Den problematiske pasienten Den adipøse pasienten: Kirurgiske og anestesiologiske utfordringer Johan Ræder Dept of Anaesthesia Oslo University Hospital, Ullevål Oslo - Norway mail: johan.rader@medisin.uio.no
Dagkirurgi og fedme: - En økende 3 utfordring!
Dagkirurgi og fedme: - En økende 3 utfordring! 1) Flere pasienter med fedme 2) Økende andel sykelig fedme 3) Adipøse pasienter lever lengre enn tidligere Adipøse pasienter kan ha behov for alle typer vanlig kirurgi,..men noen typer mer hyppig: Øsofagus reflux Ortopedisk kirurgi Gallekirurgi Hjertekirurgi.. Økende behov for fedme kirurgi: mer fedmekirurgi enn gallekirurgi i USA lange ventelister
og muligheter
Er inngrep på fete pasienter farlig?
KIRURGI -Varighet -Invasivitet -Blodtap GENERELL HELSE - ASA? - fedme? RISIKO ANESTESI -Luftveier -Lungefunksjon -Kardiovaskulært PSYKO-SOS ASPEKTER
Spørreskjema, 13 norske enheter: Nina Hagelund, Nordaf Øvre vektgrense, BMI: 28 (kun mammareduksjon) 35: 3-4 enheter 40: 3 enheter Maxvekt op. bord: 150 kg: 7 sentre 250-360 kg: 3 sentre Andre kriterier/råd: Tilleggsdiagnoser, klinisk skjønn, hode/hals Oppfordring til å gå ned i vekt (3 enh) Slutte å røyke (3 enh), Skjegg bort??
Vekt? Reell vekt: = Total vekt Ideal vekt: Høyde 100 (105 for kvinner) Lean vekt: = fett-fri kroppsvekt Korrigert ideal vekt: = ideal vekt + 20-40% (?) av forskjell opp til total vekt -------------------------------------------------------------- Body Mass Index = Vekt (kg) høyde (m) x høyde (m)
Body mass index (BMI) vekt / høyde x høyde BMI < 25 kg m -2 BMI 25-30 kg m -2 BMI > 30 kg m -2 BMI > 35 kg m -2 BMI > 55 kg m -2 normal overvekt fedme sykelig fedme ekstremt sykelig fedme G Bry, Am J of Clin Nutrition 55:448S-94S, 1992
BMI: vekt : (høyde x høyde) 180 cm; BMI = 30 97 kg; BMI = 35 113 kg 160 cm; BMI = 30 77 kg; BMI = 35 90 kg Et grovt regnestykke: Sykelig fedme (BMI>35): > Ideal vekt + 50% Ekstremt sykelig fedme (BMI>55): > Ideal vekt + 100% Andre parametre? Hudfold tykkelse Mage/hofte omkrets (> 1?)
Doyle Sl et al. Obesity Rev 2009:11:875
Doyle Sl et al. Obesity Rev 2009:11:875
6 x økt risiko ved fedme!
- Kirurgisk tilgang - Fettavleiringer - Vevsischemi - Tilheling - Infeksjon - Suturbelastninger - Endoskopi bedre - Mobilisering - Opptrening - Trombose Fedme: Kirurgiske aspekter
Obesity per se?? - Moderat risiko faktor alene (!) MEN REDUSERTE RESERVER - OFTE TILLEGGSLIDELSER RISIKO I SEG SELV
Preoperativ evaluering - Andre tilstander? Høyt blodtrykk Sukkersyke Gastro-øsophageal reflux Artrose /muskel-skjelett smerte (+ analgetika?) Vanskelig intubasjon (?) Lunge atelektaser Hjerte svikt Coronar hjerte sykdom
Post-operative problemer hos overvektige (Chung F): Post-op luftveisproblemer (3-4 x oftere!): - Lav oksygen metning(shunting) - Dårlig ventilasjon/utlufting - Øvre luftveisobstruksjon - Søvn apnoe syndrom (SAS) *? Dangerous to send home in textbooks, but *Farlig å sende hjem i lærebøker, men How do we treat them in hospital? Hvordan blir de overvåket behandlet som inneliggende? Rapporter Reports påon dødelighet mortality/morbidity ved for tidlig hjemsendelse? at home?
