Anesthetic Considerations for the Morbidly Obese

1
Anesthetic Considerations for the Morbidly Obese

• Art Zwerling,
• DNP, MS, MSN, CRNA, DAAPM
• University of Pennsylvania College of Nursing
  Nurse Anesthesia Program
• Fox Chase Cancer Center
• a.to.z_at_comcast.net
• MANA Spring 2009

2
Why We Are Here Oops Wrong Lecture.
3
Its always about the airway
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Society for Airway Management

• 2009 SAM Meeting   September 25-27, 2009
• The Venetian
• Las Vegas, NV 
• September 25-27, 2009
• The Venetian
• Las Vegas, NV 

• http//sam.zorebo.com/index.php

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Eritrea School of Nurse Anesthesia

• Class of 2007

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(No Transcript)
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Friday , 3-31-06 after 2 weeks of Zwerling-Wilson
Brain Washing
9
Kessete Teweldebrhan, CRNA Program Director
Heather Wilson, CRNA, MS NAO Volunteer
10
Awet
11
Isack
12
Kissamet
13
Mekonen
14
Yemane
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Yukunot
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(No Transcript)
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Upside to being a PD

• Have to commit to an evidence based practice.
• Vow of poverty.
• Learn the negotiation skills of an UN mediator.
• Learn to delegate as if theres anyone to
  delegate to.
• Participate in clinical research

18
Applied Clinical Research 2004
19
Collate Outcome Data
20
AIRWAY JEOPARDY

• SRNAs Only!!!!!!!!!!!
• For 20.00 and the BRAINIAC Award
• Topic Area Famous Experimental Subjects in
  Airway research.
• Who was.?
• The first SRNA to get the correct answer to me
  before I leave for Philly wins.

21
Take homes

• Airway is the predominant clinical concern with
  morbidly obese patients.
• Utilization of central alpha 2 agonists along
  with low solubility inhalational agents is an
  ideal approach to decrease residual airway
  compromise.
• Dexmedatomidine is an easily titrateable central
  alpha two agonist with potent analgesic and MAC
  sparing properties.

22
FCCC Applications

• Sedation for awake FOI
• Cardioprotection
• Narcotic sparing
• MAC sparing
• OSA patients /or compromised airway
• Opioid tolerant
• Avoidance of emergence delirium

23
How Did a Receptor Specificity Purest Get
Subverted?

• They hid all his infusion pumps?
• His chairman told him he can use all the propofol
  he wants if hes buying?
• The surgeons were complaining about all those dn
  beeping pumps?
• He developed a new appreciation for the
  titrability of inhalational agents?
• The Sevo rep had fresher bagels than the propofol
  rep?

24
Inhaled Anesthetics and Immobility Mechanisms,
Mysteries, and Minimum Alveolar Anesthetic
Concentration

• James M. Sonner, et. al.
• Anesth Analg 200397718-740

25
Mechanisms of action of inhalational anesthetics
Neurotransmitter receptor candidates

• Inhibitory Neurotransmitter Receptors
• GABAA
• Glycine

• Excitatory
• Transmitters
•   NMDA
•  AMPA
•  Kainate
•   Nicotinic
•  5-HT3

Anesth Analg 200397718-740
26
The anatomical candidates
27
Morbid Obesity
28
Anyone who wants to ask what the ROI on obesity
treatment is must first tell me what the ROI is
for the treatment of Erectile Dysfunction ?

