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Morbid obesity and optimization of preoperative fluid therapy
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. (Heart centre)
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
2013 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 23, no 11, 1799-1805 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Preoperative venous return (VR) optimization and adequate blood volume is essential in management of morbidly obese patients (MO) in order to avoid perioperative circulatory instability. In this study, all subjects underwent a preoperative 3-week preparation by rapid-weight-loss-diet (RWL) as part of their treatment program for bariatric surgery.

METHODS: This is a prospective, observational study of 34 morbidly obese patients consecutively scheduled for bariatric surgery at Sunderby County Hospital, Lulea, Sweden. Preoperative transthoracic echocardiography (TTE) was performed in the awake state before and after intravascular volume challenge (VC) of 6 ml colloids/kg ideal body weight (IBW). Effects of standardized VC were evaluated by TTE. Dynamic and non-dynamic echocardiographic indices for VC were studied. Volume responsiveness and level of VR before and after VC were assessed by TTE. An increase of stroke volume >/=13 % was considered as a volume responder.

RESULTS: Twenty-nine out of 34 patients were volume responders. After VC, a majority of patients (23/34) were euvolemic, and only 2/34 were hypovolemic. Post-VC hypervolemia was observed in 9/34 of patients.

CONCLUSIONS: The IBW-based volume challenge regime was found to be suitable for preoperative rehydration of RWL-prepared MO. Most of the patients were volume responders. Preoperative state of VR was not associated with volume responsiveness. IBW estimates and appropriate monitoring avoids potential hyperhydration in MO. For VC assessment, conventional Doppler indices were found to be more suitable compared to tissue Doppler, giving sufficient information on pressure-volume correlation of the left ventricle in morbidly obese.

Place, publisher, year, edition, pages
Springer Science+Business Media B.V., 2013. Vol. 23, no 11, 1799-1805 p.
Keyword [en]
Morbid obesity, Preoperative volume challenge, Transthoracic echocardiography, TTE, Rapid weight loss, Bariatric surgery, Diastolic function, Rehydration, Venous return
National Category
Anesthesiology and Intensive Care
URN: urn:nbn:se:umu:diva-71363DOI: 10.1007/s11695-013-0987-yISI: 000325185500012PubMedID: 23695437OAI: diva2:623371
Available from: 2013-05-27 Created: 2013-05-27 Last updated: 2014-04-14Bibliographically approved
In thesis
1. Assessment and management of bariatric surgery patients
Open this publication in new window or tab >>Assessment and management of bariatric surgery patients
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In morbidly obese individuals (MO) cardiorespiratory comorbidities and body habitus challenge the perioperative management of anesthesia. To implement safe and reproducible routines for anesthesia and fluid therapy is the cornerstone in order to minimize anesthesia-related complications and to meet individual variability in rehydration needs.

Methods: Paper I: Impact of rapid-weight-loss preparation prior to bariatric surgery was investigated. Prevalence of preoperative dehydration and cardiac function were assessed with transthoracic echocardiography (TTE). Paper II: The anesthetic technique for rapid sequence induction (RSI) in MO based on a combination of volatile and i.v. anesthetics was developed. Pre- and post-induction oxygenation, blood pressure levels and feasibility of the method was evaluated. Paper III: The preoperative ideal body weight based rehydration regime was evaluated by TTE. Paper IV: Need of rehydration during bariatric surgery was evaluated by comparing conventional monitoring to a more advanced approach (i.e. preoperative TTE and arterial pulse wave analysis).

Results: Rapid-weight-loss preparation prior to bariatric surgery may expose MO to dehydration. TTE was shown to be a robust modality for preoperative screening of the level of venous return, assessment of filling pressures and biventricular function of the heart in MO. The combination of sevoflurane, propofol, alfentanil and suxamethonium was demonstrated to be a safe method for RSI regardless of BMI. The preoperative rehydration regime implemented by colloids 6 ml/kg IBW was an adequate treatment to obtain euvolemia. In addition, preoperative rehydration seems to increase hemodynamic stability during intravenous induction of anesthesia and even intraoperatively.

Conclusion: This thesis describes a safe and comprehensive perioperative management of morbidly obese individuals scheduled for bariatric surgery. Hemodynamic and respiratory stability can be achieved by implementation of strict and proven methods of anesthesia and fluid therapy. Much focus should be placed on feasible monitoring and preoperative optimization in morbidly obese individuals for increased perioperative safety.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2014. 86 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1632
Bariatric surgery, morbid obesity, anesthesia, echocardiography, fluid therapy, preoperative, perioperative, venous return, rehydration, volatile rapid sequence induction, spontaneous breathing, sevoflurane.
National Category
Anesthesiology and Intensive Care
Research subject
urn:nbn:se:umu:diva-87546 (URN)978-91-7459-807-0 (ISBN)
Public defence
2014-05-16, Stora Aulan, Sunderby Sjukhus, 97180 Luleå, 09:00 (Swedish)
Available from: 2014-04-11 Created: 2014-04-02 Last updated: 2014-04-14Bibliographically approved

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