Obesity and Anaesthesia Dr Nick Woodall. Obesity UK Prevalence 24.5% Information Centre for health...
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Obesity and AnaesthesiaObesity and Anaesthesia
Dr Nick WoodallDr Nick Woodall
Obesity – UK Prevalence 24.5%
Information Centre for health and social care. The health survey for England - 2009 trend tables. London: Health and Social Care Information Centre, 2010.
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All Adults Males Female
Morbid Obesity - Prevalence 2%
Information Centre for health and social care. The health survey for England - 2008 trend tables. London: Health and Social Care Information Centre, 2009.
Obesity Complications
• 184 reports received, 77 were obese • 133 reports of anaesthesia, 53 were obese
• Deaths 16 (4)• Brain damage 3 (1)• Emergency surgical airways 25 (19)• ICU admission or prolongation of stay 33 (29)
Body Mass Index
>40kg.m-2 >30kg.m-2 20-30kg.m-2 <20kg.m-2
All reports 184 14(8%) 77 (42%) 89(48%) 18(10%)
Anaesthesia 133 8(6%) 53 (40%) 65(49%) 15 (11%)
ICU 36 4(11%) 17 (47%) 17 (47%) 2 (6%)
Emergency Department 15 1(6%) 7 (46%) 7 (46%) 1(7%)
Body Mass Index
>40kg.m-2 >30kg.m-2 20-30kg.m-2 <20kg.m-2
All reports 184 14(8%) 77 (42%) 89(48%) 18(10%)
Body Mass Index
>40kg.m-2 >30kg.m-2 20-30kg.m-2 <20kg.m-2
All adults 171 14(8%) 76 (44%) 77(45%) 18(10%)
Obesity Inclusion
• Obesity – BMI > 30kg.m-2
– Obese body habitus
• Morbid obesity – BMI > 40kg.m-2
Obesity• Co-morbidities• Aspiration risk• Potential airway problems
– Bag mask ventilation – Tracheal intubation– Difficult surgical airway
• Increased oxygen demand• Reduced oxygen reserve• Alternatives available
– Awake intubation– Regional anaesthesia– SAD selection
Obesity and Anaesthesia
• 53 reports
Obesity and Anaesthesia
• 53 reports• Female 49%
Obesity and Anaesthesia
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<20 21-40 41-60 61-80 >80 Not stated
Anaesthesia events - age distribution of reports and BMI
BMI of ≥30 (n=53) BMI of <30 (n=80)
• 53 reports• Female 49%
• Middle-aged
Obesity and Anaesthesia
• 53 reports• Female 49%
• Middle-aged• Co-morbidities
– HT/IHD (47%)– OSA (17%)– DM (17%)– Asthma (15%)
Obesity and Anaesthesia
• 53 reports• Female 49%
• Middle-aged• Co-morbidities• Reduced consultant
input
Reported more commonly in the obese
• LMA/SAD problems• Failed mask ventilation• Difficult or delayed intubation/CICV• Iatrogenic airway trauma• Problems on emergence
• Conversion of regional or local anaesthesia to GA
Primary Airway Problem
Case Review - Areas of Interest
• Assessment and preparation• Regional anaesthesia • Awake intubation• Supra-glottic airway use• Conduct of general anaesthesia• Organisational factors
Case Report
• Male 150kg• OSA HT/IHD• Minor hand surgery• Needle phobic GA• Self removal of LM• Cardiac arrest• ICU trach, full recovery after 7days
Case Report
• Male, morbidly obese• Reduced palatal view, limited neck mobility• Urgent perineal surgery• Limited pre-oxygenation• Trainee anaesthetist• GA Difficult LM/BMV• Tracheal/oesophageal intubation• Cardiac arrest, failed resuscitation
Assessment and preparation
• Co-morbidities were common• Signs of airway difficulty may be absent• Airway assessment not performed in 30%• Recognised airway problems were ignored
Loco-regional anaesthesia
• Not used or not considered• Inappropriate techniques/sedation• Failure of regional anaesthesia • Intra-operative conversion is high risk in
the presence obesity
Awake intubation
• Not used• Failed
– lack of co-operation– airway obstruction– bleeding– apnoea
• Problems with sedation
Conduct of General Anaesthesia
• Poor anticipation of problems– Preparation– Planning of a response to difficulty
• Inappropriate techniques– SV, lithotomy with trendellenburg
• Supra-glottic airway devices (SAD)– Usage similar in obese and non-obese– Inappropriate patient selection– Inappropriate device
Organisational Factors
• Obesity not recognised as a risk factor at all levels
• Poor communication• Insufficient time allocated • Inadequate assessment• Inappropriate location• Inappropriate staff deployed
Recommendations
• Greater level of awareness of additional risks posed by obesity is required
• Morbidly obese patients require thorough POA without time constraints
• Airway assessment should include feasibility of rescue techniques with consideration of awake intubation
• Plan for management of conversion to GA
The EndThe End