Page 12 - 麻醉与监护论坛2015年第12期

Laboratory and Clinical Investigation
the bag to ventilate. About three to four minutes when the
Narcotrend index decreased to 60 and SpO2 maintained 98%;
orotracheal intubation with an endotracheal tube (internal
diameter, 7.5mm) was performed. It is too hard to use the
visible laryngoscope to insert his small mouth. With the help
of another anesthesiologist and appropriate adjustment, we
enter into his mouth. But the large tongue body obstructed
our scope, glottis exposure failed at first. During the second
attempt, we could see the glottis in the screen and then
intubated successfully. After intubation, propofol and
remifentanil was administrated respectively 2μg/ml and
0.2μg/(kg.min). And 4%sevoflurane was added to reach the
required anesthesia depth that narctrend maintained between
50 and 40. The infusion rate of cisatracurium was 0.2μg/(kg.
min) to provide sufficient muscle relaxation. Ventilation was
performed to keep end-tidal carbon dioxide partial pressure
between 35 and 45 mmHg. Tidal volume was administrated
at 650ml, respiratory rate at 13 breaths/min and positive end- Cormack and Lehane classification was Ⅲ. Neither obesity
expiratory pressure at 5 cmH2O. Circulation and respiratory
function monitored stably during the operation.
The patient was sent to Post-anesthesia Care Unit (PACU)
after the surgery completed successfully. The anesthesia
recovery period was longer than other normal patients,
which could due to much fat influence pharmacokinetics
of the anesthetics. We used atropine 1mg, neostigmine 2mg
and aminophylline 125mg to antagonize the residual muscle
relaxant. After extubation, SpO2 maintained 98%, respiratory
rate 18 breathes/min, pulses 80 bpm and blood pressure
135/85 mmHg, he was conscious and sent back to sickroom.
Interview followed the surgery after 24 hours, no nausea and
vomiting, no urine retention and no headache were found.
Verbal Rating Scale tested 1 point with mild pain.
Discussion
Anesthesia for such obese patients has many problems,
especially in airway management, intubation choice,
dose of anesthetics and postoperative analgesia. The
pathophysiologic changes in obese patients would decrease
lung volume and capacity along with BMI increasing,
while increase the oxygen consumption, carbon dioxide
production and work of breathing. Preoperative evaluation
must make the global assessment, and also should be toward
the coexisting diseases. Sufficient preoperative evaluation
lays a solid foundation of the surgery success. Some
experts recommend that anesthesia induction of morbidly
obese patients in a 30° head-up position could improve
laryngoscopic view, increase well-tolerated apneic time
by relieving pressure on the diaphragm from abdominal
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contents, and improves oxygenation[13].
Because of the patient’s super obesity, small mouth,
and Mallampati classification III, difficult intubation was
suspected[14].
Therefore, we prepared all the devices for difficult
intubation in our operating room. We first tried intubation
with shikani optical stylet but glottis exposure failed
because of his small mouth and large tongue body. Then,
intubation was successful after appropriate adjustment while
nor BMI predicted difficult intubation, whereas the high
Mallampati classification increased the potential for difficult
laryngoscopy and intubation[15]. This patient recovery from
the anesthesia about 20 minutes, which longer than 10 to 12
minutes of normal patients. Considering this patient has no
coexisting disease and sufficient preparation, we successfully
treated a 126kg female patient for inguinal herniorrhaphy by
general anesthesia with propofol and remifentanil, pressure-
controlled ventilation.
REFERENCES
[1] Conway, B. and A. Rene, Obesity as a disease: no lightweight
matter. Obesity Reviews, 2004. 5(3): p. 145-151.
[2] Katzmarzyk, P., I. Janssen, and C. Ardern, Physical inactivity, excess
adiposity and premature mortality. Obesity Reviews, 2003. 4(4): p. 257-290.
[3] Adams, J. and P. Murphy, Obesity in anaesthesia and intensive care.
British journal of anaesthesia, 2000. 85(1): p. 91-108.
[4] Després, J.-P., I. Lemieux, and D. Prud'homme, Treatment
of obesity: need to focus on high risk abdominally obese patients.
BMJ: British Medical Journal, 2001. 322(7288): p. 716.
[5] Kopelman, P., Health risks associated with overweight and obesity.
Obesity Reviews, 2007. 8: p. 13-17.
[6] Scopinaro, N., et al., Long-term control of type 2 diabetes
mellitus and the other major components of the metabolic syndrome
after biliopancreatic diversion in patients with BMI<35kg/m2.
Obesity surgery, 2007. 17(2): p. 185-192.
[7] Valera-Mora, M.E., et al., Predictors of weight loss and reversal of
comorbidities in malabsorptive bariatric surgery. The American
journal of clinical nutrition, 2005. 81(6): p. 1292-1297.
[8] Voyagis, G., et al., Value of oropharyngeal Mallampati classification
in predicting difficult laryngoscopy among obese patients. European
journal of anaesthesiology, 1998. 15(3): p. 330-334.
[9] Benumof, J.L., Obstructive sleep apnea in the adult obese patient:
implications for airway management. Journal of clinical anesthesia,
2001. 13(2): p. 144-156.
[10] Wilson, M., et al., Predicting difficult intubation. British journal of
anaesthesia, 1988. 61(2): p. 211-216.
[11] Blouin, R., J. Kolpek, and H. Mann, Influence of obesity on drug
disposition. Clinical pharmacy, 1987. 6(9): p. 706.
[12] Backman, L., et al., Cardiovascular function in extreme obesity.
Acta Medica Scandinavica, 1973. 193(1-6): p. 437-446.
[13] Sinha, A.C., Some anesthetic aspects of morbid obesity. Current
Opinion in Anesthesiology, 2009. 22(3): p. 442-446.
[14] El-Ganzouri, A.R., et al., Preoperative airway assessment:
predictive value of a multivariate risk index. Anesthesia & Analgesia,
1996. 82(6): p. 1197-1204.
[15] Brodsky, J.B., et al., Morbid obesity and tracheal intubation.
Anesthesia & Analgesia, 2002. 94(3): p. 732-736.
FAM 2013 Mar/Apr Vol.20 Issue 2