Perioperative Management of Obese Patients

AUTHOR USER Page PAGE 1 DATE \ "dd /MM /yyyy " 09 /02 /2007

Perioperative Management of the Obese Patient

AUTHOR USER Page PAGE 2 DATE \ "dd /MM /yyyy " 09 /02 /2007

An increasing number of obese patients in the operating room are inevitable due to the well-known associated chronic health problems such as cardiovascular disease , diabetes mellitus , arthritis and cancer Bariatric surgery is also likely to be increasingly performed Perioperative issues for such patients would include airway management phrmacokinegics , preoperative positioning , regional anaesthesia , intense monitoring , laparoscopy and minimization of hypoxia

during anaesthesia (Passannante and Rock , 2005

With nearly a third of American adults considered be obese , it is increasingly important that orthopaedic surgeons be familiar with management issues pertinent to these patients . It is imperative to carry out assessment on cardiopulmonary status and other comorbid conditions particularly diabetes . Intraoperative considerations include requirements for special equipment , patient positioning , intravenous line placement , central monitoring lines , and anesthesia specific to the physiologic changes in obese patients . Postoperatively , obese patients have higher rates of deep vein thrombosis and wound sepsis than non-obese patients , and they may differ from other patients in supplemental oxygen requirements , medication dosing , and outcomes in intensive care units . Although , obese patients are observed to undergo virtually all orthopaedic procedures , obese patients have the probability of higher rates of prosthetic failure , infection , hardware failure , and fracture malunion , although many of these complications can be minimized by appropriate counter measures (Guss and Bhattacharyya 2006

Non-alcoholic fatty liver disease (NAFLD ) has become recognized as one of the most common abnormalities observed in obese individuals Perioperative procedure before a liver

AUTHOR USER Page PAGE 3 DATE \ "dd /MM /yyyy " 09 /02 /2007

surgery in an obese patient includes routine abdominal ultrasound to role out cholelithiasis and evaluates liver size . Most patients with NALFD are asymptomatic and have mild to moderate increase of serum aminotransferase levels , clinical hepatomegaly , and features of fatty liver on imaging . Hepatomegaly imposes technical difficulties in performing laparoscopic colectomy in these patients . In patients with NALFD and hepatomegaly , usually 2 weeks of high-protein liquid diet is prescribed before surgery . This dietary manipulation is associated with weight loss and a decrease in liver volume (Lascano et al , 2006

Many patients with clinically severe obesity have peripheral veins that are hard to access , making both intravenous line insertion and laboratory draws more difficult . Central venous catheters should be used when peripheral intravenous access cannot be obtained (Abir and Bell 2004

Sleep apnea is the most important respiratory problem associated with obesity , with several studies confirming that obesity is a major risk factor for the development of obstructive sleep apnea (OSA (Horner et al , 1989 . Anesthesia , combined with narcotics and OSA , puts the patient at greater risk of developing respiratory arrest . To alleviate intraoperative and postoperative respiratory complications in the obese patients , there is need to carefully monitor patients for oxygen saturation and the use of narcotics . For the first 24 hours after surgery , all patients must be routinely admitted to an...