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Orozco González BN, Rodriguez Plascencia N, Palma Zapata JA, Llamas Domínguez AE, Rodríguez González JS, Diaz JM, Ponce Muñoz M, Ponce-Campos SD. Obesity hypoventilation syndrome, literature review. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2024; 5:zpae033. [PMID: 38966619 PMCID: PMC11223067 DOI: 10.1093/sleepadvances/zpae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/12/2024] [Indexed: 07/06/2024]
Abstract
Obesity is a global health concern that has been increasing over the years, and it is associated with several pathophysiological changes affecting the respiratory system, including alveolar hypoventilation. Obesity hypoventilation syndrome (OHS) is one of the six subtypes of sleep-hypoventilation disorders. It is defined as the presence of obesity, chronic alveolar hypoventilation leading to daytime hypercapnia and hypoxia, and sleep-disordered breathing. The existence of a sleep disorder is one of the characteristics that patients with OHS present. Among them, 90% of patients have obstructive sleep apnea (OSA), and the remaining 10% of patients with OHS have non-obstructive sleep hypoventilation without OSA or with mild OSA. This review aims to provide a comprehensive understanding of the epidemiological and pathophysiological impact of OHS and to highlight its clinical features, prognosis, and severity, as well as the available treatment options.
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Affiliation(s)
| | - Nidia Rodriguez Plascencia
- Pneumology Service, Hospital of Specialties at the National Medical Center of the West (IMSS), Guadalajara, México
| | | | | | | | - Juan Manuel Diaz
- Department of Microbiology and Immunology, University of Western Ontario, London, ON, Canada
| | - Miguel Ponce Muñoz
- Department of Medicine, Autonomous University of Aguascalientes, Aguascalientes, México
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Parel PM, Bergstein VE, Agarwal AR, Ramesh A, Pearson ZC, Mikula JD, Knapp B, Zimmer Z, Srikumaran U. Data-driven body mass index threshold associated with increased risk of 2-year periprosthetic joint infection following total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:1261-1266. [PMID: 38036252 DOI: 10.1016/j.jse.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 09/17/2023] [Accepted: 10/18/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Body mass index (BMI) is a modifiable risk factor for medical and infectious complications following total shoulder arthroplasty (TSA). Previous studies investigating BMI were limited to the conventional classification system, which may be outdated for modern day patients. Therefore, the purpose of this study was to identify BMI thresholds that are associated with varying risk of 90-day medical complications and 2-year prosthetic joint infection (PJI) following TSA. METHODS A national database was utilized to identify 10,901 patients who underwent primary elective TSA from 2013 to 2022. Patients were only included if they had a BMI value recorded within 1 month prior to TSA. Separate stratum-specific likelihood ratio analyses, an adaptive technique to identify data-driven thresholds, were performed to determine data-driven BMI strata associated with varying risk of 90-day medical complications and 2-year PJI. The incidence rates of these complications were recorded for each stratum. To control for confounders, each BMI strata was propensity-score matched based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disease, and diabetes mellitus to the lowest identified BMI strata for both outcomes of interest. The risk ratio (RR) and 95% confidence interval (CI) were recorded for each matched analysis. RESULTS The average age and BMI of patients was 70.5 years (standard deviation ±9.8) and 30.7 (standard deviation ±6.2), respectively. Stratum-specific likelihood ratio analysis identified two BMI strata associated with differences in the rate of 2-year PJI: 19-39 and 40+. The same strata were identified for 90-day major complications. When compared to the matched BMI 19-39 cohort, the risk of 2-year PJI was higher in the BMI 40+ cohort (RR: 2.7; 95% CI 1.39-5.29; P = .020). After matching, there was no significant difference in the risk of 90-day major complications between identified strata (RR: 1.19, 95% CI: 0.86-1.64; P = .288). CONCLUSION A data-driven BMI threshold of 40 was associated with a significantly increased risk of 2-year PJI following TSA. This is the first TSA study to observe BMI on a continuum and observe at what point BMI is associated with increased risk of 2-year PJI following TSA. Our identified BMI strata can be incorporated into risk-stratifying models for predicting both PJI and 90-day major complications to minimize both.
