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Steenackers N, Eksteen G, Wauters L, Augustijns P, Van der Schueren B, Vanuytsel T, Matthys C. Understanding the gastrointestinal tract in obesity: From gut motility patterns to enzyme secretion. Neurogastroenterol Motil 2024; 36:e14758. [PMID: 38342973 DOI: 10.1111/nmo.14758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND AND PURPOSE The pathophysiology of obesity has been the product of extensive research, revealing multiple interconnected mechanisms contributing to body weight regulation. The regulation of energy balance involves an intricate network, including the gut-neuroendocrine interplay. As a consequence, research on the gut-brain-microbiota axis in obesity has grown extensively. The physiology of the gastrointestinal tract, far from being underexplored, has significant implications for the development of specific complications in people living with obesity across the fields of gastroenterology, nutrition, and pharmacology. Clinical research indicates higher fasting bile acids serum levels, and blunted postprandial increases in bilious secretions in people living with obesity. Findings are less straightforward for the impact of obesity on gastric emptying with various studies reporting accelerated, normal, or delayed gastric emptying rates. Conversely, the effect of obesity on gastrointestinal pH, gastrointestinal transit, and gastric and pancreatic enzyme secretion is largely unknown. In this review, we explore the current evidence on the gastrointestinal physiology of obesity.
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Affiliation(s)
- Nele Steenackers
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Gabriel Eksteen
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Lucas Wauters
- Translational Research Center for Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Matthys
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
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Pimenta GP, Dandin O, Caporossi C, Aguilar Nascimento JE. RESIDUAL GASTRIC VOLUME IN MORBIDLY OBESE DIABETICS AFTER AN OVERNIGHT FASTING OR 3 HOURS OF A CARBOHYDRATE-ENRICHED SUPPLEMENT: A RANDOMIZED CROSSOVER PILOT STUDY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 36:e1791. [PMID: 38324852 PMCID: PMC10841525 DOI: 10.1590/0102-672020230073e1791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/08/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND To reduce the risk of regurgitation during anesthesia for elective procedures, residual gastric volumes (RGV) have traditionally been minimized by overnight fasting. Prolonged preoperative fasting presents some adverse consequences and has been abandoned for most surgical procedures, except for obese and/or diabetic patients. AIMS The aim of this study was to assess the RGV in morbidly obese diabetic patients after traditional or abbreviated fasting. METHODS This study was approved by the Ethics Committee for Research with Human Beings from the Federal University of Mato Grosso, under number 179.017/2012. This is a prospective, randomized, and crossover design study in eight morbidly obese type II diabetic patients. RGV was measured endoscopically after either traditional overnight fasting of at least 8 hours, or after abbreviated fasting of 6 hours for solids and 3 hours for a drink containing water plus 25 g (12.5%) of maltodextrin. Data were expressed as mean and range and differences were compared with paired t-tests at p<0.05. RESULTS The study population had a mean age of 41.5 years (28-53), weight of 135 kg (113-196), body mass index of 48.2 kg/m2 (40-62.4), and type II diabetes for 4.5 years (1-10). The RGV after abbreviated fasting was 21.5 ml (5-40) vs 26.3 ml (7-65) after traditional fasting. This difference was not significant (p=0.82). CONCLUSIONS Gastric emptying in morbidly obese diabetic patients is similar after either traditional or abbreviated fasting with a carbohydrate drink.
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Affiliation(s)
| | | | - Cervantes Caporossi
- Universidade de Varzea Grande, Department of Surgery - Varzea Grande (MT), Brazil
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Ngo F, Urman RD, English W, Kothari S, DeMaria E, Wadhwa A. An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity. Surg Obes Relat Dis 2023; 19:171-177. [PMID: 36732143 DOI: 10.1016/j.soard.2022.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023]
Abstract
Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).
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Affiliation(s)
- Fallon Ngo
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Richard D Urman
- International Society of Perioperative Care of Patients with Obesity, Lynnwood, Washington; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wayne English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shanu Kothari
- Department of Surgery, University of South Carolina Greenville, Prisma Health - Greenville Memorial Medical Campus, Greenville, South Carolina.
| | - Eric DeMaria
- Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Anupama Wadhwa
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, Texas; International Society of Perioperative Care of Patients with Obesity, Lynnwood, Washington; Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
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4
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Adams AJ, Songster JC, Harig JP, Markin NW. Perioperative gastric ultrasound: utility and limitations. Int Anesthesiol Clin 2022; 60:45-54. [PMID: 35499911 DOI: 10.1097/aia.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Austin J Adams
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jeffrey C Songster
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jason P Harig
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah
| | - Nicholas W Markin
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Berton M, Bettonte S, Stader F, Battegay M, Marzolini C. Repository Describing the Anatomical, Physiological, and Biological Changes in an Obese Population to Inform Physiologically Based Pharmacokinetic Models. Clin Pharmacokinet 2022; 61:1251-1270. [PMID: 35699913 PMCID: PMC9439993 DOI: 10.1007/s40262-022-01132-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/24/2022]
Abstract
Background Obesity is associated with physiological changes that can affect drug pharmacokinetics. Obese individuals are underrepresented in clinical trials, leading to a lack of evidence-based dosing recommendations for many drugs. Physiologically based pharmacokinetic (PBPK) modelling can overcome this limitation but necessitates a detailed description of the population characteristics under investigation. Objective The purpose of this study was to develop and verify a repository of the current anatomical, physiological, and biological data of obese individuals, including population variability, to inform a PBPK framework. Methods A systematic literature search was performed to collate anatomical, physiological, and biological parameters for obese individuals. Multiple regression analyses were used to derive mathematical equations describing the continuous effect of body mass index (BMI) within the range 18.5–60 kg/m2 on system parameters. Results In total, 209 studies were included in the database. The literature reported mostly BMI-related changes in organ weight, whereas data on blood flow and biological parameters (i.e. enzyme abundance) were sparse, and hence physiologically plausible assumptions were made when needed. The developed obese population was implemented in Matlab® and the predicted system parameters obtained from 1000 virtual individuals were in agreement with observed data from an independent validation obese population. Our analysis indicates that a threefold increase in BMI, from 20 to 60 kg/m2, leads to an increase in cardiac output (50%), liver weight (100%), kidney weight (60%), both the kidney and liver absolute blood flows (50%), and in total adipose blood flow (160%). Conclusion The developed repository provides an updated description of a population with a BMI from 18.5 to 60 kg/m2 using continuous physiological changes and their variability for each system parameter. It is a tool that can be implemented in PBPK models to simulate drug pharmacokinetics in obese individuals.
