Anesthesia For The Patient With Obesity

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Anesthesia for the patient with obesity

Author: Roman Schumann, MD
Section Editor: Stephanie B Jones, MD
Deputy Editor: Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2021. | This topic last updated: Mar 01, 2021.
INTRODUCTION
As the prevalence of obesity increases worldwide, an increasing number of obese surgical patients will require
anesthesia. Obesity is typically defined by body mass index (BMI), the ratio of weight (in kilograms) to the square
of height (in meters) (calculator 1). In adults, the World Health Organization and the National Institute of Health
define obesity as a BMI ≥30 kg/m2.
This topic reviews the changes in anatomy and physiology in obese patients that affect anesthetic management,
anesthetic drug dosing in obesity, and planning the anesthetic as it differs from patients with normal BMI.
Preoperative medical evaluation of obese patients, the impact of obstructive sleep apnea on anesthetic
management, and general principles and techniques in anesthesia are discussed separately.
● (See "Preanesthesia medical evaluation of the obese patient".)

● (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep
apnea".)
● (See "Intraoperative management of adults with obstructive sleep apnea".)
● (See "Postoperative management of adults with obstructive sleep apnea".)
The choice of inpatient versus ambulatory surgery in obese patients is also discussed separately. (See
"Preanesthesia medical evaluation of the obese patient", section on 'Ambulatory versus inpatient surgery'.)
PHYSIOLOGIC CHANGES ASSOCIATED WITH OBESITY
Increasing obesity leads to respiratory and cardiovascular changes that impact the delivery of anesthesia and
perioperative analgesia.
Alterations in airway anatomy caused by obesity are discussed separately. (See "Preanesthesia medical
evaluation of the obese patient", section on 'Airway assessment'.)
Respiratory physiology — Obesity-related respiratory changes occur as a consequence of physical

impingement on lung volumes and chest movement as well as the increased metabolic requirements of excess
tissue; these in turn lead to increased work of breathing [1], increased oxygen (O2) consumption [2], increased
carbon dioxide (CO2) production [3,4], and disordered ventilation to perfusion matching [5].
As a consequence, respiratory rates are increased, and functional residual capacity (FRC) and expiratory reserve
volume (ERV) are decreased, even in mild obesity [6]. FRC may be sufficiently reduced such that small airways
and alveoli remain closed during spontaneous ventilation, leading to ventilation-perfusion mismatch and right
to left shunting [7]. Lung volumes and intrapulmonary shunt worsen with the induction of general anesthesia in
all patients, but to a much greater degree in obese patients [8,9]. Supine position and obstructive sleep apnea
(OSA) increase the magnitude of these effects [10,11].
Consequences of these changes of concern to anesthesiologists include the following:
● Decreased time to desaturation during apnea [12]

● Increased O2 requirements [2]
● Hypoventilation with supine spontaneous ventilation [11]
Modifications of airway management, patient positioning, and ventilation in response to these issues are
discussed below. A general discussion of respiratory changes in obesity is found separately. (See "Chest wall
diseases and restrictive physiology", section on 'Obesity'.)
Cardiovascular physiology — Cardiovascular physiologic changes in obesity include:
● Increased circulating blood volume, although it is a lower proportion of total weight (50 mL/kg as compared
with 75 mL/kg) compared with patients with normal body mass index (BMI) [13].
● Decreased systemic vascular resistance [14,15].
● Increased cardiac output by 20 to 30 mL per kilogram of excess body fat.
Stroke index, cardiac index, and heart rate remain normal; the increased cardiac output occurs by means of
expanded stroke volume [16].
● Left ventricular hypertrophy, related to the duration of obesity [17].
The increased cardiac output can lead to either left ventricular failure (especially when associated with
hypertension) or right heart failure (especially when associated with the hypoxia and hypercapnia of OSA) (
figure 1).
Hypertension and cardiovascular disease are more prevalent in obese patients and when present may produce
additional structural and hemodynamic changes ( table 1). (See "Preanesthesia medical evaluation of the
obese patient", section on 'Cardiovascular disease' and "Obesity: Association with cardiovascular disease".)
DOSING ANESTHETIC DRUGS
The optimal method for calculating weight based doses of many medications in obese patients is unclear, with
limited available literature. When possible and appropriate, anesthetic medications should be titrated to effect
with incremental doses or incrementally adjusted infusions. Our dosing strategy for obese patients is based on
available pharmacokinetic and pharmacodynamic data in obesity, such data in non-obese patients, clinical
experience, and the clinical use of the drug. Suggested dosing scalars for commonly used medications are
shown in a table ( table 2).
Modified drug dosing may be required because of obesity-related increases in lean body weight (LBW), cardiac
output, and blood volume, as well as changes in regional blood flow ( table 3); these can affect peak plasma
concentration, clearance, and elimination half-life of many drugs [18]. Dosing is generally based on volume of
distribution for bolus doses, and on clearance for infusions or repeat boluses. Some effects of obesity on
pharmacokinetics are as follows:
● The volume of distribution (Vd) is the principal determinant of loading dose of drugs. The Vd of relatively
lipophilic drugs is increased by obesity; less lipophilic drugs have little change in Vd in obese patients, as
blood flow to fat tissue is lower than blood flow to vessel-rich or lean tissue [19]. Vd is largely dependent on
the physiochemical attributes of a drug and varies with plasma protein binding and tissue blood flow, but
changes are not consistent for all drugs within a category, and in many cases have not been determined
[18].
● Drug clearance is generally higher in obese individuals than non-obese individuals [18]. This is largely
controlled by hepatic and renal physiology. Obesity affects hepatic metabolic pathways in different ways,
with some only slightly and others significantly enhanced in obesity [19]. Renal elimination includes
glomerular filtration, tubular secretion, and tubular reabsorption; changes are observed in obesity, but vary
by drug and are not completely understood.
● The elimination half-life (t1/2) impacts dosing interval and dosing of continuous infusions. The t1/2 of a drug
varies directly with Vd, and inversely with the clearance, both of which are altered in obesity. For prolonged
infusion of highly lipophilic drugs, the t1/2 and drug effect may be markedly prolonged after discontinuation
of the infusion, due to increased Vd.
While somewhat difficult to predict, pharmacodynamic changes also occur in severely obese individuals; for
example, therapeutic windows may be narrowed or side-effects exaggerated for some drugs.
Weight based drug dosing in obese patients can be based on actual total body weight (TBW), or one of several
calculated scalars, including the following:
● Ideal body weight – Ideal body weight (IBW) is the weight associated with maximum life expectancy. It is
calculated solely from the patient's height, with different equations for males and females, based on
actuarial tables (calculator 2).
● Lean body weight – LBW is the difference between total body weight and fat mass. It is usually calculated
with a sex-specific formula that includes both height and weight (calculator 3 and calculator 4), and
accounts for the fact that as weight increases, lean body mass increases as well. Thus calculated LBW in
obese patients is generally higher than IBW ( table 4). Lean body weight calculations have not been
validated for extremely obese patients and may be inaccurate for patients who weigh more than
approximately 200 kg [20].
● Adjusted body weight – Adjusted body weight (AdjBW) is calculated by applying an adjustment factor to
estimate the proportion of adipose tissue to which a drug distributes. For drug dosing in severely obese
patients (>20 percent above IBW), an adjustment factor of 40 percent is usually used, as follows:
AdjBW = IBW + 0.4 [TBW – IBW]
When the optimal dosing method for a specific drug is unknown, it is reasonable to base doses on AdjBW,
except for highly lipophilic drugs (eg, midazolam, fentanyl, sufentanil) for which TBW should usually be used
[18]. The rationale for using AdjBW is to avoid the underdosing that may occur with use of LBW, and the
overdosing that may occur with use of TBW. However, because of the complexities of pharmacokinetics and
pharmacodynamics introduced by obesity, the choice of the most appropriate dosing scalar for some drugs is
debated.
While somewhat difficult to predict, pharmacodynamic changes also occur in severely obese individuals; for
example, therapeutic windows may be narrowed or side-effects exaggerated for some drugs.
Dosing algorithms for target controlled infusion devices (not available in the United States) in obese patients
have been published, though the optimal weight scalar for obese patients is unclear [21-23] . (See "Intravenous
infusion devices for perioperative use", section on 'Target-controlled infusion systems'.)
Effects of obesity on the required concentrations of inhaled anesthetics are discussed below. (See 'Maintenance'
below.)
CHOICE OF ANESTHETIC DRUGS
Due to the high prevalence of sleep apnea in obese patients and associated potential sensitivity to sedatives and
opioids, the use of long-acting respiratory depressants should be minimized in obese patients. The guiding
principle should be to use shorter acting and minimally fat soluble agents whenever feasible to allow for rapid
recovery of consciousness, protective reflexes, and mobility [24,25].
SPECIAL EQUIPMENT NEEDS
The ability to safely anesthetize severely obese patients may require additional equipment that is not typically
immediately available. These include:
● Specialized or extra equipment for positioning – (See 'Patient positioning' below.)
● Large and/or high weight capacity beds and operating tables – Designated weight limits for operating
tables may not remain valid if the patient is shifted on the table, the table is positioned other than level (eg,
Trendelenburg, reverse Trendelenburg, lateral tilt), or the table is unlocked [26]. Additional arm supports to
widen the table, or the use of two operating tables, may be necessary.
● Mechanical transfer mechanisms – Various means of mechanically assisting the transfer of severely obese
patients between stretchers and beds have been developed (eg, inflatable lateral transfer mattress). These
may improve patient safety and prevent injury to care personnel.
● Additional personnel – Assistance may be needed to transfer and position patients safely.
● Extra-long needles – Normal length epidural, spinal, and nerve block needles may be insufficient to access
structures in severely obese patients.
● Ultrasound – Ultrasound may be used to assist in vascular access, nerve block, and neuraxial procedures
[27,28]. (See "Overview of peripheral nerve blocks", section on 'Ultrasound guidance'.)
PATIENT PREPARATION FOR ANESTHESIA
Preparation for anesthesia includes measures to prevent aspiration, and application of standard American
Society of Anesthesiologists (ASA) monitors.
Aspiration prophylaxis — Standard preoperative fasting guidelines should be followed for obese patients; for
patients without additional risk factors for aspiration (eg, gastroesophageal reflux, gastroparesis, bowel
obstruction), this means fasting for two hours for clear liquids, and six hours for solid food (eight hours for high
protein or fatty food), prior to anesthesia ( table 5). In most studies gastric emptying of both liquids and solids
is not delayed in obese patients and may be more rapid than in normal weight patients [29-31].
We agree with the practice guidelines of the ASA that do not recommend routine use of pharmacologic
medication to decrease aspiration risk in patients without an increased risk of aspiration [32]. Morbid
obesity did not correlate with gastroesophageal reflux in a study of 250 patients [33], and there is no
evidence that aspiration risk is increased in obesity. Obese patients who are at increased risk of aspiration
are managed in the same manner as non-obese patients.
As point of care ultrasound is increasingly used in the operating room for a variety of purposes, gastric
ultrasound has been utilized in clinical trials to assess gastric volume. In one small study in severely obese
patients, gastric ultrasound estimated gastric volume correlated well with volume of gastric aspirate, with
accuracy similar to that reported for gastric ultrasound in non-obese patients [34]. However, similar to other
methods for assessing gastric volume, results have not been correlated with the risk of aspiration during
anesthesia.
Sedative premedication — If premedication is required for obese patients, sedatives should be administered
incrementally, at lower doses than typically used, titrated to effect and to avoid side effects. Premedication of
the obese patient should ideally allow anxiolysis without abolishing airway reflexes or preventing patient
cooperation prior to induction of general anesthesia.
MANAGEMENT OF ANESTHESIA
Blood pressure monitoring — In patients with obesity, during general anesthesia we measure intermittent
non-invasive blood pressure no less than every three minutes, and more often as needed. Accurate, frequent or
continuous blood pressure measurement is important in clinical practice. (See "Hemodynamic management
during anesthesia in adults", section on 'Blood pressure'.)
Noninvasive blood pressure measurement in obese patients is often complicated by the size and conical shape
of their upper arms [35]. Invasive arterial blood pressure monitoring should be considered when surgical and/or
patient conditions suggest a critical need for accurate blood pressure monitoring and or repeated intraoperative
blood sampling.
Blood pressure cuffs must often be applied for obese patients in either a crisscross fashion, or with gaps at the
lower end of the cuff, which may result in inaccurate measurement. Alternate cuff locations (eg, forearm or
lower leg) are often used to obtain a better fit. Two small observational studies of intraoperative [36] and
postoperative blood pressure measurement [37] in severely obese patients suggest that the lower arm may be a
reasonable alternative to the upper arm. Compared with upper arm measurement, both studies reported better
or acceptable agreement between the forearm mean arterial cuff pressure versus invasive mean arterial
pressure. We frequently place a forearm cuff when upper arm cuff does not fit adequately, although validation
of the accuracy in a large patient cohort has yet to be conducted.
The optimal size blood pressure cuff for lower arm placement has not been determined, and practice varies. In
the studies mentioned above, a standard adult blood pressure cuff was used for all patients [36], and the other
used cuff sizes recommended for the patients' arm circumference [37]. However, arm circumference is rarely
measured in clinical practice. One retrospective study of over 100 bariatric surgical patients found that a regular
size cuff fit best on the forearm in patients with BMI between 40 and 55 kg/m2, and a large cuff fit best for
patients with BMI >55 kg/m2 [38].
A conical shaped blood pressure cuff is commercially available and may be an option for improved accuracy for
noninvasive blood pressure measurement in obese patients. In a study including 34 obese non-surgical patients
with a mean body mass index (BMI) of 33 kg/m2, lower arm blood pressure measurements with the conical cuff
were validated against a radial arterial line and determined to be acceptable, defined as an absolute average
error of ≤5 mmHg, with a standard deviation of ≤8 mmHg [39]. Larger perioperative studies, including patients
with higher mean BMI, are required before recommending this cuff for routine use.
The volume clamp system is a new technology that uses a finger cuff for noninvasive continuous beat to beat
blood pressure measurement as well as assessment of additional hemodynamic parameters. Studies comparing
this technology with arterial pressure measurement in obese bariatric surgical patients have reported
conflicting results [36,40,41]. Two studies using the same device found good agreement with invasive arterial
blood pressures with respect to trending and absolute values for mean arterial blood pressures [36,41]. Another
study using a different device based on the same physiologic principle found good trending agreement, but
absolute values for mean arterial pressure were not interchangeable [40]. Larger scale trials are needed to
validate these reports, which included a limited number of patients and clinical circumstances. (See "Monitoring
during anesthesia", section on 'Noninvasive blood pressure monitoring'.)
Patient positioning — Particular care is required when positioning obese patients for surgery. The improperly
positioned patient can experience physiologic derangement (eg, impaired ventilation), nerve or tissue damage,
rhabdomyolysis, or injury related to falls. The risk of developing rhabdomyolysis after bariatric surgery increases
with male gender, elevated BMI, and prolonged operating time [42]. Nerve and tissue injury related to patient
positioning for surgery are discussed in detail separately. (See "Patient positioning for surgery and anesthesia in
adults", section on 'Nerve injury' and "Patient positioning for surgery and anesthesia in adults", section on 'Skin
and tissue injury'.)
Considerations related to different positions for obese patients include the following:
● Supine or head-down (Trendelenburg) positions – Decreased lung volumes and increased work of
breathing (caused by the weight of the intra-abdominal contents on the diaphragm), and increased venous
blood return (leading to increased cardiac output) occur when compared with the head-up (reverse
Trendelenburg) or sitting positions. In obese patients, these changes can cause more rapid oxygen
desaturation during apneic periods, increased pulmonary shunt, hypoventilation with spontaneous
breathing, and edema of the head and neck after lengthy periods [43]. (See "Patient positioning for surgery
and anesthesia in adults", section on 'Trendelenburg'.)
● Head-up position (reverse Trendelenburg, or semi-sitting/"semi-Fowler") – Upright or semiupright

