MORBID OBESITY

Perioperative Anesthetic Considerations for the Morbidly Obese Patient.

Errol Lobo MD PhD
University of California San Francisco
Introduction:
Morbid obesity has become a significant public health problem in the USA. Recent
reports indicate that one-third of the population suffers from obesity. The prevalence is
higher in Americans of Mexican and African ancestry, although obesity is seen in all
Americans. A significant number of patients do no respond to diet and exercise as a
means of weight loss. Surgical treatment by gastric bypass surgery is increasingly used as
an alternative for weight loss.
Obesity is defined as a Body Mass Index (BMI) of 30 kgm-2 with morbid obesity defined
as > 35 kgm-2. More recently the categories of super morbid obesity, >50 kgm-2, and ultra
obesity, >70 kgm-2 have been recognized
Morbidly obese patients, especially those with a central distribution of fat, often have
significant cardiopulmonary changes that affect the pulmonary and cardiovascular
system. This often is a challenge to the anesthesiologist both in the intra-operative and
post-operative setting.
These patients also have co-existing diseases including diabetes, hypertension arthritis
and acid-reflux disease. Pain management also poses a significant problem as some these
patients have a narcotic tolerance due to frequent use for chronic pain. Finally a
significant number of individuals may have the Pickwickian syndrome either as
obstructive Sleep Apnea (SAS) or as Obesity Hypoventilation Syndrome.
Preoperative Considerations
Morbid obesity and Respiratory Changes:
Respiratory compliance decreases with BMI (up to 70%) mainly by the lung component
due to the FRC reduction and the increased pulmonary blood volume. The chest wall
compliance may decrease for the progressively increased mass added to the chest wall
and abdomen in these patients. Also the respiratory system resistance increase with
increasing BMI mainly because of an increase in lung resistance for the large decrease in
FRC and/or and intrinsic narrowing of the airways in obesity.
Spirometry reveals decreases in lung volumes underlying a restrictive pulmonary disease.
In particular, the expiratory reserve volume (ERV) is probably the most sensitive
indicator of obesity on pulmonary function test.. The reduction in ERV is mediated by a
combination of factors:

Encroachment of abdominal contents on the diaphragm

Chest wall fat decrease respiratory system compliance

Impairment of respiratory muscle strength due to chronic respiratory muscle
loading associated with increased work of breathing
Mechanical disadvantage caused by overstretching of the diaphragm (particularly
in the supine position)
Fatty infiltration of the respiratory muscles in extreme obesity

The oxygenation decrease with increasing BMI is due to the reduction in FRC and the
increase of shunt fraction (the lung bases are well perfused but they are unventilated
because of airway closure and alveolar collapse). Oxygen consumption is increased
especially with mild exercise in the morbid obese.

Figure 1
Effect of Obesity on Lung Volumes and Closing Pressures
The question remains on whether preoperative pulmonary function testing is necessary.
While there is no consensus in the literature, there is no evidence that preoperative
pulmonary function tests may significantly change intraoperative management. Many
clinicians may opt pre-operative room air blood gas, which will provide information on
ventilation as well as oxygenation. The same may be said about sleep tests, for
obstructive sleep apnea, the diagnosis can be may based on clinical symptoms. For those

suspected with the obesity hypoventilation syndrome, an assessment for the severity of
pulmonary hypertension may be necessary.
Airway management:
There is limited information in the literature about the airway assessment. Some variables
must be considered such as the sterno-mental and thyromental distance, the mouth
opening, the Mallampati score but the most important seems to be the neck
circumference. In fact it has been showed that there is a proportional relation between the
increasing of the neck circumference and the probability of problematic intubation. In a
study in 2002 involving airway management of morbidly obese patients, Brodsky et. Al
that in patients with a neck circumference greater than 50 cm and wit a Mallampta score
of 3 or 4, an awake fiberoptic intubation technique may be indicated for elective cases,
(See Figures below). Neither absolute obesity nor increasing BMI is indicators of
difficult airway.
It is important to evaluate if the patient deserve a rapid sequence intubation or an awake
intubation. In some patients it could be indicated to spray the airway with Lidocaine 4%
and take an awake look of the cords: if the cords are not visualized easily a fiberoptic
intubation is mandatory.