• Attributable Deaths
• per year in U.S.
• Obesity 25-300K
• Impotence 0

Range of estimates from CDC Excludes death
from embarrassment

But theres a new trend. Organizations that own
someone for life are starting to offer obesity
treatment.
29
How Does Obesity Cause Disease?Abnormal
production of hormones and inflammation in fat
Hypertension
á Lipoprotein Lipase
Type 2 DM
á Lactate
á Angiotensinogen
Inflammation
Dyslipidemia
á IL - 6
á Fat Stores
Arthritis
á Leptin
á FFA
á Insulin
Type 2 DM
á TNF- a
Asthma
áResistin
á Adipsin (Complement D)
Thrombosis
áEstrogen
á Plasminogen Activator Inhibitor 1 (PAI-1)
?Adiponectin
ASCVD
DMdiabetes mellitus FFAfree fatty acid
PAI-1plasminogen activator inhibitor-1
TNF?tumor necrosis factor alpha
IL-6interleukin 6. Slide After Dr. G Bray
30
Medical Complications of Obesity Almost every
organ system is affected
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Coronary heart disease
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Diabetes
Dyslipidemia
Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Skin
Phlebitis venous stasis
Gout
31
Conceptual Framework for the Metabolic Syndrome

• Environmental causes are responsible for the
  epidemic of the metabolic syndrome (NCEP)
• Treatment reduce obesity and increase
  activity
• Insulin resistance is the underlying cause of the
  metabolic syndrome (WHO)
• Treatment a) reduce obesity and increase
  activity b) insulin
  sensitizers
• Inflammation is the underlying cause of the
  metabolic syndrome
• Treatment a) reduce obesity and increase
  activity b) insulin
  sensitizers c) statins,
  ACE Inhibitors, ARBs

32
How does weight loss improve health?Reducing fat
cell mass reduces hormone production and
inflammation
Prevent these
Prevent these
Hypertension
Shrink This
á Lipoprotein Lipase
Type 2 DM
á Lactate
á Angiotensinogen
Inflammation
Dyslipidemia
á IL - 6
á Fat Stores
Arthritis
á Leptin
á FFA
á Insulin
Type 2 DM
á TNF- a
Asthma
áResistin
á Adipsin (Complement D)
Thrombosis
áEstrogen
á Plasminogen Activator Inhibitor 1 (PAI-1)
?Adiponectin
ASCVD
DMdiabetes mellitus FFAfree fatty acid
PAI-1plasminogen activator inhibitor-1
TNF?tumor necrosis factor alpha
IL-6interleukin 6. Slide After Dr. G Bray
33
Why is it so hard to lose weight? Weight is
controlled by a feedback system.
Hypothalamus, etc
Afferent
Efferent
Ghrelin PYY CCK
AutonomicNervousSystem
External Factorsfood availability, palatability

Vagus Nerve
Food Intake
Gut and Liver
Meal Size
Pancreas
Insulin
Energy Balance and Adipose Stores
Energy Expenditure
Adipose Tissue
Leptin
Adrenal Cortex
Adrenal Steroids
Adiponectin
Aronne LJ. Adapted from Campfield LA, et al.
Science. 19982801383-1387 and Porte D, et al.
Diabetologia. 199841863-881.
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Weight change at 1 year is consistent across all
trialsThe plateau is a physiological phenomenon!
Completers
Weight change (kg)
Weeks
35
Synergy of Leptin and Sibutramine in Treatment of
Dietary Obesity in Rats
4
-35
0
-19
CN Boozer, RJ Love, MC Cha, R Leibel, LJ Aronne.
Metabolism, 2001.
36
Central Weight Regulating Mechanisms

• Food intake
• energy expenditure

• food intake
• energy expenditure

Science, Feb 7, 2003, Vol 299 Illustration by
Katharine Sutliff
37
Central Weight Regulating Mechanisms and
Treatments Which Will Impact Them

• Food intake
• energy expenditure

IGS
Implantable Gastric Stimulator
PYY analog

• food intake
• energy expenditure

Pramlintide Exenatide
Pramlintide Rimonabant
Science, Feb 7, 2003, Vol 299 Illustration by
Katharine Sutliff
38
Alternative perspectives

• The epidemic of morbid obesity is an issue for
  all providers.
• The perspective that this is a chronic,
  progressive, ultimately fatal disease process is
  a reasonable start.

