Big on Safety: Key Safety recommendations in anaesthesia for the morbidly obese Symposium organized by The European Society for Perioperative care of the Obese Patient (ESPCOP)

Who’s ESPCOP? President: Luc De Baerdemaeker University Hospital Ghent Belgium Vice president: Mike Margarson, St. Richards Hosptital Chichester UK Secretary: Daniela Godoroja, University of Bucarest, Romania Treasurer: Jan Paul Mulier, St Jan Hospital Bruges, Belgium

Our goals ESPCOP is an ESA subsociety ESPCOP, ISPCOP, SOBA, SASM, ... all these societies have a lot in common. By joining forces we can share our interests and efforts and create a network for exchange of ideas, education and research Join the network if you’re interested www.espcop.org, or want to receive e-newsletter

Concept of this session ESPCOP organized a survey amongst its members. Q: Give Your top five or six tips, that they would pass on to a senior trainee, on providing safer anaesthesia for a morbidly obese patient. Each of the responders had an experience > 500 cases. The top 20 safety tips were channeled in 5 topics that will be presented in brief 15 minutes sessions followed by discussion. Safety tips will be made available on www.espcop.org

The 5 topics from the survey positioning the morbidly obese staff and equipment requirements that improve safety respiration and airway management anaesthetic dosage and drug the perioperative care

Position and positioning of the morbidly obese patient Luc De Baerdemaeker, PhD, MD, DEAA Department of anaesthesia University hospital Ghent Belgium

Position and positioning: Points from the survey that made Top 20 Use specific induction position Extubate in sitting/Fowler position Forbid the obese lying supine Fastidious attention to positioning and pressure points

content Role of body position in this type of pathology during different stage of the perioperative path of the patient Positioning the morbidly obese patient: cave at

ESPCOP/ISPCOP logo

induction Aspiration FRC, ERV and atelectasis Intubation in the HELP position

the “intravenous barbiturate/muscle relaxant/rapid intubation” Morton et al Anesthsia 1951;6:190-201 used a 40-degree head-up tilt so that the larynx would be raised to a height above the cardia greater than the intragastric pressure. CP by Sellick 1961: The CP maneuver seemed to overcome many of the disadvantages of the sitting position. Snow and Nunn, as well as Sellick, emphasized the importance of oxygen administration before anesthetic induction. Sellick used CP to prevent gastric inflation during manual ventilation. these early investigators recommended and used manual ventilation before intubation during RSII.

How to increase FRC, and prevent atelectasis? pre-oxygenation with FIO2 0.8 ?? Pre-oxygenation in 30° reverse trendlenburg Pre-oxygenation with CPAP (5 min) and PCV (< 20 cm H2O) with PEEP (5 min) via a face mask during induction Before extubation: vital capacity manoever and avoiding FIO2 of 1.0 ? PEEP during surgery but always with recruitment manoever! post-op: sitting position NIV, CPAP or BIPAP(Boussignac masker) Is er een strategie om atelectase te voorkomen? Ja, en deze is multimodaal. Pre-oxygenatie met 100% heeft het nadeel dat er resorptie atelectasen ontstaan. 80% zuurstof bevat 20% stikstof en geeft minder resorptieatelectase. Een zittende houding tijdens inductie verhoogd het FRC en brengt ons weg van het closing volume maar zal terzelfdertijd onze zuurstoftank vergroten. Moderne anesthesietoestellen geven ons de mogelijkheid om te pre-oxygeneren met CPAP, sommige scholen gebruiken een korte periode van maskerventilatie met PEEP tijdens de inductie na het ingaan van de apneu. Vlak voor extubatie is het zinvol om nog eens de longen te recruiteren en op minder dan 100% zuurstof te extuberen. PEEP tijdens chirugie heeft zin met waarden die volgens publicatie variëren tussen 6-12 cm H2O. Belangrijk is wel dat dit steeds in combinatie met een recruitment manoever moet gebeuren. Tijdens de postoperative periode is the aanhouden van een zittende houding belangrijk. Indien de patient obstructief slaap apneu syndroom heeft wordt CPAP zo snel mogelijk herstart. Vele chirurgen vrezen maaginsufflatie met lekken van de anastomose maar recente literatuur verwijzen deze visie naar het rijk der fabeltjes. Met de komst van non-invasieve ventilatie hebben we de mogelijkheid om CPAP en BIPAP toe te passen bij deze patiënten waar oxygenatie een probleem is geworden.