Patient Characteristics Stratified by

Problematic and Easy Intubation
Problematic intub Easy intubation
Variable
Median
25th pct
75th pct
Median25th pct
75th pct
P valu
Age (yr)
44 39.5 49.5 44
36 51.5 0.995
Height (cm)
168 159.7 176.9 168 160.3 171.2 0.647
Weight (kg)
124.8 124 144.1 137 122.3 156.8 0.858
BMI (kg/m2)
46.5 42.5 47.3 48.9 44.2 58.1 0.939
Neck circumference
50.5(cm)
44.7 54
46
42
48 0.032
Sternomental d 13.5 12.7 16.2 12
14
17 0.497
Thyromental dis 9.5 7.7
10
9.5
8
11 0.655
Mouth opening (cm)
5
4.1 5.2 5.5
4
6.3 0.128

Neck Circumference and Probability of

Problematic Intubation

Positioning for Laparoscopic Surgery:

For Laparoscopic Surgery, the initial surgery involves a head down position
(Trendelenburg) and the insufflation of the abdomen with CO2 11-15 mmHg. The
cephalic shift of the abdominal viscera and the diaphragm lead to a decrease of the total
lung volume and the compliance. The shunt fraction also increase due to the V/Q
mismatch resulting in hypoxemia.
After insufflation, a steep head up position (Reverse Trendelenburg) is needed to
facilitate the surgical dissection. Casati et al.demonstrated in a recent study that this
position does not have any beneficial effects on gas exchange and on lung/chest
compliance as previously believed. In fact, only after deflating the abdomen and the end
of anesthesia with the patient supine the lung/chest compliance comes back to its baseline
value.
In general, pneumoperitoneum results in systemic absorption of CO2 and alteration of
acid-base balance. Absorption of CO2 across the peritoneum is normally eliminated

through the lungs because of its high aqueous solubility and diffusibility. If intraoperative
ventilation is impaired, CO2 absorption can result in hypercapnia and acidosis.
Hypercapnia can cause cardiac arrhythmias, vasoconstriction of the pulmonary vessels,
and a mixed response in cardiac function. Acidosis associated with hypercapnia has a
depressive effect on myocardial contractility, whereas hypercapnia can stimulate the
autonomic nervous system leading to tachycardia and increased myocardial contractility.
All of these effects are detrimental in the morbidly obese patient with pulmonary vessel
disease.

Figure 2
Effect of Positioning in Morbid Obese Patients
During laparoscopic surgery the patient is positioned to produce gravitational displacement of the
abdominal viscera away from the surgical site. Gravity has profound effects on the cardiovascular and
pulmonary systems. The head-down tilt of 1020 degrees commonly used both in gynecologic procedures
and for the initial trocar insertion in laparoscopic gastric bypass is accompanied by an increase in central
blood volume and a decrease in vital capacity and diaphragmatic excursion, whereas the reverse
Trendelenburg (rT) position favors improved pulmonary dynamics but reduced venous return. These
changes associated with positioning may be influenced by the extent of the tilt, the patients age,
intravascular volume status, associated cardiac disease, anesthetic drugs administered, and ventilation
techniques.

Sleep Apnea Syndrome (SAS):

Sleep Apnea is associated with morbid obesity patients and may present with an
obstructive or central pattern. The obstructive sleep apnea is defined as the presence of 10
seconds or more of total cessation of airflow despite the respiratory efforts while the
central sleep apnea is characterized by the diminished or absent respiratory effort and
may be due to a disorder of ventilatory control or neuromuscular function or excessive
respiratory muscle loading. Severe SAS can be treated with nocturnal nasal continuous
positive airway pressure (CPAP). Unfortunately many patients cannot tolerate the device
because it is cumbersome, noisy and tends to dry out the upper airway. The most
important test to study this pathology is the nocturnal polysomnography (NPSG).