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Affiliation(s)
- Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Periprocedural Management during Therapeutic Cardiac Catheterization in Patients with Sleep Apnea Syndrome: Report of Three Cases and Review of Literature. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1750114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractMost of the patients with sleep apnea syndrome (SAS) also known as sleep disordered breathing are not diagnosed before undergoing any cardiac interventional procedure. Many of them can safely undergo outpatient procedure under sedation or anesthesia. Few of them with moderate to severe grade of SAS, who are not optimized medically, may create problem and need special consideration. We managed three such cases in cardiac catheterization laboratory; two of them were not diagnosed before. The periprocedural problems we faced in these patients are narrated in this article along with review of literature. Some suggestions for management of such patients undergoing therapeutic cardiac catheterization are also highlighted.
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The Inflammatory Profile of Obesity and the Role on Pulmonary Bacterial and Viral Infections. Int J Mol Sci 2021; 22:ijms22073456. [PMID: 33810619 PMCID: PMC8037155 DOI: 10.3390/ijms22073456] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 12/16/2022] Open
Abstract
Obesity is a globally increasing health problem, entailing diverse comorbidities such as infectious diseases. An obese weight status has marked effects on lung function that can be attributed to mechanical dysfunctions. Moreover, the alterations of adipocyte-derived signal mediators strongly influence the regulation of inflammation, resulting in chronic low-grade inflammation. Our review summarizes the known effects regarding pulmonary bacterial and viral infections. For this, we discuss model systems that allow mechanistic investigation of the interplay between obesity and lung infections. Overall, obesity gives rise to a higher susceptibility to infectious pathogens, but the pathogenetic process is not clearly defined. Whereas, viral infections often show a more severe course in obese patients, the same patients seem to have a survival benefit during bacterial infections. In particular, we summarize the main mechanical impairments in the pulmonary tract caused by obesity. Moreover, we outline the main secretory changes within the expanded adipose tissue mass, resulting in chronic low-grade inflammation. Finally, we connect these altered host factors to the influence of obesity on the development of lung infection by summarizing observations from clinical and experimental data.
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Moon TS, Van de Putte P, De Baerdemaeker L, Schumann R. The Obese Patient: Facts, Fables, and Best Practices. Anesth Analg 2021; 132:53-64. [PMID: 32282384 DOI: 10.1213/ane.0000000000004772] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The prevalence of obesity continues to rise worldwide, and anesthesiologists must be aware of current best practices in the perioperative management of the patient with obesity. Obesity alters anatomy and physiology, which complicates the evaluation and management of obese patients in the perioperative setting. Gastric point-of-care ultrasound (PoCUS) is a noninvasive tool that can be used to assess aspiration risk in the obese patient by evaluating the quantity and quality of gastric contents. An important perioperative goal is adequate end-organ perfusion. Standard noninvasive blood pressure (NIBP) is our best available routine surrogate measurement, but is vulnerable to greater inaccuracy in patients with obesity compared to the nonobese population. Current NIBP methodologies are discussed. Obese patients are at risk for wound and surgical site infections, but few studies conclusively guide the exact dosing of intraoperative prophylactic antibiotics for them. We review evidence for low-molecular-weight heparins and weight-based versus nonweight-based administration of vasoactive medications. Finally, intubation and extubation of the patient with obesity can be complicated, and evidence-based strategies are discussed to mitigate danger during intubation and extubation.
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Affiliation(s)
- Tiffany S Moon
- From the Department of Anesthesiology and Pain, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, Massachusetts
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Ruiz RF, Jukemura J, Alves PRA, dos Santos MEL. Evaluation of pH and residual gastric volume after colon preparation with mannitol: prospective randomized study comparing procedure performed after 3 hours versus 6 hours. Clinics (Sao Paulo) 2020; 75:e1847. [PMID: 33206752 PMCID: PMC7603285 DOI: 10.6061/clinics/2020/e1847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/18/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Our goal was to compare the hydrogen potential (pH) and residual gastric volume (RGV) of patients undergoing colonoscopy after 3 and 6 hours of colon preparation with mannitol. METHODS We described a prospective randomized trial with a 50:50 allocation rate of two distinct times of colonoscopy after colon preparation with 10% mannitol. We included outpatients aged over 18 years, with no history of gastric surgeries and an American Society of Anesthesiologists (ASA)-rated anesthetic risk below III. Colonoscopy was performed after upper digestive endoscopy at two different times: 3 versus 6-hour after mannitol ingestion. During upper gastrointestinal endoscopy, we measured RGV and evaluated pH with a digital pH meter. Clinical trials.gov: 71123317.9.3001.0065. RESULTS We randomized a total of 100 participants to the 3 and 6-hour groups, with the patients in the 6-hour group being younger and presenting a higher body mass index (BMI). The intervention did not result in any statistically significant differences between the two groups, neither for the RGV (p=0.98) or the pH (p=0.732). However, the subgroup of patients with diabetes mellitus showed statistically significant higher RGV values in the 3-hour group. CONCLUSION There was no difference between RGV and pH values at 3 versus 6-hour after bowel preparation with mannitol, except for RGV in diabetic patients at 3 hours. As prolonged fasting protocols may result in adverse events such as dehydration and electrolyte imbalance, we can infer that colonic preparation with mannitol in shorter fasting periods, such as 3 hours, can be adopted safely and routinely.
