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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24 Review Course Lecture Bariatric Times • May 2018 higher desaturation and bradycardia when compared to rocuronium (recommended dose 0.6mg/kg ideal body weight) in patients with MO. The hypoxemia due to succinylcholine might be partially due to the increased oxygen consumption by skeletal muscle fasciculations. More likely and with serious risk of morbidity (and potential mortality) is the profound oxyhemoglobin desaturation attributed to the loss of functional residual capacity (FRC) secondary to the deep and profound neuromuscular blockade. This hypoxemia becomes even more clinically relevant when the return of spontaneous respiration is unpredictably delayed, leading to serious complications from the CICO scenario. Even when the airway is secured quickly and successfully, the desaturation due to succinylcholine continues and possibly explained by extensive basal atelectasis secondary to diaphragmatic paralysis. Till further and more definitive evidence becomes available, it might be prudent to avoid succinylcholine in elective, fasted patients. It is also advisable to limit the use of succinylcholine in patients with MO to rapid sequence inductions and intubations (RSII) where the benefits of preventing regurgitation and aspiration outweigh the risks from potential hypoxemia. POSTOPERATIVE AIRWAY MANAGEMENT IN MORBID OBESITY The postoperative airway is the last and final piece of the "7Ps" puzzle for DA management in patients with MO. Once again, careful attention should be paid to this phase as was highlighted in the NAP4 report. Other reports also suggest that major adverse airway-related events in patients with MO occur after emergence from anesthesia (ASA Closed Claims Database). In a rather indirect way, successful airway management in patients with MO requires adequate emergence from anesthetic, reversal of neuromuscular blockade and appropriate analgesia. Extreme caution and care should be exercised during emergence in patients with MO especially those with anticipated (or unanticipated) difficulty in airway management. Use of reversal agents such as suggamadex and naloxone have been described elsewhere and should be considered as indicated. Adequate and appropriate monitoring should be continued as appropriate. Meticulous attention should be paid to keeping the patient with MO in the HELP position and supplementing oxygen with nasal prongs or face mask while in the early phases of recovery. A very useful strategy in these patients is the insertion of a modified nasal trumpet (MNT) airway. Patients with severe OSA and or those with high CPAP settings might require immediate post extubation resumption of their respiratory support therapy. Monitoring expired CO 2 levels in these patients will aid the early detection of airway obstruction, hypoventilation and/or impending respiratory failure. 36 SUMMARY As obesity continues to increase globally, patients with MO will continue to frequently present for elective and emergency procedures where they require airway management. We need to carefully predict DA in these patients and manage them appropriately as described in this chapter. To improve patient safety and outcomes from airway management, accumulating evidence and vast experience from bariatric anesthesia also needs to be continually incorporated into MO- specific DA algorithms. COPYRIGHT For good consideration, the Assignor (International Anesthesia Research Society), as copyright holder, hereby grants permission to Assignee (Matrix Medical Communications) to reprint, publish, and use for global distribution the following material: Eipe N. RCL-16 Predicting and Managing "MODA": The Morbid Obesity Difficult Airway. IARS 2017 Review Course Lectures. 2017; 48-51. This material shall be used only in the following publication: Bariatric Times. REFERENCES 1. Hagberg CA, Vogt Harenkamp C, Kamal J. A retrospective analysis of airway management in obese patients at a teaching institution. J Clin Anesth. 2009;21:348–3 51. 2. Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management —part 2 —the anticipated difficult airway. Can J Anaesth. 2013;60:1119 –1138. 3. Cook TM, Woodall N, Frerk C, Fourth National Audit Project. 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. Br J Anaesth. 2011;106:617 –631. 4. Lavi R, Segal D, Ziser A. Predicting difficult airways using the intubation difficulty scale: a study comparing obese and non - obese patients. J Clin Anesth. 2009;21:264 –267. 5. Riad W, Vaez MN, Raveendran R, et al. 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Difficult mask ventilation in obese patients: analysis of predictive factors. Minerva Anestesiol. 2014;80:149–1 57. 21. Cattano D, Melnikov V, Khalil Y, et al. An evaluation of the rapid airway management positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery. Obes Surg. 2010;20:1436–14 41. 22. Shah U, Wong J, Wong DT, Chung F. Preoxygenation and intraoperative ventilation strategies in obese patients: a comprehensive review. Curr Opin Anesthesiol. 2016;29:109–118. 23. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25-degree head-up position than in the supine position in severely obese patients. Anesthesiology. 2005;102:1110–1115. 24. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010;22:164 –168. 25. 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;100:580–584. 26. Maassen R, Lee R, Hermans B, et al. A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesth Analg. 2009;109:1560–156 5. 27. Abdelmalak BB, Bernstein E, Egan C, et al. GlideScope® vs flexible fibreoptic scope for elective intubation in obese patients. Anaesthesia. 2011;66:550–555. 28. Abdellatif AA, Ali MA. GlideScope videolaryngoscope versus flexible beroptic bronchoscope for awake intubation of morbidly obese patient with predicted difficult intubation. Middle East J Anaesthesiol. 2014;22:385–3 92. 29. Sinha A, Jayaraman L, Punhani D. ProSeal LMA increases safe apnea period in morbidly obese patients undergoing surgery under general anesthesia. Obes Surg. 2013;23:580–584. 30. Gaszynski T, Gaszynska E, Szewczyk T. Dexmedetomidine for awake intubation and an opioid free general anesthesia in a superobese patient with suspected difficult intubation. Drug Des Devel Ther. 2014;8:909–9 12. 31. Huitink JM, Eipe N, Coccicante A, et al. Problem Based Approach to Awake Flexible Optical Intubation. 2013 iBook (available to download at iTunes). 32. Ingrande J, Lemmens HJ. Anesthetic pharmacology and the morbidly obese patient. Curr Anesthesiol Rep. 2013;3:10– 17. 33. Brodsky JB, Lemmens HJM. Succinylcholine and morbid obesity: the debate continues… Obes Surg. 2010;20:132. 34. Members of the Working Party, Nightingale CE, Margarson MP, et al. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia. 2015;70:859–876. 35. Tang L, Li S, Huang S, et al. Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand. 2011;55:203–208. 36. Taha SK, El Khatib MF, Baraka AS, et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia. 2010; 65:358–361. FUNDING: No funding was provided. DISCLOSURES: The author reports no conflicts of interest relevant to the content of this manuscript. AUTHOR AFFILIATION: Dr. Eipe is the Clinical Lead for Bariatric Anesthesia at The Ottawa Hospital in Ottawa, Canada and Assistant Professor, Department of Anesthesiology and Pain Medicine, University of Ottawa in Ottawa and currently is the VP (Education), International Society for the Perioperative Care of the Obese Patient (ISPCOP). ADDRESS FOR CORRESPONDENCE: Naveen Eipe, MD; E-mail: BT As obesity continues to increase globally, patients with MO will continue to frequently present for elective and emergency procedures where they require airway management.

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