This page intentionally left blank MORBID OBESITY PERI-OPERATIVE MANAGEMENT Dr Adrian O. Alvarez is at present one ofthe most recognized experts in the anesthetic management ofthe mor- bidly obese patient in the world. Being an anesthesiologist and also general surgeon he early recognized the importance of the multidisciplinary approach to these kind ofindividuals. He has been working in this scenario in close relationship with experts of other fields (bariatric surgeons, internists, nutritionists) since many years ago, and this spirit is clearly reflected in this work “Morbid Obesity, Perioperative Management”. MORBID OBESITY PERI-OPERATIVE MANAGEMENT Editor in Chief Adrian O. Alvarez Medical Director, IMETCO (Instituto Multidisciplinario Especializado en el Tratamiento y Cirugía de la Obesidad), Buenos Aires, Argentina Associate Editors Jay B. Brodsky Professor, Department ofAnesthesia, Stanford University School of Medicine, Stanford, CA, USA Martin A. Alpert Chairman, Department ofMedicine, St. John’s Mercy Medical Center, St. Louis, Missouri, MO, USA Clinical Professor ofMedicine, University ofMissouri School of Medicine, Columbia, MO, USA George S.M. Cowan Jr. Professor Emeritus, University ofTennessee, Memphis, TN, USA Past-President, International Federation for the Surgery of Obesity (IFSO) Past-President, American Society for Bariatric Surgery (ASBS) Founder, Obesity Surgery Journal CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9781841101880 © Cambridge University Press 2004 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2004 ISBN-13 978-0-511-26480-1 eBook (EBL) ISBN-10 0-511-26480-1 eBook (EBL) ISBN-13 978-1-841-10188-0 hardback ISBN-10 1-841-10188-5 hardback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. CONTENTS Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi M. Deitel Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii J.B. Brodsky Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Section 1 General aspects ................................................................................................................ 1 1. Introduction to peri-operative management: reasons for a multidisciplinary approach . . . . . . . . . . . . 3 A.O. Alvarez & A. Baltasar 2. Peri-operative risks and frequent complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 L. Brusco Jr. 3. Informed consent in bariatric surgery and anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 G.S.M. Cowan Jr. Section 2 Pathophysiology ............................................................................................................... 43 4. Lung physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 M.A. Campos & A. Wanner 5. Cardiac morphology and ventricular function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 M.A. Alpert 6. Pathophysiology ofcardiovascular co-morbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 T.J.J. Blanck, I. Muntyan & H. Zayed-Moustafa 7. Physiological changes during laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 M. Fried 8. Digestive physiology and gastric aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 P. Marko, A. Gabrielli, L.J. Caruso & A.J. Layon Section 3 Pre-operative management ............................................................................................. 111 9. Pre-operative evaluation ofthe patient for bariatric surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 R.A. Beers & M.F. Roizen Section 4 Peri-operative management ofco-morbidities ............................................................. 129 10. Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 F.G. Mihm 11. Co-existing cardiac disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 S. Akhtar, V. Kurup & L. Helgeson 12. Deep venous thrombosis prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 C.A. Barba& F.N. Lamounier 13. Surgical antibiotic prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 A. Lepetic, C. Vujacich, A. Calmaggi, G.M. Guerrini & M.d.R.G. Arzac vi CONTENTS 14. Renal dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 D.M. Rothenberg & A. Rajagopal Section 5 Pharmacology .................................................................................................................. 209 15. Pharmacokinetics and pharmacodynamics: essential guide for anesthetic drugs administration . . . . . 211 L.E.C. De Baerdemaeker, E.P. Mortier & M.M.R.F. Struys 16. Remifentanil in morbidly obese patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 A.O. Alvarez Section 6 Monitoring ........................................................................................................................ 241 17. Electrocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 M.A. Alpert 18. Respiratory monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 M. Tucci, V. Bansal & E.M. Camporesi 19. Cortical electrical activity monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 G.M. Gurman Section 7 Intra-operative management .......................................................................................... 271 20. Positioning the morbidly obese patient for surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 J.B. Brodsky 21. Airway management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 A.P. Reed & D.C. Kramer 22. Inhalational anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 L.H. Hanowell 23. Total intravenous anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 A.O. Alvarez 24. Anesthetic management for the obese parturient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 J.T. Sullivan & C.A. Wong Section 8 Post-operative care .......................................................................................................... 