Intubation in the HELP = head elevated laryngoscopy position Veel van de intubatieproblemen bij morbide obese patiënten kunnen opgelost of verbeterd worden door de patiënt correct te positioneren. De correcte positie voor het uitvoeren van de directe laryngoscopie bij morbide obesen wordt bekomen door op een drastische manier het hoofd en bovenste lichaam omhoog te brengen met behulp van kussens en/of dekens en wel op een dergelijke wijze dat de uitwendige gehoorgang en de sternale inkeping op één horizontale lijn komen te liggen (HELP = head elevated laryngoscopy position of the ramped position)

RAMP: Rapid Airway Management Positioner www.airpal.com

During surgery Prevent sliding down Sitting position with flexing of the hips improves working space for the surgeon Robotic surgery steap head down Thoracotomy Arthroscopy. 2014 Nov;30(11):1520-7. doi: 10.1016/j.arthro.2014.05.042. Epub 2014 Aug 6. Cerebral oxygenation using near-infrared spectroscopy in the beach-chair position during shoulder arthroscopy under general anesthesia. Pant S1, Bokor DJ2, Low AK3. Author information Abstract PURPOSE: To examine the risks of shoulder arthroscopy in the beach-chair position (BCP) as opposed to the lateral decubitus position. The challenge during general anesthesia, particularly with the patient in the BCP, has been to ascertain the lower limit of blood pressure autoregulation, correctly measure mean arterial pressure, and adequately adjust parameters to maintain cerebral perfusion. There is increasing concern about the BCP and its association with intraoperative cerebral desaturation events (CDEs). Assessment of CDEs intraoperatively remains difficult; the emerging technology near-infrared spectroscopy (NIRS) may provide noninvasive, inexpensive, and continuous assessment of cerebral perfusion, offering an "early warning" system before irreversible cerebral ischemia occurs. METHODS: A systematic review was undertaken to determine the incidence of intraoperative CDEs as measured by NIRS and whether it is possible to risk stratify patients for intraoperative CDEs, specifically the degree of elevation in the BCP. RESULTS: Searching Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception until December 30, 2013, we found 9 studies (N = 339) that met our search criteria. The Level of Evidence was III or IV. CONCLUSIONS: There remains a paucity of high-level data. The mean incidence of CDEs was 28.8%. We found a strong positive correlation between CDEs and degree of elevation in the BCP (P = .056). Emerging evidence (Level IV) suggests that we may be able to stratify patients on the basis of age, history of hypertension and stroke, body mass index, diabetes mellitus, obstructive sleep apnea, and height. The challenge remains, however, in defining the degree and duration of cerebral desaturation, as measured by NIRS, required to produce measureable neurocognitive decline postoperatively. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies

Advantage of beach chair, disadvantage of beach chair Obesity related IC hypertension: sitting postion decreases ICP Shoulder surgery: reports of cerebral desaturations at moments op hypotension; Salazar et al. J Shoulder Elbow Surg (2013) 22, 1228-1235 Increased body mass index (BMI) was found to have a statistically significant association with intraoperative Cerebral Desaturation Events (mean BMI 37.32 vs 28.59, P < .0001). There was no statistical significance in pre- vs postoperative neurological assessment .

Postoperative position Sitting Have the right equipment!

Continue to use CPAP or NIPPV treatment in the immediate postoperative period Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea AA 2014;120:268-86 With or without supplemental oxygen unless contraindicated by the surgical procedure. AHI scores improve when OSA patients sleep in the lateral prone or sitting position OSA patients should be placed in the NON SUPINE POSITIONS throughout the recovery process

positioning Extra attention to pressure points Extra attention to nerve injury: don’t forget the head and the brachial plexus Long procedures in the sitting positon: rhabdomyolysis

The huge leg is resting on the sitting piece, extra padding for the lower legs RHABDOMYOLYSIS

Arms horrizontal with extra padding

Conclusions and take home messages Gravity: make use of it in the obese by sitting them up in the reclining position!!

Thank you for your attention