Del I: -15 kasuistikker på mors etter operasjon og Søvnapne Del II: -ca 1000 søvnapne pas studert systematisk ingen mors Chung F: Anesth Analg 2008:107:1543-6
Stierer TL: ASA lecture- 2010 2139 Dagkirurgiske pasienter Screenet for Søvn Apne Syndrom (SAS) 103 hadde trolig SAS (4-5%) Anestesi team ikke fortalt om screening: SAS pasienter oftere vanskelig laryngoskopi SAS pasienter lavere gj.snitt O2-metning på recovery Ikke flere virkelige problemer
Stierer TL: ASA lecture- 2010 2139 Dagkirurgiske pasienter Screenet for Søvn Apne Syndrom (SAS) 103 hadde trolig SAS (4-5%) Anestesi team ikke fortalt om screening: SAS pasienter oftere vanskelig laryngoskopi SAS pasienter lavere gj.snitt O2-metning på recovery Ikke flere virkelige problemer
Mistenk søvn apnoe syndrom: Kraftig snorking Trett på dagtid til tross for normal søvnlengde Observert Apne + hypertoni? Høy BMI? > 50 yr?, mann? Nakke > 50 cm??
Fedme: Anestesi håndtering
Døds sonen = sone med kontinuerlig fysiologisk forverring -Ødeleggende cellulær hypoxi - Ventilatorisk restriksjon - Luftvei obstruksjon - Alveolær (+) atelektase - Overtrykk ventilasjon - Rgurgitering av mageinnhold
Døds sonen = sone med kontinuerlig fysiologisk forverring -Ødeleggende cellulær hypoxi - Ventilatorisk restriksjon - Luftvei obstruksjon - Alveolær (+) atelektase - Overtrykk ventilasjon - Regurgitering av mageinnhold
Kortest mulig tid i døds sonen : - raskt ned til basecamp - rask recovery til normal aktivitet - Tormod Granheim: Første non-stop opp+ned på Mt.Everest - Lokal-regional anestesi om mulig - Minimere per-operativ varighet - Kort virkende medikamenter
Preoperative evaluering - Gode råd, tiltak på forhånd? Stopp røyking: 6 uker før eller (minst!) 6 timer før Redusere vekt (bare litt hjelper metabolisme/fettlever!!) Protein rik Karbohydratefattig diett bedre lever!! Proton pumpe hemmer /reflux kontroll CPAP for søvn apne pasienter Lunge fysioterapi Fastende? normale faste rutiner! Barbere bort skjegg (maske/luftvei kontroll) ----------------------------- EKG: høyre ventrikkel hypertrofi? Arteriell blod gass: Hypoventilations syndrome? Rtg-pulm: Atelektase? Hjerte hypertrofi? Funksjons test: Gå i trapper?
Opioider /anxiolytica? Unngå om mulig! Premedikasjon? Reflux profylaxe? Omeprazole (Nexium ) Na-citrate Trombose profylakse? Antibiotika profylakse Ikke-opioid smerte profylakse?
Tema v/ operasjon/anestesi start: I.V. tilgang (evt Doppler? sentral v.line?) Posisjon på bordet? Pre-oxygenering? Hurtig ( crash ) innledning m/curacit? Valg av anestesimedikamenter? Dosering? Larynx maske eller intubasjon?
Posisjon på bordet: - minimere reflux - bedre lunge expansjon - optimal for laryngoskopi
Fedme og luftveiskontroll: Maske? Laryx maske? (skifte til intub x 7 vs kontrol) Endotracheal intubasjon
Preoxygenering: PEEP: 10 cm H 2 O 4-5 minutter (Et O 2 80-90) Heve hode ende (15-25 ) Induction: Fentanyl 0,1 mg Propofol 4,5 µg/ml (effecttci) Remifentanil 8 ng/ml (TCI) Vecuronium 0,1 mg/kg All drugs by idealweight (!!) (Height 100)
BMI = 44 (mean) -Non-eventful intubation 495 cases -McCoy scope intubation 5 cases -Serious problems 0 Acta Anaesthesiol Scand 2008:52:394-1399
BMI = 44 (mean) -Non-eventful intubation 495 cases -McCoy scope intubation 5 cases -Serious problems 0 Acta Anaesthesiol Scand 2008:52:394-1399 - One patient suffered from basal pneumonia and was hospitalized for 6 days; - One was reoperated for intestinal leak on the first post-operative day. - One patient conservatively treated for a proximal oesophagus perforation due to gastric tube insertion.
By 2010: 2000 elective patients, intubation: One attempt conventional then expert + device -1950 traditional laryngoscopy (short handle), first attempt - 50 (2.5%) McCoy device or Bouguie Acta Anaesthesiol Scand 2008:52:394-1399
Intubation algorithme: 1 st 2 nd 3 rd
Avslutte anestesi
Avslutte anestesi: Desfluran og remifentanil stopp når skopet tas ut. Bolus med propofol Lunge recruitment Neuromusc. reversering Kvalme / Smerte profylakse: Droperidol 1,25 mg Ondansetron 4 mg Dexametason 8 mg Parecoxib 40 mg Paracetamol 1 (- 2?) g Bupivacain i alle sår
Postoperative tema: Smerte/opioid strategi? Minst mulig opioid Mobilisere? Ja! Oxygen? CPAP? Kun v/behov Trombose profylakse (økt trombose risiko) Søvn apne? Observer pasienten under søvn, evt utsette utskrivelse
Fedme og dagkirurgi: Økende antall pasienter Pragmatisk tilnærming Forberedelser pre-operativt Fokusert anestesi håndtering Post-operativ optimalisering Minimere opioid Multimodal analgesi Multimodal antiemese Obs v/søvnapne
REKLAME!!! Cambridge University Press, June 2010, ISBN 978-0-521-73781-4
Takk!