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Affiliation(s)
- Renzo Feitosa Ruiz
- Hospital Alemao Oswaldo Cruz, Sao Paulo, SP, BR
- Departamento de Gastroenterologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
| | - Jose Jukemura
- Departamento de Gastroenterologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
| | - Paulo Roberto Arruda Alves
- Hospital Alemao Oswaldo Cruz, Sao Paulo, SP, BR
- Departamento de Gastroenterologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
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Dongare PA, Bhaskar SB, Harsoor SS, Garg R, Kannan S, Goneppanavar U, Ali Z, Gopinath R, Sood J, Mani K, Bhatia P, Rohatgi P, Das R, Ghosh S, Mahankali SS, Singh Bajwa SJ, Gupta S, Pandya ST, Keshavan VH, Joshi M, Malhotra N. Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: Practice Guidelines from the Indian Society of Anaesthesiologists. Indian J Anaesth 2020; 64:556-584. [PMID: 32792733 PMCID: PMC7413358 DOI: 10.4103/ija.ija_735_20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Pradeep A Dongare
- Assistant Professor, Department of Anaesthesiology, ESIPGIMSR, Bengaluru, India
| | - S Bala Bhaskar
- Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, India
| | - S S Harsoor
- Professor, Department of Anaesthesiology, Dr BR Ambedkar Medical College and Hospital, Bengaluru, India
| | - Rakesh Garg
- Additional Professor, Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Sudheesh Kannan
- Professor, Department of Anaesthesiology, BMCRI, Bengaluru, India
| | - Umesh Goneppanavar
- Professor, Department of Anaesthesiology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, India
| | - Zulfiqar Ali
- Associate Professor, Department of Anesthesiology and Critical Care, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ramachandran Gopinath
- Professor and Head,Department of Anaesthesiology and Intensive Care, ESIC Medical College and Hospital, Hyderabad, India
| | - Jayashree Sood
- Honorary. Joint Secretary, Board of Management, Chairperson, Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Kalaivani Mani
- Scientist IV, Department of Biostatistics, AIIMS, New Delhi, India
| | - Pradeep Bhatia
- Professor and Head, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Rekha Das
- Professor and Head, Department Anaesthesiology, Critical care and Pain, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, India
| | - Santu Ghosh
- Assistant Professor, Department of Biostatistics, St John's Medical College, Bengaluru, India
| | | | - Sukhminder Jit Singh Bajwa
- Professor and Head, Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Punjab, India
| | - Sunanda Gupta
- Professor and Head, Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, India
| | - Sunil T Pandya
- Chief of Anaesthesia and Surgical ICU, AIG Hospitals, Hyderabad, India
| | - Venkatesh H Keshavan
- Senior Consultant and Chief, Department of Neuroanaesthesia and Critical Care, Apollo Hospitals, Bengaluru, India
| | - Muralidhar Joshi
- Head, Department of Anaesthesia and Pain Medicine, Virinchi Hospitals, Hyderabad, India
| | - Naveen Malhotra
- Professor, Department of Anaesthesiology and In Charge Pain Management Centre, Pt BDS PGIMS, Haryana, India
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Cheung ZB, Vig KS, White SJW, Lima MC, Hussain AK, Phan K, Kim JS, Caridi JM, Cho SK. Impact of Obesity on Surgical Outcomes Following Laminectomy for Spinal Metastases. Global Spine J 2019; 9:254-259. [PMID: 31192091 PMCID: PMC6542168 DOI: 10.1177/2192568218780355] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To determine the effect of obesity (body mass index >30 kg/m2) on perioperative morbidity and mortality after surgical decompression of spinal metastases. METHODS The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registry that collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent decompression with laminectomy for treatment of metastatic spinal lesions between 2010 and 2014. Patients were separated into 2 cohorts based on the presence of absence of obesity. Univariate analysis and multivariate logistic regression analysis were used to analyze the effect of obesity on perioperative morbidity and mortality. RESULTS There was a significantly higher rate of venous thromboembolism (VTE; obese 6.6% vs nonobese 4.2%; P = .01) and pulmonary complications (obese 2.6% vs nonobese 2.2%; P = .046) in the obese group compared with the nonobese group. The nonobese group had prolonged hospitalization (obese 62.0% vs nonobese 69.0%; P = .001) and a higher incidence of blood transfusions (obese 26.8% vs nonobese 34.2%; P < .001). On multivariate analysis, obesity was found to be an independent risk factor for VTE (odds ratio = 1.75, confidence interval = 1.17-2.63, P = .007). CONCLUSIONS Obese patients were predisposed to an elevated risk of VTE following laminectomy for spinal metastases. Early postoperative mobilization and a low threshold to evaluate for perioperative VTE are important in these patients in order to appropriately diagnose and treat these complications and minimize morbidity.
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Affiliation(s)
- Zoe B. Cheung
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Khushdeep S. Vig
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Mauricio C. Lima
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,University of Campinas (UNICAMP), Campinas, São Paulo, Brazil,Scoliosis Group of AACD (Associação de Assistência à Criança Deficiente), São Paulo, Brazil
| | | | - Kevin Phan
- Prince of Wales Private Hospital, Sydney, New South Wales, Australia,University of New South Wales, Sydney, New South Wales, Australia
| | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John M. Caridi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 4th Floor, New York, NY 10029, USA.
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12
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13
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Butterfield KJ. Outpatient Anesthetic Safety Considerations for Obstructive Sleep Apnea. Oral Maxillofac Surg Clin North Am 2017; 29:189-196. [PMID: 28417891 DOI: 10.1016/j.coms.2016.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Most patients with obstructive sleep apnea (OSA) are not diagnosed preoperatively. The STOP-Bang questionnaire may identify patients at risk of OSA, especially those with severe OSA. Patients with mild to moderate OSA, with optimized comorbidities, can usually safely undergo outpatient surgery. Patients with severe OSA, who are not optimized medically, should avoid outpatient surgery.
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Affiliation(s)
- Kevin J Butterfield
- Division of Dentistry/Oral and Maxillofacial Surgery, Department of Otolaryngology, Ottawa Hospital, University of Ottawa School of Medicine, Ottawa, Ontario, Canada.
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Shiraishi T, Kurosaki D, Nakamura M, Yazaki T, Kobinata S, Seki Y, Kasama K, Taniguchi H. Gastric Fluid Volume Change After Oral Rehydration Solution Intake in Morbidly Obese and Normal Controls. Anesth Analg 2017; 124:1174-1178. [DOI: 10.1213/ane.0000000000001886] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology 2017; 126:376-393. [DOI: 10.1097/aln.0000000000001452] [Citation(s) in RCA: 475] [Impact Index Per Article: 67.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is available in the text.
