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   2022| July-September  | Volume 16 | Issue 3  
    Online since June 20, 2022

 
 
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EDITORIALS
Special issue on “Bariatric Anesthesia”
Abdelazeem A Eldawlatly
July-September 2022, 16(3):275-275
DOI:10.4103/sja.sja_394_22  
  1,369 272 -
ORIGINAL ARTICLE
Comparison of ultrasound-guided residual gastric volume measurement between diabetic and non-diabetic patients scheduled for elective surgery under general anesthesia
Avinash Haramgatti, Sanjeev Sharma, Amit Kumar, Sarita Jilowa
July-September 2022, 16(3):355-360
DOI:10.4103/sja.sja_223_22  
Background and Aims: The presence of gastric content increases the risk of aspiration during general anesthesia. Diabetic patients have delayed gastric emptying; however, despite adequate fasting because of diabetic gastroparesis these patients have a high risk of aspiration. This study aimed to compare ultrasound-guided measurement of residual gastric volume between diabetic and non-diabetic patients scheduled for elective surgery under general anesthesia. Methods: This prospective observational study included 80 patients divided into two groups of 40 diabetic patients with a minimum of 8 years history of diabetes and 40 nondiabetic patients aged >18 years, American Society of Anesthesiologists' physical status I–II kept with similar fasting intervals. Before induction of general anesthesia, gastric ultrasound was performed using standard gastric scanning protocol to measure craniocaudal (CC) and anteroposterior (AP) diameters followed by calculation of antral cross-sectional area (CSA) and gastric volume in semi-sitting (SS) and right lateral decubitus (RLD) position using curved array probe. The gastric antrum volume (GV) was classified as Grade 0, 1, or 2, and risk stratification for aspiration was done. The nasogastric tube was inserted after induction of anesthesia to aspirate and compare the gastric content. Results: In the semi-sitting position, the mean CC and AP diameters were 16.38 ± 3.31 mm and 10.1 ± 2.53 mm in the non-diabetic group and 25.19 ± 4.08 mm and 15.8 ± 3.51 mm in the diabetic group, respectively. In RLD, CC was 1.91 ± 0.38 cm and AP was 1.19 ± 0.34 cm in the non-diabetic group as compared to the CC of 2.78 ± 0.4 cm and AP of 1.81 ± 0.39 cm in the diabetic group. The calculated CSA of 318.23 ± 97.14 mm2 and 4 ± 1.1 cm2 in diabetic were significantly higher than 133.12 ± 58.56 mm2 and 1.83 ± 0.83 cm2 of non-diabetic, in SS (p < 0.0001) and RLD (p < 0.0001) positions, respectively. The GV of 15.48 ± 11.18 ml in the diabetic group was significantly higher than (-) 9.77 ± 18.56 ml in the non-diabetic group (p < 0.0001). Despite the differences in CSA and GV between diabetic and non-diabetic groups, both groups showed a low gastric residual volume (<1.5 ml/kg). The gastric tube aspirate in the non-diabetic and diabetic groups was 0.3 ± 0.78 ml and 1.24 ± 1.46 ml, respectively, and was statistically significant (p = 0.0006). Conclusion: Patients with long-standing diabetes showed higher gastric residual and antral CSA when compared with non-diabetic patients. The clinical significance of these findings needs further evidence for the formulation of specific guidelines for diabetic patients.
  1,306 295 -
REVIEW ARTICLES
Preoperative preparation and premedication of bariatric surgical patient
Marina Varbanova, Brittany Maggard, Rainer Lenhardt
July-September 2022, 16(3):287-298
DOI:10.4103/sja.sja_140_22  
The prevalence of obesity has tripled worldwide over the past four decades. The United States has the highest rates of obesity, with 88% of the population being overweight and 36% obese. The UK has the sixth highest prevalence of obesity. The problem of obesity is not isolated to the developed world and has increasingly become an issue in the developing world as well. Obesity carries an increased risk of many serious diseases and health conditions, including type 2 diabetes, heart disease, stroke, sleep apnea, and certain cancers. Our ability to take care of this population safely throughout the perioperative period begins with a thorough and in-depth preoperative assessment and meticulous preparation. The preoperative assessment begins with being able to identify patients who suffer from obesity by using diagnostic criteria and, furthermore, being able to identify patients whose obesity is causing pathologic and physiologic changes. A detailed and thorough anesthesia assessment should be performed, and the anesthesia plan individualized and tailored to the specific patient's risk factors and comorbidities. The important components of the preoperative anesthesia assessment and patient preparation in the patient suffering from obesity include history and physical examination, airway assessment, medical comorbidities evaluation, functional status determination, risk assessment, preoperative testing, current weight loss medication, and review of any prior weight loss surgeries and their implications on the upcoming anesthetic. The preoperative evaluation of this population should occur with sufficient time before the planned operation to allow for modifications of the preoperative management without needing to delay surgery as the perioperative management of patients suffering from obesity presents significant practical and organizational challenges.
