Anestesia para obesidade mórbida

Michelle Nacur Lorentz; Viviane Ferreira Albergaria; Frederico Augusto Soares de Lima

doi:10.1590/S0034-70942007000200010

Artigo de Revisão

Anestesia para obesidade mórbida

Anesthesia for morbid obesity

Michelle Nacur Lorentz; Viviane Ferreira Albergaria; Frederico Augusto Soares de Lima

http://dx.doi.org/10.1590/S0034-70942007000200010 Braz J Anesthesiol, vol.57, n2, p.199-213, 2007

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JUSTIFICATIVA E OBJETIVOS: A obesidade mórbida é uma doença muito freqüente em nosso meio, enquanto nos EUA já assumiu caráter epidêmico. O paciente obeso apresenta uma série de alterações fisiopatológicas, além de importantes comorbidades, o que exige do anestesiologista pleno conhecimento da fisiopatologia da doença. O procedimento cirúrgico de redução gástrica tem sido cada vez mais realizado e o período perioperatório apresenta características únicas com alterações cardiovascular e pulmonar que o tornam um verdadeiro desafio para os profissionais envolvidos. O hospital também deve estar preparado para receber esses pacientes, com equipamentos adequados, equipe multidisciplinar e cuidados pós-operatórios. O objetivo deste estudo foi demonstrar que o paciente obeso mórbido não é apenas um paciente com excesso de peso, e, portanto, procurou-se nortear as principais condutas a serem observadas. CONTEÚDO: São apresentadas neste artigo as principais alterações fisiopatológicas do obeso mórbido, bem como dados de epidemiologia e doenças correlacionadas. É realizada uma revisão das doses dos medicamentos usados na anestesia, bem como a melhor abordagem pré-, intra- e pós-operatória pelo anestesiologista. CONCLUSÕES: A abordagem do paciente com obesidade mórbida exige um planejamento minucioso que se inicia na seleção dos pacientes, tem continuidade com pré-operatório detalhado e intra-operatório individualizado, e se estende até o pós-operatório, quando a incidência de complicações pulmonar, cardiovascular e infecciosa é maior que na população não-obesa. Para que os resultados sejam favoráveis é extremamente importante o envolvimento de uma equipe multiprofissional que inclui Clínica Geral, Anestesiologia, Cirurgia Geral, Enfermagem, Psicologia, Fisioterapia, Nutrologia e Terapia Intensiva.

Palavras-chave

CIRURGIA, Abdominal, DOENÇAS, Obesidade

Abstract

BACKGROUND AND OBJECTIVES: Morbid obesity is very frequent in our society, having achieved the level of an epidemic in the United States. Obese patients present several physiopathologic changes and important comorbidities, which the anesthesiologist must be aware of. Gastric reduction surgery is increasingly more frequent, and the perioperative period has unique characteristics, with cardiovascular and pulmonary changes that make it a real challenge for the professional involved. The hospital should also be prepared to receive those patients, with adequate equipment, a multidisciplinary team, and postoperative care. The objective of this study was to demonstrate that the patient with morbid obesity is not only a person with weight excess and, therefore, we attempted to describe the main conducts to be followed. CONTENTS: Here we present the main physiopathologic changes in the patient with morbid obesity, as well as the epidemiological data and correlated diseases. We review the doses of the drugs used in anesthesia, and the best pre, intra, and postoperative approach. CONCLUSIONS: The care of the patient with morbid obesity demands careful planning, which begins with patient selection, continues with a detailed preoperative and individualized intraoperative periods, and extends through the postoperative period, when the incidence of pulmonary, cardiovascular, and infectious complications is greater than in the non-obese population. The involvement of a multidisciplinary team, including Internal Medicine, Anesthesiology, General Surgery, Nursing, Psychology, Physical Therapy, Nutrition, and Intensive Care, is extremely important for good results.

Keywords

DISEASES, Obesity, SURGERY, Abdominal

Referências

Appropriate body-mass index for Asian populations and its implications for policy and interventions strategies. Public Heath. Lancet. 2004;363:157-163.

Mokdad AH, Serdula MK, Dietz WH. The continuing epidemic of obesity in the United States. JAMA. 2000;284:1650-1651.

Kuczmarski RJ, Flegal KM, Campbell SM. Increasing prevalence of overweight among US adults. The National Health and Nutrition Examinations Surveys, 1960 to 1991. JAMA. 1994;272:205-211.

Cameron AJ, Welborn TA, Zimmet PZ. Overweight and obesity in Australia The 1999-2000 Australian Diabetes, Obesity and Lifestyle Study. Med J Aust. 2003;178:427-432.

Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics. 1998;101:497-504.