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Affiliation(s)
- Philip M Parel
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Victoria E Bergstein
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amil R Agarwal
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abhisri Ramesh
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Zachary C Pearson
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacob D Mikula
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brock Knapp
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Zachary Zimmer
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Rivera D, Muniz-Sarriera AB, Marcial J, Torres H, Colón-Rodríguez E, Crespo MJ. Acute Respiratory Failure Secondary to Low-Dose Opioid Administration in a Patient With Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome After Undergoing Trans-sphenoidal Tumor Resection. Cureus 2024; 16:e56973. [PMID: 38665747 PMCID: PMC11045160 DOI: 10.7759/cureus.56973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
We present a case of an obese 56-year-old male with obstructive sleep apnea (OSA), obesity hypoventilation syndrome (OHS), and pituitary macroadenoma, who underwent nasal endoscopic trans-sphenoidal resection. Surgery was performed under general anesthesia, uneventfully as planned. The patient experienced, however, delayed emergence despite receiving adequate neuromuscular blockade agent reversal. Extubation was performed and the patient was transferred to the recovery room on a Venturi mask (50% fraction of inspired oxygen, FIO2)and 93% saturation. Postoperatively, the patient was complaining of acute pain that did not resolve with non-opioid medications and a low morphine dose (0.035 mg/kg) for pain management was administered. Subsequently, he developed severe respiratory depression, requiring intubation. After three hours, the patient was extubated, transferred to the intensive care unit, and discharged five days later. Although the patient recovered favorably, this case highlights the risks of administering opioids to patients with OSA and OHS. To our knowledge, this is the first case reporting extreme respiratory depression secondary to the administration of a very low dose of morphine in patients with these comorbidities. Therefore, it is essential to be cautious with the use of opioids and to explore multimodal pain relief methods for these patients.
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Affiliation(s)
- Dennys Rivera
- Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
| | | | - Joshua Marcial
- Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
| | - Hector Torres
- Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
| | | | - Maria J Crespo
- Physiology and Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
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Pierpoint SA, Burke JL. Comparing nasopharyngeal apnoeic oxygenation at 18 l/min to preoxygenation alone in obese patients - A randomised controlled study. J Clin Anesth 2023; 88:111126. [PMID: 37167798 DOI: 10.1016/j.jclinane.2023.111126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/23/2023] [Accepted: 04/16/2023] [Indexed: 05/13/2023]
Abstract
STUDY OBJECTIVE Investigate a low-cost, nasopharyngeal apnoeic oxygenation technique, establish its efficacy, and compare it to preoxygenation only in an obese population. The study's hypothesis was that nasopharyngeal apnoeic oxygenation at 18 l.min-1 would significantly prolong safe apnoea time compared to preoxygenation alone. DESIGN Randomised controlled study. SETTING Theatre complex of a resource constrained hospital. PATIENTS 30 adult, obese (BMI ≥ 35 kg.m-2) patients presenting for elective surgery. Patients with limiting cardio-respiratory disease, suspected difficult airway, risk of aspiration, and that were pregnant, were excluded. Patients were allocated by block randomisation in a 1:2 ratio to a preoxygenation-only (No-AO) and an intervention group (NPA-O2). INTERVENTIONS All patients were preoxygenated to an Et-O2 > 80%, followed by a standardised induction. The intervention group received oxygen at 18 l.min-1 via the nasopharyngeal catheter intervention. The desaturation process was documented until an SpO2 of 92% or 600 s was reached. MEASUREMENTS Baseline demographic and clinical characteristics were collected. The primary outcome was safe apnoea time, defined as the time taken to desaturate to an SpO2 of 92%. Secondary outcomes were rate of carbon dioxide accumulation and factors affecting the risk of desaturation. MAIN RESULTS The study was conducted in a morbidly obese population (NoAO = 41,1 kg.m-2; NPA-O2 = 42,5 kg.m-2). The risk of desaturation was signifantly lower in the intervention group (Hazzard Ratio = 0,072, 95% CI[0,019-0,283]) (Log-Rank test, p < 0.001). The median safe apnoea time was significantly longer in the intervention group (NoAO = 262 s [IQR 190-316]; NPA-O2 = 600 s [IQR 600-600]) (Mann-Whitney-U test, p < 0.001). The mean rate of CO2 accumalation was significantly slower in the intervention group (NoAO = 0,47 ± 0,14 kPa.min-1; NPA-O2 = 0,3 ± 0,09 kPa.min-1) (t-test, p = 0.003). There were no statistically significant risk factors associated with an increased risk of desaturation found. CONCLUSIONS Nasopharyngeal apnoeic oxygenation at 18 l/min prolongs safe apnoea time, compared to preoxygenation alone, and reduces the risk of desaturation in morbidly obese patients. CLINICAL TRIAL REGISTRATION PACTR202202665252087; WC/202004/007.