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Kruisselbrink R, Arzola C, Jackson T, Okrainec A, Chan V, Perlas A. Ultrasound assessment of gastric volume in severely obese individuals: a validation study. Br J Anaesth 2017; 118:77-82. [DOI: 10.1093/bja/aew400] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2016] [Indexed: 12/27/2022] Open
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Duration of Nil Per Os is causal in hospital length of stay following laparoscopic bariatric surgery. Surg Endosc 2016; 31:1901-1905. [DOI: 10.1007/s00464-016-5191-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 08/17/2016] [Indexed: 10/20/2022]
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Affiliation(s)
- Sam R. Sharar
- From the Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA
| | - Michael J. Bishop
- From the Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA
- From the Department of Medicine, University of Washington School of Medicine, Seattle, WA
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Phillips S, Liang SS, Formaz-Preston A, Stewart PA. High-Risk Residual Gastric Content in Fasted Patients Undergoing Gastrointestinal Endoscopy: A Prospective Cohort Study of Prevalence and Predictors. Anaesth Intensive Care 2015; 43:728-33. [DOI: 10.1177/0310057x1504300610] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this prospective cohort study, we examined the residual gastric contents of 255 fasted patients undergoing gastrointestinal endoscopy. The volume and pH of residual gastric contents collected by suction under direct visualisation during gastroscopy were accurately quantified. All patients completed the minimum two-hour fast for clear fluids and 97.2% of patients completed the minimum six-hour fast for solids. High-risk residual gastric content, defined as volume >25 ml and pH <2.5, was present in 12.2% (95% CI 8.7% to 16.7%) of patients. We used multiple logistic regression analysis to identify demographic and clinical factors associated with high-risk residual gastric content. The odds of having high-risk residual gastric content were reduced with increase in age (adjusted odds ratio 0.77, 95% CI 0.61 to 0.96, P=0.0230), and use of a proton pump inhibitor or histamine type 2 receptor antagonist (adjusted odds ratio 0.24, 95% CI 0.10 to 0.55, P=0.0013), and were increased in male patients (adjusted odds ratio 2.36, 95% CI 1.06 to 5.28, P=0.0348). Notably, residual gastric content was classified as high-risk in 20.4% of patients who did not take a proton pump inhibitor or histamine type 2 receptor antagonist versus only 5.6% of those who did. Our findings suggest that, despite currently recommended fasting, males presenting for endoscopy are more likely to have high-risk gastric content than females, and that the incidence appears to be reduced with increasing age, and by the use of proton pump inhibitors or histamine type 2 receptor antagonists, we were unable to confirm or exclude an effect of body mass index, peptic pathology, diabetes or other clinical or demographic factors in our study population.
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Affiliation(s)
- S. Phillips
- Department of Anaesthesia, Sydney Adventist Hospital, Sydney Adventist Hospital Clinical School, Wahroonga, and Sydney Medical School, University of Sydney, New South Wales
| | - S. S. Liang
- Blacktown Hospital, and Conjoint Lecturer at the School of Medicine, University of Western Sydney, Sydney, New South Wales
| | | | - P. A. Stewart
- Department of Anaesthesia, Sydney Adventist Hospital and Sydney Adventist Hospital Clinical School, Wahroonga, Sydney Medical School, University of Sydney, Sydney, New South Wales
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Tetenev K, Cloutier ME, von Reyn JA, Ather JL, Candon J, Allen GB. Synergy between acid and endotoxin in an experimental model of aspiration-related lung injury progression. Am J Physiol Lung Cell Mol Physiol 2015; 309:L1103-11. [PMID: 26408552 DOI: 10.1152/ajplung.00197.2014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/17/2015] [Indexed: 01/11/2023] Open
Abstract
Aspiration is a common cause of lung injury, but it is unclear why some cases are self-limited while others progress to acute respiratory distress syndrome (ARDS). Sporadic exposure to more than one insult could account for this variable progression. We investigated whether synergy between airway acid and endotoxin (LPS) amplifies injury severity in mice and whether LPS levels in human patients could corroborate our experimental findings. C57BL/6 mice aspirated acid (pH 1.3) or normal saline (NS), followed by LPS aerosol or nothing. Bronchoalveolar lavage fluid (BALF) was obtained 2 to 49 h later. Mice were injected with FITC-dextran 25 h after aspiration and connected to a ventilator, and lung elastance (H) measured periodically following deep inflation (DI). Endotracheal and gastric aspirates were also collected from patients in the intensive care unit and assayed for pH and LPS. Lung instability (ΔH following DI) and pressure-volume hysteresis in acid- or LPS-exposed mice was greater than in controls but markedly greater in the combined acid/LPS group. BALF neutrophils, cytokines, protein, and FITC-dextran in the acid/LPS mice were geometrically higher than all other groups. BALF from acid-only mice markedly amplified LPS-induced TNF-α production in cultured macrophages. Human subjects had variable endotracheal LPS levels with the highest burden in those at higher risk of aspiration. Acid aspiration amplifies LPS signaling in mice to disrupt barrier function and lung mechanics in synergy. High variation in airway LPS and greater airway LPS burden in patients at higher risk of aspiration could help explain the sporadic progression of aspiration to ARDS.
