Preanesthesia medical evaluation of the obese patient
- Roman Schumann, MD
Roman Schumann, MD
- Associate Professor of Anesthesiology
- Tufts University School of Medicine
As the prevalence of obesity increases worldwide, an increasing number of obese surgical patients will require anesthesia. Planning for anesthesia must take into account both physiologic changes caused by obesity, and the presence of comorbid conditions associated with obesity; consequently, the preanesthetic evaluation should determine and evaluate the relevant issues for the individual patient.
Obesity is typically defined by body mass index (BMI), the ratio of weight (in kilograms) to the square of height (in meters) (calculator 1). In adults, the World Health Organization (WHO) and the National Institutes of Health (NIH) have adopted a classification of obesity defined by BMI:
●Overweight – BMI ≥25 to 29.9 kg/m2.
●Obesity – BMI ≥30 kg/m2.
●Obesity class 1 – BMI of 30 to 34.9 kg/m2.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Dindo D, Muller MK, Weber M, Clavien PA. Obesity in general elective surgery. Lancet 2003; 361:2032.
- Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 2009; 250:166.
- Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med 2008; 36:151.
- Giles KA, Hamdan AD, Pomposelli FB, et al. Body mass index: surgical site infections and mortality after lower extremity bypass from the National Surgical Quality Improvement Program 2005-2007. Ann Vasc Surg 2010; 24:48.
- Valentijn TM, Galal W, Hoeks SE, et al. Impact of obesity on postoperative and long-term outcomes in a general surgery population: a retrospective cohort study. World J Surg 2013; 37:2561.
- Abhyankar S, Leishear K, Callaghan FM, et al. Lower short- and long-term mortality associated with overweight and obesity in a large cohort study of adult intensive care unit patients. Crit Care 2012; 16:R235.
- Valentijn TM, Galal W, Tjeertes EK, et al. The obesity paradox in the surgical population. Surgeon 2013; 11:169.
- Glance LG, Wissler R, Mukamel DB, et al. Perioperative outcomes among patients with the modified metabolic syndrome who are undergoing noncardiac surgery. Anesthesiology 2010; 113:859.
- Schumann R, Jones SB, Ortiz VE, et al. Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obes Res 2005; 13:254.
- Wilson PW, D'Agostino RB, Sullivan L, et al. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med 2002; 162:1867.
- Stengel B, Tarver-Carr ME, Powe NR, et al. Lifestyle factors, obesity and the risk of chronic kidney disease. Epidemiology 2003; 14:479.
- Mickelson SA. Preoperative and postoperative management of obstructive sleep apnea patients. Otolaryngol Clin North Am 2007; 40:877.
- Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812.
- Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth 2012; 108:768.
- Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001; 76:897.
- Poirier P, Alpert MA, Fleisher LA, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 2009; 120:86.
- Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229.
- Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006; 105:885.
- Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94:732.
- Bond A. Obesity and difficult intubation. Anaesth Intensive Care 1993; 21:828.
- Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75:1087.
- Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth 1988; 61:211.
- Lundstrøm LH, Møller AM, Rosenstock C, et al. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology 2009; 110:266.
- Heinrich S, Birkholz T, Irouschek A, et al. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia : a single-center analysis of 102,305 cases. J Anesth 2013; 27:815.
- Gonzalez H, Minville V, Delanoue K, et al. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg 2008; 106:1132.
- Ryan CF, Lowe AA, Li D, Fleetham JA. Magnetic resonance imaging of the upper airway in obstructive sleep apnea before and after chronic nasal continuous positive airway pressure therapy. Am Rev Respir Dis 1991; 144:939.
- Golbin JM, Somers VK, Caples SM. Obstructive sleep apnea, cardiovascular disease, and pulmonary hypertension. Proc Am Thorac Soc 2008; 5:200.
- Cartagena R. Preoperative evaluation of patients with obesity and obstructive sleep apnea. Anesthesiol Clin North America 2005; 23:463.
- Dorkova Z, Petrasova D, Molcanyiova A, et al. Effects of continuous positive airway pressure on cardiovascular risk profile in patients with severe obstructive sleep apnea and metabolic syndrome. Chest 2008; 134:686.
- Hofer RE, Kai T, Decker PA, Warner DO. Obesity as a risk factor for unanticipated admissions after ambulatory surgery. Mayo Clin Proc 2008; 83:908.
- Thomas H, Agrawal S. Systematic review of same-day laparoscopic adjustable gastric band surgery. Obes Surg 2011; 21:805.
- Moon TS, Joshi GP. Are morbidly obese patients suitable for ambulatory surgery? Curr Opin Anaesthesiol 2016; 29:141.
- Joshi GP, Ahmad S, Riad W, et al. Selection of obese patients undergoing ambulatory surgery: a systematic review of the literature. Anesth Analg 2013; 117:1082.
- Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009; 361:445.
- Kakarla VR, Nandipati K, Lalla M, et al. Are laparoscopic bariatric procedures safe in superobese (BMI ≥50 kg/m2) patients? An NSQIP data analysis. Surg Obes Relat Dis 2011; 7:452.
- Yeats M, Wedergren S, Fox N, Thompson JS. The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery. Am Surg 2005; 71:152.
- Müller MK, Dedes KJ, Dindo D, et al. Impact of clinical pathways in surgery. Langenbecks Arch Surg 2009; 394:31.
- Campillo-Soto A, Martín-Lorenzo JG, Lirón-Ruíz R, et al. Evaluation of the clinical pathway for laparoscopic bariatric surgery. Obes Surg 2008; 18:395.
- THE "OBESITY PARADOX" IN ANESTHESIA
- PREOPERATIVE EVALUATION
- Patients with known comorbidities
- Screening for comorbidities
- Airway assessment
- - Predictors of airway difficulty
- PREOPERATIVE PREPARATION
- Positive airway pressure therapy
- Patients with previous weight-loss surgery
- Ambulatory versus inpatient surgery
- SUMMARY AND RECOMMENDATIONS