Regional anesthesia and obesity

Spinal anesthesia in ambulatory patients

PURPOSE OF REVIEW

To assess current practice in the use of spinal anesthesia in major ambulatory surgery, highlighting its advantages over general anesthesia and identifying potential areas for improvement to facilitate a transition to a sustainable healthcare system.

RECENT FINDINGS

Spinal anesthesia might be preferred in selected populations when compared to general anesthesia providing the highest standards of healthcare quality.The use of local anesthetics with short half-life has proven to be efficient in achieving high anesthesia success rates. Spinal anesthesia does not increase perioperative complications; instead, it has shown a reduction in postoperative nausea and vomiting, an improvement in patient comfort, and a favorable economic impact when compared to general anesthesia.

SUMMARY

Spinal anesthesia is an appropriate method for anesthesia in ambulatory patients, offering advantages over general anesthesia in selected populations.The use of spinal anesthesia is expanding to meet surgical needs. Therefore, it is crucial to plan ahead and anticipate organizational failures in the ambulatory setting to maintain safety and efficiency during outpatient procedures and surgeries.

Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study

BACKGROUND

Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients.

METHODS

Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated.

RESULTS

Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05).

CONCLUSIONS

US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

TRIAL REGISTRATION

NCT04596787.

Effective Dose Range of Intrathecal Isobaric Bupivacaine to Achieve T5–T10 Sensory Block Heights for Elderly and Overweight Patients: An Observational Study

Background and Objectives: The dose selection for isobaric bupivacaine determines the success of spinal anesthesia (SA). A dose higher than the optimal dose causes high SA, whereas an underdose leads to inadequate spread of cephalad. As it involves anatomical and physiological alterations, the dosing should be reduced with advancing age and body mass index values. Therefore, this study aimed to demonstrate the association between the isobaric bupivacaine dose and block height, and to determine the dose intervals of bupivacaine to achieve the T5–T10 sensory block with a low probability of high SA in elderly and overweight patients. Material and Methods: This retrospective observational study recruited 1079 adult patients who underwent SA with 0.5% isobaric bupivacaine from 2018 to 2021. The patients were divided into four categories: category 1 (age < 60, BMI < 25), category 2 (age < 60, BMI ≥ 25), category 3 (age ≥ 60, BMI < 25), and category 4 (age ≥ 60, BMI ≥ 25). The bupivacaine dose and sensory block height (classified into three levels: high (T1–T4), favorable (T5–T10), and low (T11–L2)) were recorded. Results: The sensory block level increased significantly with increasing doses of bupivacaine for patients in categories 1 and 2. The suggested dose ranges for the favorable block heights were 15–17 and 10.5–16 mg in patient categories 1–2 and 3–4, respectively. In these dose ranges, the probability range of high SA was 10–15%. Conclusions: The sensory block height following SA was associated with the bupivacaine dose in patients aged <60 years. Regardless of the BMI, the suggested dose ranges of 0.5% isobaric bupivacaine are 15–17 mg (3.0–3.4 mL) and 10.5–16 mg (2.1–3.2 mL) for patients aged <60 and ≥60 years, respectively.

Changing a clinical pathway to increase spinal anesthesia use for elective hip arthroplasty: a single-centre historical cohort study

PURPOSE

International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to promote spinal anesthesia within a clinical pathway would result in increased use of this technique.

METHODS

We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019-one year before vs one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia.

RESULTS

The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, -7 to 23; P = 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (vs III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%.

CONCLUSION

Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.

ASSESSMENT OF THE EFFICIENCY OF ANALGETIC ACTION OF ULTRASOUND-GUIDED FICB AS A COMPONENT OF PERIOPERATIVE MULTIMODAL ANALGESIA IN ERAS- STRUCTURE IN OBESE PATIENTS UNDERGOING TOTAL HIP REPLACEMENT

OBJECTIVE

The aim: To compare the efficiency of analgetic action of Ultrasound-guided FICB and prolonged EA as the components of perioperative multimodal analgesia in ERAS-structure in obese patients undergoing THR.

PATIENTS AND METHODS

Materials and methods: The retrospective study included 80 patients with obesity, who underwent elective anterolateral THR under conditions of low-flow inhalation anesthesia with sevoflurane in combination with PEA (n1=38) or with FICB (n2=42). Primary endpoints: VAS pain level during the first postoperative day.