  1,174 251 -
Perioperative Pain Management in Bariatric Anesthesia
Naveen Eipe, Adele S Budiansky
July-September 2022, 16(3):339-346
DOI:10.4103/sja.sja_236_22  
Weight loss (bariatric) surgery is the most commonly performed elective surgical procedure in patients with morbid obesity. In this review, we provide an evidence-based update on perioperative pain management in bariatric anesthesia. We mention some newer preoperative aspects—medical optimization, physical preparation, patient education, and psychosocial factors—that can all improve pain management. In the intraoperative period, with bariatric surgery being almost universally performed laparoscopically, we emphasize the use of non-opioid adjuvant infusions (ketamine, lidocaine, and dexmedetomidine) and suggest some novel regional anesthesia techniques to reduce pain, opioid requirements, and side effects. We discuss some postoperative strategies that additionally focus on patient safety and identify patients at risk of persistent pain and opioid use after bariatric surgery. This review suggests that the use of a structured, step-wise, severity-based, opioid-sparing multimodal analgesic protocol within an enhanced recovery after surgery (ERAS) framework can improve postoperative pain management. Overall, by incorporating all these aspects throughout the perioperative journey ensures improved patient safety and outcomes from pain management in bariatric anesthesia.
  1,124 248 -
Physiologic and pharmacologic considerations in morbid obesity and bariatric anesthesia
Kimberley C Brondeel, Alexis C Lakatta, Grant B Torres, Joshua J Hurley, Illan L Kunik, Kaley F Haney, Elyse M Cornett, Alan D Kaye
July-September 2022, 16(3):306-313
DOI:10.4103/sja.sja_185_22  
Obesity is a growing worldwide health hazard that is characterized by excess malnutrition. Excess food intake leads to dysregulated energy homeostasis and increased adiposity, activating pro-inflammatory physiologic pathways that can contribute to the chronic inflammatory state associated with many chronic illnesses. Obesity is a preventable illness, but its multifaceted etiology, including genetic, behavioral, and environmental variables, is critical to understanding its epidemiology and pathophysiology. Obesity is a critical predisposing factor for illnesses including type II diabetes, cardiovascular disease, and cancer, with higher morbidity and death. Obesity rates are rising, and so will the need for perioperative anesthesia for subjects with obesity. Obesity epidemiology, biochemistry, and pathophysiology are significant concepts in perioperative anesthesia management for subjects with obesity. To provide optimal intraoperative care for subjects with obesity, preoperative cardiovascular assessment for coronary artery disease and drug monitoring is required. Individuals suffering from obesity have significantly higher oxygen consumption rates and a higher risk of desaturation and surgical complications. Individuals suffering from obesity require specialized perioperative treatment related to higher prevalence of perioperative complications.
  1,064 296 -
EDITORIALS
On language – first, do no harm
Roman Schumann
July-September 2022, 16(3):276-277
DOI:10.4103/sja.sja_319_22  
  1,150 151 -
REVIEW ARTICLES
Patients with sleep-disordered breathing for bariatric surgery
Matthew W Oh, Joy L Chen, Tiffany S Moon
July-September 2022, 16(3):299-305
DOI:10.4103/sja.sja_300_22  
The prevalence of patients with obesity continues to rise worldwide and has reached epidemic proportions. There is a strong correlation between obesity and sleep-disordered breathing (SDB), and, in particular, obstructive sleep apnea (OSA). OSA is often undiagnosed in the surgical population. Bariatric surgery has been recognized as an effective treatment option for both obesity and OSA. Laparoscopic bariatric procedures, particularly laparoscopic sleeve gastrectomy (LSG), have become the most frequently performed procedures. OSA has been identified as an independent risk factor for perioperative complications and failure to recognize and prepare for patients with OSA is a major cause of postoperative adverse events, suggesting that all patients undergoing bariatric surgery should be screened preoperatively for OSA. These patients should be treated with an opioid-sparing analgesic plan and continuous positive airway pressure (CPAP) perioperatively to minimize respiratory complications. With the number of bariatric surgical patients with SDB likely to continue rising, it is critical to understand the best practices to manage this patient population.
