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UK consensus

Obesity: best practice statement for anaesthetists

The paper is a result of the consultation and highlights the key principles for best practice

A panel of experts from the UK have published a consensus statement designed to provide much needed guidance for provide guidance for specialist and non-specialist anaesthetists.

Published online in the journal Perioperative medicine, the authors claim that although the current guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), “Peri-Operative Management of the Morbidly Obese Patient”, give an “excellent overview of organisational issues”, unfortunately they leave much clinical detail to the discretion of the individual clinician.

The increasing prevalence of obesity in the UK, the paucity of evidence to guide best clinical practice for anaesthetists and the ever-increasing number of morbidly obese patients led to a panel of experts, in consultation with the UK’s Society for Obesity and Bariatric Anaesthesia (SOBA), convening in May 2010 to develop a consensus on anaesthesia of overweight, obese and morbidly obese patients.

All members are practicing clinicians from bariatric surgical training centres, and have significant experience in anaesthesia of overweight and obese patients (please go to the end of the article for a full list of the members of the panel).

The paper is a result of the consultation and highlights the key principles for best practice, provides evidence-based justification for best-practice techniques (where this exists), guidance and dispels misconceptions of anaesthetic practice when treating overweight, obese and morbidly obese patients. 

In addition, the statement highlights other areas in which anaesthetists can contribute towards enhanced recovery and the overall quality of patient care, such as part of an Enhanced Recovery Programme to focus on quality, improve productivity, eliminate waste and curtail spiralling costs.It highlights the role anaesthetists can play in:

  • Improving outcomes and shortening the length of stay for the patient, including early mobilisation;
  • Structuring approaches for optimal pre-operative, peri-operative and post-operative care; and
  • Reducing the physiological stress of surgery.

Best-practice

The consensus statement claims that one of the key principles for anaesthesia is the employment of techniques that are familiar, reproducible, and safe. Therefore, the anaesthetist should not “necessarily have to change practice just because the patient is larger than the average they encounter. Rather, a better outcome may be achieved by awareness of the issues that may arise in this population. The risk should not be exacerbated by incorporating new or unfamiliar techniques.”

A second key principle is maintaining control and minimising periods of potential risk or instability. “In particular, care should be taken during the transition from spontaneous breathing to controlled ventilation during induction and during the periods of emergence and extubation”, the statement adds.

The consensus statement also discusses:

  • Premedication and preparation techniques
  • Placement of an inflatable hover mattress to facilitate post-operative transfer
  • Thromboprophylaxis
  • Facemask ventilation
  • Monitoring of neuromuscular blockade
  • Rapid sequence induction
  • Additional risk factors (gender, large neck circumference, limited neck mobility, etc)
  • Pharmacokinetics
  • Rapid wake-up
  • Minimal respiratory depression 
  • Haemodynamic considerations
  • Early mobilisation
  • Extubation

The statement also highlights priorities for further clinical research including:

  • Mechanistic investigation: molecular and pathophysiologic mechanisms to affect peri-operative medicine;
  • Potential disease response modifiers; and
  • A programme of translational research to bring the bench to the bedside. 

As a result, the authors write that the following are priorities for clinical research:

  • Identify how co-morbidities significantly affect the peri-operative course;
  • Design anaesthetic strategies to minimse risk of peri-operative morbidity, particularly nausea;
  • Improve tests that predict difficult intubation; and
  • Define the role of co-analgesic agents in reducing opioid requirements and discomfort.      

Conclusion

“Ultimately, the choice of specific technique depends on clinician experience, patient characteristics, and centre facilities,” the statement concludes. “As well as providing guiding principles for anaesthesia, this consensus statement also highlights other areas where anaesthetists can contribute towards the enhanced recovery and overall quality of patient care.”

The members of the expert panel are Drs Euan Shearer, University Hospital Aintree, Liverpool; Andrew Paix, Princess Royal University Hospital, Orpington, UK; Claire Nightingale, Wycombe Hospital, High Wycombe, UK; Nick Kennedy, Consultant Anesthetist and Intensivist, Musgrove Park Hospital, Taunton, UK; Andy Kendall, Consultant Anesthetist, St Richard’s Hospital, Chichester, UK ; William Fox, Consultant Anesthetist Royal Cornwall Hospital, Truro, UK; Jonathan Cousins, Consultant Anesthetist, Charing Cross and The Hammersmith Hospitals, London, UK; Olumuyiwa Bamgbade, Consultant Anesthetist, Manchester Royal Infirmary, Manchester, UK; and Kamran Abbas, Consultant Anesthetist, Manchester Royal Infirmary, Manchester, UK.  

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