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Affiliation(s)
- S A Pierpoint
- (MBChB, FCA(SA), MMed (Stell)), Department of Anaesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Francie Van Zyl Drive, Cape Town, South Africa.
| | - J L Burke
- (MBChB, FCA(SA), MMed (Stell)), Department of Anaesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Francie Van Zyl Drive, Cape Town, South Africa
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Shapses M, Tang L, Layne A, Beri A, Rotman Y. Fatty Liver Is an Independent Risk Factor for Delayed Recovery from Anesthesia. Hepatol Commun 2021; 5:1848-1859. [PMID: 34558821 PMCID: PMC8557314 DOI: 10.1002/hep4.1772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/31/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
Fatty liver (FL) is associated with altered activity of hepatic drug-metabolizing enzymes, but the clinical significance is unknown. Many anesthetic agents are metabolized in the liver. We aimed to determine whether FL impacts recovery from anesthesia as a surrogate for altered drug metabolism. This was a single-center, retrospective, case-control study of all adults who underwent anesthesia and concurrent abdominal imaging (n = 2,021) in a hospital setting. FL (n = 234) was identified through radiology reports. Anesthesia recovery, the primary endpoint, was defined by Aldrete's recovery score (RS, 0-10), assessed following postanesthesia care unit (PACU) arrival, with RS ≥8 considered discharge eligible. FL and controls were compared using univariate and multivariate analyses, adjusting for confounders. A secondary matched-pairs analysis matched FL and controls 1:1 for confounders. Time from airway removal to discharge eligibility was compared using multivariate Cox regression. On PACU arrival, 54.1% of FL were discharge eligible compared to 61.7% of controls (P = 0.03), with lower activity scores on univariate (P = 0.03) and multivariate analysis (P = 0.03). On matched-pairs analysis, discharge eligibility, activity, consciousness, and total RSs were lower in FL (P ≤ 0.04 for all). Median time from airway removal to discharge eligibility was 43% longer in FL (univariate, P = 0.01; multivariate hazard ratio, 1.32; P = 0.046). To further exclude confounding by obesity, we performed a sensitivity analysis limited to a body mass index <30, where FL was still associated with lower activity (P = 0.03) and total RS (P = 0.03). Conclusion: Patients with FL have delayed recovery from anesthesia, suggesting altered drug metabolism independent of metabolic risk factors.
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Affiliation(s)
- Mark Shapses
- Liver and Energy Metabolism SectionLiver Diseases BranchNational Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMDUSA
| | - Lin Tang
- Department of Perioperative MedicineNational Institutes of Health Clinical CenterBethesdaMDUSA
| | - Austin Layne
- Biomedical Translational Research Information SystemNational Institutes of Health Clinical CenterBethesdaMDUSA
| | - Andrea Beri
- Biomedical Translational Research Information SystemNational Institutes of Health Clinical CenterBethesdaMDUSA
| | - Yaron Rotman
- Liver and Energy Metabolism SectionLiver Diseases BranchNational Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMDUSA
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Diagnosis and Management of Obesity Hypoventilation Syndrome during Labor. Case Rep Anesthesiol 2021; 2021:8096212. [PMID: 34484837 PMCID: PMC8413020 DOI: 10.1155/2021/8096212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/29/2021] [Accepted: 08/14/2021] [Indexed: 11/17/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is a disorder in which patients with a body mass index ≥30 kg/m2 develop awake hypercapnia with a partial pressure of carbon dioxide ≥45 mm Hg, in the absence of other diseases that may produce alveolar hypoventilation. Additional clinical features include sleep disordered breathing, restrictive lung disease, polycythemia, hypoxemia, and an increased serum bicarbonate concentration (≥27 mEq/L). Anesthesia providers should be familiar with OHS because it is often undiagnosed, it is associated with a higher mortality rate than obstructive sleep apnea, and it is projected to increase in prevalence along with the obesity epidemic. In this case, a 33-year-old obese woman with presumed OHS developed respiratory acidosis during induction of labor. Continuous positive airway pressure treatment was initiated, but the patient continued to have hypercapnia. A cesarean delivery was recommended. The patient had baseline orthopnea due to her body habitus; thus, despite adequate labor analgesia, a cesarean delivery was completed with general endotracheal anesthesia. We believe this patient had OHS despite a serum bicarbonate <27 mEq/L, a partial pressure of oxygen >70 mm Hg, and a hemoglobin <16 g/dL, which would typically rule out OHS. Pregnant women experience a decrease in serum bicarbonate concentration due to progesterone-mediated hyperventilation, an increase in arterial oxygenation from increased minute ventilation and higher cardiac output, and a decrease in hemoglobin due to the physiologic anemia of pregnancy. Thus, OHS may be defined differently in pregnant than in non-pregnant patients.