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Affiliation(s)
- Konstantin Tetenev
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont; Siberian State Medical University, Tomsk, Russia; and
| | - Mary E Cloutier
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont
| | - Jessica A von Reyn
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont
| | - Jennifer L Ather
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont
| | - James Candon
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont
| | - Gilman B Allen
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont
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Corstens MN, Berton-Carabin CC, de Vries R, Troost FJ, Masclee AAM, Schroën K. Food-grade micro-encapsulation systems that may induce satiety via delayed lipolysis: A review. Crit Rev Food Sci Nutr 2015; 57:2218-2244. [DOI: 10.1080/10408398.2015.1057634] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Meinou N. Corstens
- Department of Agrotechnology & Food Sciences, Food Process Engineering Group, Wageningen University and Research Center, Wageningen, The Netherlands
| | - Claire C. Berton-Carabin
- Department of Agrotechnology & Food Sciences, Food Process Engineering Group, Wageningen University and Research Center, Wageningen, The Netherlands
| | - Renko de Vries
- Department of Agrotechnology & Food Sciences, Physical Chemistry and Colloid Science Group, Wageningen University and Research Center, Wageningen, The Netherlands
| | - Freddy J. Troost
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ad A. M. Masclee
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Karin Schroën
- Department of Agrotechnology & Food Sciences, Food Process Engineering Group, Wageningen University and Research Center, Wageningen, The Netherlands
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Comparative evaluation of gastric pH and volume in morbidly obese and lean patients undergoing elective surgery and effect of aspiration prophylaxis. J Clin Anesth 2015; 27:396-400. [DOI: 10.1016/j.jclinane.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 03/02/2015] [Indexed: 11/22/2022]
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Hashimoto Y, Asai T, Arai T, Okuda Y. Effect of cricoid pressure on placement of the I-gel™ : a randomised study. Anaesthesia 2014; 69:878-82. [PMID: 24866121 DOI: 10.1111/anae.12731] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2014] [Indexed: 11/30/2022]
Abstract
We studied 40 adult patients to see if cricoid pressure affected placement of the I-gel(™). In a randomised crossover design, the i-gel was placed with and without cricoid pressure, and we compared the success rate of adequate ventilation through the i-gel, time to placement and the rate of optimal position of the device between the two circumstances. Cricoid pressure significantly decreased the success rate of adequate ventilation through the i-gel (40 vs 34 patients) (p = 0.041, 95% CI for difference 4-26%), and significantly decreased the rate of the optimal position (39 vs 17 patients) (p < 0.001). The time to achieve adequate ventilation was significantly longer (p < 0.001) with cricoid pressure than without (median difference 8 s; 95% CI for median difference 3-12 s). Cricoid pressure significantly decreases the success rate of ventilation through the i-gel, but the success rate of ventilation through the i-gel is reasonably high.
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Affiliation(s)
- Y Hashimoto
- Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
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Nutritional care of the obese adult burn patient: a U.K. Survey and literature review. J Burn Care Res 2014; 35:199-211. [PMID: 24784903 DOI: 10.1097/bcr.0000000000000032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Obesity is an emerging healthcare problem and affects an increasing number of burn patients worldwide. An email survey questionnaire was constructed and distributed among the 16 U.K. burn services providing adult inpatient facilities to investigate nutritional practices in obese thermally injured patients. Responses received from all dieticians invited to participate in the study were analyzed, and a relevant literature review of key aspects of nutritional care is presented. The majority of services believe that obese patients warrant a different nutritional approach with specific emphasis to avoid overfeeding. The most common algebraic formulae used to calculate calorific requirements include the Schofield, Henry, and modified Penn State equations. Indirect calorimetry despite being considered the "criterion standard" tool to calculate energy requirements is not currently used by any of the U.K. burn services. Gastric/enteral nutrition is initiated within 24 hours of admission in the services surveyed, and a variety of different practices were noted in terms of fasting protocols before procedures requiring general anesthesia/sedation. Hypocaloric regimens for obese patients are not supported by the majority of U.K. facilities, given the limited evidence base supporting their use. The results of this survey outline the wide diversity of dietetic practices adopted in the care of obese burn patients and reveal the need for further study to determine optimal nutritional strategies.
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Laparoscopy in the Morbidly Obese: Physiologic Considerations and Surgical Techniques to Optimize Success. J Minim Invasive Gynecol 2014; 21:182-95. [DOI: 10.1016/j.jmig.2013.09.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 09/26/2013] [Accepted: 09/26/2013] [Indexed: 01/13/2023]
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Abstract
The population of overweight patients presenting to burn facilities is expected to increase significantly over the next decades due to the global epidemic of obesity. Excess adiposity mediates alterations to key physiological responses and poses challenges to the optimal management of burns. The purpose of this study is to document the general epidemiological aspects of thermal injuries in the obese population, outline relevant physiological aspects associated with obesity, and draw attention to topics relating to the management, rehabilitation, and prognosis of burns in this emerging subpopulation of patients.
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Sakr Y, Elia C, Mascia L, Barberis B, Cardellino S, Livigni S, Fiore G, Filippini C, Ranieri VM. Being overweight or obese is associated with decreased mortality in critically ill patients: a retrospective analysis of a large regional Italian multicenter cohort. J Crit Care 2012; 27:714-21. [PMID: 23102526 DOI: 10.1016/j.jcrc.2012.08.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 08/08/2012] [Accepted: 08/19/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe the epidemiology of obesity in a large cohort of intensive care unit (ICU) patients and study its impact on outcomes. METHODS All 3902 patients admitted to one of 24 ICUs in the Piedmont region of Italy from April 3 to September 29, 2006, were included in this retrospective analysis of data from a prospective, multicenter study. RESULTS Mean body mass index (BMI) was 26.0 ± 5.4 kg/m(2): 32.8% of patients had a normal BMI, 2.6% were underweight, 45.1% overweight, 16.5% obese, and 2.9% morbidly obese. ICU mortality was significantly (P < .05) lower in overweight (18.8%) and obese (17.5%) patients than in those of normal BMI (22%). In multivariate logistic regression analysis, being overweight (OR = 0.73; 95%CI: 0.58-0.91, P = .007) or obese (OR = 0.62; 95%CI: 50.45-0.85, P = .003) was associated with a reduced risk of ICU death. Being morbidly obese was independently associated with an increased risk of death in elective surgery patients whereas being underweight was independently associated with an increased risk of death in patients admitted for short-term monitoring and after elective surgery. CONCLUSIONS In this cohort, overweight and obese patients had a reduced risk of ICU death. Being underweight or morbidly obese was associated with an increased risk of death in some subgroups of patients.
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Affiliation(s)
- Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University, Erlanger Allee 103, 07743 Jena, Germany.