39
Scope of the ProblemThe Metric

• Men Women Risk Factor
• less than 20.7 less than 19.1 Underweight. The
  lower the BMI the greater the risk
• 20.7 to 26.4 19.1 to 25.8 Normal, very low risk
• 26.5 to 27.8 25.9 to 27.3 Marginally overweight,
  some risk
• 27.9 to 30 27.4 to 30 Overweight. Moderate risk
• 30.1 to 34.9 30.1 to 34.9 Severely overweight,
  high risk

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Scope of the ProblemThe Metric

• 35 to 39.9 35 - 39.9 Obesity Class II - Candidate
  for surgery with comorbities.
• Greater than 40 greater than 40 Obesity Class III
  -
• Morbid obesity, very high risk
• Candidate for surgery

41
Mortality Ratio

• Morbid obesity is defined by a Body Mass Index
  (BMI) of greater than 40 or between 35 and 40
  where there are other major medical conditions
  such as high blood pressure and diabetes are
  present.
• Look at the escalation in mortality at BMIgt32-35

42
I was thinking about how people seem to read the
Bible a whole lot more as they get older then it
dawned on me . . they're cramming for their final
exam.

• George Carlin

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The Epidemiology

• The numbers are down right scary!!
• From 1986 to 2000 the prevalence of Americans
  with a BMI of 40 or greater has quadrupled from
  1200 to 150
• There are approximately 325,000 deaths/yr
  attributable to obesity
• This approaches the 400,000 excess death/yr
  attributable to smoking
• The nation spends approximately 75 billion/yr on
  obesity related morbidities.

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Laws of Anesthesia The Essentials

• Air goes in and out.
• Blood goes round and round.
• Numb is good.
• Numb and hemodynamically stable is better.
• Numb, hemodynamically stable and amnestic is
  best.
• Numb, hemodynamically stable, amnestic and warm
  is better yet.
• Dead meat dont beat.

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Airway.airwayairway!
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And Airway
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The Challenge!

• Airway..Airway.Airway Potentially difficult,
  decreased FRC, decreased compliance, increased
  airway resistance- just wait until we have a
  peritoneum full of CO2.
• Higher incidence of CAD, HTN, DVP, PE and pump
  failure geez and how about venous and arterial
  access. Superb teaching for ultrasound
  guidance!!!
• The joys of neuroaxial anesthesia without
  palpable landmarks. But what better population
  for epidural analgesia.

48
FRC.FRC..FRC..FRC.FRC

• Obesity in anaesthesia and intensive care
• J. P. Adams and P. G. Murphy British Journal of
  Anaesthesia, 2000, Vol. 85, No. 1 91-108

49
Prevention of Atelectasis Formation During the
Induction of General Anesthesia in Morbidly Obese
Patients

• Marta Coussa, MD, Stefania Proietti, MD , Pierre
  Schnyder, MD , Philippe Frascarolo, PhD, Michel
  Suter, MD PhD , Donat R. Spahn, MD, and Lennart
  Magnusson, MD PhD
• Departments of Anesthesiology, Diagnostic
  Radiology, and General Surgery, University
  Hospital, Lausanne, Switzerland

Anesth Analg 2004981491-1495
50
IMPLICATIONS

• Application of positive end-expiratory pressure
  during induction of general anesthesia in
  morbidly obese patients prevents atelectasis
  formation and improves oxygenation.
• Therefore, this technique should be considered
  for anesthesia induction in morbidly obese
  patients.
• After intubation with a fraction of inspired
  oxygen of 1.0, PaO2 was significantly higher in
  the PEEP group compared with the control group
  (457 130 mm Hg versus 315 100 mm Hg,
  respectively P 0.035)

51
Respiratory System Resistance Desflurane vs.
Sevoflurane and Thiopental
Goff et al, Anesthesiology  200093(2)404-408
52
Atheism is a non-prophet organization.

• George Carlin

53
Work Release
54
Anesthesia for a patient with morbid obesity
using dexmedetomidine without narcotics

• Roger E. Hofer, MD, Juraj Sprung, MD PhD,
  Michael G. Sarr, MD and Denise J. Wedel, MD
  From the Departments of Anesthesiology, and
  Surgery, Mayo Clinic College of Medicine, Mayo
  Clinic, Rochester, Minnesota, USA.