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The effects of doxapram on time to tracheal extubation and early recovery in young morbidly obese patients scheduled for bariatric surgery: A randomised controlled trial. Eur J Anaesthesiol 2021; 37:457-465. [PMID: 31842026 DOI: 10.1097/eja.0000000000001144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Bariatric surgery is a well established treatment of the obese. Postoperative respiratory failure and airway obstruction after bariatric surgery can often be attributed to the residual depressant effects of anaesthetics, sedatives and opioids. Peri-operative management of morbidly obese patients is still a concern for operating room professionals. OBJECTIVE The evaluation of the effects of doxapram on the outcomes of general anaesthesia following bariatric surgical procedures in the morbidly obese. DESIGN A single-blind randomised controlled trial with two parallel arms. SETTING A tertiary care teaching hospital, Tehran, Iran, from 2017 to 2018. PARTICIPANTS In total, 100 patients (69 women) with at least class two obesity were included in two groups of equal sizes and underwent bariatric surgery. MAIN OUTCOME MEASURES The primary outcome was the time from the administration of doxapram to tracheal extubation. Secondary outcomes included vital signs and variables including peak expiratory flow rate, time to return to spontaneous breathing, time to eye-opening and hand-squeezing on the commands, and time to recovery. INTERVENTIONS Both groups underwent general anaesthesia. The intervention group received a single dose of doxapram 1 mg kg ideal body weight, immediately after reversal of neuromuscular blockade and after discontinuation of all anaesthetics. RESULTS Doxapram decreased time to extubation, time to eye-opening and hand-squeezing, shortened recovery time and lowered end-tidal CO2 significantly (all P < 0.001). Moreover, it increased peak expiratory flow rate, oxygen saturation, temperature, heart rate and blood pressure (all P < 0.001). The two groups were similar in the bispectral index and mean arterial pressure (both P > 0.05). None of our participants had complications attributable to doxapram. CONCLUSION The postoperative use of doxapram improves peak expiratory flow rate, and decreases respiratory complications of anaesthesia during recovery in the morbidly obese undergoing bariatric surgery. Doxapram is well tolerated in young ASA physical status classes 1 to 2 morbidly obese patients; however, the anaesthesiologist should cautiously evaluate the vital signs for at least half an hour following the administration of doxapram. REGISTRATION Iranian Registry of Clinical Trials (IRCT) http://www.irct.ir/ number IRCT2017060712203N9.
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Ramírez Molina VR, Masa Jiménez JF, Gómez de Terreros Caro FJ, Corral Peñafiel J. Effectiveness of different treatments in obesity hypoventilation syndrome. Pulmonology 2020; 26:370-377. [PMID: 32553827 DOI: 10.1016/j.pulmoe.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity, defined as daytime hypoventilation, sleep disorder breathing and obesity; during the past few years the prevalence of extreme obesity has markedly increased worldwide consequently increasing the prevalence of OHS. Patients with OHS have a lower quality of life and a higher risk of unfavourable cardiometabolic consequences. Early diagnosis and effective treatment can lead to significant improvement in patient outcomes; therefore, such data has noticeably raised interest in the management and treatment of this sleep disorder. This paper will discuss the findings on the main current treatment modalities OHS will be discussed.