Must A, Jacques PF, Dallal GE. Long-term morbidity and mortality of overweight adolescents: A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992:327:1350-1355.

Deitel M. The International Obesity Task Force and "globesity". Obes Surg. 2002;12:613-614.

Samuels PJ. Anesthesia for adolescent bariatric surgery. Int Anesthesiol Clin. 2006;44:17-31.

Kotchen JM, Kotchen TA, Guthrie GP Jr. Correlates of adolescent blood pressure at five-year follow up. Hypertension. 1980;2:124-129.

Rodriguez MA, Winkleby MA, Ahn D. Identification of population subgroups of children and adolescents with high asthma prevalence: findings from the Third National Health and Examination Survey. Arch Pediatr Adolesc Med. 2002;156:269-275.

Sinha R, Fisch G, Teague B. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med. 2002;346:802-810.

Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813-1819.

Drenick EJ, Bale GS, Seltzer F. Excessive mortality and causes of death in morbidly obese men. JAMA. 1980;243:443-445.

Postlethwait RW, Johnson WD. Complications following surgery for duodenal ulcer in obese patients. Arch Surg. 1972;105:438-440.

Sturm R. The effects of obesity, smoking and drinking on medical problems and costs. Health Aff. 2002;21:245-253.

Auler JOC Jr, Giannini CG, Saragiotto DF. Desafios no manuseio perioperatório de pacientes obesos mórbidos: como prevenir complicações. Rev Bras Anestesiol. 2003.

Buckley BF. Anesthesia and Obesity and Gastrointestinal Disorders. Clinical Anesthesia. 1992:1169-1183.

Brolin RE. Update: NIH consensus conference. Gastrointestinal surgery for severe obesity. Nutrition. 1996;12:403-404.

Pentin PL, Nashelsky J. What are the indications for bariatric surgery?. J Fam Pract. 2005;54:633-634.

Inge TH, Krebs NF, Garcia VF. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114:217-223.

Sugerman HJ, Sugerman EL, DeMaria EJ. Bariatric surgery for severely obese adolescents. J Gastrointest Surg. 2003;7:102-108.

Garcia VF, Langford L, Inge TH. Application of laparoscopy for bariatric surgery in adolescents. Curr Opin Pediatr. 2003;15:248-255.

Presutti RJ, Gorman RS, Swain JM. Primary care perspective on bariatric surgery. Mayo Clin Proc. 2004;79:1158-1166.

Prystowsky JB. Surgical management of obesity. Semin Gastrointest. 2002;13:133-142.

Davis MM, Slish K, Chao C. National trends in bariatric surgery, 1996-2002. Arch Surg. 2006;141:71-75.

Balsiger BM, Murr MM, Poggio JL. Bariatric surgery. Surgery for weight control in patient with morbid obesity. Med Clin North Am. 2000;84:477-489.

Forsell P, Hallerback B, Glise H. Complications following Swedish adjustable gastric banding: a long-term follow-up. Obes Surg. 1999;9:11-16.

Kunath U, Susewind M, Klein S. Success and failure in laparoscopic "gastric banding": A report of 3 years experience. Chirurg. 1998;69:180-185.

Westling A, Bjurling K, Ohrvall M. Silicone-adjustable gastric banding: disappointing results. Obes Surg. 1998;8:467-474.

Provost DA, Jones DB. Minimally invasive surgery for the treatment of severe obesity. Dallas Med J. 1999;87.

Schirmer BD. Laparoscopic bariatric surgery. Surg Clin North Am. 2000;80:1253-1267.

Nguyen NT, Goldman C, Rosenquist CJ. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279-291.

Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y: 500 patients technique and results, with 36 month follow-up. Obes Surg. 2000;10:233-239.

Ezri T, Muzikant G, Medalion B. Anesthesia for restrictive bariatric surgery (gastric bypass not included): laparoscopic vs open procedures. Int J Obes Related Metab Disord. 2004;28:1157-1162.

Juvin P, Marmuse JP, Delerme S. Postoperative course after conventional or laparoscopic gastroplasty in morbidly obese patients. Eur J Anaesthesiol. 1999;16:400-403.

Sjostrom L, Lindroos AK, Peltonen M. Lifestyle, diabetes and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683-2693.

Ballantyne GH. Measuring outcomes following bariatric surgery: weight loss parameters, improvement in co-morbid conditions, change in quality of life and patient satisfaction. Obes Surg. 2003;13:954-964.

Buchwald H, Avidor Y, Braunwald E. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737.

Brodsky JB. Anesthesia for bariatric surgery. ASA. 2005;33:49-63.

