Idea Transcript
ASPCOP OSSANZ 28th of October, Doltone House, Sydney
Jan Paul Mulier Departement of Anesthesiology AZ Sint – Jan AV Brugge Belgium
1150
2015
What extra ERAS recommendations do we need for obese patients? 2016 ISPCOP Chicago
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Potential conflicts of interest. •
I have been giving lectures for or received research support from following companies in the last two years:
– – – – – – • •
Abbvie General Electric Johnson & Johnson, Ethicon Medec Merck (MSD) Orion
No important shareholder in any medical company This lecture on obesity is not supported by any company Jan P Mulier AZ Sint Jan Brugge
2016 ISPCOP Chicago
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Main elements of ERAS • Multimodal recovery programme for elective bowel surgery. – Henri Kehlet Denmark 2001 – Lassen K. ERAS Group recommendations. Arch surg 2009; 144: 961-969
2016 ISPCOP Chicago
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www.ESPCOP.org The European Society for Perioperative Care of the Obese Patient
Key points to remember in anaesthesia for the morbidly obese patient. 1. Key points in pre operative planning: • Record body mass index BMI and total body weight (TBW) on operating list. If central obesity (weight >half height), look for metabolic syndrome. • Metabolic syndrome = visceral obesity plus diabetes, dyslipidaemia, hypertension. These are the high risk patients. • Atrial fibrillation, long QT, heart failure, pulmonary hypertension or a cardiomyopathy?
• 10% pre operative body weight reduction is important if visceral obesity. Improves respiratory function and laparoscopic surgical access. • “STOP BANG ”questionnaire ≥ 5 or Obesity Hypoventilation Syndrome (OHS) (paCO2 >45mmHg) -> regional or opioid free anaesthesia or postoperative CPAP.
2. Key points in anaesthesia induction. • HELP:30 degree head up position, add ramping device or • Mallampati and large neck circumference = difficult bag under thorax. laryngoscopy /intubation. 2016 ISPCOP Chicago • Pre-oxygenation and 10 cmH2O CPAP until the • Facemask ventilation is frequently problematic –needs
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Key points to remember in anaesthesia for the morbidly obese patient. ERAbS The European Society for Perioperative Care of the Obese Patient
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight (TBW) on operating list. If central obesity (weight >half height), look for metabolic syndrome. • Metabolic syndrome = visceral obesity plus diabetes, dyslipidaemia, hypertension. These are the high risk patients. • Atrial fibrillation, long QT, heart failure, pulmonary hypertension or a cardiomyopathy?
• 10% pre operative body weight reduction is important if visceral obesity. Improves respiratory function and laparoscopic surgical access. • “STOP BANG ”questionnaire ≥ 5 or Obesity Hypoventilation Syndrome (OHS) (paCO2 >45mmHg) -> regional or opioid free anaesthesia or postoperative CPAP.
Key points to remember in anaesthesia for the morbidly obese patient. 2. induction. 1. Key Key points points in in anaesthesia pre operative planning: •• HELP:30 degree upBMI position, add ramping device or Record body masshead index and total body weight bag under (TBW) on thorax. operating list. If central obesity (weight >half • Pre-oxygenation and 10 cmH2O CPAP until the height), look for metabolic syndrome. intubation. • Metabolic syndrome = visceral obesity plus diabetes, • dyslipidaemia, Know the correct dosing scalars agents and hypertension. Thesefor areinduction the high risk patients. muscular relaxants. • Atrial fibrillation, long QT, heart failure, pulmonary hypertension or a cardiomyopathy?
•• Mallampati and large neck circumference = difficult 10% pre operative body weight reduction is important laryngoscopy /intubation. if visceral obesity. Improves respiratory function and • Facemask ventilation is frequently problematic –needs laparoscopic surgical access. two hands ventilation and airways. • “STOP BANG ”questionnaire ≥ 5 or Obesity • Avoid laryngeal and supraglottic devices, Hypoventilation Syndrome (OHS) (paCO2endotracheal >45mmHg) tubes shouldorbeopioid the default airway. or postoperative -> regional free anaesthesia CPAP.