RESULTS

Results: Static and dynamic VAS pain scores were similar in both groups during the first 6 hours. Since the 8th postoperative hour, there was a statistically significant increase in both static and dynamic VAS pain scores in the FICB group. A significant difference in static and dynamic VAS pain scores was obtained with a trend toward an increase in the PEA group within 48 hours (p < 0.05).

CONCLUSION

Conclusions: USG- FICB is an effective, practically feasible, minimally invasive and safe regional method for eleclive anterior-lateral THR and can be an alternative to PEA in obese patients.

The effects of body mass index on postoperative pain in patients undergoing thoracic paravertebral block after video-assisted thoracoscopic surgery: A retrospective analysis

Aim: Postoperative pain is an important problem in patients undergoing video-assisted thoracic surgery (VATS). Thoracic paravertebral block (TPVB) is among the commonly used techniques for pain control after VATS. Despite the analgesic methods applied, the desired level of pain control can not be achieved in all patients. Therefore, clinicians and researchers are interested in factors affecting postoperative pain. One factor is the relationship between postoperative pain and body mass index (BMI). Although it has been reported that acute or chronic pain is more common in the general population with a BMI, the relationship between postoperative pain and BMI is still controversial. This study aims to investigate the effects of BMI on postoperative pain in patients who underwent TPVB in the treatment of pain after VATS. Material and Method: Patients who had elective VATS and TPVB were included in the study. Patients who underwent TPVB with ultrasonography (USG) and postoperative intravenous (iv) morphine patient-control-analgesia (PCA) for postoperative analgesia were divided into three groups according to BMI. Group-I BMI: 18-24.99 kg/m2, Group-II BMI: 25-29.9 kg/m2, Group-III BMI: 30-40 kg/m2. Results: 146 patients were included in the study. There was no significant difference between the postoperative 30th minute, 1st hour, 6th hour, 12th hour, and 24th-hour VAS values of the patients in Group-I, Group-II, and Group-III. There was no statistically significant difference in terms of morphine consumption, additional analgesic requirement, and complications in all three groups. Conclusion: It was determined that there was no relationship between BMI and postoperative pain scores in the first 24 hours in patients who underwent TPVB after VATS. In addition, it was determined that postoperative morphine consumption and additional analgesic needs were not associated with BMI. Effective pain control can be achieved in all patients, regardless of BMI, with effective peripheral nerve blocks and analgesics using practical imaging techniques such as USG.

Is there a relationship between body mass index and postoperative pain scores in thoracotomy patients with thoracic epidural analgesia?

Postoperative efficacy of thoracic epidural analgesia (TEA) following thoracic surgery may vary in patients with different body mass index (BMI) values, regardless of the success of the method. This study aimed to investigate the effects of BMI on postoperative pain scores in patients who underwent thoracotomy with TEA.After obtaining the ethical committee approval (Date: May 11, 2021, Number: 2012-KEAK-15/2305) the data of 1326 patients, who underwent elective thoracic surgery in high volume tertiary thoracic surgery center between January 2017 and January 2021, were analyzed retrospectively. Patients between the age of 18 and 80 years, who underwent thoracotomy and thoracic epidural catheterization (TEC), and who were assigned American Society of Anesthesiologists I to III physical status were included to the study. Of the 406 patients, who underwent a successful TEC, 378 received postoperative analgesia for 72 hours. Visual analog scale (VAS) scores of these patients were evaluated statistically. Based on BMI, patients were categorized into the following 5 groups: Group I: BMI < 20 kg/m2, Group II: BMI = 20 to 24.9 kg/m2, Group III: BMI = 25 to 29.9 kg/m2, Group IV: BMI = 30 to 34.9 kg/m2, and Group V: BMI ≥ 35 kg/m2.There were no statistically significant differences in TEC success across different BMI groups (P > .05). Catheter problems and VAS scores significantly increased with higher BMI values in the postoperative 72-hours period (P < .05). Rates of rescue analgesic use were higher in BMI groups of 30 toto 34.9 kg/m2 and ≥35 kg/m2 compared to the other BMI groups.This study revealed that higher BMI in patients may increase VAS scores, who administered TEA for pain management following thoracotomy. This correlation was supported by the increased need for additional analgesics in patients with high BMI. Therefore, patients with high BMI values would require close monitoring and follow-up.