Canadian Journal of Anesthesia 52176-180 (2005)
55
Clinical Features

• Clinical features We describe a 433-kg morbidly
  obese patient with obstructive sleep apnea and
  pulmonary hypertension who underwent Roux-en-Y
  gastric bypass. Because of the concern that the
  use of narcotics might cause postoperative
  respiratory depression, we substituted their
  intraoperative use with a continuous infusion of
  dexmedetomidine (0.7 µgkg1hr1). The
  anesthesia course was uneventful, and the
  intraoperative use of dexmedetomidine was
  associated with low anesthetic requirements (0.5
  minimum alveolar concentration). After completion
  of the operation and after tracheal extubation,
  the dexmedetomidine infusion was continued
  uninterrupted throughout the end of the first
  postoperative day. The analgesic effects of
  dexmedetomidine extended narcotic-sparing effects
  into the postoperative period the patient had
  lower narcotic requirements during the first
  postoperative day 48 mg of morphine by
  patient-controlled analgesia (PCA) while still
  receiving dexmedetomidine, compared to the second
  postoperative day (morphine 148 mg by PCA) with
  similar pain scores.

Canadian Journal of Anesthesia 52176-180 (2005)
56
Choice of volatile anesthetic for the morbidly
obesepatient sevoflurane or desflurane

• Shahbaz R. Arain MD, Christofer D. Barth MD1,
  Hariharan Shankar MD,
• Thomas J. Ebert MD, PhD

Journal of Clinical Anesthesia (2005) 17, 413419
57
Design

• A randomized, prospective blinded study to
  determine the emergence profiles of desflurane
  and sevoflurane in MO patients when anesthetic
  drug titration is used.
• Patients were induced with fentanyl, midazolam,
  and propofol and maintained with
• desflurane or sevoflurane, mixed in air and
  oxygen. Intraoperative bispectral index (BIS) was
  targeted to 45 to 50 and to 60 in the last 15
  minutes of surgery

58
Main Results

• Demographic data (age, 61 36-83 years body
  mass index, 38 35-47 kg/m2), surgical
  procedures, length of anesthesia (3.5 hours),
  adjuvant drugs, and intraoperative BIS, heart
  rate, and mean arterial pressure were not
  significantly different.
• Hemodynamics, time to follow commands and to
  extubation, and results of Digit Symbol
  Substitution Test and Mini-Mental Status Test did
  not differ between anesthetic groups during
  recovery.

59
AIRWAY AIRWAY AIRWAY

• Dexmedetomidine and low-dose ketamine provide
  adequate sedation for awake fibreoptic intubation
  
• Corey S. Scher, MD and Melvin C. Gitlin, MD
  From the Department of Anesthesiology, Tulane
  Health Sciences Center, New Orleans, Louisiana,
  USA.
• Address correspondence to Dr. Corey S.
  Scher, Department of Anesthesiology, Tulane
  Health Sciences Center, 1415 Tulane Ave. SL-4,
  New Orleans, LA 70112, USA. Phone [phone],
  Fax [phone] E-mail cscher_at_anes.tulane.edu

• Canadian Journal of Anesthesia 50607-610 (2003)