positions improve respiratory function in obese patients by reducing pressure on the chest wall and
diaphragm. (See "Patient positioning for surgery and anesthesia in adults", section on 'Reverse
Trendelenburg'.)
Head up positioning is useful during preoxygenation and improves both mask ventilation and the view at
laryngoscopy. (See "Emergency airway management in the morbidly obese patient", section on 'Positioning'
and 'Positioning for airway management' below.)
When the entire bed is tilted, care must be taken to prevent the patient sliding down the bed, especially if
arms are secured to fixed arm supports; use of a foot plate may be helpful and should be strongly
considered.
● Prone – Obese patients who are properly positioned prone for general anesthesia may have improved
respiratory function, with increased functional residual capacity (FRC), lung compliance, and oxygenation,
compared with supine position [44]. (See "Prone ventilation for adult patients with acute respiratory distress
syndrome".)
Patient supports should be placed under the chest and pelvis rather than the abdomen (which should be
compression-free) to avoid increasing intra-abdominal pressure [45]. In selected cases, patients have been
intubated awake, and then allowed to comfortably position themselves prone, prior to the induction of
anesthesia; this eliminates the need for operating room personnel to turn and position the patient, and
allows identification of pressure points by the patient before injury occurs [46,47]. (See "Patient positioning
for surgery and anesthesia in adults", section on 'Prone'.)
● Lateral decubitus – The lateral position removes the weight of the abdomen from the diaphragm and
increases the diameter of the pharyngeal airway [48]. The lateral decubitus position combined with head
and upper body elevation may be helpful during recovery from general anesthesia, unless contraindicated
due to the nature of the surgery.
Chest pads or rolls used to avoid axillary compression during lateral positioning may need to be larger than
is standard. It can be challenging to support the head in a neutral position, as the neck is often short and
wide; extra pieces of foam and rolled towels can be helpful. Standard bean-bags may be too narrow to
support obese patients, so alternatives should be sought to maintain the patient in lateral position. Use of
gel-pads may prevent injury to pressure points such as the hip. (See "Patient positioning for surgery and
anesthesia in adults", section on 'Lateral decubitus'.)
● Lithotomy position – Lithotomy position decreases lung volumes by shifting abdominal contents towards
the diaphragm, which may contribute to hypoxia and hypoventilation. Correct positioning and adequate
padding of the legs is critical; neurologic injury or compartment syndrome may result from prolonged
pressure [49,50]. Specially designed leg holders may be necessary to accommodate the size and weight of
the legs. (See "Patient positioning for surgery and anesthesia in adults", section on 'Lithotomy'.)
Beds and equipment used to support obese patients must be constructed to support the additional weight and
must provide sufficient space to avoid pressure from side-rails. Carefully padding pressure points will help to
prevent pressure-related peripheral nerve injuries.
Positioning of the obese patient should be checked regularly during the maintenance phase of general
anesthesia, as large patients are prone to shift position when the operating table is tilted and may need to be
repositioned. The use of Velcro to attach the mattress to the bed can help prevent slipping.
Choice of anesthetic technique — General anesthesia, regional anesthesia, and sedation have all been
employed safely in obese patients, and overall, no technique has been found to be superior to another with
respect to important patient outcomes specifically in obese patients (eg, mortality, cardiopulmonary
complications).
When regional anesthesia (ie, neuraxial anesthesia, peripheral nerve blocks, local anesthesia) is feasible, these
techniques are often considered in obese patients, particularly those with obstructive sleep apnea (OSA), to
reduce the potential for respiratory or airway related problems [51-53]. However, these benefits are reduced if
the obese patient requires moderate or deep sedation to tolerate a procedure with regional anesthesia.
Neuraxial anesthesia and peripheral nerve blocks offer the advantages of improved postoperative pain control,
reduced use of opioids for postoperative analgesia, and consequently decreased potential for drug-induced
respiratory depression. Postoperative epidural analgesia may mitigate postoperative respiratory dysfunction in
obese patients who undergo upper abdominal or thoracic procedures, though it has not been shown to improve
outcomes [54,55]. Whereas landmarks for neuraxial anesthesia and nerve blocks may be less palpable in obese
patients, in most cases these techniques can be accomplished [56-58]. Ultrasound guidance and long needles
may be required. (See 'Neuraxial anesthesia' below and 'Peripheral nerve blocks' below.)
When either regional anesthesia or general anesthesia would be possible for a particular procedure, the
following factors should be considered, and may make general anesthesia preferable:
● Positioning – Obese patients have decreased respiratory tolerance for supine, lithotomy, or head-down
positioning, and may require ventilatory assistance or airway control in these positions. (See "Patient
positioning for surgery and anesthesia in adults", section on 'Physiologic effects of Trendelenburg
positioning'.)
Obese patients may also be uncomfortable in the prone position due to pressure on the abdomen, and may
require more sedation to tolerate this discomfort.
● Need for controlled ventilation – Spontaneous breathing in patients with prominent abdominal obesity
may interfere with the need for an immobile abdominal or pelvic surgical field; these patients may require
controlled ventilation under general anesthesia, with either an endotracheal tube (ETT) or supraglottic
airway designed for controlled ventilation (eg, Proseal laryngeal mask airway [LMA]). (See 'Airway
management' below.)
● Anticipated difficult mask ventilation or intubation – If airway difficulty is anticipated, it may be prudent
to intubate in a controlled manner at the beginning of the case, rather than after problems develop. This
decision should be individualized, based partly on access to the airway during surgery, and the likelihood
that regional anesthesia will be effective for the duration of the procedure. (See "Preanesthesia medical
evaluation of the obese patient", section on 'Airway assessment' and 'Airway management' below.)
● Need for sedation – When sedation is offered to obese patients, they should understand that the sedation
level may be light. Patients who are particularly anxious, or who would require deeper levels of sedation to
tolerate longer procedures (particularly in uncomfortable positions), may not be good candidates for
regional anesthesia, due to potential for sedatives or opioids to cause airway obstruction or
hypoventilation. Hypercapnia may be especially problematic in patients with pulmonary hypertension due
to OSA or obesity hypoventilation syndrome.
General anesthesia — Modifications of the approach to general anesthesia in obese patients center largely on
respiratory issues. Obese patients have a higher incidence of hypoxia and respiratory events in the perioperative
period than patients with normal BMI [59,60]. Because these patients desaturate more quickly during apneic
periods, the anticipation and management of respiratory problems is critical.
Airway management
Choice of airway device — Obese patients are seldom managed with mask ventilation alone; mask
ventilation is generally restricted to brief anesthetics (eg, an examination under anesthesia, or knee
manipulation). Face mask ventilation can be technically challenging in the obese patient because of difficulty
with mask fit and handling, or obstruction related to abundant oropharyngeal tissue or a large tongue.
Obese patients are more likely to require intubation rather than a supraglottic airway (SGA; eg, LMA). Obese
patients are more likely to require controlled ventilation to prevent hypoventilation, and during positive
pressure ventilation, an SGA may not maintain a seal at the higher airway pressures needed in obese patients.
Use of a pressure support ventilation mode in the presence of an SGA may be a feasible alternative in some
cases. Obesity-specific criteria for the use of a supraglottic airway have not been established, and practice
varies. However, we consider the degree and distribution of obesity, type and length of surgery, and patient
position to determine whether an SGA is appropriate. We prefer to control ventilation with an endotracheal tube
in any of the following circumstances:
● Patients with BMI >40 kg/m2