The effects of shoulder arthroscopy on ultrasound image quality of the interscalene brachial plexus: a pre-procedure vs post-procedure comparative study

BACKGROUND

Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative).

METHODS

This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes.

RESULTS

Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period (p < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p < .05) and confidence in block performance (3.8 vs 4.4; p < .05).

CONCLUSION

Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03657173 ; September 4, 2018).

Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery

BACKGROUND

The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair.

MATERIALS AND METHODS

The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions.

RESULTS

A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used.

CONCLUSIONS

Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.

Obesity and Obstructive Sleep Apnea in the Ambulatory Patient

Obesity and obstructive sleep apnea (OSA) are often associated with increased perioperative risks and challenges for the anesthesiologist. This article addresses the current controversies surrounding perioperative care of morbidly obese patients with or without OSA scheduled for ambulatory surgery, particularly in a free-standing ambulatory center. Topics discussed include preoperative selection of obese and OSA patients for ambulatory surgeries, intraoperative methods to reduce perioperative risk, and appropriate postoperative care.

Peri-operative management of overweight and obese children and adolescents

Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.

The Impact of Obesity on Orthopedic Upper Extremity Surgery

Obese patients have increased rates of upper extremity injury, carpal tunnel syndrome, and upper extremity osteoarthritis. Preoperative considerations include cardiovascular disease, pulmonary disease, and diabetes mellitus. Intraoperative and anesthetic considerations include specialized equipment, patient positioning, and the physiology of obese patients. Postoperative considerations should include increased risk of cardiovascular complications as well as surgical site infections and malunion. Surgery of the hand and upper extremity may be less prone to the postoperative complications seen in other regions of the body. There are currently no direct contraindications for obese patients to undergo orthopedic procedures if the appropriate considerations have been made.

Perioperative Care of the Obese Cardiac Surgical Patient

Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient.

Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis

BACKGROUND

Intraoperative anesthetic typically consists of either general anesthesia (GA) or isolated regional anesthesia (RA).

METHODS

A retrospective propensity-matched cohort analysis on patients undergoing TSA was performed to determine differences between GA and RA in regard to patient population, complications, LOS and hospital readmission.

RESULTS

4158 patients underwent TSA with GA or isolated RA. Propensity-matching resulted in 912 patients in each cohort. RA had lower overall in-hospital complications and greater homebound discharge disposition with lower 90-day readmission rates than GA.

CONCLUSION

After TSA, isolated RA was associated with lower in-hospital complications, readmission rates and odds of hospital readmission than GA.

Echo-Guided Differential Popliteal Block in an Obese Patient With Intractable Painful Leg Ulcer for Early Discharge in Day Surgery

Pain management is extremely important in day surgery, and it is one of the limiting factors for this type of procedures. Locoregional anesthesia is strongly recommended for day surgery; nevertheless, it could be very difficult to localize nerve position especially in obese patients. Furthermore, a complete nerve blockade could result in a delayed discharge. We present a case of analgesic ultrasound-guided block of tibial and common peroneal nerves in the popliteal fossa without any motor function involvement in an obese patient undergoing debridement of an infected lower limb ulcer; all previous attempts of surgical debridement in day surgery with topical anesthetics had failed because of discomfort due to pain. Our aim was to ensure an optimal degree of analgesia and, at the same time, to save motor function in order to make early discharge possible. We used 15 mL ropivacaine 0.375% to obtain a differential block, taking advantage of sensitive fibers selectivity of ropivacaine. Surgical debridement was performed successfully. Our peripheral blockade was able to provide significantly prolonged analgesia without motor block that guaranteed a safe and early discharge according to the Post Anesthetic Discharge Scoring System. The satisfaction expressed by the patient and her comfort during the procedure support the choice of this approach for intractable painful ulcers of lower limb.

Teaching practices of thoracic epidural catheterizations in different grade of anesthesia residents

BACKGROUND AND OBJECTIVES

In this study, we aimed to clarify the importance of residency grade and other factors which influence the success of thoracic epidural catheterization in thoracotomy patients.

