Obese patients anesthetized for bariatric surgeries require special anaesthesiological preparation for the procedure and care during its implementation. We talk to Dr. n. med. Marcin Możański from the Department of Anaesthesiology and Intensive Therapy of the Military Medical Institute in Warsaw.
An anesthesiologist is one of those specialists who qualify an obese patient for bariatric surgery. Why?
Marcin Możański:Obese patients require special attention. Over the years, obesity causes changes in the respiratory system and the circulatory system, as well as numerous accompanying diseases (such as diabetes), which significantly affect the course of anesthesia. Due to the significant limitations of the efficiency of such patients, it is worth implementing a procedure that will prepare them for surgery, and only then assess them before the procedure itself.
Is there any difficulties in intubating a bariatric patient?
M.M.:Yes. Difficulties arise from anatomical changes that occur in obese patients. They develop an overgrowth of all the soft tissues of the throat and the palatine tonsils. Such patients also have a much shorter and thicker neck and much less space in the throat for inserting devices with which we perform endotracheal intubation. So sometimes you need a videolaryngoscope or a bronchofiberoscope with which you can safely insert the tube into the trachea of an obese patient.
What is the difference between an ordinary laryngoscope and a videolaryngoscope?
M.M.:The laryngoscope is a metal blade with a light source. When we use it, we have to move all the tissues away ourselves so that we can see the larynx and the entrance to it. On the other hand, video laryngoscopes and all other optical devices make the doctor's eyes see a camera or optical fiber that transmits the image to the monitor. The video laryngoscope gives more possibilities and increases the patient's safety.
Are such devices also used in non-bariatric surgeries?
M.M.:Yes. For example, in maxillofacial surgery and in general wherever there are so-called difficult airways.
Obesity is a diseasepartner's material
Obesity has been officially recognized as a disease by the World He alth Organization. Obesity has reached epidemic proportions in Poland. Already 700,000 Poles with third degree obesity need a life-saving bariatric surgery. A bariatric patient requires the interdisciplinary care of specialists in the fields of surgery, psychology, dietetics and physiotherapy.
read moreIs there an increased risk of embolism in obese patients?
M.M.:All operated patients are at risk of venous thromboembolism. Therefore, in the period of preparation for the operation, patients are given drugs that reduce blood clotting. In addition, we try to perform the operation as soon as possible and start the patient as quickly as possible, because movement reduces the risk of embolism. We also use mechanical prophylaxis with the use of special stockings or bandaging of the lower limbs during surgery or special cuffs that compress the limbs. These cuffs mimic the movements of the muscles that stimulate blood flow in the extremities.
What determines the choice of the method of this prevention?
M.M.:This is an individual matter. It all depends on the severity of obesity and the degree of risk that a given patient has.
How must the operating room be adapted for an obese patient?
M.M.:First of all, the operating table must have the appropriate load-bearing capacity, it must also bend in the right places so as to adapt to the patient's position and the surgeon's needs. The position during surgery is not always flat. Sometimes it is very much inclined towards the legs, sometimes the other way round. In addition to the table, all devices that allow you to position the patient are very useful. These are such gel pads. We call them "positioners". They are useful because an obese patient cannot always be placed on the flat surface of the operating table. This is due to various dysfunctions of the locomotor system. The limbs do not bend properly and the back cannot be stretched, e.g. due to a fatty hump. Therefore, the patient requires neck, head, limbs and knee pads so that the muscles, nerves or tendons are not damaged during prolonged stay in the supine position. When operating on obese patients, the usual grade is also useful. Thanks to it, the patient can enter the operating table before the procedure, and the anesthesiologist can stand over it in a comfortable position. We also need rollers and lifts that help us move the patient to bed after surgery.
In what position is the patient operated duringbariatric surgery?
M.M.:Most often in a position strongly inclined towards the legs. That is why we often use foot rests during such procedures so that the patient does not slide off the operating table. Sometimes we also use vacuum mattresses, which - suctioned - freeze in the set position and stiffen the patient so that he does not move on the operating table.
Why does the patient have to lie tilted towards the legs during bariatric surgery?
M.M.:This position is needed by surgeons. They operate mainly in the upper abdominal cavity, so they want the intestines and intraperitoneal fat to move downward under the action of gravity. Then they reveal the upper part of the abdominal cavity, i.e. the operated stomach. If the patient was completely flat, the surgeons would have a narrowed operating field and it would be more difficult to perform the procedure.
What is the greatest challenge for the anaesthesiologist during bariatric surgery?
M.M.:When it comes to monitoring the level of anesthesia, we have several devices that measure the depth of anesthesia and how the patient's brain responds to it. In an obese patient, the effects of hypnotics, painkillers and muscle relaxants change. This is because it has much more body fat, less water and a differently built circulatory system, so the same medications given to a slim and obese patient may work differently. It may turn out that the dose of the drug calculated according to body weight is too high, or vice versa, and the patient may wake up during the procedure. To be sure that we do not use too small or too large doses of drugs, device monitoring of the depth of anesthesia should be used.
What is the greatest risk for obese patients during bariatric surgery?
M.M.:These patients are heavily burdened, mainly due to numerous respiratory and circulatory diseases and the frequent occurrence of obstructive sleep apnea syndrome, which, unfortunately, is often undiagnosed. It is a very dangerous pathology for obese patients. Obstructive sleep apnea causes the patient to lose airway and stop breathing during sleep. She suffers from her own tongue and a rebuilt throat. Then it comes to respiratory failure. If we give him sleeping pills, painkillers or muscle relaxants, this process deepens. After surgery, such a patient may have difficulty breathing. Moreover, if the patient does not treat sleep apnea (because sometimes he does not even know about it), very serious changes occur.in the lungs and heart. The resulting remodeling of these organs is extremely dangerous and can lead to death even without surgery. In monitoring patients with perioperative sleep apnea, the usual oxygen saturation is not enough. It is also useful to estimate the amount of carbon dioxide in the exhaled air - it shows, among other things, the quality of your breathing. An effective method increasing the safety of bariatric patients is capnographic monitoring, which enables immediate detection of apnea and early intervention to prevent potential complications, e.g. cardiac arrest, which poses a direct threat to the patient's life.
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