J P Mulier, MD PhD B Dillemans, MD

1. Solutions for difficult situations in bariatric surgery : What to do ? The real risk patient in Anaesthesia J P Mulier, MD PhD B Dillemans, MD

2. High risk in bariatric surgery • Pulmonary diseases • Asthma • COPD • Cardiac disease • Right ventricular failure • Coronary atheromatose • Muscle disease • Seldom obese patients, however • Other rarities • Search active for them / dangerous for every anesthesia CHL 12 06 2009 J P Mulier

3. Is there a risk ? • According to the media: yes! Bariatric surgery kills 5 percent of patients: Weight loss surgery takes deadly toll Wednesday, March 22, 2006 by: Mike Adams, the Health Ranger, NaturalNews Editor • According to the scientific publications: overall 10 year mortality decreased with 24 % SOS study Sjöström 2008 CHL 12 06 2009 J P Mulier

4. Individual risk pre op? Which patient is at risk ? • Very high BMI ? • 70 > 60 > 50 CHL 12 06 2009 J P Mulier

5. The higher the BMI the higher the risk? • Not the BMI itself but • Central fat intra abdominal: apple > pear • No weight reduction is a risk • Not absolute weight. -30 kg creates space to breath, laparoscopic work space, improved liver function • Higher BMI more difficult but not a higher risk? • Table positioning • Intubation positioning • Mobilization in bed • Aspiration risk at induction • Post operative insufficient breathing CHL 12 06 2009 J P Mulier

6. Individual risk pre op? Which patient is at risk ? • High BMI ? • Older patient ? • Less frequent in bariatrics, but … CHL 12 06 2009 J P Mulier

7. Individual risk pre op? Which patient is at risk ? • High BMI ? • Older patient ? • Diabetes ? • Many co morbidities • Frequent glucose follow up lower risks? CHL 12 06 2009 J P Mulier

8. Individual risk pre op? Which patient is at risk ? • High BMI ? • Older patient ? • Diabetes ? • Sleep apnea ? CHL 12 06 2009 J P Mulier

9. Sleep apnea patient high risk? • Is a clinical diagnosis of sleep disturbance, • not of post operative hypoxia • no study yet confirms risk. No numbers of resp obstruction post op! • Use cpap mask post op if used at home • Active search pre op ? CHL 12 06 2009 J P Mulier

10. Individual risk pre op? Which patient is at risk ? • High BMI ? • Older patient ? • Diabetes ? • Sleep apnea ? Which patient has complications ? • What are the most frequent complications? CHL 12 06 2009 J P Mulier

11. 30 days Complications in 2606 gastric bypass sint Jan Brugge B Dillemans 2009 CHL 12 06 2009 J P Mulier

12. Complications and anaesthesia • Hemorrhage Surgical problem but we can help to prevent it • Post operative re-intubation, ventilation -> pneumonia Anaesthesiological problem: • Leakage Surgical problem but we can help to prevent. Transdisciplinary: we as anesthesiologists must think: Ask not what the surgeon can do for you, ask what you can do for the surgeon CHL 12 06 2009 J P Mulier

13. 1. Post operative hemorrhage • Ask your anesthesiologist to raise the blood pressure above 140 mmHg SAP at end of procedure. • Inspect and stop local bleeding • Coagulate, clip, stitch • Ask to control intra luminal bleeding by pouch aspiration test before extubation. CHL 12 06 2009 J P Mulier

14. Prevent per op bleeding: Search active 110/57 145/78 J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric bypass surgery. Obes Surg 2007; 17: 1051 CHL 12 06 2009 J P Mulier

15. Aspiration test to detect intra luminal bleeding • Treat if red blood detected CHL 12 06 2009 J P Mulier

16. 2. Leakage • Ask your anesthesiologist • To perform a good leakage test. • To keep blood pressure sufficient during inspection for ischemia • JPMulier B Dillemans 2007 • To increase cardiac output and splanchnic perfusion by • Raising end tidal CO2 • Give sufficient volume expansion • Work at lowest IAP possible • JPMulier B Dillemans 2008 CHL 12 06 2009 J P Mulier

17. Post operative pneumonia due to A: Aspiration at induction Mask ventilation with oxygen? Sufficient O2 when mask cpap Rapid sequence? No mask ventilation Risk of hypoxia ! Re-intervention after band, bypass, stenosis, … Crush induction? (Crocoid pressure) Sellick maneuver even more dangerous! Difficult intubation: risk of blood aspiration Empty stomach, use safety bird, CHL 12 06 2009 J P Mulier

18. Post operative pneumonia due to B: Silent aspiration during surgery ? Cuffed tube leaks! Use KY gel or taperguard tube CHL 12 06 2009 J P Mulier

19. Methyleen blue leak testJ P Mulier B Dillemans 2009 CHL 12 06 2009 J P Mulier

20. Post operative pneumonia due to C: Post extubation aspiration ? • Superficial breathing • Use pressure support during end of operation • Non invasive support ventilation • Insufficient decurarization • Use Brideon • Not fully awake • Use short acting desflurane, remifentanyl, pressure support,… CHL 12 06 2009 J P Mulier

21. Hypercapnic pressure support ventilation JPMulier 2008 • Increases cardiac output • Less wound infections • Lowers airway pressures • Improves saturation per op • Rapid awakening and spontaneous breathing • Non surgical time between OP < 20 min • Less pain when awakening • Extra doses morphine given during end of surgery • Better post op breathing • less post op aspiration pneumonia CHL 12 06 2009 J P Mulier

22. Turn over time is very shortASA 2008 JPMulier • A: induction next pat before awakening prev • B: use pre induction room without anesthesia • C: no use of pre induction room • Multifactorial • Pre induction room? • Rapid awakening techniques • Active management, supporting all team members to improve quality results in time gain! • Know what you do, simplify • Do it right from the first time CHL 12 06 2009 J P Mulier

23. Conclusion • J F Kennedy: • Inventor of the transdisciplinarity • ‘Ask not only what the anaesthesiologist can do for you, ask also what you can do for the anaesthesiologist.’ CHL 12 06 2009 J P Mulier

24. Make your anaesthesiologist member of ESPCOP • And he will ask you what he can do for you! CHL 12 06 2009 J P Mulier

25. Scientific meeting CHL 12 06 2009 J P Mulier

26. Be a transdisciplinary team • Jan.Mulier@azbrugge.be • www.publicationslsit.org/jan.mulier • www.espcop.org CHL 12 06 2009 J P Mulier