METHODS

After the ethical committee approval, data were recorded retrospectively from the charts of 415 patients. All patients had given written informed consent. The thoracic epidural catheterization attempts were divided into two groups as second-third year (Group I) and fourth year (Group II) according to residency grade. We retrospectively collected demographic data, characteristics of thoracic epidural catheterization attempts, and all difficulties and complications during thoracic epidural catheterization.

RESULTS

Overall success rate of thoracic epidural catheterization was similar between the groups. Levels of catheter placement, number and duration of thoracic epidural catheterization attempts were not different between the groups (p>0.05). Change of needle insertion level was statistically higher in Group II (p=0.008), whereas paresthesia was significantly higher in Group I (p=0.007). Dural puncture and postdural puncture headache rates were higher in Group I. Higher body mass index and level of the insertion site were significant factors for thoracic epidural catheterization failure and postoperative complication rate and those were independence from residents' experience (p<0.001, 0.005).

CONCLUSION

Body mass index and level of insertion site were significant on thoracic epidural catheterization failure and postoperative complication rate. We think that residents' grade is not a significant factor in terms overall success rate of thoracic epidural catheterization, but it is important for outcome of these procedures.

Finger width as a measure of femoral block puncture site: an ultrasonographic anatomical-anthropometric study

STUDY OBJECTIVE

Femoral nerve blockade is a regional anesthetic procedure that may be used in prehospital and emergency settings in cases of femoral trauma. Its speed and performance depend on how well the puncture site can be accurately located, something that usually is achieved via visible landmarks and/or by combining various universal preestablished measurements. Most of these methods have been derived from cadaver studies, which often suffer limitations in clinical settings. To facilitate a quick and easy determination of the puncture site, we here attempt to find an in vivo anthropometric measure that closely corresponds to the distance between the femoral artery and femoral nerve.

DESIGN

This is a prospective observational study.

PATIENTS

The study includes 67 patients presenting for elective surgery.

MEASUREMENTS

The distance from the femoral nerve to the femoral artery, projected to the skin, was measured by a 13-MHz ultrasonographic linear probe. Anthropometric measurements of the width of the hand fingers were carried out at the distal interphalangeal joints.

RESULTS

The distance from the femoral artery to the femoral nerve projected to the skin was found to closely correspond to the width of the fifth finger of the dominant hand measured at the distal interphalangeal joint.

CONCLUSION

Because it relies on individual anthropometric information, this finding offers an individualized approach to determining the puncture site in a given patient. We believe that such an approach can improve and simplify femoral nerve blockade procedures in prehospital and emergency settings.

Obesity in regional anesthesia--a risk factor for peripheral catheter-related infections

BACKGROUND

Obesity is believed to increase the risk of surgical site infections and possibly increase the risk of catheter-related infections in regional anesthesia. We, therefore, analyzed the influence of obesity on catheter-related infections defined within a national registry for regional anesthesia.

METHODS

The German Network for Regional Anesthesia database with 25 participating clinical centers was analyzed between 2007 and 2012. Exactly, 28,249 cases (13,239 peripheral nerve and 15,010 neuraxial blocks) of patients ≥ 14 years were grouped in I: underweight (BMI 13.2-18.49 kg/m(2) , n = 597), II: normal weight (BMI 18.5-24.9 kg/m(2) , n = 9272), III: overweight (BMI 25.0-29.9 kg/m(2) , n = 10,632), and IV: obese (BMI 30.0-70.3 kg/m(2) , n = 7,744). The analysis focused on peripheral and neuraxial catheter-related infections. Differences between the groups were tested with non-parametric ANOVA and chi-square (P < 0.05). Binary logistic regression was used to compare obese, overweight, or underweight patients with normal weight patients. Odds ratios (OR and 95% confidence interval) were calculated and adjusted for potential confounders.

RESULTS

Confounders with significant influence on the risk for catheter-related infections were gender, age, ASA score, diabetes, preoperative infection, multiple skin puncture, and prolonged catheter use. The incidence (normal weight: 2.1%, obese: 3.6%; P < 0.001) and the risk of peripheral catheter-related infection was increased in obese compared to normal weight patients [adjusted OR: 1.69 (1.25-2.28); P < 0.001]. In neuraxial sites, the incidence of catheter-related infections differed significantly between normal weight and obese patients (normal weight: 3.2%, obese: 2.3%; P = 0.01), whereas the risk was comparable [adjusted OR: 0.95 (0.71-1.28); P = 0.92].