Levi D, Goodman ER, Patel M. Critical care of the obese and bariatric surgery patient. Crit Care Clin. 2003;19:11-32.

Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55:615S-619S.

Herbert PN. Doenças Metabólicas Distúrbios Alimentares. Medicina Interna Básica. 1993:370-373.

Cheah MH, Kam CA. Obesity: basic science and medical aspects relevant to anaesthetists. Anaesthesia. 2005;60:1009-1021.

Garsynski T. Anesthetic complications of gross obesity. . 2004;17:271-276.

Must A, Spadano J, Coakley EH. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-1529.

Lilienfeld DE, Vlahov D, Tennay JH. Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery. Am J Infect Control. 1988;16:3-6.

Clain DJ, Lefkowitch JH. Fatty liver disease in morbid obesity. Gastroenterol Clin North Am. 1987;16:239-252.

Ramsey-Stewart G. Hepatic steatosis and morbid obesity. Obes Surg. 1993;3:157-159.

Palmer M, Schaffner F. Effect of weight reduction on hepatic abnormalities in overweight patients. Gastroenterology. 1990;99:1408-1413.

Gholam PM, Kotler DP, Flancbaum LJ. Liver pathology in morbidly obese patients undergoing Roux-en-Y gastric bypass surgery. Obes Surg. 2002;12:49-51.

Cheymol G. Effects of obesity on pharmacokinetics: implications for drug therapy. Clin Pharmacokinet. 2000;39:215-231.

Marik P, Varon J. The obese patient in UCI. Chest. 1998;113:492-498.

Pivalizza EG. Obesity and airway contro. Anaesth Intensive Care. 1994;22:315-316.

Lins AAA, Barbosa MAS, Brodsky JB. Anestesia para gastroplastia no paciente obeso. Rev Bras Anestesiol. 1999;49:282-287.

McNeely W, Goa KL. Sibutramine.: A review of its contribution to the management of obesity. Drugs. 1998;56:1093-1124.

Davidson M, Hauptman J, DiGirolamo M. Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial. JAMA. 1999;281:235-242.

Abir F, Bell R. Assessment and management of the obese patient. Crit Care Med. 2004;32(^s4):S87-S91.

Kral JG. Morbid obesity and related health risks. Ann Intern Med. 1985;103:1043-1047.

Shenkman Z, Shir Y, Brodsky JB. Perioperative management of the obese patient. Br J Anaesth. 1993;70:349-359.

Hillman DR, Platt P, Eastwood PR. The upper airway during anaesthesia. Br J Anaesth. 2003;91:31-39.

Frappier J, Guenoun T, Journois D. Airway management using the intubating laryngeal mask airway for the morbidly obese patient. Anesth Analg. 2003;96:1510-1515.

Ezri T, Medalion B, Weisenberg M. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anaesth. 2003;50:179-183.

Braga AFA, Silva ACM, Cremonessi E. Obesidade mórbida: considerações clínicas e anestésicas. Rev Bras Anestesiol. 1999;49:201-212.

Salem MR, Dalal FY, Zygmunt MP. Does PEEP Improve Intraoperative arterial oxygenation in grossly obese patients?. Anesthesiology. 1998;48:280-281.

Perilli V, Sollazzi L, Bossa P. The effects of the reverse trendelemburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91:1520-1525.

Boyce J, Ness T, Castroman P. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13:4-9.

Brodsky J, Lemmens HJ, Brock-Utne J. Anesthetic considerations for bariatric surgery: proper positioning is important for laryngoscopy. Anesth Analg. 2003;96:1841-1842.

Juvin P, Blarel A, Bruno F. Is peripheral line placement more difficult in obese than in lean patient?. Anesth Analg. 2003;96:1218.

Salihoglu Z, Karaca S, Kose Y. Total intravenous anesthesia versus single breath technique and anesthesia maintenance with sevoflurane for bariatric operations. Obes Surg. 2001;11:496-501.

Strum EM, Szenohradszki J, Kaufman WA. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: a prospective, randomized study. Anesth Analg. 2004;99:1848-1853.

Sollazzi L, Perilli V, Modesti C. Volatile anesthesia in bariatric surgery. Obes Surg. 2001;11:623-626.

Higuchi H, Satoh , Arimura S. Serum inorganic fluoride levels in mildly obese patients during and after sevoflurane anesthesia. Anesth Analg. 1993;77:1018-1021.

De Baerdemaeker LE, Struys MM, Jacobs S. Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an "inhalation bolus" technique. Br J Anaesth. 2003;91:638-650.

Brodsky JB, Lemmens HJ, Collins JS. Nitrous oxide and laparoscopic bariatric surgery. Obes Surg. 2005;15:494-496.

