OR Manager - November 2019 - 31

AMBULATORY
SURGERY CENTERS
are well controlled, there is no reason
why an obese patient can't undergo a
procedure in an ASC, he says.
Gaganpreet
Grewal, MD
" You have to look at the
whole person, " says Dr
Grewal. Many obese patients
who don't have
comorbidities will do
just fine, whereas others
may be struggling
with cardiac or pulmonary
issues. These patients
might be more likely to experience
risks with surgery, she says.
The bottom line, she adds,
is that
a higher BMI is associated with higher
risk of comorbidities, " but not always,
which is why we always have to assess
the patient. "
OSA can become a concern if it's
untreated. However, if an obese patient
is sleeping soundly and wears a
Continuous Positive Airway Pressure
(CPAP) mask every night, it means the
problem is being managed. Patients
who carry their weight in the torso and
have thick necks are more likely to have
airway problems and sleep apnea than
patients who carry their weight on their
hips. " This is why patients have to be
assessed individually, " she says.
Preop, postop measures
A thorough preoperative workup can
help determine which patients should or
should not undergo surgery. Surgeons
treating any patient with a BMI over 40
kg/m2 should ensure that any comorbidities
can be adequately addressed,
Dr Joshi says. A surgeon who has concerns
may want to enlist the help of an
anesthesiologist to learn whether the
patient has ever had a difficult IV start
or other problems that will inform the
care strategy. The use of ultrasound to
start IVs may help the anesthesiologist
see the vein more clearly.
Desaturation is the most common
postoperative complication in obese
patients. Anesthesia drugs tend to linger
because they get caught in the fatty
tissue. Obese patients are also more
www.ormanager.com
likely to suffer from respiratory effects
following surgery. For these reasons, clinicians
should use fast-track anesthetic
techniques or short-acting anesthesia
drugs and try to reduce opioids by incorporating
non-opioids such as acetaminophen,
nonsteroidal anti-inflammatory
drugs, nerve blocks, or surgical site
infiltration techniques as alternatives.
By using fewer combinations of shortacting
drugs at the lowest doses possible,
patient safety can be maintained.
Avoiding long-acting general anesthetics
or opioids is a good strategy for
all patients, not just obese patients,
Dr Grewal notes. " You want patients
to clear the meds quickly, so if they do
have OSA, there's less likely to be an
obstruction. "
To mitigate the risk of desaturation,
it's important to rule out any possibility
of postoperative respiratory depression
before discharging these patients. " To
meet this requirement, patients should
be able to maintain adequate oxygen
saturations while in an unstimulated
environment, and while breathing room
air, " say Dr Joshi and Dr Grewal.
Drawing the line
Patients with a BMI under 40 kg/m2
should be able to proceed with surgery.
Those with a BMI between 40 and 50
kg/m2 and known OSA who use a CPAP
mask preoperatively should receive
CPAP after discharge. For patients in
this category with presumed OSA, Dr
Joshi recommends limited opioid use.
He draws the line on patients with
a BMI over 50 kg/m2, particularly if
they need general anesthesia. His own
analysis showed that higher readmission
rates were associated with obese
patients over this threshold. " We really
don't know why there's a higher risk "
in patients with BMIs over 50, he says,
adding that these patients may not be
suitable for surgery with general anesthesia
in an ASC.
Clinicians must consider the patient
and the procedure to assess safety, Dr
Grewal says. Some surgeons in ASCs
may want to send patients to a hospital
if their BMI is over 40 kg/m2. However,
" just because someone is obese
it doesn't mean everything is different
about them and they can't undergo surgery.
If comorbidities are well managed,
it's possible for these patients to safely
have surgical procedures, " she says. ✥
Jennifer Lubell is a healthcare writer
based in Rockville, Maryland.
References
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OR Manager | November 2019
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https://anes http://thesiology.theclinics.com/article/ https://www.cdc.gov/ https://www http://ncbi.nlm.nih.gov/pmc/articles/ https://pdfs.semanticscholar.org/ http://www.ormanager.com
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