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Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY
To the Editor:
We have appreciated the recent papers focusing on anesthesia in morbidly obese patients as well as the ensuing dialogue in the Letters to the Editor section (1–4). In our university hospital setting, we have performed approximately 2,000 laparoscopic procedures for morbid obesity over the past 4 years. Internally, we have modified our policies and procedures regarding the care of these patients.
Since 1999, we have required that two attending anesthesiologists be present at all inductions of anesthesia in morbidly obese patients that are not preceded by an awake intubation. The second attending anesthesiologist must agree with the primary attending that induction of general anesthesia is reasonable or an awake intubation is performed. Having a second qualified individual present in the operating room provides an additional measure of safety in the event of airway difficulty. We have been very fortunate in avoiding airway disasters upon induction of anesthesia in this patient population since this policy became effective.
Quite recently, we introduced a modification of our morbidly patient airway patient policy that is directed towards the last stages of anesthesia care. This policy is limited to patients with BMI >60 kg/m2. The following conditions must be met before the patient may undergo extubation of the trachea in the operating room at the end of surgery:
If any of these three conditions cannot be met for any reason at any time of the day or night, the patient must be transported from the OR to the PACU or ICU with the endotracheal tube in place. Extubation in the PACU or ICUs may proceed according to normal extubation criteria.
One of the theories behind the adoption of this policy is that placing the patient in the supine position may be associated with hypoventilation and hypoxemia. While we use a special device, HoverMatt® (HoverTech International, Bethlehem, PA), to facilitate the moving these patients to PACU beds. We seek to delay the obligatory supine positioning until the patient’s trachea has been extubated for several minutes, with adequate respiratory parameters or delay tracheal intubation until the patient has been transferred to the PACU bed, where he/she can be maintained in the semirecumbent position without interruption.
Until the questions posed by Jones (4) and others have been answered, it behooves us to "raise the bar," and treat these patients at an even higher standard of care to prevent potentially catastrophic complications of anesthetic care in this high-risk population.
References
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
In Response:
We thank Dr. Rosenblatt and colleagues for their comments and applaud them on development of internal policies that assist their department in meeting the needs of their morbidly obese patient population.
At our institution, we do not have such a policy despite the fact that we perform more than 200 bariatric procedures a year and provide anesthesia for a variety of surgical procedures in a patient population that has a high percentage of morbidly obese and super-obese patients. In our practice, we rely on history (particularly previous anesthetic experiences), thorough physical and airway examination, and "proper positioning" (1,2) to successfully orally intubate the trachea of patients who do not receive an awake fiberoptic intubation. We perform awake fiberoptic intubation in a small percentage of obese patients. We practice in an anesthesia care team environment where at least two individuals (one faculty and a house staff or CRNA) are present.
Postoperatively, we do not routinely place our morbidly obese patients in the supine position as this may be detrimental to their ventilatory efforts, especially at a time when pain contributes significantly to decreased ventilatory efforts.
At the end of surgery, we combine the Walter Henderson maneuver* (see note and illustration) with the patient transfer device (PTD®; AliMed, Dedham, MA) to move our morbidly obese patients onto their beds. The majority of our patients are transferred to their particular postoperative bed and are then extubated in the semirecumbent position. We then continue to maintain them in the semirecumbent position while administering adequate oxygen by ventimask or nonrebreathing mask.
Patients that receive excessive amounts of fluid, undergo prolonged operations or those with severe cardiopulmonary disease are left intubated postoperatively if this is deemed beneficial in the opinion of the anesthesiologist.
*Note: Walter Henderson maneuver (see Fig. 1, steps 2–5): Named after the head of our patient transport team. Basically, the operating table is raised higher than the patient’s bed and tilted 20 to 30 degrees to the side where the patient’s bed is positioned, which then allows the patient to be safely and gradually rolled downhill over a PTD® (a.k.a. patient roller).
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Department of Anesthesiology, Huntsville Hospital, Huntsville, AL
In Response:
I thank Drs. Rosenblatt, Reich, and Roth for their great suggestions. Their extubation conditions have been incorporated into our new algorithm that we have been creating over the last year.
The initial questions I posed to Dr. Ogunnaike and colleagues (1) concerned "open" Roux-en-Y procedures. Our cases lasted 4 to 6 h and were difficult in every aspect of care. Fortunately the cases have become shorter and some issues were resolved.
After any airway issues, the next challenge of the intraoperative management has been the IV fluid algorithm. We have maintained the required minimal urine output to 0.5 mL/kg/h of lean body weight (120% IBW). If this has not occurred, then placement of central line for more extensive monitoring would be done. The fluid deficit and maintenance is based on LBW and the 3rd spacing is calculated 2–6 mL/kg/h; added to any blood loss this becomes the baseline fluid management if not contraindicated.
One other major change was a weight limit moratorium (i.e., 550–600 pounds) until more information is available. Clearly, "super morbid" obese patients have substantial obesity-related comorbidities and are considered high-risk surgical patients (2).
For the super morbid obese, I wonder if a strict program of dieting prior to surgery will ever fall into favor?
References
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