Team Adaptation in the Operation of Mega Morbid Patient-Juniper Publishers
Juniper Publishers-Journal of Anesthesia
Introduction
Obesity is a preventible health problem which is
becoming increasingly common in the world and becoming one of the
important health problems. Obesity affects the quality and duration of
life significantly [1].
It is increasing rapidly especially in young people and many chronic
illnesses are developing at earlier ages. The socioeconomic burden is
also increasing associated with it.Sustainable diet has a very important
role in the treatment of obesity, but it seems nearly impossible to do
it with severe obesity. At this point, surgical treatment is an
appropriate and effective option for morbid obesity. Obese patients are a
patient group which are difficult to manage due to anesthesia because
of the lack of consensus on increased co-morbidity, difficult intubation
and drug distribution. People with body mass index (BMI)>40kg/ m2
are defined as morbid obesity and BMI>60 are defined as super obese [2].
In this article, we aimed to present the anesthesia management of a
super obese patient (240kg BKI:106kg/m2) in laparoscopic sleeve
gastrectomy (LSG.). This case, as we know, is the patient with highest
VKI had LSG surgery in our country.
Case
Obese patients are being consulted with chest
diseases, cardiology, endocrine and psychiatry by protocol of our
hospital. Preoperative laboratory values after routine consultations
were normal in this case. LSG was planned to a 36-year-old patient with a
150cm lenght, 240kg weight and a BMI of 106kg/ m2. The ideal weight was
calculated as 45kg (ideal weight in women=height-105). Comorbidities
were: sleep apnea syndrome requiring remitting CPAP (continuous positive
airway pressure), DM and HT. The history of previous surgery and
allergy was not available in that case.
It was reported in the consultation of chest diseases
that bilateral respiratory sounds were deeply and no lesion was found
in parenchyma on PA lung graphy. FEV1:61, FEV1/FVC:121 were reported in
the pulmonary function test. Preoperative blood gas samples, with
spontaneous respiration, were reported as pH:7.32,PO2:64, PCO2: 52,
HCO3: 26. There was sinus rhythm seen in the ECG and for the
ecocardiography, EF was reported as 55% at the cardiology consultation.
Any additional cardiac pathology wasn't exist. There was not found any
pathology could cause disability for surgery at endocrine and
psychiatric consultation.
In airway evaluation, mallopathy classification was
determined as class 2. Thrombus was not detected in the lower extremity
venous colour doppler USG. Our patient could walk at close range without
assistance. Our patient was brought to the operating table as the head
would be 30 degrees from inpatient service. She was admitted to the ramp
position during the operation. No premedication was performed. Pulse
oximetry, three-way ECG monitoring and BIS (bispecific index) monitoring
were performed when the patient arrived at the table. The invasive
arterial monitorization was performed from the left radial artery
following the allenal test because the patient's arm wasn't appropriate
for blood pressure cuff and sudden hypotension could happen after
induction. The blood gas sample, taken before the induction, values were
SPO2: 88, PCO2: 52, pH: 7.32, HCO3: 25. A video laryngoscope was used
for intubation. Besides, macintosh laryngoscope, emergency tracheostomy
set and stile prepared too.
The patient received 3mg midazolam, 1g paracetamol
and 100mg tradamol before induction. Vigilant intubation was not
preferred due to the concern that uncontrolled movements of people with
this weight may pose a risk for patient safety. Antidote medicines,
which will quickly reverse the effects of the drugs used during
induction, were available at the desk. Flumazenil were available for
dormicum and sugammadex were available for rocuronium. 250mg of propofol
and 100mg of rocuronium were administered to ensure adequate anesthesia
depth in all 3minutes by following the BIS (bispecific index).
Intubation were performed in one shot by using the videolaryngoscope.
Intubation was confirmed by Et CO2 because obesity-related lung sounds
were not fully audible. After the intubation, 150mcg of fentanyl,
100mg of tramadol, 50mg of ranitidine, and 8mg of ondansetron were
administered.
Sevofluran was initiated with 0,9 MAC (minimum
alveolar concentration) and remifentanyl was initiated at a dose
of0.05mcg/ kg/min, and also titrated during the anesthesia procedure due
to the blood pressure and heart rate. At the 45th minute of operation
20mg rocuronium was added. Patient was ventilated with PRVC (Pressure
Regulated Volume Control) mode to permit up to 50 +/- 50% of et CO2
peroperatively, due to the fact that there were 50mmHg of PCO2 in the
blood gas taken before the intubation. Monitor settings were made as
PEEP (positive end-expiratory pressure): 7cm/H2O, TV (tidal volume)
:480ml, Fr (frequency): 14 per minute, FiO2: 60%. The blood gases taken
before the start of surgery were reported as pH:7.36, PCO2:52mmHg, PO2:
137mmHg and pH:7.31, PCO2:54 mmHg, PO2:110mmHg were after surgery. The
intra-abdominal pressure was set at 18mmHg to provide adequate surgical
vision.