  1,062 195 -
The patient with obesity and super-super obesity: Perioperative anesthetic considerations
Alan D Kaye, Brock D Lingle, Jordan C Brothers, Jessica R Rodriguez, Anna G Morris, Evan M Greeson, Elyse M Cornett
July-September 2022, 16(3):332-338
DOI:10.4103/sja.sja_235_22  
Obesity is associated with increased morbidity and mortality related to many complex physiologic changes and the rise worldwide has had far ranging implications in healthcare. According to the World Health Organization, over 2.8 million people die each year from being overweight or obese. Patients who are obese often need surgical procedures or interventional pain procedures and are at higher risk of complications. Patients with super-super obesity are those with body mass index greater than 60 kg/m2 and are at even greater risk for complications. The present investigation reviews epidemiology, pathophysiology, and anesthesia considerations for best practice strategies in managing these higher risk patients. Clinical anesthesiologists must utilize careful assessment and consultation in developing safe anesthesia plans. Improvements in technology have advanced safety with regard to airway management with advanced airway devices and in regional anesthesia with ultrasound-guided nerve blocks that can provide increased flexibility in formulating a safe anesthetic plan. As well, newer drugs and monitors have been developed for perioperative use to enhance safety in patients with obesity.
  1,040 182 -
Airway management in patients suffering from morbid obesity
Wan Jane Liew, Asadi Negar, Prit Anand Singh
July-September 2022, 16(3):314-321
DOI:10.4103/sja.sja_90_22  
Obesity is no longer a disease of the affluent. The prevalence of obesity has risen at an exponential rate globally, with an increasing burden on healthcare resources. Perioperative management of patients with morbid obesity is known to be challenging, and this is particularly so in the management of their airway, a crucial procedure that requires meticulous planning and modifications. Anesthesiologists will expect to see more patients with obesity in their practice presenting for both bariatric and non-bariatric surgery, or even for emergency surgery. Hence, any generalist anesthesiologist should be confident in managing such a patient, with the appreciation that these patients often pose a significant challenge to the practice of anesthesia. This article describes different techniques and looks at the evidence for airway management in the morbidly obese. Other aspects of perioperative management of such patients are beyond the scope of this article.
  942 190 -
Pre-oxygenation and apneic oxygenation in patients living with obesity – A review of novel techniques
Tomasz Gaszynski, Andrew McKechnie
July-September 2022, 16(3):322-326
DOI:10.4103/sja.sja_351_22  
Morbidly obese patients are in the group of patients, who can desaturate fast because of changes in lung volumes and reduction in Functional Residual Capasity due to obesity. There are novel methods to improve preoxygenation and to maintain oxygneation during intubation efforts. In this paper we present methods of apneic oxygenation for morbidly obese patients.
  922 172 -
The role of ultrasonography in anesthesia for bariatric surgery
Sherein Diab, Jaeyeon Kweon, Ossama Farrag, Islam M Shehata
July-September 2022, 16(3):347-354
DOI:10.4103/sja.sja_80_22  
Bariatric surgeries are effective long-term management for morbid obesity with its adverse sequelae. Anesthesia of bariatric surgeries poses unique challenges for the anesthesiologist in every step starting with vascular access till tracheal extubation. The usage of ultrasound in anesthesia is becoming more prevalent with a variety of benefits, especially in the obese population. Ultrasound is successfully used for obtaining vascular access, with more than 15 million catheters placed in the United States alone. Ultrasound can also be used to predict difficult intubation, as it can confirm the tracheal intubation and assess the gastric content to prevent pulmonary aspiration. Ultrasound is also used in the management of mechanically ventilated patients to monitor lung aeration and to identify respiratory complications during positive pressure ventilation. Moreover, intraoperative echocardiography helps to discover the pulmonary embolism and guides the fluid therapy. Finally, ultrasound can be used to perform neuraxial and fascial plane block with a less overall time of the procedures and minimal complications. The wide use of ultrasound in bariatric anesthesia reflects the learning curve of the anesthesiologists and their mounting efforts to provide safe anesthesia utilizing the updated technology. In this review, we highlight the role of ultrasonography in anesthesia of bariatric surgery and discuss the recent guidelines.
  850 180 -
Intraoperative protective lung ventilation strategies in patients with morbid obesity
Konstantin Balonov
July-September 2022, 16(3):327-331
DOI:10.4103/sja.sja_386_22  
Postoperative pulmonary complications (PPCs) occur frequently and are associated with a prolonged hospital stay, increased mortality, and high costs. Patients with morbid obesity are at higher risk of perioperative complications, in particular associated with those related to respiratory function. One of the most prominent concerns of the anesthesiologists while taking care of the patient with obesity in the perioperative setting should be the status of the lung and delivery of mechanical ventilation as its strategy affects clinical outcomes. Negative effects of mechanical ventilation on the respiratory system known as ventilator-induced lung injury include barotrauma, volutrauma, and atelectrauma. However, the optimal regimen of mechanical ventilation still remains a matter of debate. While low tidal volume (VT) strategy has become a widely accepted standard of care, the protective role of PEEP and recruitment maneuvers is less clear. This review focuses on the pathophysiology of respiratory function in patients with morbid obesity, the effects of mechanical ventilation on the lungs, and optimal intraoperative strategy based on the current state of knowledge.