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Das SR, Alexander KP, Chen AY, Powell-Wiley TM, Diercks DB, Peterson ED, Roe MT, de Lemos JA. Impact of body weight and extreme obesity on the presentation, treatment, and in-hospital outcomes of 50,149 patients with ST-Segment elevation myocardial infarction results from the NCDR (National Cardiovascular Data Registry). J Am Coll Cardiol 2012; 58:2642-50. [PMID: 22152950 DOI: 10.1016/j.jacc.2011.09.030] [Citation(s) in RCA: 176] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 09/05/2011] [Accepted: 09/13/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of extreme (class III) obesity (body mass index [BMI] ≥40 kg/m(2)) on care and outcomes in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND Although its prevalence is increasing rapidly, little is known about the impact of extreme obesity on STEMI presentation, treatments, complication rates, and outcomes. METHODS The relationship between BMI and baseline characteristics, treatment patterns, and risk-adjusted in-hospital outcomes was quantified for 50,149 patients with STEMI from the National Cardiovascular Data Registry (NCDR) ACTION Registry-GWTG. RESULTS The proportions of patients with STEMI by BMI category were as follows: underweight (BMI <18.5 kg/m(2)) 1.6%, normal weight (18.5 kg/m(2) ≤BMI <25 kg/m(2)) 23.5%, overweight (25 kg/m(2) ≤BMI <30 kg/m(2)) 38.7%, class I obese (30 kg/m(2) ≤BMI <35 kg/m(2)) 22.4%, class II obese (35 kg/m(2) ≤BMI <40 kg/m(2)) 8.7%, and class III obese 5.1%. Extreme obesity was associated with younger age at STEMI presentation (median age 55 years for class III obese vs. 66 years for normal weight); a higher prevalence of diabetes, hypertension, and dyslipidemia; a lower prevalence of smoking; and less extensive coronary artery disease and higher left ventricular ejection fraction. Process-of-care measures were similar across BMI categories, including the extremely obese. Using class I obesity as the referent, risk-adjusted in-hospital mortality rates were significantly higher only for class III obese patients (adjusted odds ratio: 1.64; 95% confidence interval: 1.32 to 2.03). CONCLUSIONS Patients with extreme obesity present with STEMI at younger ages and have less extensive coronary artery disease, better left ventricular systolic function, and similar processes and quality of care. Despite these advantages, extreme obesity remains independently associated with higher in-hospital mortality.
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Affiliation(s)
- Sandeep R Das
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, 75390-9047, USA.
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Buchholz V, Berkenstadt H, Goitein D, Dickman R, Bernstine H, Rubin M. Gastric emptying is not prolonged in obese patients. Surg Obes Relat Dis 2012; 9:714-7. [PMID: 22571886 DOI: 10.1016/j.soard.2012.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Revised: 02/25/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obesity is associated with a poor anesthetic risk, in part because of the greater aspiration rates. A greater gastric residue and lower stomach pH have been implicated. The relationship of obesity to gastric emptying is ill-defined. with contradicting reports stating shorter, similar, and longer times compared with nonobese subjects. The aim of the present study was to compare gastric emptying in obese and nonobese subjects at a university hospital. METHODS A total of 19 obese (body mass index [BMI] >40 kg/m(2)) and 20 nonobese (BMI <30 kg/m(2)) subjects underwent a standardized scintigraphic gastric emptying study. The participants consumed a standard semisolid, technetium-99m-labeled meal. Images were acquired immediately and 1, 2, and 4 hours after meal completion. The interval to evacuate one half of the counts measured at meal completion) and retention (the percentage of counts in stomach at each measurement point) were recorded. RESULTS The mean age and BMI was 35 years and 45 kg/m(2) in the obese and 44 years and 26 kg/m(2) in the nonobese group, respectively. No differences were found between the 2 groups regarding gastric emptying. Regression analysis showed no statistical association between the BMI and gastric emptying, including multivariate analysis, considering BMI, age, and gender. CONCLUSION A scintigraphy test of a labeled meal was used to evaluate gastric emptying in obese and nonobese subjects. In accordance with other published data, no significant difference was found between the 2 groups. The anesthetic risks in the obese should be attributed to factors other than delayed gastric emptying (i.e., anatomic variation, increased rates of hiatal hernia and reflux).
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Affiliation(s)
- Vered Buchholz
- Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Postoperative complications after thoracic surgery in the morbidly obese patient. Anesthesiol Res Pract 2011; 2011:865634. [PMID: 22242020 PMCID: PMC3254004 DOI: 10.1155/2011/865634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/16/2011] [Accepted: 11/17/2011] [Indexed: 11/17/2022] Open
Abstract
Little has been recently published about specific postoperative complications following thoracic surgery in the morbidly obese patient. Greater numbers of patients who are obese, morbidly obese, or supermorbidly obese are undergoing surgical procedures. Postoperative complications after thoracic surgery in these patients that can lead to increased morbidity and mortality, prolonged hospital stay, and increased cost of care are considered. Complications include difficulties with mask ventilation and securing the airway, obstructive sleep apnea with risk of oversedation, pulmonary complications related to reduced total lung capacity, reduced functional residual capacity, and reduced vital capacity, risks of aspiration pneumonitis and ventilator-associated pneumonia, cardiomyopathies, and atrial fibrillation, inadequate diabetes management, positioning injuries, increased risk of venous thrombosis, and pulmonary embolism. The type of thoracic surgical procedure may also pose other problems to consider during the postoperative period. Obese patients undergoing thoracic surgery pose a challenge to those caring for them. Those working with these patients must understand how to recognize, prevent, and manage these postoperative complications.
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Donohoe CL, Feeney C, Carey MF, Reynolds JV. Perioperative evaluation of the obese patient. J Clin Anesth 2011; 23:575-86. [DOI: 10.1016/j.jclinane.2011.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 06/13/2011] [Accepted: 06/20/2011] [Indexed: 02/08/2023]
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Biodegradable wound-closing devices for gastrointestinal interventions: Degradation performance of the magnesium tip. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2011. [DOI: 10.1016/j.msec.2011.03.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Obesity is a metabolic disease that is on the increase all over the world. Up to 35% of the population in North America and 15-20% in Europe can be considered obese. Since these patients are characterised by several systemic physiopathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. Body mass is an important determinant of respiratory function before and during anaesthesia not only in morbidly but also in moderately obese patients. These can manifest as (a) reduced lung volume with increased atelectasis; (b)derangements in respiratory system, lung and chest wall compliance and increased resistance; and (c) moderate to severe hypoxaemia. These physiological alterations are more marked in obese patients with hypercapnic syndrome or obstructive sleep apnoea syndrome. The suggested perioperative ventilation management includes (a) awake and/or facilitated endotracheal intubation by using a video-laryngoscope; (b) tidal volume of 6-10 ml kg(-1) ideal body weight, increasing respiratory rate to maintain physiological PaCO2, while avoiding intrinsic positive end-expiratory pressure (PEEPi); and (c) a recruitment manoeuvre (35-55 cmH2O for 6 s) followed by the application of an end-expiratory pressure (PEEP) of 10 cmH2O. The recruitment manoeuvre should always be performed only when a volemic and haemodynamic stabilisation is reached after induction of anaesthesia. In the postoperative period, beach chair position, aggressive physiotherapy, noninvasive respiratory support and short-term recovery in intermediate critical care units with care of fluid management and pain may be useful to reduce pulmonary complications.