Doyle Sl et al. Obesity Rev 2009:11:875
Doyle Sl et al. Obesity Rev 2009:11:875
Morbid Obesity and Tracheal Intubation Claimed to be problematic: submucus fat, mucus membrane collapse.. Absolute obesity or BMI were not associated with intubation difficulties Large neck circumference and high mallampati score predictors of potential intubation problems JB Brodsky et al, Anesth Analg 94:732-6, 2002
Morbid Obesity and Tracheal Intubation Claimed to be problematic: submucus fat, mucus membrane collapse.. Absolute obesity or BMI were not associated with intubation difficulties Large neck circumference and high mallampati score predictors of potential intubation problems JB Brodsky et al, Anesth Analg 94:732-6, 2002
JB Brodsky et al, Anesth Analg 94:732-6, 2002
-More difficult intubation in obese: in 16% versus 2.3% - All patients were intubated successfully with laryngoscope - More oxygen desaturation in obese
Intubation Laryngoscope with short handle Tube with stylet Extra equipment ready (fast-track, fiberoptic, tracheotomy) Lung recruitment once after intubation + just before extubation
Issues during maintenance: Inhalational or TIVA? Choice of opioid Mode of ventilation? Dosing of curare? Monitoring devices? Endoscopic or open surgery?
Emergence vs. duration: 25 isofluran min 20 15 10 5 Propofol Sevofluran Desfluran 0 1 2 3 4 5 6 7 8 hours of anaesthesia (Smith I: D883-WCA-Sydney 1996)
1 MAC gas for 3 hrs turned off: 0.2 MAC after 4.45 min for sevoflurane 0.2 MAC after 2.45 min for desflurane
Mobid obese bariatric patients remifent + des vs sevo Breathing Eyes opening ~ 100 min anaesthesia Extubation Free airway Orientation
After induction: Propofol off Remifentanil from syst BP Desflurane 0.5 1 MAC titrated to BIS; 40-50 (endtidal may be inaccurate: pulmonal shunting) Neuromuscular block as/if needed (To4 guided) -Volume controlled ventilation with PEEP (5-10) for laparoscopy
Nausea / Pain profylaksis: Droperidol 1,25 mg Ondansetron 4 mg Dexametasone 8 mg Parecoxib 40 mg Paracetamol 1 (- 2?) g Bupivacaine in all wounds Ending the case: Desfluran og remifentanil off when scope is out. Bolus of propofol. Neuromusc. reversing
Apnea Hypopnea Index (AHI) No. of apneas and hypopneas per hour of sleep AHI 5-15 AHI 15-30 AHI >30 mild sleep apnea moderate sleep apnea severe sleep apnea
Treatment of sleep apnoea syndrome: Weight reduction CPAP Surgery +??
CPAP - nasal
Claims from 1985 1999 ( 50% of all US cases?) For the 18 claims associated with extubation in the operating room, 28% (n = 5) had a difficult intubation on induction of anesthesia, 11% (n = 2) had an awake intubation on induction, 67% (n = 12) were obese, and 28% (n = 5) had a history of obstructive sleep apnea. For the 8 claims associated with airway management during recovery, 2 had a difficult airway on induction of anesthesia, 1 had an awake intubation, and 3 were obese. Therefore, the majority (19 of 26) of the claims from extubation or recovery were associated with a difficult intubation on induction, obesity, and/or sleep apnea.
Results, 150 consecutive patients: - gastric reduction + jejuneal bypas Number of patients 150 Age (yrs) 39(18-66) Weight (kg) 134 ( 93-211) BMI (kg/m²) 44 ( 35-64) Duration of surgery (min) 58 ( 40-74) Converison to open (n) 0 Complications (n) 1 Reoperation (n) 0 Anastomosis leakage (n) 0 Bleeding (n) 0 Pneumonia (n) 1 Hematemese / melena (n) 0 Postoperative stay (days) 3 (2-6) Tidsskr. DNLF, nr 1-2007: Gislason H, Raeder J et al
Laparaskopisk gastroduodenal bypass
LAPAROSCOPIC SURGERY / ANAESTHESIA: - characteristics I Patient position: head-down regurgitation ventilation resistance head-up hypotention, low venous return beach chair hypotention, low venous return
LAPAROSCOPIC SURGERY / ANAESTHESIA: - characteristics II CO-2 insufflation increased intraabdominal pressure distention of peritoneum sympathetic stimulation: SVRI MAP CVP PCWP absorption to blood: start 8-10 min, plateau 15-20 min embolism: blood, pleura, mediastinal, subcutaneous variable ventilatory resistance: volume controlled ventilation or (pressure controlled with alarms!)