60
AIRWAY AIRWAY AIRWAY

• The patient received a bolus of dexmedetomidine 1
  µgkg-1 (Precedex-Abbott Laboratories, North
  Chicago, IL, USA) over ten minutes. After the
  bolus, the infusion was set at 0.7 µgkg-1hr-1.
  Neither hypotension or bradycardia were noted
  during dexmedetomidine administration. The
  patient reported comfort and sedation at the
  termination of the loading dose. The patient was
  rousable at all times, but when left
  unstimulated, tended to sleep. No changes in
  oxygen saturation and respiration were noted
  during the bolus or maintenance infusion. Upon
  completion of the dexmedetomidine bolus, 15 mg of
  ketamine were administered as a bolus and an
  infusion of 20 mghr-1 was initiated. After the
  ketamine bolus, and during the infusion, the
  patient reported that he was calm, comfortable,
  sedated and stated that he was ready for the
  fibreoptic intubation. This low dose of ketamine
  did not result in adverse changes in mental
  status. There continued to be no change in oxygen
  saturation and respiratory status. He did
  complain of dry mouth.
• During the continuous drug infusion, blocks of
  the recurrent laryngeal nerve and internal branch
  of the superior laryngeal nerve bilaterally were
  performed in the usual manner.1 The tongue and
  hypopharynx were sprayed with benzocaine. The
  patient remained both sedated and cooperative
  during these blocks. A Macintosh laryngoscope (4
  blade) was inserted and the patient remained very
  cooperative although the epiglottis and vocal
  cords were not visualized.

• Canadian Journal of Anesthesia 50607-610 (2003)

61
AIRWAY AIRWAY

• An endoscopic oral airway was placed in the mouth
  and fibreoptic intubation was performed. The
  endoscopist noted excellent conditions including
  a secretion free airway. The patient was able to
  respond to requests to take slow, large deep
  breaths. The epiglottis and vocal cords were
  visualized and intubation proceeded without
  difficulty. General anesthesia was then induced
  and the drug infusions were discontinued. After
  an uncomplicated surgery, the trachea was
  extubated after the patient met criteria for
  extubation. The patient had no recall of the
  nerve blocks, direct laryngoscopy, or fibreoptic
  intubation.

• Canadian Journal of Anesthesia 50607-610 (2003)

62
Anesthesia for a patient with morbid obesity
using dexmedetomidine without narcotics

• Roger E. Hofer, Juraj Sprung, Michael G. Sarr,
  and Denise J. Wedel

Canadian Journal of Anesthesia 52176-180 (2005)
63
Description

• We describe a 433-kg morbidly obese patient with
  obstructive sleep apnea and pulmonary
  hypertension who underwent Roux-en-Y gastric
  bypass.
• Because of the concern that the use of narcotics
  might cause postoperative respiratory depression,
  we substituted their intraoperative use with a
  continuous infusion of dexmedetomidine (0.7
  µgkg1hr1).
• The anesthesia course was uneventful, and the
  intraoperative use of dexmedetomidine was
  associated with low anesthetic requirements (0.5
  minimum alveolar concentration).
• After completion of the operation and
  aftertracheal extubation, the dexmedetomidine
  infusion was continued uninterrupted throughout
  the end of the first postoperative day.
• The analgesic effects of dexmedetomidine extended
  narcotic-sparing effects into the postoperative
  period the patient had lower narcoticrequirements
  during the first postoperative day 48 mg of
  morphine by patient-controlled analgesia (PCA)
  while still receiving dexmedetomidine, compared
  to the second postoperative day(morphine 148 mg
  by PCA) with similar pain scores

64
Conclusions

• Dexmedetomidine may be a useful anesthetic
  adjunct for patients who are susceptible to
  narcotic-induced respiratory depression.
• In this morbidly obese patient the
  narcotic-sparing effects of dexmedetomidine were
  evident both intraoperatively and postoperatively.

65
Dexmedetomidine infusion during laparoscopic
bariatric surgery the effect on recovery outcome
variables.

• Burcu Tufanogullari, et. al.

Anesth Analg 2008 1061741-1748
66
CONCLUSIONS

• Adjunctive use of an intraoperative Dex infusion
  (0.20.8 µg kg1 h1) decreased fentanyl use,
  antiemetic therapy, and the length of stay in the
  PACU. However, it failed to facilitate late
  recovery (e.g., bowel function) or improve the
  patients overall quality of recovery. When used
  during bariatric surgery, a Dex infusion rate of
  0.2 µg kg1 h1 is recommended to minimize
  the risk of adverse cardiovascular side effects.

