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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 101-103

A differently abled child with morbid obesity – An anesthetic challenge


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 Submission04-Dec-2018
Date of Acceptance24-Feb-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Lt Col Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_80_18

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  Abstract 


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

How to cite this URL:
Sud S, Dwivedi D, Bhatia JS, Gautam AR. A differently abled child with morbid obesity – An anesthetic challenge. J Mar Med Soc [serial online] 2019 [cited 2019 Sep 22];21:101-3. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/1/101/260677




  Introduction Top


Obesity is a part of group of noncommunicable diseases called “New World Syndrome.”[1] 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.[2] Intellectual disability (ID) with obesity poses as a double challenge for anesthesiologist.[3] 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.[4]


  Case Report Top


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.
Figure 1: Patient in the “ramped up position”

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  Discussion Top


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.[3] 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.[5] 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.[6],[7] 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.[5] 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.[3] 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.[8] 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.[9] 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.[10],[11]

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.[12] 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.[13],[14] Arabi et al. demonstrated a significant decrease in the incidence of VTE with use of IPC as an adjunct to pharmacological thromboprophylaxis.[15] 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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalra S, Unnikrishnan AG. Obesity in India: The weight of the nation. J Med Nutr Nutraceuticals 2012;1:37-41.  Back to cited text no. 1
    
2.
Mutter TC, Chateau D, Moffatt M, Ramsey C, Roos LL, Kryger M, et al. Amatched cohort study of postoperative outcomes in obstructive sleep apnea: Could preoperative diagnosis and treatment prevent complications? Anesthesiology 2014;121:707-18.  Back to cited text no. 2
    
3.
Govindarajan R, Bakalova T, Gerges M, Mendelsohn M, Michael R, Abadir A, et al. Uvulopalatopharyngoplasty for sleep apnea in mentally retarded obese 14-year-old: An anaesthetic challenge. Acta Anaesthesiol Scand 2003;47:366-8.  Back to cited text no. 3
    
4.
Ferrari LR. Do children need a preoperative assessment that is different from adults? Int Anesthesiol Clin 2002;40:167-86.  Back to cited text no. 4
    
5.
Daily DK, Ardinger HH, Holmes GE. Identification and evaluation of mental retardation. Am Fam Physician 2000;61:1059-67, 1070.  Back to cited text no. 5
    
6.
Chaudhary K, Bagharwal P, Wadhawan S. Anesthesia for intellectually disabled. J Anaesthesiol Clin Pharmacol 2017;33:432-40.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Ananthanarayan C, Sigal M, Godlewski W. General anesthesia for the provision of dental treatment to adults with developmental disability. Anesth Prog 1998;45:12-7.  Back to cited text no. 7
    
8.
Paul A, Nathroy A. Awake fiberoptic nasal intubation in a patient scheduled for commando's operation. Int J Health Allied Sci 2017;6:123-6.  Back to cited text no. 8
  [Full text]  
9.
Pösö T, Kesek D, Winsö O, Andersson S. Volatile rapid sequence induction in morbidly obese patients. Eur J Anaesthesiol 2011;28:781-7.  Back to cited text no. 9
    
10.
Strum EM, Szenohradszki J, Kaufman WA, Anthone GJ, Manz IL, Lumb PD. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: A prospective, randomized study. Anesth Analg 2004;99:1848-53.  Back to cited text no. 10
    
11.
La Colla L, Albertin A, La Colla G, Mangano A. Faster wash-out and recovery for desflurane vs. sevoflurane in morbidly obese patients when no premedication is used. Br J Anaesth 2007;99:353-8.  Back to cited text no. 11
    
12.
Talab HF, Zabani IA, Abdelrahman HS, Bukhari WL, Mamoun I, Ashour MA, et al. Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesth Analg 2009;109:1511-6.  Back to cited text no. 12
    
13.
Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW. Cardiovascular risk factors and venous thromboembolism: A meta-analysis. Circulation 2008;117:93-102.  Back to cited text no. 13
    
14.
Kabrhel C, Varraso R, Goldhaber SZ, Rimm EB, Camargo CA. Prospective study of BMI and the risk of pulmonary embolism in women. Obesity (Silver Spring) 2009;17:2040-6.  Back to cited text no. 14
    
15.
Arabi YM, Khedr M, Dara SI, Dhar GS, Bhat SA, Tamim HM, et al. Use of intermittent pneumatic compression and not graduated compression stockings is associated with lower incident VTE in critically ill patients: A multiple propensity scores adjusted analysis. Chest 2013;144:152-9.  Back to cited text no. 15
    


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