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Affiliation(s)
- Paolo Pelosi
- Dipartimento Ambiente, Salute e Sicurezza, Università degli Studi dell'Insubria, Varese: Servizio di Anestesia e Rianimazione B, Ospedale di Circolo, Fondazione Macchi, Viale Borri 57, 21100, Varese, Italy.
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Serrano PE, Khuder SA, Fath JJ. Obesity as a Risk Factor for Nosocomial Infections in Trauma Patients. J Am Coll Surg 2010; 211:61-7. [DOI: 10.1016/j.jamcollsurg.2010.03.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 02/21/2010] [Accepted: 03/03/2010] [Indexed: 12/15/2022]
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Reis LDA, Reis GFFD, Oliveira MRMD. The airways and gastric contents in obese patients. Rev Bras Anestesiol 2010; 60:98-103. [PMID: 20169269 DOI: 10.1016/s0034-7094(10)70012-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Accepted: 10/13/2009] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to review the literature and to question the concept that obese patients should be considered as having a potential full stomach and, therefore, question how the airways, considered as of difficult access due to obesity, should be approached during anesthetic induction. CONTENTS Classically, obese patients are viewed as having a potential full stomach, leading to conducts to protect the airways during anesthetic induction. Frequently, awake intubation or rapid sequence intubation is performed. However, this concept is based on a single study, which has been cited by other authors. Obese patients are also considered difficult to intubate, raising the concern on the successful approach of the airways. However, studies in the literature question this concept, leading to questioning of the techniques used to access the airways. CONCLUSIONS Studies in the literature demonstrate that gastric emptying is not slowed in obese patients as previously believed, and gastric contents are not greater in this patient population; intubation can, therefore, be safely done after anesthesia. Although obesity alone does not lead to failure to intubate, other signs can be used to predict difficult intubations.
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Mickelson SA. Anesthetic and postoperative management of the obstructive sleep apnea patient. Oral Maxillofac Surg Clin North Am 2010; 21:425-34. [PMID: 19944343 DOI: 10.1016/j.coms.2009.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sleep apnea patients pose a challenge for surgeons, anesthesiologists, and surgical facilities as there is increased risk for anesthetic and postoperative complications. Precautions before and after surgery minimize these risks. Screening for sleep apnea should be done for all surgical patients. Safe perioperative management requires judicious use of narcotics and sedating medications, reducing upper airway edema, prevention of aspiration and deep vein thrombosis, blood pressure control, use of positive airway pressure, and proper postoperative monitoring. Although the literature lacks specific recommendations, the guidelines presented in this article are based on more than 20 years of experience and supported by peer-reviewed medical literature.
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O'Neill T, Allam J. Anaesthetic considerations and management of the obese patient presenting for bariatric surgery. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.cacc.2009.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Airway management is a major factor underlying morbidity and mortality in the obese population. The validity of anthropomorphic prediction model in assessing a difficult airway is less accurate compared with lean subjects. Preoperative evaluation and anticipation of potential complications are critical for safe and successful intubation. Application of noninvasive positive airway pressure can prevent atelectasis and improve oxygenation during the anesthetic induction as well during the postoperative period and after liberation from mechanical ventilation. When performed by trained operators, bedside percutaneous dilatation tracheostomy in obese patients has a safety profile comparable to surgical tracheostomy but provides advantages including ease of performance and lesser cost, and obviates transporting a critically ill patient outside the intensive care unit.
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Affiliation(s)
- Ali A El Solh
- Veterans Affairs Western New York Healthcare System, Medical Research Building (20), Buffalo, NY 14215-1199, USA.
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Cook-Sather SD, Gallagher PR, Kruge LE, Beus JM, Ciampa BP, Welch KC, Shah-Hosseini S, Choi JS, Pachikara R, Minger K, Litman RS, Schreiner MS. Overweight/Obesity and Gastric Fluid Characteristics in Pediatric Day Surgery: Implications for Fasting Guidelines and Pulmonary Aspiration Risk. Anesth Analg 2009; 109:727-36. [DOI: 10.1213/ane.0b013e3181b085ff] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
PURPOSE OF REVIEW Obesity is a growing healthcare problem worldwide, which also affects the pregnant population. Obesity occurs with increasing frequency during pregnancy. Obesity increases the maternal, fetal and neonatal risks. Also, the anesthesiologist is confronted with significantly more problems when the parturient is overweight or obese. The present review focuses on the anesthetic implications of obesity in pregnancy. RECENT FINDINGS In recent years, many authors have stressed the consequences of obesity in pregnancy. More pregnancy-associated complications such as preeclampsia occur, and more medical interventions are also required such as operative delivery, when patients are obese compared with the nonobese population. Recent anesthetic evidence also shows that obese parturients are at increased risk of anesthesia-related complications such as failed intubation and aspiration. SUMMARY Anesthesia-related complications are more frequent in obese parturients. Most authors and opinion leaders agree that regional anesthesia is the preferred technique for Cesarean section in obese patients, and that efforts to place early labor epidural analgesia should be optimized in order to be able to avoid general anesthesia when unplanned Cesarean section is required.
