Solutions for difficult situations Solutions for difficult situations in bariatric surgery : in bariatric surgery :

What to do ? What to do ? The real risk patient in Anaesthesia

J P Mulier, MD PhDJ P Mulier, MD PhD B Dillemans, MD B Dillemans, MD

CHL 12 06 2009 J P Mulier

High risk in bariatric High risk in bariatric surgerysurgery

Pulmonary diseasesPulmonary diseases AsthmaAsthma COPDCOPD

Cardiac diseaseCardiac disease Right ventricular failureRight ventricular failure Coronary atheromatoseCoronary atheromatose

Muscle diseaseMuscle disease Seldom obese patients, howeverSeldom obese patients, however

Other raritiesOther rarities Search active for them / dangerous for every Search active for them / dangerous for every

anesthesiaanesthesia

CHL 12 06 2009 J P Mulier

Is there a risk ?Is there a risk ?

According to the media: yes!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: According to the scientific publications: overall 10 year mortality decreased with overall 10 year mortality decreased with 24 % 24 % SOS study Sjöström 2008SOS study Sjöström 2008

CHL 12 06 2009 J P Mulier

Individual risk pre op?Individual risk pre op?

Which patient is at risk ?Which patient is at risk ?1.1. Very high BMI ?Very high BMI ?

2.2. 70 > 60 > 5070 > 60 > 50

CHL 12 06 2009 J P Mulier

Not the BMI itself but Not the BMI itself but Central fat intra abdominal: apple > pearCentral fat intra abdominal: apple > pear No weight reduction is a riskNo weight reduction is a risk

Not absolute weight. -30 kg creates space to breath, Not absolute weight. -30 kg creates space to breath, laparoscopic work space, improved liver functionlaparoscopic work space, improved liver function

Higher BMI more difficult but not a higher risk?Higher BMI more difficult but not a higher risk? Table positioningTable positioning Intubation positioningIntubation positioning Mobilization in bedMobilization in bed

Aspiration risk at inductionAspiration risk at induction Post operative insufficient breathingPost operative insufficient breathing

The higher the BMI the higher the The higher the BMI the higher the risk?risk?

CHL 12 06 2009 J P Mulier

Individual risk pre op?Individual risk pre op?

Which patient is at risk ?Which patient is at risk ?1.1. High BMI ?High BMI ?

2.2. Older patient ?Older patient ?1.1. Less frequent in bariatrics, but …Less frequent in bariatrics, but …

CHL 12 06 2009 J P Mulier

Individual risk pre op?Individual risk pre op?

Which patient is at risk ?Which patient is at risk ?1.1. High BMI ?High BMI ?

2.2. Older patient ?Older patient ?

3.3. Diabetes ?Diabetes ?1.1. Many co morbiditiesMany co morbidities

2.2. Frequent glucose follow up Frequent glucose follow up

lower risks?lower risks?

CHL 12 06 2009 J P Mulier

Individual risk pre op?Individual risk pre op?

Which patient is at risk ?Which patient is at risk ?1.1. High BMI ?High BMI ?

2.2. Older patient ?Older patient ?

3.3. Diabetes ?Diabetes ?

4.4. Sleep apnea ?Sleep apnea ?

CHL 12 06 2009 J P Mulier

Sleep apnea patient high Sleep apnea patient high risk?risk?

1.1. Is a clinical diagnosis of sleep Is a clinical diagnosis of sleep disturbance, disturbance, 1.1. not of post operative hypoxianot of post operative hypoxia

2.2. no study yet confirms risk. No numbers no study yet confirms risk. No numbers of resp obstruction post op!of resp obstruction post op!

2.2. Use cpap mask post op if used at Use cpap mask post op if used at homehome

3.3. Active search pre op ?Active search pre op ?

CHL 12 06 2009 J P Mulier

Individual risk pre op?Individual risk pre op?

Which patient is at risk ?Which patient is at risk ?1.1. High BMI ?High BMI ?

2.2. Older patient ?Older patient ?

3.3. Diabetes ?Diabetes ?

4.4. Sleep apnea ?Sleep apnea ?

Which patient has complications ?Which patient has complications ?1.1. What are the What are the most frequentmost frequent

complications?complications?