Anesth Analg 2008 1061741-1748
67
Cardiovascular Considerations
Consider an Arterial Line

• Obesity in anaesthesia and intensive care
• J. P. Adams and P. G. Murphy British Journal of
  Anaesthesia, 2000, Vol. 85, No. 1 91-108

68
Cardiovascular EffectsHuman Volunteers Under
Anesthesia
MAC
plt0.05
Ebert et al, Anesth Analg 199581S11-22
69
Sevoflurane Does Not Activate Sympathetic Nervous
System


Sympathetic Nerve Activity(bursts/100 heartbeats)
Adapted from Ebert et al, Anesth Analg
199581S11-22
plt0.05 vs. baseline
70
The Challenge

• Predisposition to hemodynamic instability due to
  often increased basal increase in SVR and SVO2.
• What better patient population to test all of our
  clinical skills?
• Lets look at some of the options

71
Whom
72
Bariatric Surgery and the Prevention of
Postoperative Respiratory Complications

• Meg A. Rosenblatt, MD, David L. Reich, MD, and
  Ram Roth, MD Department of Anesthesiology, Mount
  Sinai School of Medicine, New York, NY

Anesth Analg 2004981810-1811
73
Consider

• Airway team both anesthesia providers agree on
  airway approach.
• 2 attendings and difficult airway cart available
  for all non FOB intubations.
• Thoracic Epidural Analgesia for RNY
• 5minutes of High Humidity NRB 100 with SAO2
  monitoring before transfer to PACU

74
Difficult Tracheal Intubation Is More Common in
Obese Than in Lean Patients

• Philippe Juvin, MD PhD, Elisabeth Lavaut, MD,
  Hervé Dupont, MD, Pascale Lefevre, MD, Monique
  Demetriou, MD, Jean-Louis Dumoulin, MD, and
  Jean-Marie Desmonts, MD

Anesth Analg 200397595-600
75
IMPLICATIONS

• We report a difficult intubation rate of 15.5 in
  obese patients and 2.2 in lean patients.
• None of the risk factors for difficult
  intubation described in the lean population was
  satisfactory in the obese patients.
• We also report a high risk of desaturation in
  obese patients with difficult intubation.

76
The neurosciences evidence

• Compelling evidence for the primacy of genetic
  influences.
• There is exciting evolving investigations that
  implicate dysregulation of leptin and ghrelin
  production in the etiology of morbid obesity.

77
Insulin resistance, leptin and TNF-alpha system
in morbidly obese women after gastric bypass.

• Molina A, Vendrell J, Gutierrez C, Simon I,
  Masdevall C, Soler J, Gomez JM.Obes Surg. 2003
  Aug13(4)615-21

78
The results

• Leptin and the TNF-alpha system could be involved
  in the pathogenesis of obesity and insulin
  resistance.
• We conducted a study after GBP to analyze the
  pattern of variation of anthropometric and body
  composition variables, leptin and sTNFR1 and 2.

79
The results

• METHODS 29 morbidly obese women were studied, at
  baseline and throughout 6 months after gastric
  bypass.
• RESULTS At baseline, the BMI was 49 /- 6
  kg/m(2) and patients showed a higher fasting
  insulin resistance index (FIRI), leptin,
  leptin/fat mass and sTNFR1 and 2 than did
  controls.
• CONCLUSIONS Morbidly obese women after GBP
  became less insulin resistant with lower leptin
  concentrations, but showed an initial increase of
  sTNFR1 and 2.

80
If a man is standing in the middle of the forest
speaking and there is no woman around to hear
him... is he still wrong?

• George Carlin

81
Plasma Ghrelin Levels after Diet-Induced Weight
Loss or Gastric Bypass Surgery

• David E. Cummings, M.D., David S. Weigle, M.D.,
  R. Scott Frayo, B.S., Patricia A. Breen, B.S.N.,
  Marina K. Ma, E. Patchen Dellinger, M.D., and
  Jonathan Q. Purnell, M.D.
• NEJM Volume 3461623-1630 May 23, 2002 Number 21

82
Conclusions

• Conclusions The increase in the plasma ghrelin
  level with diet-induced weight loss is consistent
  with the hypothesis that ghrelin has a role in
  the long-term regulation of body weight.
• Gastric bypass is associated with markedly
  suppressed ghrelin levels, possibly contributing
  to the weight-reducing effect of the procedure.

