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Anaesthetic management

MDT key to anaesthetic management of patients

Pertinent topics for the anaesthesiologists were; successful airway management, indications for more invasive monitoring, and the planning of the postoperative period and deposition

Bariatric patients demand a tailored approach from both the anesthesiologist and the perioperative team due to their unique physiology and anatomy, and the interaction of a multi-disciplinary team (MDT) is key to achieving positive outcomes and a low complication rate. These are the conclusions from a study by investigators from Kantonsspital Frauenfeld, Frauenfeld, Switzerland and the University of California, San Francisco, US, and published in the BMC Anesthesiology, which outlines the perioperative experiences e gained in the first two years after introducing a bariatric programme.

Approach

In early 2011 a multidisciplinary obesity programme was launched at the Kantonsspital Frauenfeld (KSF), encompassing bariatric surgical care, psychiatric/psychosomatic patient guidance, nutrition counselling, gastro-enterological and cardiac work-up, as well as the follow-up and physical therapy.

Anaesthesia and intensive care medicine physicians were involved early in the planning process. In collaboration with the surgical team, a perioperative approach for patient care was developed for each individual patient. Pertinent topics for the anaesthesiologists were; successful airway management, indications for more invasive monitoring, and the planning of the postoperative period and deposition.

Outcomes

Between 2011–2013 a total of 182 bariatric surgical procedures were performed (147 gastric bypass procedures (GBP; 146 (99.3%, n=178) performed laparascopically). On average, GBP patients were 43 years old, 78% female, BMI45, 73% ASA physical status of 2. Forty two patients (28.6%) presented with obstructive sleep apnoea syndrome.

A total of 117 GBP (79.6%) patients were intubated conventionally by direct laryngoscopy (one converted to fibre-optic intubation, one aspiration of gastric contents). 32 patients (21.8%) required an arterial line, ten patients (6.8%) a central venous line.

On average, induction lasted 25 min, the procedure itself 138 min. No blood products were required. Two patients (1.4%) presented with hypothermia (<35°C) at the end of their case. The emergence period lasted 17 min. Postoperatively, 32 patients (21.8%) were transferred to the ICU (one ventilated). The other patients spent 4.1 [0.7] h in the post anaesthesia care unit. Fifteen patients (10.2%) required take backs for surgical revision (two laparotomies). All extubations were unproblematic, no patient had to be re-intubated.

Postoperative care

Postoperatively 115 patients (78.2%) were transferred to the post anaesthesia care unit to recover from the procedure, 32 patients (21.8%) were transferred to the ICU. Fifteen of those admissions (10.2% of all gastric bypass patients) were planned preoperatively due to untreated OSA. None of these patients needed anything other than supplemental application of nasal oxygen. The reasons for unplanned ICU admission was hemodynamic instability in six patients, insufficient oxygenation in one patient, hypothermia in another patient (<35°C). The average length of stay in the post anaesthesia care unit was 4.1 hours, patients that went to the ICU remained there for 17 hours.

Anaesthesia induction time Min 25 [16]
Surgery time Min 138 [42]
Anaesthesia emergence time Min 17 [9]
Total anaesthesia time Min 238 [47]
Patients requiring re-intubation n 0
Patients requiring blood products intraoperatively n 0
PACU stay h 4.1 [0.7]
ICU stay h 17 [12]
Patients requiring blood products during hospital stay n 4 (2.7%)
Patients requiring revision surgery n 15 (10.2%)
Hospital stay Days 6 [2]

Table 1: Perioperative process times of gastric bypass surgery. Data are number, n (% of patients); or mean [standard deviation]. PACU = post anesthesia care unit, ICU = intensive care unit.

During the observation period 15 (10.2%) of the gastric bypass patients required additional surgery (four major operations), two (1.4%) of them were laparotomies. Eight patients (5.4%) needed surgical revision of some form of an incisional or internal hernia. Three patients (2.0%) presented with some form of postoperative hemorrhage that required the transfusion of blood products, two patients (1.4%) developed pneumonia, and one of them required non-invasive ventilation. There was zero in-hospital mortality. The average length of hospital stay was six days.

Conclusion

Our main finding was that the bariatric patient population presents with its unique challenges. When managed appropriately in an interdisciplinary fashion, anesthesia can be delivered safely to this patient population. The preoperative evaluation of these patients should be conducted based on an individual’s need rather than relying on standardized test batteries,” the authors conclude. “Bariatric anaesthesia comes with its unique challenges, but when approached in a thoughtful and interdisciplinary fashion it becomes safely manageable. In addition, the need for some urgent follow-up operations and appropriate postoperative monitoring capabilities have to be accounted for at all times.”

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