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Affiliation(s)
- V R Ramírez Molina
- Pulmonary and Sleep Medicine, Regional General Hospital N.2 of the Mexican Social Security Institute (IMSS), Querétaro, Mexico
| | - J F Masa Jiménez
- Division of Pulmonary Medicine, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER of Respiratory Diseases (CIBERES), Madrid, Spain.
| | | | - J Corral Peñafiel
- Division of Pulmonary Medicine, San Pedro de Alcántara Hospital, Cáceres, Spain
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Mokhlesi B, Masa JF, Brozek JL, Gurubhagavatula I, Murphy PB, Piper AJ, Tulaimat A, Afshar M, Balachandran JS, Dweik RA, Grunstein RR, Hart N, Kaw R, Lorenzi-Filho G, Pamidi S, Patel BK, Patil SP, Pépin JL, Soghier I, Tamae Kakazu M, Teodorescu M. Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 200:e6-e24. [PMID: 31368798 PMCID: PMC6680300 DOI: 10.1164/rccm.201905-1071st] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). Methods: A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. Recommendations: After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: 1) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, 2) stable ambulatory patients with OHS receive positive airway pressure (PAP), 3) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, 4) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2–3 mo), and 5) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Conclusions: Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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Smith NA, Batterham M, Peoples GE, Shulman MA. The clinical, functional and disability characteristics of patients with severe obesity presenting for non-bariatric surgery. Anaesth Intensive Care 2019; 47:522-531. [PMID: 31779477 DOI: 10.1177/0310057x19887976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical and functional characteristics of patients with severe obesity who present for non-bariatric surgery have rarely been described. For this study, 293 such patients (mean body mass index 42 kg/m2) were investigated using their medical records, a 6-minute walk test, N-terminal pro B-type natriuretic peptide measurement, and the World Health Organization Disability Assessment Schedule 2.0 measure of disability. Cardiorespiratory disease and diabetes were common, with blood tests revealing a high probability of additional unexpected and undiagnosed renal and cardiac disease in a significant proportion of patients. One-third of patients had natriuretic peptide values that identify early left ventricular dysfunction in the community, with 16% above a value described as useful in predicting adverse outcomes for elective surgical patients. Only 10% of patients walked a distance within 10% of that predicted in six minutes, and 22% did not complete the test. Over one-third of patients (34%) had a clinically significant level of disability, with those unable to walk for six minutes describing higher levels of disability. Functional capacity as measured by the 6-minute walk test was significantly lower than would be expected from age, gender, and weight alone, and was related to age and degree of disability but not body mass index. We describe a severely obese population presenting for non-bariatric surgery who had significant levels of comorbid disease, functional impairment, and disability that were not apparent on routine preoperative assessment.
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Affiliation(s)
- Natalie A Smith
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - Marijka Batterham
- Statistical Consulting Centre, School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, Australia
| | | | - Mark A Shulman
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, Australia
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11
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Hussain Z, Gadd K, Curtain C, Mirkazemi C, Peterson GM, R Zaidi ST. Anaesthetists' drug dosing practices in class III obese surgical patients: A bi-national survey. Anaesth Intensive Care 2019; 47:516-521. [PMID: 31752498 DOI: 10.1177/0310057x19886596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Class III obese (body mass index ≥ 40 kg/m2) patients, now regularly encountered clinically, have increased perioperative risks, including potentially from suboptimal drug dosing. However, current dosing guidelines are based on low-level evidence and may not be widely accepted. This study aimed to investigate anaesthetists’ dosing practices for class III obese surgical patients, explore if they had experienced an increased incidence of adverse events potentially related to drug dosing with these patients and assess which resources they consulted for dosing advice in this population. An electronic survey was emailed to 1000 randomly selected members of the Australian and New Zealand College of Anaesthetists. Data were summarised and the Pearson’s χ2 test was used to compare respondents’ genders, geographic locations and seniority designations with the greater Australian and New Zealand College of Anaesthetists’ membership. There were 230 completed responses (response rate 23%). A large proportion (46%–76%) of respondents indicated they dose class III obese patients in keeping with current recommendations; however, substantial heterogeneity in dosing practices was found. Lean body weight was the most frequently used regimen for dosing propofol, non-depolarising muscle relaxants, sugammadex and opioids, whereas total body weight was most frequently used for suxamethonium. Nearly 70% of respondents reported using at least one resource to assist their dosing practices in obesity. Importantly, increased incidences of adverse events in class III obese patients related to drug dosing were commonly experienced by respondents. Until higher-level evidence is available for dosing class III obese patients, anaesthetists should consider current recommendations and exercise increased attention to dosing. Further clinician education may assist in optimising dosing in this patient group.