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[Evaluation of tracheal intubation conditions in morbidly obese patients: a comparison of succinylcholine and rocuronium]. ACTA ACUST UNITED AC 2009; 56:3-8. [PMID: 19284121 DOI: 10.1016/s0034-9356(09)70313-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare tracheal intubation conditions in morbidly obese patients 60 seconds after administration of succinylcholine or rocuronium doses based on real weight or ideal weight. METHOD We evaluated patients with a body mass index (BMI) of 40 kg x m(-2) or more but no other indications of difficult-intubation risk. Induction was performed under fentanyl and propofol at doses calculated based on real weight. Patients were assigned to 1 of 4 groups for tracheal intubation. Group 1 received 1 mg of succinylcholine per kilogram of ideal weight, group 2 received 1 mg of succinylcholine per kilogram of real weight, group 3 received 0.6 mg of rocuronium per kilogram of ideal weight, and group 4 received 0.6 mg of rocuronium per kilogram of real weight. Tracheal intubation was performed 60 seconds later and intubation conditions were recorded using a clinical scoring system. RESULTS Eighty patients with a mean BMI of 47.5 kg x m(-2) were enrolled. The difficult intubation rate was 3.75%. All patients were intubated. Laryngoscopy conditions and position and movement of vocal cords were similar in all 4 groups. Reaction to cuff inflation revealed intergroup differences; group 3 presented slight limb movements, diaphragm movement, and sustained cough for more than 10 seconds. CONCLUSION These results suggest that administration of succinylcholine calculated based on real weight or ideal weight and rocuronium based on real weight can provide clinically acceptable conditions for tracheal intubation in morbidly obese patients with no other difficult-intubation criteria.
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Kim BS, Lee JH, Kim EJ, Lee SK, Ban JS, Min BW. Cardiac arrest after position change in a morbidly obese patient - A case report -. Korean J Anesthesiol 2009; 57:237-241. [DOI: 10.4097/kjae.2009.57.2.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bo Sung Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Ji Hyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Eun Joo Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Sang Kon Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jong Suk Ban
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Byung Woo Min
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
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Obesity is associated with increased morbidity but not mortality in critically ill patients. Intensive Care Med 2008; 34:1999-2009. [DOI: 10.1007/s00134-008-1243-0] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Accepted: 06/01/2008] [Indexed: 01/24/2023]
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Pulmonary Complications of the Morbidly Obese Patient Admitted to the Medical Intensive Care Unit. ACTA ACUST UNITED AC 2008. [DOI: 10.1097/cpm.0b013e3181677008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Preoperative gum chewing may increase gastric fluid retention. Time to change our minds and review current guidelines? Obes Surg 2008; 18:430-1. [PMID: 18236123 DOI: 10.1007/s11695-007-9327-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 10/29/2007] [Indexed: 10/22/2022]
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Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment. Acta Anaesthesiol Scand 2008; 52:6-19. [PMID: 18173431 DOI: 10.1111/j.1399-6576.2007.01483.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The incidence of obesity has been dramatically increasing across the globe. Anesthesiologists, are increasingly faced with the care for these patients. Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, diabetes, hypertension and pre-eclampsia. A thorough understanding of the physiology, associated conditions and morbidity, available options for anesthesia and possible complications is therefore important for today's anesthesiologist. METHODS This is a personal review in which different aspects of obesity in the pregnant woman, that are relevant to the anesthesiologist, are discussed. An overview of maternal and fetal morbidity and physiologic changes associated with pregnancy and obesity is provided and different options for labor analgesia, the anesthetic management for cesarean delivery and potential post-partum complications are discussed in detail. RESULTS AND CONCLUSION The anesthetic management of the morbidly obese parturient is associated with special hazards. The risk for difficult or failed intubation is exceedingly high. The early placement of an epidural or intrathecal catheter may overcome the need for general anesthesia, however, the high initial failure rate necessitates critical block assessment and catheter replacement when indicated.
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MESH Headings
- Adult
- Anesthesia, Epidural/adverse effects
- Anesthesia, Epidural/methods
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, Obstetrical/adverse effects
- Anesthesia, Obstetrical/methods
- Anesthesia, Spinal/adverse effects
- Anesthesia, Spinal/methods
- Cesarean Section
- Continuous Positive Airway Pressure
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Dyspnea/etiology
- Dyspnea/physiopathology
- Female
- Fetal Diseases/prevention & control
- Hemodynamics
- Humans
- Obesity/physiopathology
- Obesity, Morbid/physiopathology
- Obstetric Labor Complications/physiopathology
- Postoperative Complications/prevention & control
- Pregnancy
- Pregnancy Complications/physiopathology
- Puerperal Disorders/prevention & control
- Respiratory Aspiration/prevention & control
- Respiratory Mechanics
- Risk
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Affiliation(s)
- Mieke A Soens
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital, Miami, FL 33136, USA
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Mickelson SA. Preoperative and postoperative management of obstructive sleep apnea patients. Otolaryngol Clin North Am 2007; 40:877-89. [PMID: 17606028 DOI: 10.1016/j.otc.2007.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Safe perioperative management of patients with obstructive sleep apnea (OSA) requires special attention to preoperative and postoperative care. Patients with OSA are more likely to have comorbidities including hypertension, esophageal and laryngopharyngeal reflux disease, coronary artery disease, and obesity. Obesity may also contribute to deep vein thrombosis and pulmonary emboli. OSA increases the risk for anesthetic and postoperative complications. The recommendations for measures for preoperative and postoperative management of OSA presented in this article are based on a culmination of 20 years experience supported by the peer-reviewed medical literature.
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Affiliation(s)
- Samuel A Mickelson
- Advanced Ear Nose and Throat Associates, PC, The Atlanta Snoring and Sleep Disorders Institute, 960 Johnson Ferry Road, Suite 200, Atlanta, GA 30342, USA.
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Abstract
The anesthetic management of the MO patient requires an important focus on a number of issues beginning with a careful preoperative evaluation and synthesizing pre-existing disease processes with the anesthetic management plan. The common misperception that all MO patients are "full stomach" has been challenged and may be a nonissue. New approaches to pre-oxygenation to lessen the likelihood of desaturation during apnea may be a valuable tool if difficulty is encountered in tracheal intubation. In addition, promising results have been demonstrated with the use of the ILMA for ventilation and for blindly establishing tracheal tube placement. Proper patient positioning is essential to aid in successful intubation when a laryngoscope is employed. Intraoperative anesthetic management can be guided with a processed electroencephalogram monitor to help improve emergence and to enhance wakefulness in the PACU. Careful consideration must be given to postoperative analgesic needs by minimizing the use of opioids and employing nonopioid analgesics including NSAIDs, alpha2-adrenergic agonists, and low doses of ketamine.
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Affiliation(s)
- Thomas J Ebert
- The Medical College of Wisconsin, VA Medical Center, Anesthesiology/112A, 5000 W. National Avenue, Milwaukee, WI 53295, USA.
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