Bariatric Times

MAY 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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10 Opinion Review Bariatric Times • May 2018 tracheal intubation. The addition of an opioid before RSI can also improve conditions. A short-acting opioid (fentanyl, sufentanil, remifentanil, alfentanil) should be given to supplement the induction agent and decrease the incidence of awareness. Bag-mask ventilation is applied before a muscle relaxant is administered. Although fast-acting succinylcholine has historically been the relaxant of choice for RSI, there is some evidence that the fasciculations from succinylcholine increase oxygen consumption and shorten SAP. With the availability of the reversal agent suggammadex, rocuronium is now recommended before tracheal intubation. Bag-mask positive pressure ventilation should be continued until the patient is completely paralyzed and optimal conditions for tracheal intubation are achieved. Conventional direct laryngoscopy is usually successful in most patients with obesity. The use of video-laryngoscopy might further increase the success rate for tracheal intubation in patients with morbid obesity. Application of cricoid pressure is avoided since it can increase the degree of difficulty and time required for intubation, potentially increasing the risk of hypoxemia. CONCLUSION In conclusion, for many bariatric surgical patients, RSI continues to be a routine part of their management because of the misperception by some anesthesiologists that patients with obesity are at increased risk for gastric aspiration and pulmonary injury. However, RSI is not without its own risks (e.g., awareness, under- and overdosing of drugs, impaired visualization during laryngoscopy, hypoxia). These risks are probably greater than the potential risk of aspiration. Therefore, unless the patient with obesity has significant aspiration risk factors, RSI is unnecessary, potentially dangerous, and should not be performed. REFERENCES 1. El-Orbany M, Connolly LA. Rapid sequence induction and intubation: current controversy. Anesth Analg. 2010;110:1318–25. 2. Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anaesth. 2007;54:748–54. 3. Freid EB. The rapid sequence induction revisited: obesity and sleep apnea syndrome. Anesthesiol Clin North Am. 2005;23:551–64. 4. Vaughan RW, Bauer S, Wise L. Volume and pH of gastric juice in obese patients. Anesthesiology. 1975;43:686–8. 5. Juvin PH, Fevre G, Merouche M, et al. Gastric residue is not more copious in obese patients. Anesth Analg. 2001;93:1621–2. 6. Harter RL, Kelly WB, Kramer MG, et al. A comparison of the volume and pH of gastric contents of obese and lean surgical patients. Anesth Analg. 1998;86:147–52. 7. Gaszynski TM, Szewczyk T. Rocuronium for rapid sequence induction in morbidly obese patients: a prospective study for evaluation of intubation conditions after administration 1.2 mg kg 2 ideal body weight of rocuronium. Eur J Anaesthesiol. 2011;28:609–10. 8. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anesthesiol. 2011;l28:556–69. 9. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114:495–511. 10. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Brit J Anesth. 2011;106:617–31. 11. Kocian R, Spahn DR. Bronchial aspiration in patients after weight loss due to gastric banding. Anesth Analg. 2005;100:1856–7. 12. Thekkethodika A. The risk of regurgitation and pulmonary aspiration in a patient after gastric banding. Case Rep Anesthesiol. 2012; doi: 10.1155/2012/18610. 13. Jean J, Compere V, Foundrinier V, et al. The risk of pulmonary aspiration in patients after weight loss due to bariatric surgery. Anesth Analg. 2008;107:1257–9. 14. Abdemur A, Han SM, Lo Menzo E, et al. Reasons and outcomes of conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass for nonresponders. Surg Obes Relat Dis. 2016;12:113–8. 15. Sucandy I, Chrestiana D, Bonanni F, Antanavicius G. Gastroesophageal reflux symptoms after laparoscopic sleeve gastrectomy for morbid obesity. The importance of preoperative evaluation and selection. N Am J Med Sci. 2015;7:189–93. 16. Fressa EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following Roux-en-Y gastric bypass. Surg Endosc. 2002;16:1027– 31. 17. Pandit JJ, Andrade J, Bogod DG, et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Brit J Anaesth. 2014;113:549–59. 18. Smith KJ, Dobranowski J, Yip G, et al. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology. 2003;99:60–4. 19. Brimacombe JR, Berry AM. Cricoid pressure. Can J Anaesth. 1997;44:414–25. 20. Tournadre JP, Chassard D, Berrada KR, Bouletreau P. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology. 1997;86:7–9. 21. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg. 2004;14:1171–5. 22. Brodsky JB, Lemmens HJ, Brock- Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–6. 23. Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Brit J Anaesth. 1987;59:315–8. 24. Gebremedhn EG, Mesele D, Aemero D, Alemu E. The incidence of oxygen desaturation during rapid sequence induction and intubation. World J Emerg Med. 2014;5:279–85. 25. Harbut P, Gozdik W, Stjernfalt E, et al. Continuous positive airway pressure/pressure support pre- oxygenation of morbidly obese patients. Acta Anaesthesiol Scand. 2014;58:675–80. 26. Gander S, Frascarolo P, Suter M, et al. Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients. Anesth Analg. 2005;100:580–4. FUNDING: No funding was provided for this article. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this manuscript. AUTHOR AFFILIATION: Dr. Brodsky is Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine in Stanford, California. ADDRESS FOR CORRESPONDENCE: Jay B. Brodsky, MD; Email: BT [F]or many bariatric surgical patients, RSI continues to be a routine part of their management because of the misperception by some anesthesiologists that patients with obesity are at an increased risk for gastric aspiration and pulmonary injury. Call for Case Reports! Do you have a case that illustrates a new, unique, or innovative treatment method? Bariatric Times is seeking submissions! Case reports are short presentations of cases that stimulate research and the exchange of information, and illustrate new, unique, and/or innovative treatment methods or perspectives on the signs and symptoms, diagnosis, and treatment of a disorder. To submit a case report, contact: Angela Saba, Managing Editor, Matrix Medical Communications Email:

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