CHL 12 06 2009 J P Mulier

30 days Complications in 2606 gastric bypass 30 days Complications in 2606 gastric bypass sint Jan Brugge B Dillemans 2009sint Jan Brugge B Dillemans 2009

hemorrhagehemorrhage 8989 3,41%3,41%

blood transfusionblood transfusion 4646 1,89%1,89%

re operationre operation 3535 1,47%1,47%

re admissionre admission 3434 1,43%1,43%

intestinal obstructionintestinal obstruction 99 0,38%0,38%

pneumoniapneumonia 66 0,25%0,25%

CPAP and re intubationCPAP and re intubation 55 0,21%0,21%

pulm emboli DVTpulm emboli DVT 55 0,21%0,21%

leakleak 55 0,17%0,17%

food stenosisfood stenosis 44 0,17%0,17%

deathdeath 11 0,04%0,04%

perforationperforation 11 0,04%0,04%

pancreatic injurypancreatic injury 11 0,04%0,04%

intra abd abscessintra abd abscess 11 0,04%0,04%

CHL 12 06 2009 J P Mulier

Complications and Complications and anaesthesiaanaesthesia

1.1. HemorrhageHemorrhageSurgical problem but we can help to Surgical problem but we can help to

prevent itprevent it

2.2. Post operative re-intubation, Post operative re-intubation, ventilation -> pneumoniaventilation -> pneumonia

Anaesthesiological problem: Anaesthesiological problem:

3.3. LeakageLeakageSurgical problem but we can help to Surgical problem but we can help to

prevent.prevent.Transdisciplinary: we as anesthesiologists must think: Ask not what the surgeon can do for you, Ask not what the surgeon can do for you,

ask what you can do for the surgeonask what you can do for the surgeon

CHL 12 06 2009 J P Mulier

1. Post operative 1. Post operative hemorrhagehemorrhage

Ask your anesthesiologist to Ask your anesthesiologist to raise the blood pressure above raise the blood pressure above 140 mmHg SAP at end of 140 mmHg SAP at end of procedure.procedure.

Inspect and stop local bleedingInspect and stop local bleeding Coagulate, clip, stitchCoagulate, clip, stitch

Ask to control intra luminal Ask to control intra luminal bleeding by pouch aspiration test bleeding by pouch aspiration test before extubation.before extubation.

CHL 12 06 2009 J P Mulier

Prevent per op bleeding: Search activePrevent per op bleeding: Search active

110/57 145/78110/57 145/78

J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric

bypass surgery. bypass surgery. Obes Surg 2007; 17: 1051 Obes Surg 2007; 17: 1051

CHL 12 06 2009 J P Mulier

Aspiration test to detect intra Aspiration test to detect intra luminal bleedingluminal bleeding

Treat if red blood detectedTreat if red blood detected

CHL 12 06 2009 J P Mulier

2. Leakage2. Leakage

Ask your anesthesiologist Ask your anesthesiologist To perform a good leakage test.To perform a good leakage test. To keep blood pressure sufficient To keep blood pressure sufficient

during inspection for ischemiaduring inspection for ischemia JPMulier B Dillemans 2007JPMulier B Dillemans 2007

To increase cardiac output and To increase cardiac output and splanchnic perfusion bysplanchnic perfusion by Raising end tidal CO2Raising end tidal CO2 Give sufficient volume expansionGive sufficient volume expansion Work at lowest IAP possibleWork at lowest IAP possible

JPMulier B Dillemans 2008JPMulier B Dillemans 2008

CHL 12 06 2009 J P Mulier

Post operative pneumonia Post operative pneumonia due todue to

A: Aspiration at inductionA: Aspiration at inductionMask ventilation with oxygen?Mask ventilation with oxygen?

Sufficient O2 when mask cpapSufficient O2 when mask cpap

Rapid sequence? No mask ventilationRapid sequence? No mask ventilationRisk of hypoxia !Risk of hypoxia !

Re-intervention after band, bypass, stenosis, Re-intervention after band, bypass, stenosis, ……

Crush induction? Crush induction? (Crocoid pressure)(Crocoid pressure)

Sellick maneuver even more dangerous!Sellick maneuver even more dangerous!