During the operation, a total of 800cc(for ideal
weight: 10ml/ min) of fluid was given and a total of 100cc urination
(for ideal weight: 1.1ml/h) was withdrawn. The duration of the operation
was 90min and the duration of the anesthesia was 120min. Decurarisation
was provided with 400mg of sugammadex and patient was extubated after
her spontaneous breathing was adequate. The patient was transferred to
PACU (Post-op Anesthesia Care Unit), connected to its own CPAP device.
After extubation, pH was found to be 7.45, PCO2:55mmHg, PO2:70mmHg in
the blood gas. The patient underwent an intermittent CPAP mask for one
day stay in PACU. Blood glucose levels ranged from 100 to 110 in PACU.
The hourly urine output was found to be 1.2ml/h on an ideal weight
basis. The day after the PACU she was sent to the service and mobilized.
On the sixth postoperative day, the patient was discharged without any
complications.
Discussion
There are several problems for anesthesia management
in a super-obese patient. These are especially airway management,
anesthetic drug selection and dosage, fluid management and
administration of postoperative analgesia.
While planning the anesthesia management of this case, with a 700 obesity cases of experience, we planned as follows:
1) Completion of preopretive consultations
2) Presence of three anesthetists for anesthesia
3) Patient with a ramp position during induction and
application of anesthetic agents according to ideal weight and their
titration according to BIS monitoring, blood pressure and heart rate
4) Complete preparation for difficult intubation
5) Hemodynamic monitoring was performed with intraarterial cannulation because of the absence of an appropriate blood
pressure cuff fort his patient and for follow up
6) PRVC mode ventilation
7) Postoperative pain control was achieved with PCA.
The ramp position in morbid obesity during induction
improves laryngoscopy vision and facilitates intubation. In addition,
the oxygenation is better because the pressure of the abdominal organs
to diaphragma decreases in this position, so the apnea period is
tolerated better. During anesthesia induction, midazolam, propofol and
rocuronium were used. After intubation 150mcg of fentanyl was added.
Intravenous paracetamol and tramadol were administered. There are
debates about medicines used in superobese patients whether would be
based on deal body weight or not. The ideal weight of the patient is
55kg and the corrected weight is 64kg. Because of propofol and
remifentanyl are high lipophilic drugs, they can accumulate beyond
estimates in fatty tissue. However, remifentanil is rapidly metabolized
and is not expected to accumulate in fatty tissue. Therefore,
remifentanyl is adjusted by titration to ideal weight.
Patient-controlled propofol was successfully applied to a 290 kg patient over the ideal weight according to servin et al. [3]. However, Arveles et al. [4]
used propofol induction over the ideal weight over microgram/kg.
Midazolam is calculated according to ideal weight also. Because
sevoflurane is also a lipophilic drug, it can cause overdose over the
expected dose. For this reason, there is no consensus in the literature
about its use in obese patients. However, it has been successfully used
in this case based on our clinical experience. 0.4mg/kg of rocuronium
was used according to actual body weight. Because of rocuronium is a
hydrophilic drug, it does not differ much between obese patients and
other patient groups. It is recommended that rocuronium induction is
used due to ideal weight, but it has not been sufficient to provide
relaxation in this condition. Compared to the ideal weight of
rocuronium, the duration of effection of it is more than twice times
that of patients actual weight.
In this case, the use of rocuronium according to the
actual weight shortened the duration of intubation and at the same time
the antidote prevented postoperative residual drug remained. Because of
the patient's sleep apnea, 45cm of neck circumference and her small
mouth we had preparation for difficult intubation. Gaszynski et al. [5]
emphasized that the videolaryngoscope provides better laryngeal images
and that makes intubation to be faster. We chose to use a
videolaryngoscope because we had a lot of clinical experience in this
type of difficult intubation. At one time, the patient was intubated
successfully with the videolaryngoscope. Except the high BMI, 45cm of
the neck circumference increased the risk of the difficult intubation.
PVRC mode was used for ventilation. Hans and colleagues [6]
reported that they obtained high tidal volume with low pressure
throughout the operation, although they did not find any difference
between volumetric control and PVRC on partial oxygen and carbon dioxide
levels.
PEEP is set to 7cm/H2O. Tradamol and paracetamol were
preferred for postoperative analgesia. The epidural catheter was not
preferred because of its technical difficulties in this patient group.
Low-molecular-weight heparin (60mg enoxaparin sodium) was started 12
hours before the operation to reduce thromboembolic risk. During the
operation the patient was wearing anti-embolic socks. After extubation,
she was taken to PACU and intermittent CPAP was applied. Early
post-operative mobilization was emphasized and LMWH continued during
this period. On the first postoperative day, the vital signs were
stabilized and oxygenation in the blood gas sample was as same as the
preoperative values. In the service follow up, postop 1stDay only water
was given and on the 2nd day clear liquid nutrition was given to the
patient. The patient, whose respiratory exercise and mobilization was
increased, discharged on postoperative 4th day.
Results
It is obvious that super-obese patients have many
difficulties for anesthesia management. However, with appropriate
preventions and the presence of experienced team partly facilitates that
management. We performed a super obese case of LSG in this operation;
We believe that while performing LSG in that case medications according
to the ideal body weight, PVRC mode
ventilation and the pain control with tradomal and paracetamol
made this case successful.
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