|Year : 2019 | Volume
| Issue : 1 | Page : 101-103
A differently abled child with morbid obesity – An anesthetic challenge
Saurabh Sud1, Deepak Dwivedi1, Jagdeep S Bhatia1, Alok R Gautam2
1 Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||04-Dec-2018|
|Date of Acceptance||24-Feb-2019|
|Date of Web Publication||19-Jun-2019|
Lt Col Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Increased prevalence of obesity poses a challenge due to the altered physiologic and pharmacokinetic state which renders the patient under general anesthesia susceptible to delayed recovery, increased incidence of hypoxemia, and delayed healing. Smooth conduct of anaesthesia in a differently abled child with morbid obesity demands meticulous preoperative preparation to ward off separation anxiety from the parents as well as the anxiousness related to the unfamiliar environment.
Keywords: Anxiety, apnea, emotional intelligence, hypoxemia, morbid obesity, obstructive sleep, separation
|How to cite this article:|
Sud S, Dwivedi D, Bhatia JS, Gautam AR. A differently abled child with morbid obesity – An anesthetic challenge. J Mar Med Soc 2019;21:101-3
| Introduction|| |
Obesity is a part of group of noncommunicable diseases called “New World Syndrome.” The World Health Organization defines obesity as body mass index (BMI) (weight in kg/height in meter square) >30 kg/m2. Morbidly obese patients are a challenge for every anesthesiologist as they have limited cardiopulmonary reserves, have multiple comorbidities (diabetes mellitus, hypertension, and coronary arterial diseases), suffer from obstructive sleep apnea (OSA)/obesity hypoventilation syndrome, and pose a great difficulty in positioning during surgery and are more prone to injuries/nerve damage. Patients with OSA are associated with twice the incidence of postoperative desaturation, respiratory failure, postoperative cardiac events, and intensive care unit (ICU) admission. Intellectual disability (ID) with obesity poses as a double challenge for anesthesiologist. The anesthesia management of ID patients has a dual task of allaying anxiety of patients as well as their parents/caretaker as apprehension of the guardian or parent can significantly affect the patient's behavior.
| Case Report|| |
We present a 15-year-old morbidly obese female patient, a case of multiple caries teeth associated with infection of multiple root canals, for root canal treatment and multiple teeth extraction. The patient was a known case of postscrub typhus sequelae (encephalitis) with reduced higher mental functions and history of tracheostomy with prolonged mechanical ventilation of 2-month duration, about 10 years back. On examination, the patient had a BMI of 55.5 kg/m2 and was wheelchair bound with fixed flexion deformity of both the hip and knee joints. Airway examination showed reduced mouth opening and severely restricted neck extension, with neck circumference of 48 cm. Mallampati score could not be assessed in view of uncooperative patient. Systemic examination was within normal limits. “Stop bang” questionnaire confirmed obstructive sleep apnea syndrome with the score of 5 in this case. Preoperative sleep studies could not be carried out as facility was not available in our center. She was on tablet eltroxin 125 μg and tablet phenytoin sodium 100 mg once daily for last 10 years and on intermittent continuous positive airway pressure (CPAP). Her hematological and biochemical investigations were within normal limits. Surgical procedures as well as technique of anesthesia and associated complications were discussed in detail with the parents and written informed assent was obtained from them. The patient was accepted in the American Society of Anesthesiologists physical status class III (ASA-III) under high risk. Preoperatively, the site of peripheral intravenous (IV) catheter was identified and ICU bed with ventilator was kept ready. Additional preparation of operation theater (OT) included placement of bigger operation table with lateral extensions, extra-large size blood pressure cuff, pillows and cotton for padding, Patient was secured with large straps to prevent the fall from the OT table and intermittent pneumatic compression (IPC) was applied on both lower limbs to prevent deep vein thrombosis.