● Patients with primarily abdominal obesity
● Major abdominal or thoracic surgery
● Most surgery lasting >2 hours
● Head down positioning
For obese patients, we usually use second generation SGAs which are designed for controlled ventilation, allow
higher seal pressures, and provide a gastric vent. (See "Supraglottic devices (including laryngeal mask airways)
for airway management for anesthesia in adults", section on 'Choice of supraglottic airway'.)
Difficulty with airway management — Obesity is a recognized risk factor for potential difficulty with all
aspects of airway management (ie, mask ventilation, use of SGA, endotracheal intubation, extubation). These
issues are discussed separately. (See "Airway management for induction of general anesthesia", section on
'Obesity as a risk factor'.)
The plans for airway management during anesthesia follow from assessment of risk factors for difficulty with
airway management, the history of prior attempts at airway management, and the risk factors for aspiration.
Airway assessment, creation of a strategy for airway management, and management of the difficult airway are
discussed in detail separately. Algorithms for difficult airway management are also provided ( algorithm 1 and
algorithm 2). (See "Airway management for induction of general anesthesia" and "Management of the
difficult airway for general anesthesia in adults".)
Positioning for airway management — Preoxygenation is ideally performed in head-up (reverse

Trendelenburg) position to maintain oxygenation, as both the supine position and the induction of anesthesia
decrease lung volumes in the obese patient [61-63]. In addition, patients positioned with the back up and head
elevated are easier to mask ventilate, and there is a better view of the airway during direct laryngoscopy
compared with those in the flat horizontal supine position. (See "Emergency airway management in the
morbidly obese patient", section on 'Positioning'.)
For preoxygenation and intubation in obese patients, we routinely tilt the operating table head up, and in
addition place the patient in a ramped position with the back up and the head elevated [64]. The goal for this
position is to align the external auditory meatus and the sternal notch in a horizontal plane ( figure 2). The
bed can be placed in the semi-Fowler's position, or a stack of blankets or a pre-formed or inflatable ramp can be
used to achieve a ramped position. When supports are added to the bed to raise the upper trunk, it is important
to provide sufficient support to the arms in order to maintain a neutral position and prevent nerve injury from
excessive tissue stretch at the shoulders.
Preoxygenation and apneic oxygenation — Preoxygenation is used to increase oxygen reserves in order