3. Key points in anaesthesia maintenance. • Lung recruitment maneuvers after intubation followed by
• Prefer loco regional anaesthesia. Avoid long working sedatives and opioids. •• Lung protective and beach position •• Monitor the neuromuscular blockade (TOF and=PTC ) to HELP:30 degreeventilation head up position, addchair ramping device or Mallampati and large neck circumference difficult when possible. provide sufficient depth if use neuromuscular blocking agents. bag under thorax. laryngoscopy /intubation. •• Prefer water-soluble acting CPAP drugs that •• Monitoring anaesthesia limitsproblematic the anaesthetic load Pre-oxygenation andshort 10 cmH2O untilare theeasy to Facemask ventilation is depth frequently –needs dose and to monitor. and awareness.and airways. 2016 ISPCOP Chicago 5 intubation. two avoids hands ventilation • Know the correct dosing scalars for induction agents and • Avoid laryngeal and supraglottic devices, endotracheal
2. Key points anaesthesia induction. sufficient PEEPin even when oxygen saturation is normal.
2. Key points in anaesthesia induction. • HELP:30 degree head up position, add ramping device or bag under thorax. • Pre-oxygenation and 10 cmH2O CPAP until the intubation. The•European Society for Perioperative of the Know the correct dosing scalars for induction Care agents and muscular relaxants.
ERAbS
• Mallampati and large neck circumference = difficult laryngoscopy /intubation. • Facemask ventilation is frequently problematic –needs two hands ventilation and airways. Obese Patientand supraglottic devices, endotracheal • Avoid laryngeal tubes should be the default airway.
3. Key points in anaesthesia maintenance.
Key points to remember in anaesthesia for the morbidly obese patient. • Lung recruitment maneuvers after intubation followed by sufficient PEEP even when oxygen saturation is normal. • Lung protective ventilation and beach chair position when possible. • Prefer water-soluble short acting drugs that are easy to dose and to monitor.
1. Key points in pre operative planning: 4. Key points in anaesthesia emergence. • Record body mass index BMI and total body weight • Use Pressure Supportlist. Ventilation evaluate breathing (TBW) on operating If centraland obesity (weight >half frequency. height), look for metabolic syndrome. • Be sure to syndrome have full neuromuscular blockade reversal. Metabolic = visceral obesity plus diabetes, • Empty stomachhypertension. and avoid suctioning tube dyslipidaemia, These are endotracheal the high risk patients. • Atrial fibrillation, long QT, heart failure, pulmonary hypertension or a cardiomyopathy?
5. Key points in postoperative care.
• Prefer loco regional anaesthesia. Avoid long working sedatives and opioids. • Monitor the neuromuscular blockade (TOF and PTC ) to provide sufficient depth if use neuromuscular blocking agents. • Monitoring anaesthesia depth limits the anaesthetic load and avoids awareness.
• 10% pre operative body weight reduction is important (if needed obesity. follow with recruitment). if visceral Improves respiratory function and • Extubation under CPAP in beach chair position when laparoscopic surgical access. awake. • fully “STOP BANG ”questionnaire ≥ 5 or Obesity • Avoid sedation and use the lowest of opioids. Hypoventilation Syndrome (OHS)level (paCO2 >45mmHg) -> regional or opioid free anaesthesia or postoperative CPAP.