On the day of surgery, difficult airway cart with fiber-optic bronchoscope (FOB), facemask with swivel connector, extralong laryngoscope blades with short barrel handles, intubating video laryngoscopes, intubating laryngeal mask airway, a cricothyrotomy set, and an ultrasound (USG) machine were kept ready in OT. In the ward, a eutectic mixture of local anesthetic cream was applied locally for 30 min at site identified for venous cannulation on the left foot. In preoperative room, an 18-G IV line was secured in the left foot and, the patient wheeled in OT along with her father. The patient was carefully positioned on the operating table in “ramped up” position with 30° head up and pillows were placed under both knees for supporting lower limbs [Figure 1]. Standard anesthesia monitoring ensued along with bispectral index and neuromuscular muscular monitoring. Baseline hemodynamic parameters were within normal limits. The patient was preoxygenated by her father holding the mask with 100% oxygen with CPAP of 10 cm H2O. She was induced with graded inhalation induction with sevoflurane (7–8%). USG was used to delineate the cricothyroid membrane and markings were made to facilitate the airway blocks. FOB-guided intubation was done and airway was secured nasally with size 7.0 endotracheal tube. The patient was put on pressure-controlled ventilation mode with a pressure control of 10 cm H2O with a positive end-expiratory pressure (PEEP) of 08 cm H2O targeting a tidal volume of 8 ml/kg. Anesthesia was maintained with oxygen, nitrous oxide, and desflurane 5–6% targeting the minimum alveolar concentration of 1.2. Total surgical duration was 3 h during which the lung recruitment maneuver was performed twice. The patient was extubated once she was fully awake with return of all the protective reflexes and in addition when the train of four of 0.9 was achieved. She was shifted with CPAP machine to the ICU. Her remaining ICU and hospital stay were uneventful and she was discharged to home after 24 h.
| Discussion|| |
Perioperative management of an obese ID patient is a challenge for entire operating room team due to cognitive impairment, difficulty in communication, positioning, and uncooperative patient. The anxiety and fear of separation from parents and unfamiliar surroundings which may be further compounded by previous unpleasant/painful hospital experiences can lead to an aggressive, combative, and noncompliant behavior. ID patients comprise 2%–3% of the general population, and of these, about 30%–40% report for various inpatient and outpatient surgical procedures, which are mainly dental treatments, diagnostic procedures, and corrective surgeries., In our case, to make the experience pleasant, we allowed the caregiver of the child to accompany her in the OT, thereby preventing the psychological stress.
General anesthesia (GA) is a technique of choice for patients with behavioral and compliance issues. ID with morbid obesity makes GA very challenging as these patients are extra sensitive to depressive effects of narcotics, sedative agents, and induction agents, leading to rapid narrowing of airway and precipitation of OSA. Reduction in pharyngeal tone and decreased ventilator response to hypoxia and hypercapnia complicates the postanesthesia recovery in these patients. In cases of difficult airway, awake fiber-optic intubation is a gold standard, and it was successfully done in our case with deep spontaneous breathing patient under inhalation (sevoflurane) anesthesia with airway blocks. Sevoflurane induction is the safest mode of induction in patients of difficult airway because it is nonirritant and helps patients to breathe spontaneously, leading to faster and smoother induction. During maintenance phase, sevoflurane was replaced with desflurane, as evidence shows rapid recovery and awakening from GA with desflurane in comparison to sevoflurane, leading to better airway patency, oxygenation, and lesser chances of aspiration.,
Long-lasting surgeries in morbidly obese patients can lead to basal atelectasis, thereby affecting the ventilation adversely. Lung recruitment strategy was employed by applying PEEP of 40 cm H2O for 7–8 s as being suggested by Talab et al., which decreases atelectasis, improves oxygenation, and decreases pulmonary complications in morbidity obese patients. Chances of spontaneous venous thromboembolism (VTE) are twice in obese as compared to nonobese patients, whereas incidence of pulmonary embolism increases by six-folds in patients with BMI ≥35 kg/cm2., Arabi et al. demonstrated a significant decrease in the incidence of VTE with use of IPC as an adjunct to pharmacological thromboprophylaxis. Antiembolic stockings were applied in our case prophylactically for the perioperative period. Pillows were placed under her both knees to maintain her normal anatomical posture so as to avoid nerve injuries along with strapping to avoid inadvertent falling from OT table. The patient was extubated awake; CPAP mask was applied and shifted to ICU. The mainstay of management in these subsets of patients includes meticulous preoperative preparation, involvement of the caregiver to minimize the psychological stress, and a vigilant perioperative monitoring with the anesthesia tailored to suit the altered physiological and pharmacokinetic state of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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