CONCLUSION

This retrospective cohort study suggests that obesity is an independent risk factor for peripheral, but not neuraxial, catheter-related infections.

Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia

Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

Severe and morbid obesity (BMI ≥ 35 kg/m(2)) does not increase surgical time and length of hospital stay in total knee arthroplasty surgery

PURPOSE

Certain aspects of total knee arthroplasty (TKA) in severely and morbidly obese (SMO) patients (BMI ≥ 35 kg/m(2)) remain controversial. This study aimed to assess the duration of TKA surgery and hospital stay in relation to patients' BMI.

METHODS

Three operative times during TKA surgery were recorded: tourniquet time, to determine surgical difficulty, total surgical time, to assess the difficulty of achieving anaesthesia, and time in the surgical area, to assess patient management in the surgical area. Length of hospital stay was also calculated. Data were collected prospectively from consecutive patients and were recorded in a database for retrospective analysis.

RESULTS

Data were obtained from 922 consecutive patients undergoing TKA. The non-obese group comprised 418 patients (45.3%), obese group Class I 331 (36%), and the SMO group (Class II-III) 173 (18.7%). Mean tourniquet time was 53 min, mean total surgical time was 84 min, and mean time in the surgical area was 132 min. There were no differences according to BMI group. Median length hospital stay (LHS) was 6 days in all patients regardless of BMI. Factors that significantly prolonged LHS were ASA III-IV and pre-operative haemoglobin between 12 and 13 g/dl.

CONCLUSION

Severely and morbidly obese (SMO) patients (BMI ≥ 35 kg/m(2)) undergoing TKA surgery do not require longer operative time or hospital stay than non-obese or obese Class I patients. The fact that surgical time was not significantly different could be due to greater specialisation in the treatment of these patients, which may favour a lower incidence of post-operative complications.

LEVEL OF EVIDENCE

Retrospective comparative study, Level IV.

Obesity, orthopaedics, and outcomes

Obesity, one of the most common health conditions, affects an ever-increasing percentage of orthopaedic patients. Obesity is also associated with other medical conditions, including diabetes, cardiovascular disease, pulmonary disease, metabolic syndrome, and obstructive sleep apnea. These comorbidities require specific preoperative and postoperative measures to improve outcomes in this patient population. Patients who are obese are at risk for increased perioperative complications; however, orthopaedic procedures may still offer notable pain relief and improved quality of life.

Epidural anesthesia with ropivacaine with or without clonidine and postoperative pain in hemorrhoidectomies

PURPOSE

To determine the safety, pain intensity correlated with age and body mass index (BMI), epidural anesthesia with ropivacaine and clonidine in hemorrhoidectomy.

METHODS

Eighty patients, both genders, 20-70 years old, ASA I or II, for hemorrhoidectomy were randomly divided into two groups: Control (n=38), epidural anesthesia with 14 mL of ropivacaine 0.75 % plus 0.0266 mL/kg of 0.9% saline solution; Experimental (n=42) epidural anesthesia with 14 mL of 0.75% ropivacaine plus 4.0 mcg/kg of clonidine. In preoperative and postoperative period were evaluated: systolic blood pressure (SBP), diastolic blood pressure (DBP ), heart rate (HR ), pulse oximetry (SpO2), electrocardiography (ECG), pain intensity (VAS ) in four, eight and, 12 hours and analgesic consumption.

RESULTS

The VAS values differed between four, eight and 12 hours in the Experimental Group, where correlation of VAS 12h with age (p<0.05) occurred and not with BMI and more patients (p<0.05) did not receive analgesics. SBP, DBP, HR changed similarly in both groups at 15, 30 and 45 min. The ECG and SpO2 remained unchanged.

CONCLUSIONS

Clonidine (4mcg/kg) in epidural anesthesia with ropivacaine 0.75% in hemorrhoidectomy showed safety and greater analgesia within four hours. The pain at 12 hours showed correlation with age and not with body mass index.

