Recommended Citation
Rao Shuai I, Aghajani K, Knezevic N. Perioperative management and considerations of super-morbid patients in back surgeries. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Obesity is an increasingly common condition. ASA classifies obesity based on BMI, with class 3 being BMI > 40. Class 3 obesity is associated with many comorbidities, thus increasing perioperative risk.[1] There are several recommendations for obese patients, however there are not many guidelines regarding super morbid patients. This case focuses on airway management and positioning. Case presentation: A 45 years female with medical history of asthma, thrombocytopenia, BMI of 89, 165cm of height came for lumbar-sacral ulcer debridement. She has been bedridden for 1 month after laparoscopic gastrectomy. She presented with decubitus ulcer that needed surgical debridement. Initially surgeon requested prone positioning. Due to concern for ischemic optic neuropathy and increased abdominal pressure, the final position determined to be right lateral decubitus. Airway examination showed good interincissor distance, mallampati score III, thyromental distance > 7cm, good upper lip bite test. The patient was preoxygenated and the bed head was elevated to 30 degrees, as well as several blankets were placed to achieve adequate head extension. Given that previous endotracheal tubes were successfully placed with videolaryngoscope and masking was adequate, the decision was made to use videolaryngoscope with fiberoptic as a backup. Induction was done with sevoflurane, 12mcg of dexmetomidine and 120mg of propofol, after ensuring that we could mask ventilate, 80mg of succinylcholine was given and the tube was placed on first attempt. Patient desaturated to 90%. Throughout the case, a large amount of phenylephrine was used. For extubation, bedhead was placed at 30 degrees and patient was fully awake and following command, with VT > 5ml/kg of ideal body weight. Conclusion: Morbid obesity is an important risk factor for difficult airway. Despite only fulfilling 2 criteria for difficult airway, backup plans should and was considered. Preoxygenation was also optimized with elevation of bedhead and use of blankets. If we look at the difficult airway algorithm[2], the safest way to have proceeded was with awake fiberoptic intubation, however, this can be a traumatic experience for the patient and about 7% of ASA closed claims are related to awake intubation.[1] Furthermore, we shouldn't assume that all super morbid patients will be impossible to ventilate or intubate [2]. Adequate preoxygenation strategy that can be used include apneic oxygenation and elevating bed head. The surgicl position of the patient is also important because prone position is higher risk for ischemic optic neuropathy and increased abdominal pressure. This patient had several risk factors for decreased intraabdominal organ perfusion. Increased intraocular pressure is exacerbated by reduced venous return in prone positoning, leading to higher risk of underperfused optic nerve [3]. Large amount of phenylephrine used in the case prompted us to investigate whether larger volume of distribution affect use of vasopressors. Literature concluded that vasopressors should be titrated to cardiovascular goals however, other drugs, especially the lipophilic drugs have significant changes in pharmacokinetics. 1. Wan Jane, Liu. (2022) Saudi J Anesth 16: 314-321 2. Apfelbaum, Jeffrey. (2022) Anesthesiology 136: 31-81 3. Melissa, Kwee (2015). Int Surg 100: 292-303
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center