Term 2 Week 3 (w/c 30/01/12)
You are covering the emergency theatre. The surgeon informs you that he has just booked a patient for a laparoscopic gastropexy. Before you get chance to go see the patient, he warns you that she is morbidly obese (approximately 150kg, BMI >50)
List one factor that complicates anaesthesia in the bariatric patient. Answers don’t need to be specific to this case initially. You are not allowed to list a second until someone else has replied. (This slight change in format is just for the first part of this week to give junior trainees chance to participate and make it easier to follow)
You go visit the patient preoperatively. She is morbidly obese and presented as an emergency in the past 24 hours with chest pain. Her cardiac investigations were normal but her CXR (see below) showed a large para-oesophageal hiatus hernia. The surgeons want to reduce it laparoscopically.
What are the implications for anaesthesia? How are you planning on anaesthetising her?
You perform RSI and intubate her successfully. The surgeons have attempted to reduce the hernia laparoscopically but are struggling and they choose to perform a laparotomy for an open reduction. Once reduced the greater curvature of the stomach appears necrotic and they want to do a resection.
Does this concern you? Does this change any aspects of your management for this patient?
Thank you for another good week on #gasclass. We started by asking what factors complicate anaesthesia in the obese patient. We had a range of answers all of which were good. They included difficult IV access and difficulty in measurement of BP (possibly requiring arterial cannulation). There was concerns about staffing levels, handling and the availability of specialised equipment for obese anaesthetised patients. Other thoughts included higher co morbidity including diabetes, IHD, hypertension, and obstructive sleep apnoea. All of these complicate anaesthesia and are often enough to mandate HDU care for the post op patient.
Laparoscopic surgery is often the preferred technique in the obese patient due to concerns about wound healing and respiratory function post op. It is also technically easier for the surgeon as retraction of the abdominal wall is less difficult. Laparoscopic surgery is however not without it’s own issues, of particular concern is the effect of the peumoperitoneum on airway pressures, gastric pressures and cardiovascular pre / afterload.
This case was complicated by the fact that the surgeons had to perform a laparotomy due to operative difficulties. This raised concern for the post operative course, particularly with regard to respiratory function and analgaesia. Epidural anaesthesia was mentioned several times and would have been many peoples first choice technique had it been discussed preoperatively. Most people were reluctant to perform this in an anaesthetised patient, who had not given prior consent and in whom it would likely prove very difficult technically. The use of rectus sheath block / catheter was mentioned (possibly reducing opiate requirements).
There was strong support for HDU care postop and the elective use of awake CPAP (versus keeping ventilated) seemed also to have support.
There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client.