Ultrasound-guided multiple peripheral nerve blocks in a superobese patient

The number of obese patients has increased dramatically worldwide. Morbid obesity is associated with an increased incidence of medical comorbidities and restricts the application choices in anesthesiology. We report a successfully performed combined ultrasound-guided blockade of the femoral, tibial, and common peroneal nerve in a superobese patient. We present a case report of a 31-year-old, ASA-PS II, super obese man (190 kg, 180 cm, BMI: 58 kg/m²) admitted to the emergency department with a type II segmental tibia shaft fracture and ankle dislocation after a vehicle accident. After two failed spinal anesthesia attempts, we decided to apply a femoral block combined with a sciatic block. Femoral blocks were successfully performed with US guided in-plane technique. Separate blocks of the tibial and common peroneal nerves were planned after the sciatic nerve could not be located due to the thick subcutaneous tissue. We performed a tibial nerve block at 2 cm above the popliteal crease and common peroneal nerve at the level of the fibular head with US guided in-plane technique. The blocks were successful and no block-related complications were noted. Ultrasound guidance allows new approaches for multiple peripheral nerve blocks with low local anesthetic doses in obese patients.

Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal and epidural anaesthesia

BACKGROUND

Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one.

OBJECTIVES

WE PERFORMED A STUDY TO COMPARE TWO POPULAR CSE TECHNIQUES: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT).

METHODS

After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared.

RESULTS

SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups.

CONCLUSION

SDT is an acceptable alternative to DST and SST.

Anesthetic challenges in the obese patient

Obesity seems to be the modern concern to society. An increasing number of obese patients present annually to surgical wards to undergo surgical procedures. As morbid obesity affects most of the vital organs, the anesthesiologist must be prepared to deal with several challenges. These include the preoperative evaluation of the consequences of obesity, particularly on cardiac, respiratory, and metabolic systems; airway management; different pharmacokinetic and pharmacodynamic drug regimen; and perioperative management (i.e., hemodynamic, respiratory, and hyperglycemic). This paper reviews and assesses the most important anesthetic issues in managing obese patients.

Impact of obesity on orthopaedics

The prevalence of obesity among children and adults is increasing worldwide. There are substantial health risks and financial costs associated with the obesity epidemic that impact the practice of orthopaedic surgery. Patients with increased body mass index are more prone to sustaining distal extremity injuries than are those with a normal body mass index. Obese individuals are more likely than nonobese individuals to seek treatment for osteoarthritis of the knee.

Perioperative management of morbid obesity

Data from the NHS Information Centre reveals that more than one in three adults (36.9%) is overweight. In addition, almost a quarter of adults (24% of men and 25% of women aged 16 or over) are obese, with their need for treatment placing a growing burden on the NHS (The NHS Information Centre 2010). Given these proportions, and that an increasing number of morbidly obese patients are undergoing weight loss surgery and procedures related to obesity, it is an opportune time to review the perioperative care of morbidly obese patients.

Anaesthetic considerations for the obese child

The prevalence of obesity in the paediatric population is increasing worldwide. As a result, more and more children will present for anaesthetic care for surgery and other procedures. This review aims to provide some recent information regarding the anaesthetic management of the obese child. Unfortunately, there is little evidence on which to base our clinical care of these children and what information is available is often extrapolated from adult practice. Further prospective studies are required, with careful attention to definitions and terminology, so that populations can be compared and appropriate conclusions drawn.

Impact of obesity on gynecology

Rising obesity rates around the world have had a profound impact on female reproductive health. Childhood obesity is associated with early onset of puberty, menstrual irregularities during adolescence and polycystic ovary syndrome. Women of reproductive age with high BMIs have a higher risk of ovulatory problems and tend to respond poorly to fertility treatment. Strategies for fertility control can also be complex since the efficacy and safety of hormonal contraceptives can be compromised by increased body weight. Obesity can aggravate symptoms of pelvic organ prolapse, stress urinary incontinence and increase the risk of endometrial polyps and symptomatic fibroids. Weight reduction enhances reproductive outcomes, diminishes symptoms of urinary incontinence and reduces morbidity following gynecological surgery. Sustained and substantial weight loss is difficult to achieve with the lifestyle and dietary measures that are currently available. A number of pharmacological treatment options are available, and there are emerging data on reproductive outcomes following surgical treatment for obesity.