to prevent hypoxemia during apnea. Preoxygenation and apneic oxygenation are particularly beneficial for
obese patients, who are expected to desaturate rapidly during apnea related to attempts at airway
management. There is less time to rescue the obese patient in a failed airway situation (cannot ventilate, cannot
intubate) due to rapid apneic desaturation. (See "Preoxygenation and apneic oxygenation for airway
management for anesthesia".)
Preoxygenation is usually performed via a tight-fitting facemask using 100 percent oxygen (O2) at a flow rate
high enough to prevent rebreathing (10 to 12 L/min), aiming for an end-tidal concentration of O2 greater than
90 percent in order to maximize safe apnea time. Patients should be preoxygenated with either three minutes of
tidal volume (TV) breathing or eight vital-capacity breaths over 60 seconds. These two techniques have been
shown to be equally effective at preventing desaturation and are more effective than four vital-capacity breaths
over 30 seconds [65-67].
Preoxygenation with manually-applied positive end-expiratory pressure (PEEP), or the use of noninvasive
ventilation (NIV), will improve oxygenation in obese patients who tolerate it [68]. (See "Preoxygenation and
apneic oxygenation for airway management for anesthesia", section on 'Positive airway pressure techniques
during preoxygenation'.)
The use of nasal cannula for passive apneic oxygenation during laryngoscopy can prolong the time to
desaturation in high-risk patients during airway management [69-72]. We suggest the administration of oxygen
by nasal cannula at 10 L as tolerated by the patient in addition to facemask oxygen in those patients who are at
high risk for difficult laryngoscopy and intubation. Where available, heated humidified high flow nasal oxygen
can significantly delay apneic desaturation, including in obese patients [73]. As an example, in a randomized trial
including 40 morbidly obese patients, preoxygenation and apneic oxygenation with high flow nasal oxygen
prolonged time to desaturation to ≤95 percent by a mean of 76 seconds (95% CI 33-118 seconds), absolute
difference 261 versus 156 seconds [74].
When high concentration oxygen is used during induction of anesthesia, resorption atelectasis may occur,
particularly in obese patients [75-77]. Decreasing the fraction of inspired oxygen (FiO2) during preoxygenation
prevents atelectasis but reduces the duration of safe apnea. Thus the relative risk of atelectasis versus the risk of
rapid desaturation must be assessed by the clinician when deciding whether to use 100 percent oxygen for
preoxygenation, or a lower FiO2. Use of a recruitment maneuver and prompt application of PEEP after
intubation may prevent or reverse resorption atelectasis. (See 'Ventilation management' below and
"Preoxygenation and apneic oxygenation for airway management for anesthesia", section on 'Complications of
preoxygenation'.)
Induction — Anesthetic induction agents (ie, propofol, ketamine, etomidate, methohexital) should be chosen
based on patient factors other than obesity (see "General anesthesia: Intravenous induction agents"). Dose of
induction agents may require modification for obesity ( table 2).
Obesity itself is not an indication for rapid sequence induction and intubation (RSII). However, it is reasonable to
use a rapid acting neuromuscular blocking agent (ie, succinylcholine or high dose rocuronium) for endotracheal
intubation in obese patients, to shorten the interval during which mask ventilation (which may be a struggle)
may be needed.
If RSII is indicated for reasons other than obesity, low pressure mask ventilation may be required to prevent or
treat oxygen desaturation. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on
'Modified RSII'.)
Maintenance — Maintenance intravenous and inhaled anesthetic agents should be chosen based on patient
factors other than obesity. (See "Maintenance of general anesthesia: Overview".)
The literature on the use of inhaled and intravenous anesthetics in severely obese patients is conflicting
regarding anesthesia relevant endpoints and outcomes. Several studies have reported more rapid emergence
and recovery from anesthesia with the use of desflurane, compared with sevoflurane, isoflurane, or propofol
[78-80], whereas other studies have reported no differences in recovery or other outcomes [81-84].
In a study of morbidly obese adult patients, the end-tidal sevoflurane concentration required to maintain 50
percent of patients at a bispectral index (BIS) of <50 was 1.6 percent [85], higher than that reported in a separate
study of non-obese adults (0.97 percent) [86].
Nitrous oxide (N2O) may be used to supplement either volatile anesthetics or propofol in obese patients, though
the concentration of N2O may have to be limited to allow an adequate FiO2. Use of N2O during laparoscopic
surgery is controversial and is discussed separately. (See "Anesthesia for laparoscopic and abdominal robotic
surgery in adults", section on 'Use of nitrous oxide'.)
Ventilation management — When patients are managed with spontaneous respiration (either with an SGA
or an ETT), minute ventilation and end-tidal carbon dioxide (CO2) should be closely monitored to assure
adequate ventilation. We use continuous positive airway pressure (CPAP) during spontaneous respiration to
improve oxygenation. When patients are unable to maintain sufficient volumes, ventilation should be assisted or
controlled. The addition of pressure support assistance to PEEP may result in adequate ventilation; otherwise,
ventilation should be controlled with either pressure or volume control. (See "Mechanical ventilation during
anesthesia in adults", section on 'Modes of intraoperative mechanical ventilation'.)
When obese patients are managed with controlled ventilation, we recommend using a lung protective
ventilation strategy, to avoid lung damage based on the available evidence and expert opinion, including this
author [87,88]. This consists of low TVs, low levels of oxygen (as tolerated), PEEP, and perhaps recruitment
maneuvers, as follows (see "Overview of initiating invasive mechanical ventilation in adults in the intensive care
unit", section on 'Settings' and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective
ventilation during anesthesia' and "Ventilator management strategies for adults with acute respiratory distress
syndrome", section on 'Recruitment maneuvers'):
● Set TV of 6 to 8 mL/kg ideal body weight (IBW) (calculator 2).

● Adjust respiratory rate to maintain normocapnia (permissive hypercapnia is acceptable in patients without
pulmonary hypertension).
● Limit FiO2 to the level required to maintain peripheral arterial oxygen saturation (SpO2) >92 percent (ideally,
FiO2 below 0.5 to 0.8), to prevent resorption atelectasis and oxygen toxicity.
● Employ individualized PEEP to optimize plateau and driving pressure as well as lung compliance so as to
follow an "open lung" concept. (See "Ventilator management strategies for adults with acute respiratory
distress syndrome", section on 'Open lung ventilation'.)
● Use recruitment maneuvers judiciously during anesthesia (ideally delivered by a stepwise increase/decrease
in PEEP and TV respectively to a plateau pressure >40 but <55 cm H2O) to improve oxygenation and
optimize plateau pressure as needed (see "Mechanical ventilation during anesthesia in adults", section on
'Our approach'). Recruitment maneuvers should not be performed unless patients are hemodynamically
stable and euvolemic, as they may lead to a transient decrease in preload and hypotension [89-91]. (See
"Mechanical ventilation during anesthesia in adults", section on 'Recruitment maneuvers'.)
● Maintain head-up (reverse Trendelenburg) position, whenever feasible.
As in non-obese patients, the relative importance of low TVs, PEEP, and recruitment maneuvers is unclear, as
these strategies are often bundled together in studies of lung protective ventilation. We recommend protective
ventilation based on the effectiveness of various elements of this strategy in obese patients and evidence from
studies of non-obese patients. Examples of relevant studies include the following:
● In a trial of 400 non-obese adults having major abdominal surgery, patients were randomized to lung-
protective ventilation (TV 6 to 8 mL/kg IBW, PEEP 6 to 8 cm H2O, recruitment maneuvers after intubation
and every 30 minutes) or traditional ventilator settings (TV 10 to 12 mL/kg IBW, no PEEP, no recruitment
maneuvers); both groups received FiO2 <50 percent, as tolerated [92]. Protective ventilation led to:
• Decreased incidence of major pulmonary and extrapulmonary complications in the first week (10.5
versus 27.5 percent, relative risk [RR] 0.40 [95% CI 0.24-0.68])
• Lower incidence of acute respiratory failure requiring noninvasive ventilation or intubation (5 versus 17
percent, RR 0.29 [95% CI 0.14-0.61])
• Shorter median hospital stay (11 versus 13 days, between-group difference 2.45 days [95% CI 0.72-4.17
days])
● In a 2012 meta-analysis of studies of ventilation strategies (pressure- or volume-controlled ventilation, tidal

volumes, PEEP, or recruitment maneuvers) in obese patients (BMI >30 kg/m2), recruitment maneuvers
added to PEEP improved intraoperative oxygenation and compliance, compared with PEEP alone; the
incidence of adverse effects was similar between groups, and there was no significant difference between
pressure-controlled and volume-controlled ventilation [93].
● In a large international multicenter trial (Protective Intraoperative Ventilation With Higher Versus Lower
Levels of Positive End-Expiratory Pressure in Obese Patients [PROBESE]), over 2000 obese patients (BMI >35
kg/m2) undergoing open or laparoscopic surgery lasting >2 hours were randomly assigned to receive PEEP
at 4 cm H2O without recruitment maneuvers or PEEP at 12 cm H2O with hourly recruitment maneuvers [94].
All patients received a TV of 7 mL/kg predicted body weight. There was no significant difference in the
primary outcome, a composite of postoperative pulmonary complications within the first five days after
surgery (21.3 percent of the high PEEP group versus 23.6 percent of low PEEP group, RR 0.93, 95% CI 0.83 to
1.04). Intraoperative hypoxemia was more frequent in the low PEEP group, while intraoperative hypotension
and bradycardia were more frequent in the high PEEP group.
● PEEP of 15 cm H2O is effective in maintaining FRC and improving oxygenation during laparoscopic surgery
in morbidly obese patients [90,95].
Fluid management — There is very little evidence addressing perioperative fluid management specifically in
obese patients, and euvolemia in this population is poorly defined; consequently clinical judgment based upon
available measures of volume status and tissue perfusion should be used to guide fluid administration. (See
"Intraoperative fluid management".)
The use of dynamic indices to guide intravascular fluid administration has not been well studied in obese
patients. However, in a prospective study of 50 bariatric surgery patients with mean BMI over 50 kg/cm2, fluid
therapy guided by stroke volume variation (derived from arterial pressure waveform analysis) maintained all
hemodynamic parameters within 10 percent of baseline values [96]. (See "Intraoperative fluid management",
section on 'Dynamic hemodynamic parameters'.)
Reversal of neuromuscular blockade — Neuromuscular blockade may be reversed using either

