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18 Anesthetic Aspects of Bariatric Surgery Bariatric Times • January 2017 TIPPING THE SCALES IN 2016: A NEW LOOK AT REGIONAL ANESTHESIA, NEUROMUSCULAR BLOCKADE, AND OPIOIDS IN THE PATIENT WITH OBESITY In a city in the midst of celebrating the Cubs National League (and eventual World Series) Championship, the International Society for the Perioperative Care of the Obese Patient (ISPCOP) held its 5th annual symposium during the American Society of Anesthesiologists (ASA) annual meeting. ISPCOP is an international society with a mission to promote excellence in clinical management, education, and research regarding the care of patients with morbid obesity during the perioperative period. ISPCOP membership is mostly composed of interested anesthesiologists. Close to 60 attendees gathered in a beautiful historic location—the King Arthur Court at the Hotel InterContinental on Michigan Avenue. Following a brief welcome by Dr. Roman Schumann, Professor of Anesthesiology at Tufts University School of Medicine at Tufts Medical Center in Boston and current president of ISPCOP, Dr. Patrick Ziemann- Gimmel, Assistant Professor at the University of Central Florida, employed by Sheridan Healthcare at Flagler Hospital in Saint Augustine, Florida, and the evening program chair, introduced the symposium outline and speakers to the audience. Dr. Yan Lai, Assistant Professor of Anesthesiology at the Icahn School of Medicine, Mount Sinai Medical Center in New York, started the meeting with a presentation titled "BRAVO! Bariatric Regional Anesthesia for the Very Obese." Dr. Lai discussed the benefits of regional anesthesia in patients with obesity. These include avoidance of airway manipulation, improved postoperative analgesia, and the reduction of postoperative nausea and vomiting (PONV). All those factors may also improve patient satisfaction and reduce the cost of care. Obesity was identified as a risk factor for block failure and complications during the era of nerve stimulation for block placement and before the introduction of ultrasound technology. Ultrasound guided regional anesthesia (USRA) allows the anesthesiologist to observe needle advancement and spread of local anesthetic in real time. With the widespread clinical use of ultrasound technology, regional anesthesia has become less time consuming, safer, and more efficient. Dr. Lai then shared some "pearls" on how to improve ultrasound image quality. Even in this patient population, a "keep it simple" principle will be a guide to success: recognize that certain nerve blocks are challenging in these patients, choose superficial blocks, and manage patients' expectations. Next, Dr. Glenn Murphy, Clinical Professor at the University of Chicago Pritzker School of Medicine; Jeffery S. Vender Chair of Anesthesiology Research and Education and Director of Cardiac Anesthesia and Clinical Research, NorthShore University Health System spoke about "Dosing and reversal of neuromuscular blockade in the patient with obesity." Dr. Murphy has authored numerous articles, reviews, and book chapters and is a world-renowned researcher in the field of neuromuscular blockade management. Compared to normal weight patients, the patient with obesity presenting for a surgical procedure requiring neuromuscular blockade poses additional challenges to the anesthesiologist. Dr. Murphy addressed the question of dosing optimization for neuromuscular blocking agents (NMBA). Dosing for this type of medication is weight based, but it is often unclear which weight scalar to use: ideal body weight, adjusted body weight, lean body weight, or total body weight. The many physiologic changes in the patient with obesity make the decision difficult given the effect on the pharmacokinetics and pharmacodynamics of NMBAs. Few data have emerged for patients with obesity to guide administration. For example, it is beneficial to choose the dose of succinylcholine based on total body weight, providing the best intubating conditions compared to alternatives. In contrast, the dose of non-depolarizing NMBAs should be based on ideal body weight to avoid significant prolongation of neuromuscular blockade. At the end of the procedure, a reversal agent should always be administered in patients with morbid obesity and routine neuromuscular blockade monitoring should be standard. Neostigmine can have significant side effects and limited effectiveness in NMBA reversal. It needs to be administered at a high train-of-four ratio (3-4) and due to the time required to reach peak effect, it is recommended to wait at least 10 to 15 minutes before tracheal extubation. The recently FDA-approved drug sugammadex should be considered in high-risk patients. Sugammadex can readily reverse a deep neuromuscular block for a commonly used class of NMBAs with a fast onset of action and maximal effect typically within two minutes. These pharmacological features of sugammadex make it a very attractive choice for NMBA reversal in this context. These two presentations were followed by the scientific abstract session. This part of the program Column Editor: Stephanie B. Jones, MD Dr. Jones is Associate Professor, Harvard Medical School and Vice Chair for Education, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. THIS MONTH: 5 th Annual Symposium of the International Society for the Perioperative Care of the Obese Patient (ISPCOP) Chicago, October 24, 2016 by PATRICK ZIEMANN-GIMMEL, MD; and ROMAN SCHUMANN, MD Bariatric Times. 2017;14(1):18–19. This ongoing column is written by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient. ANESTHETIC ASPECTS of Bariatric Surgery Attendees of the International S ociety for the Perioperative Care of the Obese Patient (ISPCOP) 5 th annual symposium at the King Arthur Court at the Hotel InterContinental on Michigan Avenue in Chicago, Illinois Dr. Yan Lai, Assistant Professor of Anesthesiology at the Icahn School of Medicine, Mount Sinai Medical Center in New York discussed the benefits of regional anesthesia in patients with obesity.