mortality and morbidity in obese patients undergoing ... · mortality and morbidity in obese...

Mortality and Morbidity in obese patients

undergoing anesthesia

and

Preoperative preparation

Pr Philippe CUVILLON

Pôle ARDU, CHU Nîmes

Adiposity

P / T2

Body Mass Index

BMI= Weight (kg) /Height² (m²)

Adolphe Quetelet. Edinburgh Medical Journal 1817

Mortality and obese patients

Assurance program : 1950-60

Moderate < 18,5

Very low 18,5 – 24,9

low 25 – 29,9

moderate 30 – 34,9

High

Very high

Super obese

35 – 39,9

40

> 50

Abdominal adiposity

0

2

4

6

8

10

12

14

16

18

20

I II III IV

Abdominal visceral fat

Cardiac CancerAll causes

Circulation 2016 Feb 16;133(7):639-49.

WHO (Worl Hearth Organization) 1997

Obesity is a « disease »

Obesity and cancer

Male : 1,75 m

Weight : 259 Kg

Age = 23 years

max : 296 kg

HTA

OAS (Apnea)

Heart failure

Obesity

BMI = 85kg/m²

Frequence

= 30-50 %

Frequence

= 30-70 %

Frequence

= 20-40 %

Frequence

= 20-30 %

Case n°1.

Stroke

Preoperative evaluation

• Perioperative outcomes

and surgery

SurgeryNon bariatric

Bariatric

0

2

4

6

8

10

12

14

16

18

20

I II III IV

Abdominal visceral fat

Cardiac CancerAll causes

Dindo D et coll. 2003;361:2032- 2035.

6336 consecutive patients

9% obese including, 4% with BMI > 35

Non bariatric surgery

General elective surgery

Obesity, diabetes and smoking are important determinants of resource utilization in liver resection:

a multicenter analysis of 1029 patients. Gedaly R et al. Ann Surg 2009; 249:414-9.

23 studies (13 prospective, 10 retrospective): 106 119 patients

Admission : 15 of 2549 (0.59%) : pain, nausea, and dysphagia

Readmission (30-days) : 0.55% (12 of 2181 pts) : dysphagia +++

Super obese (BMI> 50):

more comorbidities, significantly longer operating times: 74 vs 81 min

The predictors of increased mortality:

BMI, ASA, type of procedure (i.e., Laparoscopic Roux-en-Y Gastric

Bypass versus LAGB), operative time.

ICU and mortality: a troubling paradox…

Mortality is reduced compared to non obese patient …

• Mortality : 0.3 %

• Complications Death

– P. Emboli and DTV: 0.3 % 50 %

– Cardiac Failure: 0.4 % 15 %

– Anastomotic leak: 0.6 to 6 % 15-30 %

– Hemorhage: 3% <low

– Parietal infection ans abscess: 1.6 % <low

– Respiratory AE, pneumonia: 4-5 % 11-15 %

Br J Anaesth. 1981, 53:811-816,

Obese Surg. 2016, May

Bariatric surgery

113,898 patients overal postdischarge complication: 3.2%- wound infection (49.4%)

- reoperation (30.7%)

- urinary tract infection (16.9%),

- shock/sepsis (12.4%)

- organ space surgical-site infection (11.0%)

Open gastric bypass: greatest postdischarge complication 8.5%.

The factors associated most strongly with increased odds of postdischarge

complications: body mass index ≥ 50, use of steroids, procedure type,

predischarge complication, prolonged duration of stay, and prolonged operative

time.

Surgery 2015


• Perioperative outcomes and surgery

• Clinical Evaluation: airway


Bariatric

Operating room, difficult intubation : 8% vs 5% non obese

grade I grade II grade III grade IV

Classification Mallampati

Classification Cormack AndLehane(laryngoscopie)

Facile DifficileIntubation

SCORE DE MALLAMPATI

Prediction of Difficult Tracheal IntubationTime for a Paradigm Change

Anesthesiology 2002Olivier Langeron, M.D., Ph.D.,* Philippe Cuvillon, M.D.,† Cristina Ibanez-Esteve,

M.D.,‡François Lenfant, M.D., Ph.D.,§ Bruno Riou, M.D., Ph.D.,‖ Yannick Le

Manach, M.D., Ph.D.#

Intubation and ventilation

• Modification of the air way

• Difficult intubation

• Difficult ventilation

- Mallampati Score

- Neck circumference > 40 cm

- Mouth opening < 3,5 cm

- Cervical motility ….

Never alone…

Neck circumference as a predictor of difficult intubation and

difficult mask ventilation in morbidly obese patients: A

prospective observational study Eur J Anaesth 2016

Riad, Waleed; Vaez, Mercedeh N.; Raveendran, Ravi; Tam, Amanda D.;

Quereshy, Fayez A.; Chung, Frances; Wong, David T.

PATIENTS: A total of 104 morbidly obese surgical patients

(BMI ≥40 kg m−2) were included in the study. 88 patients were

women and 16 were men. Exclusions were known difficult

airway and emergency surgery.

Male sex (P = 0.004) and BMI more than 50 kg m−2 (P = 0.031)

were independent predictors of difficult mask ventilation.