sugammadex or neostigmine, depending on the neuromuscular blocking agent used. Sugammadex is a slightly
lipophilic reversal agent for steroidal non-depolarizing neuromuscular blockers, used mainly to reverse
rocuronium and vecuronium. In a trial of obese patients receiving sugammadex 2 mg/kg versus neostigmine
0.05 mg/kg, both given according to adjusted body weight (AdjBW; IBW + 0.4 [total body weight (TBW) – IBW]),
the sugammadex group had a significantly faster recovery from neuromuscular blockade (2.7 versus 9.6
minutes) and a significantly better train-of-four (TOF) ratio in the recovery room (110 versus 85 percent) [97].
Anecdotal evidence suggests that sugammadex may offer additional benefits over neostigmine in certain
clinical circumstances including fatty liver disease and recurarization of the obese [98,99].
Although some authors advocate sugammadex dosing based on TBW in the obese [100], in a dose finding study
(100 obese patients at a TOF recovery between 1 and 2) sugammadex 2 mg/kg IBW resulted in adequate
reversal, with no residual neuromuscular blockade. However, reversal was achieved more quickly at a dose
adjusted to IBW + 40 percent, slightly above lean body weight (LBW) [101]. There is limited information
regarding dose adjustments of neostigmine for the obese. We administer neostigmine based on AdjBW (
table 2). (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of
neuromuscular block'.)
Extubation — The trunk and head-up position is ideal at emergence, to improve oxygenation and decrease
work of breathing. Some obese patients may be slow to emerge from anesthesia and should remain intubated
until they are awake and meet standard extubation criteria. Avoiding premature extubation is particularly
important in the obese patient, as interim airway swelling and edema following a procedure can further
complicate an already challenging intubation. Extubation should be planned as carefully as intubation;
emergency airway equipment ( table 6) and personnel to assist in airway management must be available to
manage potential difficulties. (See "Extubation following anesthesia".)
Neuraxial anesthesia — In general, neuraxial anesthetic techniques with local anesthetic (ie, without opioids)
minimally affect respiratory drive, and are safe and appropriate choices for obese patients. Spinal and epidural
anesthesia at higher dermatomal levels (ie, thoracic levels) may lead to respiratory difficulty; in one study, the
onset of spinal anesthesia decreased spirometric lung volumes, to a greater extent in more severely obese
patients [102]. Neuraxial medication should be given incrementally whenever possible, to avoid excessively high
blockade; the same dose of spinal and epidural local anesthetics can spread to higher levels in obese compared
with normal weight patients [103-105]. When planning a neuraxial technique at higher levels, it is prudent to use
a technique that allows control of the amount and interval of dosing, such as an epidural or spinal catheter, or a
low dose, sequential combined spinal epidural, rather than a "single shot" block ( table 7). (See "Overview of
neuraxial anesthesia" and "Overview of neuraxial anesthesia", section on 'Use of neuraxial anesthesia'.)
Although landmarks tend to be more difficult to identify in obese patients and a greater number of attempts are
required to place spinal and epidural anesthetics, the success rate of placement in obese individuals is
equivalent to that in normal weight patients [56-58]. Preprocedure ultrasound determination of spinal anatomy
may improve identification of the needle insertion site and successful placement for selected obese patients,
and this approach is under active investigation. (See "Spinal anesthesia: Technique", section on 'Preprocedure
ultrasonography' and "Epidural and combined spinal-epidural anesthesia: Techniques", section on
'Preprocedure ultrasonography'.)
Peripheral nerve blocks — Peripheral nerve blocks with ultrasound guidance appear to be safe in obese
patients, with relatively high block success rates, when expertise and appropriate equipment are available.
However, obesity may make peripheral nerve block more difficult to perform, and may be associated with higher
block failure rates [27]. As an example, in a retrospective study of combined ultrasound guidance and nerve
stimulation for single shot interscalene blocks, a higher BMI was associated with prolonged, more difficult
placement and less successful blocks [106]. In contrast, in a retrospective review of ultrasound guided
perineural catheter placement for continuous peripheral nerve block, there were no differences in catheter
insertion time or success rates in obese patients, compared with non-obese patients [107].
Similar to non-obese patients, ultrasound guidance for peripheral nerve blocks may be beneficial in obese
patients compared with nerve stimulator or landmark based approaches. (See "Overview of peripheral nerve
blocks", section on 'Ultrasound guidance'.)
In one small randomized study involving obese patients who underwent lateral popliteal sciatic block,
ultrasound guidance was associated with faster and less painful block placement and higher patient
satisfaction, compared with nerve stimulation [108].
Obesity may be a risk factor for catheter related infection. In a large retrospective analysis, obesity was an
independent risk factor for peripheral, but not neuraxial, catheter related infections [109].
MANAGEMENT OF POSTOPERATIVE PAIN
A multimodal, opioid sparing approach to analgesia should be used for all patients, including the obese [110].
Multimodal opioid sparing analgesic strategies may include nonopioid analgesics (eg, acetaminophen,
nonsteroidal antiinflammatory drugs [NSAIDs]), regional anesthesia techniques (eg, local anesthetic wound
infiltration, neuraxial analgesia, peripheral nerve blocks), adjunctive medication (eg, systemic lidocaine,
ketamine, gabapentinoids, alpha-2 agonists), and nonpharmacologic therapy. (See "Management of acute
perioperative pain", section on 'Strategy for perioperative pain control'.)
Several studies have reported that protocols including local anesthetic wound infiltration and NSAIDs improved
postoperative pain scores and reduced postoperative opioid use after weight loss surgery [111-114].
Examples of studies involving perioperative pain management in obese patients include the following:
● In a few small trials, obese patients who received alpha-2 agonists (preoperative oral clonidine, or
intraoperative intravenous dexmedetomidine infusion) had lower opioid use than patients who did not, and
in some cases had decreased need for antiemetic drugs and shorter post-anesthesia care unit (PACU) stays
[115-118]. Similarly, a small study reported that preoperative infusion of ketamine with clonidine during
induction of anesthesia decreased opioid consumption after open gastric bypass surgery [119].
● In a small study, 30 patients were randomly assigned to receive fentanyl or a combination of nonopioid
analgesics (ie, ketorolac, clonidine, lidocaine, ketamine, magnesium sulfate, and methylprednisolone) for
gastric bypass surgery [120]. The nonopioid analgesics resulted in comparable analgesia and less sedation,
compared with fentanyl.
● In one study involving 50 patients who underwent laparoscopic gastric reduction surgery, patients
randomly assigned to an intraoperative lidocaine infusion had modestly reduced postoperative morphine
consumption, and improved quality of recovery, compared with controls who received saline [121].
● A single preoperative dose of gabapentin or pregabalin may reduce opioid consumption, pain scores, and
nausea and vomiting after bariatric surgery [122-124].
General considerations for the management of postoperative pain and aspects of analgesic management
specific to patients with obstructive sleep apnea (OSA) are discussed separately. (See "Postoperative
management of adults with obstructive sleep apnea", section on 'Pain control'.)
POST-ANESTHESIA CARE UNIT MANAGEMENT
Issues specific to the obese patient in the post-anesthesia care unit (PACU) are largely respiratory and
ventilatory. General care in the PACU, issues specific to patients with obstructive sleep apnea (OSA), and
postoperative care of the critically ill obese patient are discussed elsewhere. (See "Overview of post-anesthetic
care for adult patients" and "Postoperative management of adults with obstructive sleep apnea" and "Bariatric
surgery: Intensive care unit management of the complicated postoperative patient".)
● Respiratory monitoring – Patients should have continuous pulse oximetry in the PACU until they have
demonstrated that they can maintain adequate oxygenation when left unstimulated. If patients do not meet
this standard when otherwise ready to be discharged from the PACU, pulse oximetry monitoring should
continue when transferred to the hospital ward. Patients who cannot maintain adequate oxygenation when
left undisturbed should not be discharged from the hospital.
An arterial blood gas measurement is the best assessment for suspected hypoventilation, such as in
patients who are unable to maintain acceptable oxygen saturation despite supplementation, possibly with a
sustained decrease in level of consciousness. (See "Arterial blood gases".)
Although adequacy of ventilation is not routinely measured in the PACU, a high level of suspicion for
hypoventilation should be maintained in patients who remain sedated or become hypoxic despite
administration of oxygen. Hypoventilation due to sedative medication should be ruled out; pharmacologic
reversal of benzodiazepines or opioids may be used as clinically indicated. Often simply arousing a drowsy
patient with a reminder to breathe deeply is sufficient, but this may need to be repeated frequently. When
upper airway obstruction occurs, an oropharyngeal airway (if the patient is sedated), a nasopharyngeal
airway, or both, may open the airway and permit adequate ventilation. When these maneuvers are
insufficient, it is reasonable to assist these patients with noninvasive ventilation (NIV), which may keep them
from requiring reintubation. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits
and contraindications".)
Newer monitors for objective assessment of ventilation in spontaneously breathing patients have been
developed. Examples include impedance-based respiratory volume monitoring devices and acoustic
respiratory rate monitors. However, the role for these newer technologies in routine perioperative care is
yet to be determined.
● Maintaining adequate oxygenation – Obese patients are at greater risk for hypoxia in the postoperative
period, compared with non-obese patients, due to physiologic changes. (See 'Respiratory physiology'
above.)
Following extubation, the following measures may be used to maintain adequate oxygenation:
• Administration of oxygen, titrated to keep oxygen saturation at >90 percent (by face mask or nasal
cannula).
• Positioning patient in head-up (sitting or semi-sitting) or lateral position (if surgically acceptable).
• Use of incentive spirometry or chest physiotherapy. (See "Strategies to reduce postoperative pulmonary
complications in adults", section on 'Lung expansion'.)
We typically provide incentive spirometry devices to obese patients in the PACU, and suggest that they
use the device every 15 minutes. Incentive spirometry is noninvasive and inexpensive, but it may be
labor intensive to monitor and ensure patient use in a busy PACU.
The literature on the benefits of postoperative incentive spirometry or chest physiotherapy in obese
patients is conflicting, and results may depend on the surgical procedure and the protocol for incentive
spirometry. In a trial that included 60 obese patients (body mass index [BMI] 30 to 40 kg/cm2) who
underwent minor surgery with general anesthesia, patients were randomly assigned to incentive
spirometry administered by a respiratory therapist every 10 to 15 minutes, starting 15 minutes after
extubation, for the first two hours after surgery, versus standard PACU care without incentive
spirometry [125]. Patients who received incentive spirometry had improved oxygen saturation and
spirometric measures of lung function in the PACU and during the first 24 postoperative hours.
In contrast, in a randomized trial including approximately 200 patients who underwent bariatric
surgery, there were no differences in postoperative hypoxemia or pulmonary complications between
patients who received self-administered incentive spirometry when awake and those who had no
incentive spirometry [126].
• Administration of continuous positive airway pressure (CPAP) or other forms of NIV in patients with
hypoxia unresponsive to incentive spirometry. (See "Postoperative management of adults with
obstructive sleep apnea", section on 'Positive airway pressure therapy'.)
Postoperative CPAP may be as effective as other lung expansion maneuvers in non-obese patients; it is
reasonable to think that obese patients may benefit as well (see "Strategies to reduce postoperative
pulmonary complications in adults", section on 'Lung expansion'). The use of NIV is feasible in patients
with no previous experience with NIV, when applied by a trained respiratory therapist [127].
Despite concern that aspiration of air during CPAP treatment might cause disruption of fresh
anastomotic suture lines following intestinal surgery, studies of gastric bypass patients receiving CPAP
or other forms of NIV in the PACU have not shown an increased risk for anastomotic leak [128-130].
Following gastrointestinal surgery such as gastric bypass, we prefer early joint decision making
between anesthesiologist, surgeon, respiratory technician, and nurse to determine CPAP or other NIV
use in selected patients, emphasizing the team concept for the perioperative care of these patients
[111].
DISCHARGE CRITERIA
Evidence regarding the optimal duration of postoperative monitoring for morbidly obese patients is lacking. We
follow the standard considerations for the discharge of surgical patients, such as those published by the
American Society of Anesthesiologists (ASA) [131]. Prior to transfer of the patient to an unmonitored setting,
oxygen saturation on room air should return to preoperative baseline, and when left undisturbed the patient
should not develop clinical hypoxemia or airway obstruction [132]. We extend use of these recommendations to
all severely obese patients, with a low threshold for prolonged recovery room monitoring based upon the
individual patient's course. The decision to discharge obese patients with diagnosed or likely OSA should take
into account the ability to use CPAP, the need for opioid medication, and comorbid medical conditions [133].
Postoperative management of OSA is discussed elsewhere. (See "Postoperative management of adults with
obstructive sleep apnea".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world
are provided separately. (See "Society guideline links: Sleep-related breathing disorders in adults".)
SUMMARY AND RECOMMENDATIONS
● Respiratory physiologic changes in obese patients include an increase in oxygen consumption and a
decreased functional residual capacity, leading to a rapid decrease in oxygen saturation during apneic
periods.
Increased blood volume, decreased systemic vascular resistance, and increased cardiac output may lead to
either left or right heart failure or both. (See 'Physiologic changes associated with obesity' above.)
● Drug doses in obese patients depend on the pharmacokinetic and pharmacodynamic parameters of the
specific drug ( table 2); when specific recommendations are not available, it is reasonable to base drug
doses on adjusted body weight (AdjBW). (See 'Dosing anesthetic drugs' above.)
● Although no anesthetic technique has been found to be superior to another with respect to important
patient outcomes (eg, mortality, cardiopulmonary complications) in obese patients, the requirement for
general anesthesia is carefully examined and alternatives are chosen when possible to minimize airway and
drug-related respiratory problems. No specific induction or maintenance agent has been shown to result in
improved clinical outcomes when compared with others. (See 'Choice of anesthetic technique' above and
'Induction' above and 'Maintenance' above.)
● Opioid and sedative administration should be minimized to decrease the risk of respiratory depression,
particularly in patients with obstructive sleep apnea. In severely obese patients, pain control with opioid-
sparing multimodal analgesia may reduce the risk of respiratory depression and other opioid- and sedative-
related side effects. This may include the use of local or regional anesthesia, nonsteroidal anti-inflammatory
drugs, acetaminophen, alpha-2 agonists, and other medications. (See 'Management of postoperative pain'
above.)
● When general anesthesia is used in obese patients, we recommend adequate pre-oxygenation (with
continuous positive airway pressure [CPAP] if tolerated) and induction in a trunk and head-up (preferably
reversed Trendelenburg) position to improve oxygenation and tolerance for apneic periods without
desaturation (Grade 1B). Mask ventilation may be more difficult and intubation may be more challenging in
obese patients. When difficulty with both is anticipated, it may be prudent to perform awake intubation.
Equipment and skilled personnel to assist with a difficult or failed airway should be readily available. (See
'Airway management' above.)
● In patients with obesity, during general anesthesia we measure intermittent non-invasive blood pressure no
less than every three minutes, and more often as needed, to identify and treat low blood pressure and avoid
prolonged hypotension. A standard blood pressure cuff may not fit the conical shape of the upper arm in
the patient with obesity, making noninvasive blood pressure monitoring challenging. Invasive arterial blood
pressure monitoring should be considered when surgical and/or patient conditions suggest a critical need
for accurate blood pressure monitoring
A forearm cuff may be used if an upper arm blood pressure cuff fits poorly. Newer continuous finger cuff
blood pressure technologies may be a reasonable alternative when an upper arm blood pressure cuff is
unsuitable. (See 'Blood pressure monitoring' above.)
● We recommend the use of a lung protective ventilation strategy for obese patients who require mechanical
ventilation (Grade 1C).
Our strategy includes the following (see 'Ventilation management' above):
• Set tidal volume (TV) of 6 to 8 mL/kg ideal body weight (IBW) (calculator 2)
• Adjust respiratory rate to maintain normocapnia (permissive hypercapnia is acceptable in patients

