Obesity and Comorbidities

Obesity is a multi-system disorder, involving the respiratory and cardiovascular systems.1 The World Health Organization classification of obesity starts with a BMI of 30 kg.m2

Body mass index: kg.m2 Classification
<18.5 Underweight
18.5-24.9 Normal
25.0-29.9 Overweight
30.0-34.9 Obese 1
35.0-39.9 Obese 2
>40.0 Obese 3 (previously "morbid obesity")

Studies show morbidity and mortality increase when BMI is >30 kg.m2, particularly in smokers, and the risk is proportional to duration of obesity.1 However, BMI alone is a poor predictor of comorbidity, surgical, or anaesthetic difficulty. Fat distribution, waist or collar circumference should be considered as are more predictive of cardiorespiratory comorbidity.1,2 Regarding fat distribution, central fat is associated with increased difficulty in intra-abdominal surgery, as well as increased difficulty in airway management and ventilation. This type of fat distribution is also associated with greater risk of metabolic and cardiovascular complications which increases with the duration of obesity.1,2

Important comorbidities to consider:
  • Approximately 5% of morbidly obese patients has obstructive sleep apnoea2
  • Mild to moderate hypertension is seen in 50–60% of obese patients and severe hypertension in 5–10%2
  • There is an increased risk of metabolic disorders (dyslipidaemia, diabetes mellitus, insulin resistance)1,5
  • There is an increased risk of thrombotic disorders (myocardial infarction, stroke and VTE)1,2,5

Obesity and Anaesthesia: Pre-operative Management

The anatomical and physiological changes associated with obesity present specific risks. Careful risk management starts with an adequate pre-operative assessment.

One of the first considerations regards cardio-respiratory function, which initially may appear asymptomatic due to limited mobility, but following further assessment may present significant dysfunction.1 For this reason, signs and symptoms of respiratory failure and cardiac failure must be assessed. Specific exams and investigations should be tailored to the individual patient, depending on comorbidity and the type and urgency of surgery.

Obesity is also associated with a 30% greater chance of difficult/failed intubation5 and therefore, careful airway assessment during the pre-operative phase is crucial. Mouth opening, Mallampati score, neck extension, and circumference (collar size >17.5 in) should be noted as it helps predict a potentially difficult airway.1 Following the assessment, a robust airway strategy must be planned and discussed, to prevent quick desaturation and increased morbidity.

Sleep disordered breathing should always be considered in obese patients

This can be assessed using the STOP-BANG questionnaire.The STOP-BANG screening questionnaire for obstructive sleep apnoea. One point is scored for eachpositice feature; a score ≥5 is a significant risk:

  • Snoring: Do you snore loudly (louder than talking or heard through a closed door)?
  • Tired: Do you often feel tired, fatigued or sleepy during the daytime? Do you fall asleep in the daytime?
  • Observed: Has anyone observed you stop breathing or chocking or gasping during your sleep?
  • Blood Pressure: Do you have, or are you being treated for, high blood pressure?
  • BMI: BMI > 35 kg.m2
  • Age: Age > 50 years
  • Neck: Circumference (measured around Adam's apple) > 43 cm (17 in) for males, > 41 cm (16 in) for females
  • Gender: Male

Obesity and Anaesthesia: Intra-operative Management

Intra-operative management of patients with obesity presents particular anaesthetic considerations, starting with the need for experienced anaesthetic and surgical staff. Several authors recommend considering regional anaesthesia as it reduces the risks associated with difficult intubation and acid aspiration and also provides safer and more effective postoperative analgesia.2,5

When regional anaesthesia is not possible, due to surgical or patient limitations, specific care must be taken when administering general anaesthesia. Many patients may not tolerate the usual supine position for general anaesthesia induction and intubation due to oxygen desaturation, airway obstruction or respiratory compromise. Awake intubation in a sitting position is often better tolerated.1

Choosing easily reversible drugs, with fast onset and offset for general anaesthesia is recommended because the pharmacokinetics of most general anaesthetic drugs are affected by the mass of adipose tissue, producing a prolonged, less predictable effect.1,5 Drug dosing should be based upon lean body weight and titrated to effect and caution is required with the use of long-acting opioids and sedatives. Using local anaesthetics is recommended as a way of minimising opioid use.

Adequate monitoring throughout anaesthesia is crucial. Invasive arterial pressure monitoring has been advocated for all but the most minor procedures in the morbidly obese. Pulse oximetry, electrocardiography, capnography and monitoring of neuromuscular block are all mandatory.2 Use of depth of anaesthesia monitoring techniques to limit anaesthetic load, particularly when neuromuscular blocking drugs and/or a total intravenous anaesthetic technique are utilised.5

Use of central venous and pulmonary artery flotation catheters should be considered in patients undergoing extensive surgery or those with serious cardiorespiratory disease.2

Obesity and Anaesthesia: Post-operative Management

When general anaesthesia has been used in obese patients, lung volumes are significantly reduced in the postoperative period. Where possible, extubation should be performed with patients wide-awake in the sitting position and then transferred to an appropriate postoperative environment. Maintaining the head–up position throughout recovery and monitoring oxygen saturations until mobile is recommended.5

Many anaesthetists consider perioperative epidural anaesthesia an important part of a multimodal approach to improving patient outcome and analgesia rather than relying solely on systemic opioid administration for pain management.1

Appropriate prophylaxis against venous thromboembolism and early mobilisation are recommended taking into consideration the increased incidence of venous thromboembolism in obese patients.5

Managing the risks of obesity and anaesthesia requires trained and experienced professionals, adequate patient assessment, preparedness of environment, careful choice of drugs, and intra and post-operative monitoring until full recovery has been achieved.

About the author

My name is Andreia Trigo RN BSc MSc, I am a nurse consultant with over a decade of experience in anaesthesia, sedation and pain management.

This involves patient care, as well as lecturing at post grad level on these topics, presenting at conferences and co-developing a very successful sedation course at SedateUK. My passion for creating safer environments for patients and professionals led me to collaborate with Medtronic and share my knowledge and expertise with our professional community.

 

The content of this article is written by a blogger with whom Medtronic has a relationship. However, the contents represent the personal objective views, comments and techniques of the blogger and are not statements from Medtronic. To the extent this material might contain images of patients or any material where a copyright is held by a third party, all necessary written permissions from the patient or copyright holder, as applicable, with respect to use, distribution or copying of such images or copyrighted materials has been obtained by the blogger.

  • 1. Lotia (2008) Anaesthesia and morbid obesity. Continuing Education in Anaesthesia Critical Care & Pain, Volume 8, Issue 5, October 2008, Pages 151–156 Available at https://academic.oup.com/bjaed/article/8/5/151/268305

  • 2. Adams, et al (2000) Obesity in anaesthesia and intensive care. British Journal of Anaesthesia, Volume 85, Issue 1, 1 July 2000, Pages 91–108 Available at https://academic.oup.com/bja/article/85/1/91/263697

  • 3. Brodsky (2018) Recent advances in anesthesia of the obese patient. Version 1. F1000Res. 2018; 7: F1000 Faculty Rev-1195. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081976/

  • 4. AAGBI (2015) Peri‐operative management of the obese surgical patient. Anaesthesia. 2015 Jul; 70(7): 859–876. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5029585/

  • 5. SOBAUK (2015) Peri‐operative management of the obese surgical patient. Guideline Available at https://anaesthetists.org/Home/Resources-publications/Guidelines/Peri-operative-management-of-the-obese-surgical-patient