  840 172 -
Launching a new fellowship: Bariatric Anesthesia
Abdelazeem A Eldawlatly
July-September 2022, 16(3):278-286
DOI:10.4103/sja.sja_311_22  
The dream is now real! We had started thinking of establishing “Bariatric Anesthesia Fellowship” (BAF) program in our setting since 2012. The reason was the increasing number of bariatric surgical cases for weight loss under general anesthesia (GA). The journey till establishing the BAF program consisted of two phases. Phase I started in 2012 to establish clinical practice guidelines (CPG) in “Anesthesia for Patients with Morbid Obesity undergoing weight loss surgery”. Phase II started in 2015 to establish BAF program. In 2021 the first draft of BAF program was submitted to the medical education for approval. In March 2022, we got the interim approval of the program. Though the journey took sometime but ultimately it ended with success and achieving the dream. In this review, we are going to discuss a roadmap consisted of two phases in an attempt to reach our goal of establishing the BAF program.
  841 164 -
CASE REPORTS
Cardioprotection with glucose insulin potassium (GIK) during non cardiac surgery in a patient with stress induced myocardial ischemia: A case report
Rosa Tesoro, Andres Hagerman, Granit Molliqaj, Christoph Ellenberger, Marc Licker
July-September 2022, 16(3):364-367
DOI:10.4103/sja.sja_195_22  
The administration of glucose-insulin-potassium (GIK) has demonstrated cardioprotective effects in cardiac surgery. A 58-year-old male with severe disabling back pain due to posterolateral lumbar pseudarthrosis was scheduled for spine surgery. He previously experienced two episodes of acute coronary syndrome that required percutaneous coronary interventions (PCIs). Coronary angiogram showed intrastent occlusions and multiple coronary lesions that were not suitable for percutaneous or surgical revascularization. During pharmacological stress imaging, myocardial ischemia developed in 19% of the ventricular mass and was reduced to 7% when GIK was administered. After anesthesia induction, the GIK solution was also infused and surgery was uneventful, with no signs of postoperative myocardial injury. Four days later, the patient was successfully discharged to a rehabilitation center. This is the first clinical report of GIK pretreatment during non-cardiac surgery in a patient with ischemic heart disease (IHD).
  662 118 -
Efficacy of HFNO during airway management of a COVID pneumonia patient with super morbid obesity undergoing emergency laparotomy
Mohamed Sayed Hajnour, Haneen Fawzi Amlih, Faisal Fahad Bin Shabr
July-September 2022, 16(3):368-370
DOI:10.4103/sja.sja_327_22  
This case report describes the use of high flow nasal oxygen (HFNO) in a patient with morbid obesity (BMI = 90 kg/m2) who underwent emergency laparotomy under general anesthesia. This 54-year-old female patient with American Society of Anesthesia classification 4 E is known to have COVID pneumonia with Obstuctive Sleep Apnea. She was admitted in the ICU for 3 days and she was on Bilevel Positive Airway Pressure (BiPAP) alternating with HFNO to keep her SpO2 91%–92%, on FiO2 60%, and respiratory rate (RR) 40–45/min. The plan for airway management was rapid sequence intubation with preoxygenation using the HFNO. We here report this case to show the usefulness of HFNO, which adds a new dimension in airway management of similar cases.
  622 132 -
Feasibility of THRIVE oxygenation and intra-operative lung-protective ventilation in morbidly obese patients undergoing neurosurgical procedures
Balaji Vaithialingam, Radhakrishnan Muthuchellappan
July-September 2022, 16(3):361-363
DOI:10.4103/sja.sja_198_22  
The conduct of anesthesia in morbidly obese patients undergoing neurosurgical procedures can be challenging considering the multi-system organ involvement. Implementation of conventional lung-protective ventilation in morbidly obese patients can have a negative impact on the intra-cranial dynamics. We report a series of three patients with morbid obesity and a difficult airway for the neurosurgical procedure. The patients were oxygenated with high-flow oxygen devices to ensure an adequate oxygen reserve in the peri-operative period. A modified intra-operative lung-protective ventilation with normocarbia was implemented with no impact on the intra-cranial pressure in the prone position in two of the patients. Oxygenation with high-flow devices should be considered during the peri-operative period in morbidly obese patients to avert an adverse respiratory event, and a modified lung-protective ventilation technique is feasible with normal intra-cranial dynamics intra-operatively.
  596 133 -
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