without pulmonary hypertension)
• Adjust fraction of inspired oxygen (FiO2) to maintain peripheral arterial oxygen saturation (SpO2) >92
percent (ideally below 0.5 to 0.8), to prevent resorption atelectasis and oxygen toxicity
• Employ individualized positive end-expiratory pressure (PEEP) to optimize driving pressure and lung
compliance so as to follow an "open lung" concept
• Use recruitment maneuvers judiciously during anesthesia (ideally delivered by a stepwise

increase/decrease in PEEP and TV respectively to a plateau pressure >40 but <55 cm H2O) to improve
oxygenation when needed
• Maintain head-up (reverse Trendelenburg) position, whenever feasible
● Postoperative oxygenation should be monitored until patients can maintain adequate oxygenation when
left unstimulated. A reasonable approach to hypoxia and hypoventilation is to maintain a head-up position
with oxygen by face mask and encouragement to breathe deeply, followed by a trial of CPAP or other
noninvasive ventilation (NIV), with reintubation for the refractory patient. (See 'Post-anesthesia care unit
management' above.)
● Prior to transfer to an unmonitored setting, oxygen saturation on room air should return to preoperative
baseline, and when left undisturbed, the patient should not develop clinical hypoxemia or airway
obstruction. (See 'Discharge criteria' above.) [134-141]
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Topic 14932 Version 46.0

GRAPHICS
Cardiovascular physiologic changes in obesity
Proposed pathophysiology of obesity cardiomyopathy. This diagram shows the central hemodynamic
alterations that result from excessive adipose accumulation in severely-obese patients and their subsequent
effects on cardiac morphology and ventricular function. LV hypertrophy in severe obesity may be eccentric or
concentric. Factors influencing LV remodeling and geometry include severity and duration of obesity, duration
and severity of adverse LV loading conditions (particularly hypertension), and, possibly, neurohormonal and
metabolic abnormalities, such as increased sympathetic nervous system tone, activation of the renin-
angiotensin-aldosterone system, insulin resistance with hyperinsulinemia, leptin resistance with
hyperleptinemia, adiponectin deficiency, lipotoxicity, and lipoapoptosis. These alterations may contribute to the
development of LV failure. LV failure, facilitated by pulmonary arterial hypertension from sleep apnea/obesity
hypoventilation, may subsequently lead to RV failure.
LV: left ventricle; RV: right ventricle.
Reproduced from: Alpert MA, Omran J, Mehra A, Ardhanari S. Impact of obesity and weight loss on cardiac performance and
morphology in adults. Prog Cardiovasc Dis 2014; 56:391. Illustration used with the permission of Elsevier Inc. All rights
reserved.
Graphic 90114 Version 2.0
Comparison of cardiac structural and hemodynamic alterations in patients with morbid obesity and
hypertension
Obesity alone Hypertension alone Obesity and hypertension
Variable
Heart rate Normal Normal Normal
Blood pressure Normal Increased Increased
Stroke volume Increased Normal Increased
Cardiac output Increased Normal Increased
Systemic vascular resistance Decreased Increased Normal or increased
LV volume Increased Normal Increased
LV wall stress Normal or increased Normal or increased Increased
LV hypertrophy Eccentric Concentric Hybrid
LV diastolic dysfunction Usually present Usually present Usually present
LV systolic dysfunction Occasionally present Usually absent Occasionally present
LV failure Occasionally present Occasionally present Commonly present
RV hypertrophy Occasionally present Usually absent Occasionally present
RV enlargement Occasionally present Usually absent Occasionally present
RV failure Occasionally present Usually absent Occasionally present
LV: left ventricular; RV: right ventricular.
Adapted from: Alpert MA, Hashimi MW. Obesity and the heart. Am J Med Sci 1993; 306:117.