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Affiliation(s)
- Zahid Hussain
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia.,Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Karl Gadd
- Department of Anaesthesia, Launceston General Hospital, Tasmania, Australia.,Anaesthesia Discipline Lead, Launceston Clinical School, University of Tasmania, Tasmania, Australia
| | - Colin Curtain
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia
| | - Corinne Mirkazemi
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia
| | - Gregory M Peterson
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia.,Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Syed Tabish R Zaidi
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Tasmania, Australia.,School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,National Institute for Health Research Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
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12
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Castellana G, Dragonieri S, Marra L, Quaranta VN, Carratù P, Ranieri T, Resta O. Nocturnal Hypoventilation May Have a Protective Effect on Ischemic Heart Disease in Patients with Obesity Hypoventilation Syndrome. Rejuvenation Res 2019; 22:13-19. [DOI: 10.1089/rej.2017.2030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Giorgio Castellana
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Silvano Dragonieri
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Lorenzo Marra
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | | | - Pierluigi Carratù
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Teresa Ranieri
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Onofrio Resta
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
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13
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Subramani Y, Nagappa M, Wong J, Mubashir T, Chung F. Preoperative Evaluation: Estimation of Pulmonary Risk Including Obstructive Sleep Apnea Impact. Anesthesiol Clin 2018; 36:523-538. [PMID: 30390776 DOI: 10.1016/j.anclin.2018.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
One in 4 deaths occurring within a week of surgery are related to pulmonary complications, making it the second most common serious morbidity after cardiovascular events. The most significant predictors of the postoperative pulmonary complications (PPCs) are American Society of Anesthesiologists physical status, advanced age, dependent functional status, surgical site, and duration of surgery. The overall risk of PPCs can be predicted using scores that incorporate readily available clinical data.
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Affiliation(s)
- Yamini Subramani
- Department of Anesthesia and Perioperative Medicine, London Health Science Centre, St. Joseph Health Care, Western University, Centre, Victoria Hospital, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Science Centre, St. Joseph Health Care, Western University, University Hospital, 339 Windermere Road, London, Ontario N6A 5A5, Canada
| | - Jean Wong
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst street, Toronto, Ontario M5T2S8, Canada
| | - Talha Mubashir
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst street, Toronto, Ontario M5T2S8, Canada
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst street, Toronto, Ontario M5T2S8, Canada.
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Subramani Y, Nagappa M, Wong J, Patra J, Chung F. Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of critical complications. Br J Anaesth 2017; 119:885-899. [DOI: 10.1093/bja/aex341] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Abstract
PURPOSE OF REVIEW With the prevalence of obesity rapidly growing, bariatric anaesthesia becomes everyday anaesthesia rather than a subspecialty. In this review, we are aiming to draw attention to this complex group of patients and their comorbidities, relevant to everyday practice for contemporary anaesthetists. RECENT FINDINGS We wanted to focus greatly on sleep-related breathing disorders, because preoperative screening, diagnosis and treatment of the aforementioned make a huge impact in the improvement of preoperative morbidity and mortality, including positive effects on the cardiovascular system. The overview is touching on main obesity-related comorbidities and guides the anaesthetist and associated health professionals on how to approach and manage them. A multidisciplinary approach widely used in bariatric care may be adopted in the care of obese patients in order to reduce preoperative morbidity and mortality. We advocate the early involvement of the anaesthetic team in the preoperative assessment of obese patients in order to achieve appropriate risk stratification and optimise the care.