Obstructive Sleep Apnoea (OSA) Prevalence Men 4% Women 2% Associated with obesity enlarged tonsils and/or adenoids (children) OSA is as frequent in the population as asthma! T Young, NEJM 1993; 328:1230-5
JL Benumof, J Clin Anesth 2001; 13:144-56
RJ Schwab, Otolaryngol Clin North Am 1998; 31:931-68
Suspect sleep apnoea syndrome: Snoring associated with: respiratory arrest ( > 10 sec) frequent change in posistion during sleep tired in spite of normal lenght of sleep morning headache family history male gender obesity Polysomnography?
From Akre H. 2007 Polysomnography: Reference method in diagnostics EEG, EMG sleep quality registration Multiple channels for respiration SaO2, pulse ECG Leg - electrodes Position in bed Snoring
Cardiorespiratoric-function - Apnoea / hypopnoea
Apnea Hypopnea Index (AHI) No. of apneas and hypopneas per hour of sleep AHI 5-15 AHI 15-30 AHI >30 mild sleep apnea moderate sleep apnea severe sleep apnea
Three compartment model Tivatrainer www.eurosiva.org
Propofol Steady state 70 kg / 170 cm V2 V1 V3 16 16 38 liters Stretching up-concentrated compartments = plasma concentration sum=70 Konsentr: 2Y 2x Yx 6 xy
Propofol Steady state 70 kg / 170 cm V2 V1 V3 32 16 202 liters kons: x Y Yx xy X
170 cm 70 kg 170 cm 140 kg????
170 cm 70 kg 170 cm 140 kg Drug Physiology changes: Propofol: -Initially drug only in V1, then in V2 - ~ ideal weight + a little more VD and clearance -Eventually: -Distributing highly (but slowly) into the big V3 - Almost no increase in clearance - Dosing for actual total weight -Finally (> 12-24 hrs): -Saturated in V3, very high total VD -Almost no increase in clearance - Dose for ideal weight, prepare for long T1/2
Propofol and obesity No TCI algoritm avilable: small distribution volume by start ( ideal weight) huge distribution volume eventually (> 10 30 min?): accumulates in fat (> than proportional to normal weight) BIS guided maintenance in obese patients! Still with propofol: rapid, reliable for induction pleasant emergence, anti-emetic protection
Concentration ng/ml 0 10 20 30 0 900 800 700 600 500 400 300 200 100 1000 Inf. Rate(ml/hr) + Decr. Time Simulation, Plasma target = 3 µg/ml, total dose given, mg (Marsh) 170 cm 70 kg 170 cm 140 kg 1.5 min 65 130 3 min 84 168 5 min 108 216 PROPOFOL 10 min 164 328 Double weight = Double dose 30 min 353 710 120 min 1020 2040 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
Concentration ng/ml 0 10 20 30 0 900 800 700 600 500 400 300 200 100 1000 Inf. Rate(ml/hr) + Decr. Time Simulation, Plasma target = 3 µg/ml, total dose given, mg (Schnider) 170 cm 70 kg 170 cm 140 kg 1.5 min 29 ( Marsh=65) 40 3 min 46 (Marsh=84) 68 5 min 68 (Marsh= 108) 105 Double weight = +30% +95% 10 min 120 (Marsh=164) 194 30 min 292 (Marsh=353) 507 120 min 920 (Marsh=1020) 1780 15 14 13 12 11 10 9 8 7 6 5 4 3?? 2 1 0
170 cm 70 kg 170 cm 140 kg Drug Physiology changes: Remifentanil: -Do not reach V3 -Slight increase V1 and V2? -Slight increase in total clearance? -Fat person ~ (>) Slim person!! -Use Ideal weight!
Concentration ng/ml 0 10 20 30 0 900 800 700 600 500 400 300 200 100 1000 Inf. Rate(ml/hr) + Decr. Time Simulation, Plasma target = 10 ng/ml, total dose given, mg (Minto model) 170 cm 70 kg 170 cm 140 kg 1.5 min 0.12 0.13 3 min 0.17 0.19 5 min 0.25 0.27 REMIFENTANIL 10 min 0.40 0.43 Double weight ~ 5-10% more 30 min 0.94 1.04 120 min 3.3 3.6 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0