Intravenous anesthetic drug dosing for obese patients [1-20]
Drug Weight for dosing Notes
Sedative/hypnotics
Propofol bolus doses AdjBW
Propofol maintenance AdjBW Titrate to clinical endpoint.

infusions
Etomidate AdjBW
Ketamine AdjBW
Thiopental AdjBW Doses should be adjusted for high or low cardiac output, and rapid redistribution may
result in more rapid awakening after a single bolus dose than in lean patients.
Midazolam (and other TBW For sedation, usually dosed in small increments (eg, midazolam 1 mg IV) titrated to effect.
benzodiazepines) bolus Caution should be exercised as patients with OSA may have increased central sensitivity to
doses the sedative and respiratory effects of benzodiazepines. TBW is used for induction of
anesthesia, due to high lipophilicity and thus increased volume of distribution in obese
patients.
Midazolam (and other AdjBW Titrate to effect.

benzodiazepines)
continuous infusions
Dexmedetomidine TBW Titrate to effect. Dose adjustments may be required for comorbidities or other sedative or
anesthetic drugs used concomitantly.
Opioids
Synthetic opioids TBW When possible, titrate to effect.

(fentanyl, sufentanil,
alfentanil, and
remifentanil)
Morphine IBW Initial dosing should be based on IBW and further administration titrated to effect.
Hydromorphone IBW As with morphine, initial dosing is based on IBW and then further titrated to effect.
Lidocaine, systemic
Bolus AdjBW
Infusion AdjBW
Neuromuscular blocking agents
Nondepolarizing agents IBW versus TBW The dosing scalar will depend on the clinical circumstance. In general, a higher (ie, closer to
(eg, vecuronium, TBW) intubating dose will result in faster onset and shorter time to complete NMB, but a
rocuronium) longer duration of action. An IBW-based dosing will prolong the time to ideal intubating
conditions, but assure a faster recovery from NMB.
Succinylcholine TBW
Reversal agents
Sugammadex AdjBW
Neostigmine AdjBW
The optimal method for calculating weight based doses of many medications in obese patients is unclear, with limited available literature. When
possible and appropriate, anesthetic medications should be titrated to effect with incremental doses or incrementally adjusted infusions. The dosing
strategy in this table is based on available pharmacokinetic and pharmacodynamic data in obesity, such data in non-obese patients, clinical
experience, and the clinical use of the drug.
AdjBW: adjusted body weight; TBW: total body weight; IV: intravenous; OSA: obstructive sleep apnea; IBW: ideal body weight; NMB: neuromuscular blockade.
References:
1. Wada DR, Björkman S, Ebling WF, et al. Computer simulation of the effects of alterations in blood flows and body composition on thiopental pharmacokinetics in
humans. Anesthesiology 1997; 87:884.
2. Ingrande J, Brodsky JB, Lemmens HJ. Lean body weight scalar for the anesthetic induction dose of propofol in morbidly obese subjects. Anesth Analg 2011; 113:57.
3. Echevarria GC, Elgueta MF, Donosoto MT, et al. The effective effect-site propofol concentration for induction and intubation with two pharmacokinetic models in
morbidly obese patients using total body weight. Anesth Analg 2012; 115:823.
4. Greenblatt DJ, Abernethy DR, Locniskar A, et al. Effect of age, gender, and obesity on midazolam kinetics. Anesthesiology 1984; 61:27.
5. Feld J, Hoffman WE. Response entropy is more reactive than bispectral index during laparoscopic gastric banding. J Clin Monit Comput 2006; 20:229.
6. Bakhamees HS, El-Halafawy YM, El-Kerdawy HM, et al. Effects of dexmedetomidine in morbidly obese patients undergoing laparoscopic gastric bypass. Middle East
J Anesthesiol 2007; 19:537.
7. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth
Analg 2008; 106:1741.
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9. Leykin Y, Pellis T, Lucca M, et al. The effects of cisatracurium on morbidly obese women. Anesth Analg 2004; 99:1090.
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11. Abernethy DR, Greenblatt DJ. Lidocaine disposition in obesity. Am J Cardiol 1984; 53:1183.
12. Schwartz AE, Matteo RS, Ornstein E, et al. Pharmacokinetics of sufentanil in obese patients. Anesth Analg 1991; 73:790.
13. Scholz J, Steinfath M, Schulz M. Clinical pharmacokinetics of alfentanil, fentanyl and sufentanil. An update. Clin Pharmacokinet 1996; 31:275.
14. Egan TD, Huizinga B, Gupta SK, et al. Remifentanil pharmacokinetics in obese versus lean patients. Anesthesiology 1998; 89:562.
15. Schwartz AE, Matteo RS, Ornstein E, et al. Pharmacokinetics and pharmacodynamics of vecuronium in the obese surgical patient. Anesth Analg 1992; 74:515.
16. Pühringer FK, Keller C, Kleinsasser A, et al. Pharmacokinetics of rocuronium bromide in obese female patients. Eur J Anaesthesiol 1999; 16:507.
17. Rose JB, Theroux MC, Katz MS. The potency of succinylcholine in obese adolescents. Anesth Analg 2000; 90:576.
18. Jung D, Mayersohn M, Perrier D, et al. Thiopental disposition in lean and obese patients undergoing surgery. Anesthesiology 1982; 56:269.
19. De Oliveira GS Jr, Duncan K, Fitzgeral P, et al. Systemic Lidocaine to Improve Quality of Recovery after Laparoscopic Bariatric Surgery: A Randomized Double-
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20. Carabalona JF, Delwarde B, Duclos A, et al. Serum Concentrations of Lidocaine During Bariatric Surgery. Anesth Analg 2020; 130:e5.

Factors affecting drug pharmacokinetics in obesity [1]
Volume of distribution
Increased fat mass
Increased lean body mass
Increased total body water
Increased blood volume
Increased cardiac output
Organomegaly
Protein binding*
Possible increased lipoproteins (eg, cholesterol or triglycerides)
Altered alpha1-acid glycoprotein
Drug metabolism
Increased activity of some CYP P450 enzymes ¶
Increased phase II drug metabolism via glucuronidation and sulfation
Excretion
Increased renal blood flow
Increased GFR
Increased renal tubular secretion and reabsorption
Individual organ system comorbid conditions
Pharmacokinetics for many drugs have not been well studied in obese patients, and depend on the degree of lipophilicity or hydrophilicity, protein
binding, and mechanisms of metabolism and excretion. The increased volume of distribution can prolong the half-life of elimination, particularly for
lipophilic drugs and prolonged infusion, despite increased drug clearance. Alterations in body composition and physiologic parameters vary with the
degree of obesity, and may be affected by comorbidities that are commonly associated with obesity (eg, diabetes mellitus, hypertension,
cardiovascular disease, fatty liver disease) or other etiologies.
CYP: cytochrome; GFR: glomerular filtration rate.

* The effects of obesity on various plasma proteins have not been well established, and may vary among patients. Serum albumin is generally unchanged in
obesity.

¶ Effects of obesity on the CYP enzymes is variable among the different enzymes. Obesity increases activity of CYP2E1, but studies on the effects of obesity on
other isozymes are inconsistent.
Reference:
1. Shenkman Z, Shir Y, Brodsky JB. Perioperative management of the obese patient. Br J Anaesth 1993; 70:349.

Ideal body weight and approximate lean body weight in obesity (adult)
Approximate LBW in
Height (in) Height (cm) IBW* (kg)
class III obesity ¶ (kg)
Female (adult) 60 152 46 52
65 165 57 60
70 178 68 70
75 191 80 80
Male (adult) 60 152 50 63
65 165 62 73
70 177 76 85
75 191 89 97
80 203 103 112
IBW: ideal body weight; LBW: lean body weight; TBW: total body weight; BMI: body mass index
* IBW male = 50 + (2.3 x height in inches over 5 feet); IBW female = 45.5 + (2.3 x height in inches over 5 feet).
¶ Approximate LBW in class III obesity (BMI 40-45 kg/m2) for dosing emergency drugs; LBW estimate (kg) = (9270 x TBW)/(A + B x BMI) where A and B are 6680
and 216 respectively for males and 8780 and 244 respectively for females.
Formulas from: Devine BJ. Drug Intell Clin Pharm 1974; 8:560 and Hanley, MJ et al. Clin Pharmacokinet 2010; 49:71.

Fasting guidelines of international anesthesia societies
Fasting requirements at time of

Country, year Comments
induction
American Society of Anesthesiologists, 2017 [1] 2 hours clear liquids, not including alcohol Healthy patients, elective surgery, pregnant
4 hours breast milk patients not in labor
6 hours nonhuman milk, infant formula, light Light meal defined as toast or cereal with
meal clear liquid
8 hours or more fried or fatty food or meat
European Society of Anesthesiology, 2011 [2,3] 2 hours clear liquids Applies to patients with obesity, diabetes,
1 hour clear liquids for children GERD, nonlaboring pregnant patients
4 hours breast milk Encourages oral fluid up to 2 hours prior to
6 hours milk, infant formula, solid food induction
Chewing gum and sucking hard candy

allowed up until time of induction
Canadian Anesthesiologists' Society, 2014 [4,5] 2 hours clear liquids

1 hour clear liquids for children
4 hours breast milk
6 hours light meal, infant formula, and
nonhuman milk
8 hours meat, fried, or fatty food
Association of Anaesthetists in Great Britain and 2 hours clear liquids Gum chewing should be treated as clear
Ireland, 2010 [3,6] 1 hour clear liquids for children
4 hours breast milk
6 hours solid food, infant formula, and cow's
milk
Scandinavian Society of Anaesthesiology and 2 hours clear liquids 2 hours for preoperative carbohydrate drinks
Intensive Care Medicine, 2005 [7] 4 hours breast milk and infant formula intended for preoperative nutrition
6 hours solid food and cow's milk
2 hours chewing gum and any form of
tobacco
Up to 1 hour prior to induction, 150 mL water
German Society of Anesthesiology and Intensive 2 hours clear liquids