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Affiliation(s)
- Asta Lukosiute
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed St, London, W2 1NY, UK.
| | - Anil Karmali
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed St, London, W2 1NY, UK
| | - Jonathan Mark Cousins
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed St, London, W2 1NY, UK
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Yorulmaz İS, Demiraran Y, Salihoğlu Z, Umutoğlu T, Özaydın İ, Doğan S. Effect of PEEP, Zero PEEP and Intraabdominal Pressure Levels on Cerebral Oxygenation in the Morbidly Obese Undergoing Sleeve Gastrectomy. Bariatr Surg Pract Patient Care 2017. [DOI: 10.1089/bari.2017.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- İlknur Suidiye Yorulmaz
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Duzce University, Duzce, Turkey
| | - Yavuz Demiraran
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Mega Medipol Hospital, Istanbul Medipol University, Istanbul, Turkey
| | - Ziya Salihoğlu
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Tarık Umutoğlu
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Bezmialem Vakif University, Istanbul, Turkey
| | - İsmet Özaydın
- Faculty of Medicine, Department of General Surgery, Duzce University, Duzce, Turkey
| | - Sami Doğan
- Faculty of Medicine, Department of General Surgery, Duzce University, Duzce, Turkey
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Understanding Phenotypes of Obstructive Sleep Apnea: Applications in Anesthesia, Surgery, and Perioperative Medicine. Anesth Analg 2017; 124:179-191. [PMID: 27861433 DOI: 10.1213/ane.0000000000001546] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnea (OSA) is a prevalent sleep-disordered breathing with potential long-term major neurocognitive and cardiovascular sequelae. The pathophysiology of OSA varies between individuals and is composed of different underlying mechanisms. Several components including the upper airway anatomy, effectiveness of the upper airway dilator muscles such as the genioglossus, arousal threshold of the individual, and inherent stability of the respiratory control system determine the pathogenesis of OSA. Their recognition may have implications for the perioperative health care team. For example, OSA patients with a high arousal threshold are likely to be sensitive to sedatives and narcotics with a higher risk of respiratory arrest in the perioperative period. Supplemental oxygen therapy can help to stabilize breathing in OSA patients with inherent respiratory instability. Avoidance of supine position can minimize airway obstruction in patients with a predisposition to upper airway collapse in this posture. In this review, the clinically relevant endotypes and phenotypes of OSA are described. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for most patients with OSA but tolerance and adherence can be a problem. Patient-centered individualized approaches to OSA management will be the focus of future research into developing potential treatment options that will help decrease the disease burden and improve treatment effectiveness.
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de Raaff CA, Gorter-Stam MA, de Vries N, Sinha AC, Jaap Bonjer H, Chung F, Coblijn UK, Dahan A, van den Helder RS, Hilgevoord AA, Hillman DR, Margarson MP, Mattar SG, Mulier JP, Ravesloot MJ, Reiber BM, van Rijswijk AS, Singh PM, Steenhuis R, Tenhagen M, Vanderveken OM, Verbraecken J, White DP, van der Wielen N, van Wagensveld BA. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis 2017; 13:1095-1109. [DOI: 10.1016/j.soard.2017.03.022] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 12/31/2022]
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Elsayed AY, El-Shafey MM, Abdelgawad TT, Abdelhady Ali R. Predictors of early diagnosis of obesity hypoventilation syndrome among patients with sleep disordered breathing. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2016.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ramírez-Molina VR, Gómez-de-Terreros FJ, Barca-Durán J, Masa JF. Non-invasive Positive Airway Pressure in Obesity Hypoventilation Syndrome and Chronic Obstructive Pulmonary Disease: Present and Future Perspectives. COPD 2017; 14:418-428. [DOI: 10.1080/15412555.2017.1317730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Victor R. Ramírez-Molina
- Clinica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias ‘Ismael Cosio Villegas’, Ciudad de Mexico, Mexico
| | | | - Javier Barca-Durán
- University of Extremadura, Cáceres, Spain
- Coordinator of the Research Group on Bio-Anthropology and Cardiovascular Sciences, University of Extremadura, Cáceres, Spain
| | - Juan F. Masa
- Sleep Unit, San Pedro de Alcantara Hospital, Cáceres, Spain
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
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Maia LDA, Silva PL, Pelosi P, Rocco PRM. Controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. Expert Rev Respir Med 2017; 11:443-452. [PMID: 28436715 DOI: 10.1080/17476348.2017.1322510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The obesity prevalence is increasing in surgical population. As the number of obese surgical patients increases, so does the demand for mechanical ventilation. Nevertheless, ventilatory strategies in this population are challenging, since obesity results in pathophysiological changes in respiratory function. Areas covered: We reviewed the impact of obesity on respiratory system and the effects of controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. To date, there is no consensus regarding the optimal invasive mechanical ventilation strategy for obese surgical patients, and no evidence that possible intraoperative beneficial effects on oxygenation and mechanics translate into better postoperative pulmonary function or improved outcomes. Expert commentary: Before determining the ideal intraoperative ventilation strategy, it is important to analyze the pathophysiology and comorbidities of each obese patient. Protective ventilation with low tidal volume, driving pressure, energy, and mechanical power should be employed during surgery; however, further studies are required to clarify the most effective ventilation strategies, such as the optimal positive end-expiratory pressure and whether recruitment maneuvers minimize lung injury. In this context, an ongoing trial of intraoperative ventilation in obese patients (PROBESE) should help determine the mechanical ventilation strategy that best improves clinical outcome in patients with body mass index≥35kg/m2.