Harrison GG. Height-weight tables. Ann Intern Med. 1985;103:989-994.

Leykin Y, Pellis T, Lucca M. The effects of cisatracurium on morbidly obese women. Anesth Analg. 2004;99:1090-1094.

Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg. 2006;102:438-442.

Schumann R, Shikora S, Weiss JM. A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery. Anesth Analg. 2003;96:469-474.

Shenkman Z, Shir Y, Brodsky JB. Perioperative management of the obese patient. Br J Anaesth. 1993;70:349-359.

Ogunnaike BO, Jones SB, Jones DB. Anesthetic considerations for bariatric surgery. Anesth Analg. 2002;95:1793-1805.

Bardoczky GI, Yernault JC, Houben JJ. Large tidal volume ventilation does not improve oxygenation in morbidly obese patients during anaesthesia. Anesth Analg. 1995;81:385-388.

Benseñor FEM, Auler JOC Jr. P ET CO2 e SpO2 permitem ajuste ventilatório adequado em pacientes obesos mórbidos. Rev Bras Anestesiol. 2004;54:542-552.

Kufel TJ, Grant BJB. Arterial Blood Gas Monitoring: Respiratory Assessment. Principles and Practice of Intensive Care Medicine. 1998:197-215.

Pelosi P, Ravagnan I, Giurati G. Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. Anesthesiology. 1999;91:1221-1231.

Whalen FX, Gajic O, Thompson GB. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg. 2006;102:298-305.

Kabon B, Kurz A. Optimal perioperative oxygen administration. Curr Opin Anesthesiol. 2006;19:11-18.

Coussa M, Proietti S, Schnyder P. Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients. Anesth Analg. 2004;98:1491-1495.

Tusman G, Bohm SH, Vazquez de Anda GF. Alveolar recruitment strategy" improves arterial oxygenation during general anaesthesia. Br J Anaesth. 1999;82:8-13.

Sprung J, Whalley DG, Falcone T. The impact of morbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy. Anesth Analg. 2002;94:1345-1350.

Passannante AN, Rock P. Anesthetic management of patients with obesity and sleep apnea. Anaesthesiol Clin North America. 2005;23:479-491.

Sprung J, Whalley D, Falcone T. The effects of tidal volume and respiratory rate on oxygenation and respiratory mechanisms during laparoscopy in morbidly obese patients. Anesth Analg. 2003;97:268-274.

Dindo D, Muller M, Weber M. Obesity in general elective surgery. Lancet. 2003;361:2032-2035.

Ezri T, Hazin V, Warters D. The endotracheal tube moves more often in obese patients undergoing laparoscopy compared with open abdominal surgery. Anesth Analg. 2003;96:278-282.

Blouw EL, Rudolph AD, Narr BJ. The frequency of respiratory failure in patients with morbid obesity undergoing gastric bypass. AANA J. 2003;71:45-50.

Oberg B, Poulsen TD. Obesity: an anaesthetic challenge. Acta Anaesthesiol Scand. 1999;40:191-200.

Sugerman HJ. Pulmonary function in morbid obesity. Gastroenterol Clin North Am. 1987;16:225-237.

Huerta S, DeShields S, Shpiner R. Safety and efficacy of postoperative continuous positive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass. J Gastrointest Surg. 2002;6:354-358.

Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis. 1984;130:12-15.

Fox GS, Whalley DG, Bevan DR. Anaesthesia for the morbidly obese patient. Experience with 110 patients. Br J Anaesth. 1981;53:811-816.

Rawal N, Sjostrand U, Christoffersson E. Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function. Anesth Analg. 1984;63:583-592.

Carli F, Trudel JL, Belliveau P. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomizes trial. Dis Colon Rectum. 2001;44:1083-1089.

Juvin P, Marmuse JP, Delerme JP. Postoperative course after conventional or laparoscopic gastroplasty in morbidly obese patients. Eur J Anaesthesiol. 1999;16:400-403.

Helling TS, Willoughby TL, Maxfield DM. Determinants of the need for intensive care and prolonged mechanical ventilation in patients undergoing bariatric surgery. Obes Surg. 2004;14:1036-1041.

Sacks BC, Mattar SG. What plastic surgeons should know about bariatric surgery. Seminars in Plastic Surg. Post Bariatric Body Contouring. 2006;20:9-14.

Jacobs JMS, Schechners S, Jacobs J. Abdominoplasty following massive weightloss. Seminars in plastic surgery. Post Bariatric Body Contouring. 2006;20:15-23.

Anestesia para obesidade mórbida

Anesthesia for morbid obesity

Michelle Nacur Lorentz; Viviane Ferreira Albergaria; Frederico Augusto Soares de Lima

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