83
Treatment options

• Pharmacologic
• Diet
• Exercise
• Surgery
• Combinations

84
Gastric Banding

• Decreases stomach surface area
• No associated malabsorbtive syndromes
• Now adjustable laparoscopic gastric banding
  available

85
Gastric Bypass

• Decreases stomach surface area
• Bypasses significant portion of duodenum
  jejunal digestive surface area
• Malabsorptive syndromes common
• Open vs laparoscopic

86
Sevoflurane Anesthesia in the Obese Surgical
Patient Overview

• Numerous clinical studies document the
  suitability of sevoflurane anesthesia for the
  obese surgical patient
• Sevoflurane has distinctive properties that are
  well-suited to these patients
• Nonpungent and does not cause respiratory
  irritability
• Rapid, predictable hemodynamic response to
  titration
• Does not increase heart rate at concentrations
  below 2 MAC
• Smooth emergence and rapid recovery from
  anesthesia

Torri et al. J Clin Anesth. 200113565 Torri et
al. Minerva Anestesiol. 200268523Sollazzi et
al. Obes Surg. 200111623 Martinotti et al.
Obes Surg. 19999180 Roizen In Anesthesia.
5th ed. 2000903 Ultane (sevoflurane) complete
Prescribing Information, Abbott Laboratories.
87
Sevoflurane for Laparoscopic Gastric Banding

• Randomized, blinded study of 30 ASA status II and
  III morbidly obese patients (BMI gt35)
• Following standard IV induction, anesthesia was
  maintained with sevoflurane or isoflurane (1.4
  MAC-hr exposure per group)
• Extubation, emergence, and response times were
  significantly shorter in the sevoflurane group
• Median time to PACU discharge eligibility was 15
  min in the sevoflurane group vs 27 min in the
  isoflurane group
• Overall, no between-group differences in
  hemodynamic effects
• 20 of sevoflurane patients required therapy for
  minor hemodynamic side effects vs 46 of
  isoflurane patients

Torri et al. J Clin Anesth. 200113565.
88
Sevoflurane for Laparoscopic Gastric Banding

• Randomized, blinded study of 30 ASA status II and
  III morbidly obese patients (BMI gt35)
• Following standard IV induction, anesthesia was
  maintained with sevoflurane or isoflurane (1.4
  MAC-hr exposure per group)
• Extubation, emergence, and response times were
  significantly shorter in the sevoflurane group
• Median time to PACU discharge eligibility was 15
  min in the sevoflurane group vs 27 min in the
  isoflurane group
• Overall, no between-group differences in
  hemodynamic effects
• 20 of sevoflurane patients required therapy for
  minor hemodynamic side effects vs 46 of
  isoflurane patients

Torri et al. J Clin Anesth. 200113565.
89
Would a fly without wings be called a walk?

• George Carlin

90
Sevoflurane for Gastric Bypass Procedures
Extubation

• Times to Extubation

38 difference
Plt0.05 vs isoflurane.
Sollazzi et al. Obes Surg. 200111623.
91
Sevoflurane for Gastric Bypass Procedures
Recovery Scores

• Aldrete Recovery Scores After Surgery

Plt0.05 vs isoflurane.
Sollazzi et al. Obes Surg. 200111623.
92
References

• Sugerman HJ. Pulmonary function in morbid
  obesity. Gastroenterol Clin North Am 1987 16
  2537.
• Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert
  TJ. Sedative, amnestic, and analgesic properties
  of small-dose dexmedetomidine infusions. Anesth
  Analg 2000 90 699705.
• Bradley C. Dexmedetomidine--a novel sedative for
  postoperative sedation. Intensive Crit Care Nurs
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Thats all folks..