• Modification of the air way

• Difficult intubation

• Difficult ventilation

• Inhalation and regurgitation

- Gastric paresis (diabetic)

- By pass surgery

Never alone…

Intubation and ventilation



• Clinical Evaluation: Venous access


Bariatric

Venous access

- Ultrasound

- Jugular vein

Head : neutral postion

Femoral access

Hind D, BMJ 2009

Fujiki M, Obes Surg 2008

Head : neutral position

VJI

Venous access



• Clinical Evaluation: Labs


Bariatric

Labs• Chemistry, liver function, renal function

• Lipid Profile

• CBC

• Iron Profile- TIBC, total iron, saturation

• B-1, B-12 levels

• HbA1c

• H-Pylori

• Drug Screen (optional)



• Clinical Evaluation: cardiac evaluation


Bariatric

Cardiac dysfunction and obesity

Except for bariatric surgery, few data are available regarding

the morbidity and mortality associated with severe obesity and

specific surgical procedures.

There are 6 known risk factors for perioperative cardiovascular

morbidity in the general population according to the Revised

Cardiac Risk Index

These include:

- high-risk surgery, such as emergency surgical

procedures or major thoracic, abdominal, or vascular

surgery

- history of CHD

- history of congestive heart failure

- history of cerebrovascular disease

- preoperative treatment with insulin

- preoperative serum creatinine levels >2.0 mg/dL

Risk Class/ complication rate

Class I Zero 0.4%

Class II One 0.9%

Class III Two 6.6%

Class IV Three 11.0%

Obese patients with no CHD risk factors who are referred

for elective surgery may not require further testing.

On the other hand, patients with ≥3 CHD risk factors or

diagnosed CHD may require additional noninvasive

testing if the results will change management.

If significant coronary artery disease is found, surgery

could be delayed to allow the institution and titration of

appropriate medical therapy, such as statin or β-blocker

therapy, or even coronary revascularization in appropriate

patients with severe 3-vessel or left main disease



• Clinical Evaluation: cardiac evaluation


Bariatric

Clinical

evaluation

Dyspnea

HTA

ECG

US echography



• Clinical Evaluation: Pulmonary Function


Bariatric

Obstructive Sleep Apnea

(testing and treatment).

• Asthma.

• Smokers.

Obstructive Sleep Apnea incidence

IOSA-defined as an apnea/hypopnea index (AHI) ≥ 5.0 events/h

Study 1: 1 089 patients for bariatric surgery

OSA was 74 % J Brazil Pneumol 2015

Study 2: 120 patients (Canada) Obes Surg 2015

BMI 35-39.9 kg/m2 : 71 %.

BMI 40-40.9 kg/m2) : 74 %

Superobese (BMI 50-59.9 kg/m2): 77 %

> BMI 60 kg/m2: 95 %

Pulmonary complication after surgery : Chest 2016 Jan;149(1):84-91

• Pulmonary evaluation

– Spirometry (effect of β2 agonist)

– Polysomnography showed an obstructive

sleep apnea-hypopnea syndrome

(OSAHS)

• STOP-BANG questionnaire

OUI

OUI NON

OK pour la

chirurgie

24 heures

post-

opératoires

en

chambre

Snoring (ronflemment)

Tired (fatigue diurne)

Observed (apnées observées)

Blood Pressure (HTA)

BMI > 35

Age > 50

Neck tour de cou > 40 cm

Gender (homme)

Venir avec

l’appareillage

OK pour la

chirurgie

24 heures

post-

opératoires

en soins

continus

SAS

appareillé

NONSAHOS

connu

OUI NONSAS

diagnostiqué

Exploration nécessaireContacter pneumologue référent

OUIOUI NONSAS

appareillé

OUI

OK pour la

chirurgie

24 heures

post-

opératoires

en soins

continus

Venir avec

l’appareillage

≥ 3

facteurs de

risque

Ventilation en

pression positive

pendant 4 à 6

semaines

NON

6 weeks before surgery

3-4h / night

Film 4

Dose ?

• Enoxaparine 2 x 3000 (n=19) vs 2 x4000 (n=33)

• BMI :50 kg/m²

• Mesure activité anti-Xa: 1° and 3° dose

• Cible: 0,18-0,44UI/ml

• Bariatric surgery: banding + bypass

Rowan et al, obes Surg 2008; 18: 162-6

Dose ?

• Pic 3è dose

• Cible atteinte 42% pour 4000UI

Mais chirurgie non homogène,

Groupes successifs, 1è dose J-1 ou J0

Quelle thromboprophylaxie ?

Adaptation posologique

• Enoxaparine 2x4000(n=24) vs 2x6000(n=16)

• BMI 50 kg/m²

• Chirurgie bariatrique: banding ou bypass

• Cible: 0,18-0,44

• Mesure anti-Xa 1è et 3è dose

Simone et al Surg Endosc 2008

Quelle thromboprophylaxie ?

Adaptation posologique

• 44% sous dosage

pour 4000UI

• 57% surdosage

pour 6000UI

Mais étude groupes successifs

Choix des valeurs limites??

Poso optimale: 5000UI?



• Clinical Evaluation

– airway (intubation, ventilation)

– Labs

– Cardiac evaluation (physical status)

– Pulmonary evaluation (OSA and B2)

– Venous access

– DTV and EP

mortality and morbidity in obese patients undergoing ... · mortality and morbidity in obese...

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