Difficult intubation: risk of blood aspirationDifficult intubation: risk of blood aspirationEmpty stomach, use safety bird,Empty stomach, use safety bird,

CHL 12 06 2009 J P Mulier

Post operative pneumonia Post operative pneumonia due todue to

B: Silent aspiration during B: Silent aspiration during surgery ?surgery ?Cuffed tube leaks!Cuffed tube leaks!

Use KY gel or taperguard tubeUse KY gel or taperguard tube

CHL 12 06 2009 J P Mulier

Methyleen blue leak testMethyleen blue leak testJ P Mulier B Dillemans 2009J P Mulier B Dillemans 2009

% Bronchoscopic visualized methyleen blue leakall patients had 5 peep

0%

20%

40%

60%

80%

100%

Hi contourMallinckrodt

Hi contourMallinckrodt with KY

gel

TaperGuard Mallinckrodt

leak

no leak

CHL 12 06 2009 J P Mulier

Post operative pneumonia Post operative pneumonia due todue to

C: Post extubation aspiration ?C: Post extubation aspiration ?1.1.Superficial breathingSuperficial breathing

1.1.Use pressure support during end of Use pressure support during end of operationoperation

2.2.Non invasive support ventilationNon invasive support ventilation

2.2. Insufficient decurarizationInsufficient decurarization1.1.Use BrideonUse Brideon

3.3.Not fully awakeNot fully awake1.1.Use short acting desflurane, Use short acting desflurane,

remifentanyl, pressure support,…remifentanyl, pressure support,…

CHL 12 06 2009 J P Mulier

Hypercapnic pressure Hypercapnic pressure support ventilation support ventilation JPMulier JPMulier

20082008

Increases cardiac outputIncreases cardiac output Less wound infectionsLess wound infections

Lowers airway pressuresLowers airway pressures Improves saturation per op Improves saturation per op Rapid awakening and spontaneous Rapid awakening and spontaneous

breathingbreathing Non surgical time between OP < 20 minNon surgical time between OP < 20 min

Less pain when awakeningLess pain when awakening Extra doses morphine given during end of Extra doses morphine given during end of

surgerysurgery Better post op breathingBetter post op breathing

less post op aspiration pneumonialess post op aspiration pneumonia

CHL 12 06 2009 J P Mulier

NST: non surgical time

0,00

10,00

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40,00

50,00

60,00

70,00

A B C

min

ute

s

RNU: room not used

0,00

5,00

10,00

15,00

20,00

25,00

30,00

35,00

40,00

45,00

A B C

min

ute

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Turn over time is very shortTurn over time is very shortASA 2008 JPMulierASA 2008 JPMulier

A: induction next pat before A: induction next pat before awakening prevawakening prev

B: use pre induction room B: use pre induction room without anesthesiawithout anesthesia

C: no use of pre induction C: no use of pre induction roomroom

MultifactorialMultifactorial Pre induction room?Pre induction room? Rapid awakening techniquesRapid awakening techniques

Active management, Active management, supporting all team members supporting all team members to improve quality results in to improve quality results in time gain!time gain! Know what you do, simplifyKnow what you do, simplify Do it right from the first timeDo it right from the first time

NST non surgical time between procedures

0,0

5,0

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CHL 12 06 2009 J P Mulier

ConclusionConclusion

J F Kennedy: J F Kennedy: Inventor of the Inventor of the transdisciplinaritytransdisciplinarity

‘‘Ask not only what the Ask not only what the anaesthesiologist can do for you, ask anaesthesiologist can do for you, ask also what you can do for the also what you can do for the anaesthesiologist.’anaesthesiologist.’

CHL 12 06 2009 J P Mulier

Make your Make your anaesthesiologist member anaesthesiologist member

of ESPCOPof ESPCOP And he will ask you what he can do for you!And he will ask you what he can do for you!

CHL 12 06 2009 J P Mulier

Scientific meetingScientific meeting

CHL 12 06 2009 J P Mulier

Be a transdisciplinary Be a transdisciplinary teamteam

Jan.Mulier@azbrugge.beJan.Mulier@azbrugge.be www.publicationslsit.org/jan.mulierwww.publicationslsit.org/jan.mulier www.espcop.orgwww.espcop.org