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Affiliation(s)
- Lígia de Albuquerque Maia
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil
| | - Pedro Leme Silva
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,b National Institute of Science and Technology for Regenerative Medicine , Rio de Janeiro , Brazil
| | - Paolo Pelosi
- c Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST , University of Genoa , Genoa , Italy
| | - Patricia Rieken Macedo Rocco
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil.,b National Institute of Science and Technology for Regenerative Medicine , Rio de Janeiro , Brazil
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Guimarães J, Pinho D, Nunes CS, Cavaleiro CS, Machado HS. Effect of Boussignac continuous positive airway pressure ventilation on Pao2 and Pao2/Fio2 ratio immediately after extubation in morbidly obese patients undergoing bariatric surgery: a randomized controlled trial. J Clin Anesth 2016; 34:562-70. [DOI: 10.1016/j.jclinane.2016.06.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 05/09/2016] [Accepted: 06/07/2016] [Indexed: 01/06/2023]
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Hodgson E. Airway management of the morbidly obese patient. J Perioper Pract 2016; 26:196-200. [PMID: 29328812 DOI: 10.1177/175045891602600902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/22/2016] [Indexed: 06/07/2023]
Abstract
A UK study found that obese patients are twice as likely as non-obese patients to develop airway problems during general anaesthesia (Cook et al 2011). This article focuses on airway management of morbidly obese patients during anaesthesia and examines the associated respiratory, gastric, and existing co-morbidity complications that can be expected. Strategies that practitioners can use to reduce these risks are discussed.
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Affiliation(s)
- Emma Hodgson
- Student Operating Department Practitioner, University of Central Lancashire, UK
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Böing S, Randerath WJ. Chronic hypoventilation syndromes and sleep-related hypoventilation. J Thorac Dis 2015; 7:1273-85. [PMID: 26380756 PMCID: PMC4561264 DOI: 10.3978/j.issn.2072-1439.2015.06.10] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 06/05/2015] [Indexed: 01/21/2023]
Abstract
Chronic hypoventilation affects patients with disorders on any level of the respiratory system. The generation of respiratory impulses can be impaired in congenital disorders, such as central congenital alveolar hypoventilation, in alterations of the brain stem or complex diseases like obesity hypoventilation. The translation of the impulses via spinal cord and nerves to the respiratory muscles can be impaired in neurological diseases. Thoraco-skeletal or muscular diseases may inhibit the execution of the impulses. All hypoventilation disorders are characterized by a reduction of the minute ventilation with an increase of daytime hypercapnia. As sleep reduces minute ventilation substantially in healthy persons and much more pronounced in patients with underlying thoraco-pulmonary diseases, hypoventilation manifests firstly during sleep. Therefore, sleep related hypoventilation may be an early stage of chronic hypoventilation disorders. After treatment of any prevailing underlying disease, symptomatic therapy with non-invasive ventilation (NIV) is required. The adaptation of the treatment should be performed under close medical supervision. Pressure support algorithms have become most frequently used. The most recent devices automatically apply pressure support and vary inspiratory and expiratory pressures and breathing frequency in order to stabilize upper airways, normalize ventilation, achieve best synchronicity between patient and device and aim at optimizing patients' adherence.
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La ventilation non invasive en chirurgie pulmonaire. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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