P = 0.25).

CONCLUSIONS

Our study suggests that obesity may not have a significant impact on surgical outcomes after cranial surgery.

Impact of Body Mass Index on the Outcomes of Open Reduction for Mandibular Fractures

PURPOSE

Little is known about the impact of body mass index (BMI) on the postoperative outcomes of open reduction for mandibular fractures. The aim of this study was to investigate the relationship between BMI and short-term outcomes of surgery for mandibular fractures.

MATERIALS AND METHODS

We searched the Japanese Diagnosis Procedure Combination database to identify patients who underwent open reduction for mandibular fractures from July 2010 to March 2013. BMI was divided into three groups: less than 18.5 kg/m(2) (underweight), 18.5 to 24.9 kg/m(2) (normal weight), and 25 kg/m(2) or greater (overweight). The outcomes included postoperative complication rates, duration of anesthesia, length of stay, and total costs. We analyzed the relationships between BMI and the outcomes by multivariable regression analyses.

RESULTS

We analyzed 309 patients who underwent open reduction for mandibular fractures during the study period. The group with a BMI of 25 kg/m(2) or greater had a significantly longer hospital stay (3.8 days; 95% confidence interval, 0.5 to 7.1 days, P = .03) than the group with a normal BMI. BMI was not significantly associated with duration of anesthesia, postoperative complication rates, or total costs.

CONCLUSIONS

Regarding open reduction for mandibular fractures, overweight status may be associated with a prolonged length of stay, but may have little impact on operating time, postoperative morbidity, or overall costs.

Safety of adjunct pre-emptive intravenous tramadol with midazolam sedation for third molar surgery

PURPOSE

The purpose of this study was to evaluate patient safety, in terms of adverse events, alterations in blood pressure or oxygen saturation (SpO2) in two routine sedation procedures, with and without intravenous analgesia.

METHODS

Patients referred for surgical removal of mandibular third molars were treated in a randomized, controlled, single-blinded procedure. Eighty-seven men and women, aged 18 to 44 years, were allotted to either of two treatment groups, midazolam + tramadol (M + T) and midazolam + saline (M + S) or to a control group (C), given no sedation.

RESULTS

Tramadol at 1 mg/kg body weight resulted in a higher frequency of oxygen desaturation (SpO2 < 90 %) than a placebo (p = 0.002) but had no effect on mean SpO2 at the end point or at the end of surgery. In both the test groups, there was a significant decrease in diastolic blood pressure (p < 0.001) from baseline to the end of surgery.

CONCLUSION

The results confirm that pre-emptive intravenous tramadol, administered at 1 mg/kg body weight as an adjunct to midazolam sedation for third molar surgery, offers a safe method. But, it should be noted that our previous study shows that it is not a particularly effective analgesic. Further testing is therefore warranted, using other doses or other drugs, to find a better intravenous protocol for postoperative analgesia, with maximum effect and minimal risk, in outpatient oral and maxillofacial surgery procedures.

No association between obesity and post-tonsillectomy haemorrhage

Background:

The prevalence of overweight and obesity is increasing worldwide. The impact of overweight on post-tonsillectomy haemorrhage rates in children and adults is unclear.

Methods:

Body mass index and post-tonsillectomy haemorrhage were evaluated in all patients treated with tonsillectomy within one year in a tertiary referral centre. Bleeding episodes were categorised according to the Austrian Tonsil Study.

Results:

Between June 2011 and June 2012, 300 adults and children underwent tonsillectomy. Post-tonsillectomy haemorrhage occurred in 55 patients. Of those, 29 were type A (history of blood in saliva only, no active bleeding), 15 were type B (active bleeding, treatment under local anaesthesia) and 11 were type C (active bleeding, treatment under general anaesthesia). The return to operating theatre rate was 3.7 per cent. Post-tonsillectomy haemorrhage was more frequent in adolescents and adults than in children. Overweight or obesity was positively correlated with age. Post-tonsillectomy bleeding was recorded in 11.1 per cent of underweight patients, 18.9 per cent of normal weight patients and 18.7 per cent of overweight patients (p = 0.7). Data stratification (according to age and weight) did not alter the post-tonsillectomy bleeding risk (p = 0.8).

Conclusion:

Overweight or obesity did not increase the risk of post-tonsillectomy haemorrhage in either children or adults.

Obese oral and maxillofacial surgical patient

The incidence of obesity is rising in many countries around the world. With obesity exerting a direct impact on oral health, more obese patients are likely to report for oral and maxillofacial surgical procedures. The obese patient population presents with unique anatomic and physiologic challenges that can significantly influence treatment strategies. The implications of obesity must be understood by the maxillofacial surgeon to avoid potential pitfalls. This study focuses on the relevant issues concerning obesity with regard to oral and maxillofacial surgery.