· 40 year old man
· 180kg 170cm BMI+++
· Not known to any doctors
· SBO requiring urgent laparotomy
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Overall |
· Major comorbidity + major surgery · Risky anaesthetic and surgery · Risky intra-op and post-op |
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Obesity itself |
· Airway: difficulty bag-mask ventilation due to obstruction; difficult intubation due to positioning · Breathing: difficulty ventilating due to restriction, difficulty oxygenating due to shunt · Circulation: difficult vascular access and BP monitoring · Logistics: difficulty positioning and transferring |
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Secondary pathology |
· Airway and breathing: sleep-disordered breathing · Circulation: AF, coronary artery disease, cardiomyopathy, cor pulmonale · Other: diabetes, GORD |
Assessment:
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Questions |
· What is the severity of obesity? · What secondary pathologies are present? · What needs testing? · What needs optimizing? |
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What to do pre-op:
-Assessment (HxExIx)
Severity of illness: evidence of hypovolaemia, sepsis, organ dysfunction
Presence and severity of comorbidities
Prev anaes esp airway
-Optimisation:
Time to test anything? e.g. sleep studies (?OSA), TTE (?PHTN, RV dysfx)
Needs review by anyone? e.g. peri-op med
Need treatment of anything? e.g. diabetes
-Planning for the entire stay:
People: second anaesthetist to help me, peri-op physician of some sort
Equipment: hover mat, oxford ramp, HFNP, locked analgesic infusion pumps
Facilities: HDU
Intra-op:
-Pre-induction
Access: 2 x 18g IV and arterial line
Monitoring: standard + 5 lead ECG + arterial
-Induction: modified rapid-sequence
2nd anaesthetist!
Positioning: oxford ramp + HFNP 50L/min highest FiO2
Say airway plan: 1)video scope size 8 ETT with stylet 2) iGel size 4 3) BMV with red guedel 4) scalpel bougie cric
Give drugs: alfentanil 15mcg/kg LBW + propofol 2g/kg LBW + rocuronium 1.2mg/kg
-Maintenance
Anaesthetic: deflurane to minimize uptake
Analgesia: ketamine 0.3mg/kg + infusion 0.1mg/kg/h + lignocaine 1mg/kg + infusion 1mg/kg/h + titrated fentanyl 0.5mcg/kg + paracetamol 1g + parecoxib 40mg
Fluid: CSL how much?
-Emergence
Suction
Bite block
Reversal: sugammadex + TOF >0.9 confirmation
On bed
Sitting up
Obeying commands
Ensure all systems good: airway/breathing/circ/neuro/neuromusc/acid-base/temp
Post-op:
-Disposition: HDU due to risk of airway obstruction and death
-Analgesic plan: paracetamol + ketamine infusion + fentanyl PCA +/- rectus sheath catheters + APS referral
-Rectus sheath catheters: load ropiv 0.75% 10mL each, infuse ropiv 0.2% 6mL/h each