OBSTRUCTIVE SLEEP APNEA

Persistent effort without airflow
Floppy upper airway
Profound muscle relaxation during sleep or anesthesia worsens syndrome
Pharynx tends to collapse due to Bernoulli effect with resultant partial or
complete obstruction

Central Sleep Apnea

Diminished or absent respiratory effort
Disorder of ventilatory control, neuromuscular function, excessive respiratory
muscle loading
Profound muscle relaxation during sleep or anesthesia worsens syndrome

Obesity Hypoventilation Syndrome

The obesity hypoventilation syndrome (OHS) is defined by extreme obesity and alveolar
hypoventilation during wakefulness. In its classic form, it is also characterized by the
following findings:
Hypersomnolence
Dyspnea
Hypoxemia, with resulting cyanosis, polycythemia, and plethora
Pulmonary hypertension, leading to right ventricular failure and peripheral edema
In addition most patients have Alveolar hypoventilation associated with OHS. This
occurs as a result of one or both of the following factors:
An increase in the work of breathing to a level that is inconsistent with
maintenance of normal alveolar ventilation.

A decrease in the "drive" to breathe.

It is prudent that in order to avoid post-operative ventilation and oxygenation problems,

the use of medications that ventilatory depressants should be minimized. The can be done
by the use of pre-emptive analgesia with medications that do not cause respiratory
depression. Preemptive analgesia is an antinociceptive therapy whose aim is to prevent
both peripheral and central sensitization, thereby attenuating (or, ideally, preventing) the
postoperative amplification of pain sensation. Treatment can be aimed at the periphery, at
inputs along sensory axons, or at CNS sites using single or combinations of analgesics
applied either continuously or intermittently.
Drugs that can be used for pre-emptive analgesia are elaborated in the figure below

Pharmacologic agents:
NMDA (N-methyl-D-aspartate) antagonists
alpha-2-receptor agonists
NSAIDs (non-steroidal anti-inflammatory drugs)
GABA like compounds

Morbid Obesity and Cardiovascular changes:

Cardiovascular disease is prevalent in most individuals who are morbidly obese.
Hypertension is the most common obesity-related disease. It is mild to moderate in 50
60% and severe in 510% of obese patients. Studies have demonstrated that for every
10 kg of weight gained, systolic arterial pressure increases by 35 mmHg and diastolic
pressure by 2 mmHg. The most plausible explanation for increased occurrence of
hypertension in obesity is the presence of hyperinsulinemia, which contributes to
hypertension by activating the sympathetic nervous system and causing sodium retention.
This results in expansion of the extra-cellular volume and an increase in cardiac output is
characteristic of obesity-induced hypertension. Several studies have demonstrated that
weight loss decreases hypertension in obesity.
In addition to Hypertension, cardiac failure, ischemic heart disease, cardiomyopathy,
sudden cardiac death, cardiac arrhythmias and dyslipidemia cause an increased mortality
and morbidity in obesity. Obesity is an independent risk fact for Coronary Heart Disease.
For each BMI increase of 1, the increase of CHF increases by 5% for men and 7% for
women. Over time by systolic and diasystolic dysfunction develop. Weight loss will
decreases body oxygen consumption, blood volume, cardiac output, stroke volume and

blood pressure. More important with weight loss, left ventricular volume and diastolic
pressures are reduced at rest and during exercise.
Morbid obesity patients have an increased total blood volume, which is correlated with
the body fat and an increased resting cardiac output. They poor tolerate the supine
position due to the increased preload and work of breathing by increasing the cardiac
output. Also oxygen consumption significantly increases in obese individuals lying
supine. Compression of inferior vena cava must be avoided either by tilting the operating
table slightly to the left or by placing a wedge under the patient.

Effects of Hypertension on the Heart in Morbid Obesity.

Conclusion
The morbid obese patient represents a significant challenge for the
anesthesiologist. Careful evaluation and planning are necessary for a
successful outcome. Also limiting the use of medications that may cause
ventilatory depression may also improve outcome.

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