337 25. Post-anesthetic care unit management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 J.C. Flores 26. Respiratory management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 E. Fam & P.E. Marik 27. Management ofthe obese critically ill patient in intensive care unit . . . . . . . . . . . . . . . . . . . . . . . . . . 363 P.E. Marik & F. Brun 28. Nursing management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 S.M. Burns, D. Charlebois, M. Deivert, J. Krenitsky & D. Wilmoth 29. Post-operative analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 A.G. Haidbauer Section 9 Conclusions ...................................................................................................................... 397 30. Anesthesia and morbid obesity: present and future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 A.O. Alvarez Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 A.O. Alvarez &G.S.M. Cowan Jr. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 CONTRIBUTORS Shamsuddin Akhtar University ofConnecticut Department ofAnesthesiology CT, USA Yale University School ofMedicine Boston, MA, USA R.A. Beers Department ofAnesthesia Alejandro Lepetic State University ofNew York Upstate Medical Fundación Centro de Estudios Infectológicos University (FUNCEI) Syracuse, NY, USA Buenos Aires, Argentina Martin A. Alpert Thomas J.J. Blanck Chairman, Department ofMedicine Professor and Chairman St. John’s Mercy Medical Center Department ofAnesthesiology St. Louis, Missouri, MO, USA New York University Medical Center Clinical Professor ofMedicine NY, USA University ofMissouri School ofMedicine Columbia, MO, USA Jay B. Brodsky Professor, Department ofAnesthesia María del Rosario González Arzac Stanford University School ofMedicine Hospital Interzonal de Agudos Stanford, CA, USA Prof. Dr. Rodolfo Rossi La Plata, Buenos Aires, Argentina Francisco Brun Luc E.C. De Baerdemaeker Critical Care Fellow StaffAnesthesiologist University ofPittsburgh Ghent University Hospital Pittsburgh, PA, USA Gent, Belgium Louis Brusco Jr. Aniceto Baltasar Assistant Professor ofClinical Anesthesiology Chairman, Department ofSurgery Columbia University Hospital Virgen de los Lirios College ofPhysicians and Surgeons Alcoy, Spain Associate Medical Director Past-President St. Luke’s-Roosevelt Hospital Center International Federation for the Surgery New York, NY, USA ofObesity (IFSO) Director Critical Care Anesthesiology Vipin Bansal Co-Director Resident, Department ofAnesthesiology Surgical Intensive Care Unit Upstate Medical University St. Luke’s-Roosevelt Hospital Center Syracuse, NY, USA New York, NY, USA Carlos A. Barba Medical Director Suzanne M. Burns Center for Bariatric Surgery Professor ofNursing (APN 2) Saint Francis Hospital and Medical Center MICU Associate Professor ofSurgery McLeod Hall School ofNursing Traumatology and Emergency Medicine Charlottesville, VA, USA viii CONTRIBUTORS Aníbal Calmaggi Universidad de Buenos Aires Unidad de Transplante de Médula Ósea Argentina Hospital Interzonal de Agudos Prof. Dr. Rodolfo Past-President Rossi. La Plata Federación Argentina de Asociaciones de Buenos Aires, Argentina Anestesiologia Argentina Enrico M. Camporesi Professor and Chairman Martin Fried Department ofAnesthesiology Associate Professor ofSurgery Upstate Medical University 1st Medical Faculty Syracuse, NY, USA Charles University Prague, Czech Republic Michael A. Campos Chiefsurgeon Assistant Professor ofMedicine Obesity Treatment Center Division ofPulmonary and Critical Care Medicine Prague, Czech Republic University ofMiami School ofMedicine Past-President FL, USA International Federation for the Surgery of Obesity (IFSO) Lawrence J. Caruso Associate Professor ofAnesthesiology Andrea Gabrielli University ofFlorida College ofMedicine Associate Professor ofAnesthesiology and Surgery Gainesville, FL, USA University ofFlorida College ofMedicine Gainesville, FL, USA Donna Charlebois Pulmonary Transplant Coordinator and APN 1 Graciela M. Guerrini University ofVirginia Health System Unidad de Transplante de Médula Ósea Charlottesville, VA, USA Hospital Interzonal de Agudos Prof. Dr. Rodolfo Rossi La Plata, Buenos Aires, Argentina George S.M. Cowan Jr. Professor Emeritus Gabriel M. Gurman University ofTennessee Division ofAnesthesiology, Ben Gurion University Memphis, TN, USA ofthe Negev, Faculty ofHealth Sciences, Past-President Soroka Medical Center, Beer Sheva, Israel International Federation for the Surgery of Obesity (IFSO) Alejandro G. Haidbauer Past-President Vice-Chairman American Society for Bariatric Surgery (ASBS) Anesthesiology Department Founder, Obesity Surgery Journal Hospital Alemán Buenos Aires, Argentina Mervyn Deitel Editor-in-Chief, Obesity Surgery Leland H. Hanowell Past Executive Director, Department ofAnesthesia International Federation for the Surgery ofObesity Stanford University School ofMedicine Toronto, Canada Stanford, CA, USA Mary Deivert Lars Helgeson Trauma Care Coordinator Department ofAnesthesiology University ofVirginia Health System Yale University School ofMedicine Charlottesville, VA, USA Boston, MA, USA Ezz Fam David C. Kramer Critical Care Fellow Assistant Professor ofAnesthesiology University ofPittsburgh School ofMedicine Mount Sinai School ofMedicine Department ofCritical Care New York, NY, USA Pittsburgh, PA, USA Joe Krenitsky Juan C. Flores Clinical Nutritionist Chairman, Anesthesia Department University ofVirginia Health System Hospital de Clinicas Jose de San Martin Charlottesville, VA, USA