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PERIOPERATIVE GRAND ROUNDS

Weighing in on Surgical Safety


The Case:
A 54-year-old man with diabetes, hypertension, and obstructive sleep apnea (OSA) had experienced many years of pain and increasing functional limitation in his left knee. His body mass index was 40 kg/m2. The man was scheduled to undergo a total knee replacement. He was placed in a supine position for induction of general anesthesia, but he soon experienced hemodynamic instability and hypoxia. Care providers were unable to establish a functioning airway, and the patient died after failed resuscitative attempts.

neck circumference, and male gender.

Discussion:
Signicant (ie, morbid) obesity is associated with many comorbidities, including those experienced by this patient. General anesthesia and airway manipulation are best avoided in patients who are extremely obese, and regional anesthetic techniques, although technically more challenging, are preferred if practical. Severe and long-term OSA are associated with chronic hypoxemia, pulmonary and systemic hypertension, and cardiac failure. Untreated chronic OSA can increase surgical risk. The STOP questionnaire is a simple tool that can be used to determine the presence of factors associated with OSA. STOP stands for

loud snoring, tiredness during the daytime, observed apneas, and high blood pressure.1

A further renement, the STOP-BANG questionnaire, includes questions about


The results of these questionnaires are suggestive but not diagnostic of OSA. Diagnosis can only be made by polysomnography. There is a high association between OSA and morbid obesity, so it is prudent to manage all patients who are morbidly obese as if they have OSA. Nocturnal continuous positive airway pressure therapy instituted four to six weeks before surgery can reduce systemic and pulmonary hypertension and improve functional capacity. Weight loss before surgery may alleviate some comorbidities, but most patients who are morbidly obese are unable to lose signicant weight without bariatric surgery. Normally, combining general and epidural anesthesia is acceptable for patients undergoing elective knee replacement surgery, but using only an epidural may have been a better choice for this patient. A regional anesthetic alone offers many advantages, including minimal need for airway manipulation and reduced use of anesthetic agents.2 An epidural can provide excellent postoperative pain control, thereby lowering opioid requirements, an important consideration for patients prone to pulmonary complications. Sedative premedication should be avoided when possible. Many patients who are morbidly obese and have OSA are extremely sensitive to the respiratory depressive effects of sedatives and opioids.3 The combination of a large neck circumference ( 40 cm) and a Mallampati score of III and IV is the best predictor of intubation difculties.4 (continued on page 432)

body mass index, age,

This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Jay B. Brodsky, MD, and Michael Margarson, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Brodsky JB, Margarson M. Weighing In on Surgical Safety. AHRQ WebM&M [serial online]. August 2010. http://www.webmm.ahrq.gov/ case.aspx?caseID 221. Accessed January 24, 2011.) Dr Girard has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article.

doi: 10.1016/j.aorn.2011.01.008

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AORN Journal

April 2011

Vol 93

No 4

AORN, Inc, 2011

April 2011

Vol 93

No 4

PERIOPERATIVE GRAND ROUNDS


and optimize each condition before the patient is anesthetized. When the decision is made to access the airway, a list should be available of what steps to take and what equipment is needed to maintain adequate ventilation if the initial plan to intubate fails. Patients who are morbidly obese present clinical challenges, and continuous ongoing medical education on the latest strategies for care is necessary.9

(continued from page 518) For any high-risk patient, an awake, ber-optic assisted intubation or use of a video laryngoscope should be considered. A perioperative nurse or assistant experienced with airway management must be available because a second person may be needed to help with bag-mask ventilation if intubation of the airway fails. The error in this patients case was the attempt to induce general anesthesia while he was supine. Even when upright, patients who are obese have reduced functional residual capacity. Lying down leads to a decrease in already-poor chest wall compliance, greater perfusion mismatch, and a sudden shift of blood to an already borderline-hypoxic heart. In patients with inadequate cardiac reserve, these acute changes can cause fatal cardiorespiratory decompensation.5 A head-up position facilitates mask ventilation and improves the laryngoscopists view, improves lung volume, and increases oxygen reserves.6 The headelevated laryngoscopy position, in which the head and upper body are elevated so that an imaginary horizontal line can be drawn from the sternum to the ear, increases the success of direct laryngoscopy in patients who are morbidly obese.7 A head-up position also increases safe apnea time (ie, the time between preoxygenation and muscle paralysis until oxyhemoglobin begins to signicantly desaturate), which provides more time to secure the airway before hypoxia occurs. Maximum safe apnea time can be achieved with the OR bed in the reverse Trendelenburg position.8 If the patient is not successfully intubated and mask ventilation becomes impossible, then placing a laryngeal mask airway and changing from the supine to reverse Trendelenburg position may allow adequate oxygenation. If the vocal cords have been traumatized from unsuccessful attempts at tracheal intubation, a surgical airway may be the only option. Unfortunately, cricothyroidotomy or tracheostomy in a patient with a large neck is not easily or rapidly achieved. With proper preparation, monitoring, and awareness of their unique challenges, patients who are morbidly obese can safely undergo surgical procedures. The surgical team should have a plan to address comorbidities

Perioperative Points:
When caring for patients who are obese, surgical team members should

recognize, evaluate, and properly treat the patients medical comorbidities before elective surgery; use the STOP-BANG questionnaire to screen for the presence of OSA; understand effective strategies for managing anesthesia and pain control; and be aware of special positioning considerations and equipment needs.

References
1. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008:108(5):812-821. Ingrande J, Brodsky JB, Lemmens HJ. Regional anesthesia and obesity. Curr Opin Anaesthesiol. 2009;22(5):683686. Candiotti K, Sharma S, Shankar S. Obesity, obstructive sleep apnoea, and diabetes mellitus: anaesthetic implications. Br J Anaesth. 2009;103(Suppl 1):i23-i30. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94(3):732-736. Tsueda K, Debrand M, Zeok SS, Wright BD, Grifn WO. Obesity supine death syndrome: reports of two morbidly obese patients. Anesth Analg. 1979;58(4): 345-347. Perilli V, Sollazzi L, Bozza P, et al. The effects of the reverse Trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91(6):1520-1525. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the sniff and ramped positions. Obes Surg. 2004;14(9):1171-1175. Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13(1):4-9. Alvarez A, Brodsky JB, Lemmens HJM, Morton JM, eds. Morbid Obesity: Perioperative Management. 2nd ed. Cambridge, UK: Cambridge University Press; 2010.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.