Care, 2004 [8] 4 hours breast milk and infant formula
6 hours meal
Australian and New Zealand College of 2 hours clear liquids, all ages Encourages oral fluid up to 2 hours prior to
Anaesthetists, 2016 [9] 3 hours breast milk for infants <6 months of induction
age Up to 200 mL clear liquids per hour up until
4 hours formula for infants <6 months of age two hours prior to induction for adults
6 hours breast milk, formula, limited solid
food for children >6 months of age and adults
GERD: gastroesophageal reflux disease.
References:
1. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients
Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic
Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017; 126:376.
2. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;
28:556.
3. Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Paediatr Anaesth 2018;
28:411.
4. Dobson G, Chow L, Filteau L, et al. Guidelines to the Practice of Anesthesia - Revised Edition 2020. Can J Anaesth 2020; 67:64.
5. Rosen D, Gamble J, Matava C, Canadian Pediatric Anesthesia Society Fasting Guidelines Working Group. Canadian Pediatric Anesthesia Society statement on clear
fluid fasting for elective pediatric anesthesia. Can J Anaesth 2019; 66:991.
6. Association of anaesthetists of Great Britain and Ireland. Peroperative Assessment and Patient Preparation. Available at:
http://www.aagbi.org/sites/default/files/preop2010.pdf (accessed 2/1/18).
7. Søreide E, Eriksson LI, Hirlekar G, et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand 2005; 49:1041.
8. Praoperaives Nuchternheitsdebot bei Elektiven Eingriffen AU Verbankdmitteilung DGAI SO Anesthesiol Intensivmed. 2004;12:722
9. Australian and New Zealand College of Anaesthetists. Guidelines on Pre-Anaesthesia Consultation and Patient Preparation. Available at
https://www.anzca.edu.au/resources/professional-documents/guidelines/ps07bp-guidelines-on-pre-anaesthesia-consultation (Accessed on February 1, 2018).

American Society of Anesthesiologists difficult airway algorithm
SGA: supraglottic airway; LMA: laryngeal mask airway; ILMA: intubating laryngeal mask airway.
* Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO 2 .
¶ Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.
Δ Other options include (but are not limited to): surgery utilizing face mask or supraglottic airway (SGA) anesthesia (eg, LMA, ILMA, laryngeal tube), local anesthesia
infiltration, or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of
limited value if this step in the algorithm has been reached via the Emergency Pathway.
◊ Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (eg, LMA or ILMA) as
an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, and blind oral or nasal intubation.
§ Emergency noninvasive airway ventilation consists of a SGA.
¥ Consider re-preparation of the patient for awake intubation or canceling surgery.
Reproduced with permission from: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American
Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251. DOI: 10.1097/ALN.0b013e31827773b2. Copyright © 2013 by the
American Society of Anesthesiologists, Inc. Unauthorized reproduction of this material is prohibited.

Airway Approach Algorithm for anesthesia
A decision tree approach to entry in the American Society of Anesthesiologists Difficult Airway Algorithm.
TTJV: transtracheal jet ventilation.
Modified with permission from: Rosenblatt WH, Sukhupragarn W. Airway Management. In: Clinical Anesthesia, 7th ed, Barash
PG, Cullen BF, Stoelting RK, et al. (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott Williams
& Wilkins. www.lww.com.

Ramp position illustration
In the ramp position, the patient's head and torso are elevated such that the external auditory
meatus and the sternal notch are horizontally aligned (black line). This position allows for a better
view of the glottis in patients with obesity and should be used unless there are contraindications
(eg, possible cervical spine injury).

Suggested contents of difficult airway cart in the operating room
Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope.
Videolaryngoscope.
Tracheal tubes of assorted sizes.
Tracheal tube guides. Examples include (but are not limited to) semirigid stylets, ventilating tube-changer, light wands, and forceps designed to
manipulate the distal portion of the tracheal tube.
Supraglottic airways (eg, LMAs or ILMAs of assorted sizes for noninvasive airway ventilation/intubation).
Flexible fiberoptic intubation equipment.
Equipment suitable for emergency invasive airway access.
An exhaled carbon dioxide detector.
The items listed in this table represent suggestions. The contents of the portable storage unit should be customized to meet the specific needs,
preferences, and skills of the practitioner and healthcare facility.
LMA: laryngeal mask airway; ILMA: intubating LMA.
From: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of
Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013; 118:251. DOI: 10.1097/ALN.0b013e31827773b2. Copyright © 2013 American
Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

Comparison of neuraxial anesthesia techniques
Technique Advantages Disadvantages
Single shot spinal Rapid onset of block Limited duration of action

Reliably symmetric block, including sacral nerve roots Limited ability to extend block
Low doses of local anesthetic and opioids Requires dural puncture
Technically easy
Epidural Can prolong the duration and extend block Relatively slow onset of anesthesia*
Relatively slow onset of anesthesia* Higher doses of local anesthetics and opioids than spinal
May be used to provide postoperative analgesia High risk of PDPH with unintentional dural puncture
Possibility of patchy or asymmetric block
Unreliable sacral block
Combined spinal-epidural Rapid onset of block May take longer than single shot spinal
Reliably symmetric block, including sacral nerve roots Delayed confirmation of functional epidural catheter ¶
Can prolong the duration and extend block
Option to titrate level of block
Low doses of local anesthetic and opioids (spinal
component)
May be used to provide postoperative analgesia
Continuous spinal Rapid onset of block High incidence of PDPH with large dural puncture
Reliably symmetric block, including sacral nerve roots Possible higher risk of medication errors leading to a
Can prolong the duration and extend block high spinal
Low doses of local anesthetic and opioids
Option to titrate onset of block
PDPH: post-dural-puncture headache.
* Speed of onset of anesthesia depends on the drug, speed of medication administration, concentration, and volume of the epidural solution. Slower onset may
be a disadvantage in some clinical situations (eg, emergency cesarean delivery), but may be an advantage for patients who would benefit from slow onset of
sympathectomy (eg, patients with preload dependent cardiac lesions).
¶ Sequential combined spinal-epidural (CSE) technique verifies epidural catheter function soon after placement.

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● (See "Preanesthesia medical evaluation of the obese patient".)

PHYSIOLOGIC CHANGES ASSOCIATED WITH OBESITY

Respiratory physiology — Obesity-related respiratory changes occur as a consequence of physical

Consequences of these changes of concern to anesthesiologists include the following:

● Decreased time to desaturation during apnea [12]

Cardiovascular physiology — Cardiovascular physiologic changes in obesity include:

● Decreased systemic vascular resistance [14,15].

● Increased cardiac output by 20 to 30 mL per kilogram of excess body fat.

● Left ventricular hypertrophy, related to the duration of obesity [17].

DOSING ANESTHETIC DRUGS

AdjBW = IBW + 0.4 [TBW – IBW]

CHOICE OF ANESTHETIC DRUGS

SPECIAL EQUIPMENT NEEDS

● Specialized or extra equipment for positioning – (See 'Patient positioning' below.)

PATIENT PREPARATION FOR ANESTHESIA

● Head-up position (reverse Trendelenburg, or semi-sitting/"semi-Fowler") – Upright or semiupright

● Patients with BMI >40 kg/m2

Positioning for airway management — Preoxygenation is ideally performed in head-up (reverse

Preoxygenation and apneic oxygenation — Preoxygenation is used to increase oxygen reserves in order

● Set TV of 6 to 8 mL/kg ideal body weight (IBW) (calculator 2).

● In a 2012 meta-analysis of studies of ventilation strategies (pressure- or volume-controlled ventilation, tidal

Reversal of neuromuscular blockade — Neuromuscular blockade may be reversed using either

MANAGEMENT OF POSTOPERATIVE PAIN

POST-ANESTHESIA CARE UNIT MANAGEMENT

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

Our strategy includes the following (see 'Ventilation management' above):

• Adjust respiratory rate to maintain normocapnia (permissive hypercapnia is acceptable in patients

• Use recruitment maneuvers judiciously during anesthesia (ideally delivered by a stepwise

• Maintain head-up (reverse Trendelenburg) position, whenever feasible

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Topic 14932 Version 46.0

Cardiovascular physiologic changes in obesity

LV: left ventricle; RV: right ventricle.

Obesity alone Hypertension alone Obesity and hypertension

Heart rate Normal Normal Normal

Blood pressure Normal Increased Increased

Stroke volume Increased Normal Increased

Cardiac output Increased Normal Increased

Systemic vascular resistance Decreased Increased Normal or increased

LV volume Increased Normal Increased

LV wall stress Normal or increased Normal or increased Increased

LV hypertrophy Eccentric Concentric Hybrid

LV diastolic dysfunction Usually present Usually present Usually present

LV systolic dysfunction Occasionally present Usually absent Occasionally present

LV failure Occasionally present Occasionally present Commonly present

RV hypertrophy Occasionally present Usually absent Occasionally present

RV enlargement Occasionally present Usually absent Occasionally present

RV failure Occasionally present Usually absent Occasionally present

LV: left ventricular; RV: right ventricular.

Graphic 74883 Version 3.0

Drug Weight for dosing Notes

Propofol bolus doses AdjBW

Propofol maintenance AdjBW Titrate to clinical endpoint.

Midazolam (and other AdjBW Titrate to effect.

Synthetic opioids TBW When possible, titrate to effect.

Neuromuscular blocking agents

Graphic 90705 Version 6.0

Increased fat mass

Increased lean body mass

Increased total body water