• Continue with CPAP mask if used before surgery. tromboprophylaxis. • Beach chair position or better sitting up to 60°. • Look for SpO2 desaturations and hypercarbia. 2. Key points in anaesthesia induction. • Sufficient pain and PONV treatment. • Be aware of rhabdomyolysis when prolonged surgery in HELP:30early degree head up position, add ramping device or • Mallampati and large neck circumference = difficult • Promote mobilization and provide the sitting position. bag under thorax. laryngoscopy /intubation. • Pre-oxygenation and 10 cmH2O CPAP until the • Facemask ventilation is frequently problematic –needs Key points to remember in anaesthesia for the morbidly patientChicago © www.Espcop.org 2016 obese ISPCOP 6 intubation. two hands ventilation and airways. Claire Nightingale, Michael Margarson, Paolo Pelosi, Thomas Gazynski, Luc de Baerdemaeker, Jan Mulier • Know the correct dosing scalars for induction agents and • Avoid laryngeal and supraglottic devices, endotracheal
What extra information do you need in obese patients pre operative to adapt your treatment? 1.
Fat distribution is more important than BMI or weight – –
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Predictive factors for difficult mask ventilation or intubation – –
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Stop bang questionaire or sleep study Opioid free anesthesia with low opioid mulimodal analgesia Continue home cpap in hospital
Saturation without oxygen before and after deep inspiration Apply all methods to open and keep lungs open peri operative Request intensive care if assiociated lung disease
Predicted size of workspace if laparoscopy – –
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covered by Claire Nightingale
Amount of spontaneous atelectasis and ability to open it by the patient (or COPD and diffusion problems) – – –
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covered by Claire Nightingale
Neck circumference, mouth opening and mallampatti score, beard Nasal cpap-PSV during induction, correct positioning and equipment available
OSAS and use of CPAP mask at home – – –
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covered by Claire Nightingale Waist to height or waist to hip circumference; intra abdominal fat versus subcutaneous fat Prevent surgical and anesthesiologic troubles by extra treatment
Questionaire (fat distribution, previous lap and gravidity, weight reduction Deep NMB, higher IAP need and delay of surgery if no weight reduction
Metabolic syndrome and its impact on major organ function –
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Central obesity + any two: high Triglyceride, low HDL-C, hypertension, diabetes
2016 ISPCOP Chicago Major organ function changed: Liver, kidney, cardiac.
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1. Fat distribution • Android
vs
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Gynoid
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Thickness of external fat
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4. Amount of spontaneous atelectasis and ability to open Before Anesthesia induction, beach chair and no O2
• Saturation > 98 % ok • Saturation low < 99 %
minimal atelectasis
– Deep Inspiration 3 x without O2: • if sat rises: patient is able to open atelectasis him/herself • If sat does not rise:
– LRM after induction with 40 cmH20 for 10 s • If sat rises: we are able to open atelectasis -> maintain CPAP • If sat does not rise (95 % 91 – 95 % < 91 % Resp infect (last month) no Yes Surgical incision peripheral Upper abd Intrathoracic Duration 3h Emergency no yes
0 0.8 2.4
0 8 24
0 1.7
0 17
0 1.5 2.4
0 15 24
0 1.6 2.3
0 16 23
0 0.8
0 8
Score:
low risk moderate risk 11 high risk
80 y
ABSTRACT Background: No externally validated risk score for postoperative pulmonary complications (PPCs) is currently available. The authors tested the generalizability of the Assess Respiratory Risk in Surgical Patients in Catalonia risk score for PPCs in a large European cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe). Methods: Sixty-three centers recruited 5,859 surgical patients receiving general, neuraxial, or plexus block anesthesia. The Assess Respiratory Risk in Surgical Patients in Catalonia factors (age, preoperative arterial oxygen saturation in air, acute respiratory infection during the previous month, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration, and emergency surgery) were recorded, along with PPC occurrence (respiratory infection or failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis). Discrimination, calibration, and diagnostic accuracy measures of the Assess Respiratory Risk in Surgical Patients in Catalonia score’s performance were calculated for the Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe cohort and three subsamples: Spain, Western Europe, and Eastern Europe. Results: The full Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe data set included 5,099 patients; 725 PPCs were recorded for 404 patients (7.9%). The score’s discrimination was good: c-statistic (95% CI), 0.80 (0.78 to 0.82). Predicted versus observed PPC rates for low, intermediate, and high risk were 0.87 and 3.39% (score