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Anesthesia for a Patient with Morbid Obesity Using Dexmedetomidine Without Narcotics

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Anesthesia for a Patient with Morbid Obesity Using Dexmedetomidine Without Narcotics 176 GENERAL ANESTHESIA Anesthesia for a patient with morbid obesity using dexmedetomidine without narcotics [L’anesthésie chez un patient obèse morbide avec la dexmédétomidine sans narcotiques] Roger E. Hofer MD,* Juraj Sprung MD PhD,* Michael G. Sarr MD,† Denise J. Wedel MD* Purpose: To describe the anesthetic management of a patient with Objectif : Décrire la démarche anesthésique utilisée chez un patient extreme obesity undergoing bariatric surgery whose intraoperative atteint d’obésité morbide devant subir un pontage gastrique. Les nar- narcotic management was entirely substituted with dexmedetomi- cotiques peropératoires ont été entièrement remplacés par la dine. dexmédétomidine. Clinical features: We describe a 433-kg morbidly obese patient Éléments cliniques : Le patient pesait 433 kg, présentait une with obstructive sleep apnea and pulmonary hypertension who apnée du sommeil obstructive et de l’hypertension pulmonaire. Il underwent Roux-en-Y gastric bypass. Because of the concern that devait subir un pontage gastrique de Roux-en-Y. Inquiets de causer une the use of narcotics might cause postoperative respiratory depres- dépression respiratoire postopératoire en utilisant des narcotiques, sion, we substituted their intraoperative use with a continuous infu- nous avons substitué leur usage peropératoire par une perfusion con- sion of dexmedetomidine (0.7 µg·kg–1·hr–1). The anesthesia course tinue de dexmédétomidine (0,7 µg·kg–1·h–1). L’anesthésie s’est bien was uneventful, and the intraoperative use of dexmedetomidine déroulée et l’usage peropératoire de dexmédétomidine a été associé was associated with low anesthetic requirements (0.5 minimum à de faibles demandes d’anesthésiques (concentration alvéolaire mini- alveolar concentration). After completion of the operation and after male de 0,5). Après l’opération et l’extubation endotrachéale, la per- tracheal extubation, the dexmedetomidine infusion was continued fusion continue de dexmédétomidine a été poursuivie jusqu’à la fin du uninterrupted throughout the end of the first postoperative day. premier jour postopératoire. La dexmédétomidine a permis d’é- The analgesic effects of dexmedetomidine extended narcotic-spar- conomiser aussi les narcotiques après l’opération ; le patient a ing effects into the postoperative period; the patient had lower nar- demandé moins de narcotiques pendant le premier jour postopératoire cotic requirements during the first postoperative day [48 mg of [48 mg de morphine en analgésie autocontrôlée (AAC)] tout en rece- morphine by patient-controlled analgesia (PCA)] while still receiving vant la dexmédétomidine, comparativement au deuxième jour (148 dexmedetomidine, compared to the second postoperative day mg de morphine en AAC). Les scores de douleur étaient comparables. (morphine 148 mg by PCA) with similar pain scores. Conclusion : La dexmédétomidine peut être un ajout anesthésique Conclusion: Dexmedetomidine may be a useful anesthetic utile chez les patients susceptibles de dépression respiratoire induite adjunct for patients who are susceptible to narcotic-induced respi- par les narcotiques. Les effets d’économie de narcotiques de la ratory depression. In this morbidly obese patient the narcotic-spar- dexmédétomidine ont été évidents ici pendant et après l’opération. ing effects of dexmedetomidine were evident both intraoperatively and postoperatively. HE increasing incidence of morbid obesity is a crisis in national healthcare, which has precipitated an increase in bariatric surgery. Morbid obesity is associated with marked Trespiratory co-morbidities such as obstructive sleep apnea (OSA) and/or pulmonary hypertension that may have a profound impact on anesthetic manage- From the Departments of Anesthesiology,* and Surgery,† Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA. Address correspondence to: Dr. Juraj Sprung, Mayo Clinic College of Medicine, Department of Anesthesiology, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905, USA. Phone: 507-255-3298; Fax: 507-255-6463; E-mail: [email protected] Support for this report is provided from the Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA. Assessed May 25, 2004. Accepted for publication July 29, 2004. Revision accepted November 8, 2004. CAN J ANESTH 2005 / 52: 2 / pp 176–180 Hofer et al.: ANESTHESIA AND DEXMEDETOMIDINE 177 ment. Sugerman1 demonstrated that surgically needed, and oxycodone 40 mg, three times daily. In induced weight loss after bariatric surgery markedly addition, he was receiving heparin 10,000 units subcu- improved numerous markers of respiratory insuffi- taneously three times daily. Polysomnography con- ciency [i.e., arterial oxygenation, carbon dioxide firmed severe, rapid eye movement-dependent OSA (CO2)] retention, frequency of apnea, lung volume, syndrome. A trial of continuous positive airway pressure and polycythemia). Therefore, respiratory co-mor- (CPAP) by mask was attempted, but the patient did not bidities of morbid obesity should be considered an tolerate it. important indication for an aggressive approach to The morning of the operation the patient was posi- weight reduction. We describe a 433-kg morbidly tioned on two side-by-side heavy-duty operating room obese patient complicated by OSA and pulmonary tables (Skytron Hercules 6500HD, Grand Rapids, MI, hypertension, who underwent Roux-en-Y gastric USA), clamped together in 10° reverse Trendelenburg bypass. The patient refused preoperative epidural position. A patient lift system mattress (A.I.R. PAL placement for pain management. Because of concern Patient Lift, LCI Medical Inc, Nilfisk, Denmark) was that opioids might cause perioperative respiratory used to transfer the patient from the heavy-duty trans- depression, we substituted the intraoperative use of port cart to the operating room table. The patient narcotics with dexmedetomidine, a highly selective α2- refused epidural placement for perioperative analgesia. adrenergic agonist with hypnotic, sedative, sympa- Intravenous glycopyrrolate (0.2 mg), midazolam (4 tholytic, and analgesic properties.2 Because mg), ketamine (60 mg), and topical lidocaine were used dexmedetomidine does not cause respiratory depres- for an uneventful fibreoptic tracheal intubation (the sion, and patients can be easily aroused, it may be used patient’s airway was assessed as “not difficult,” but even after tracheal extubation.3,4 despite that assessment, fibreoptic intubation was per- formed electively primarily due to the patient’s size). Clinical features After identification of exhaled CO2 by mass spectrome- A 42-yr-old male with extreme obesity (height 198 cm, try, general anesthesia was induced with iv propofol weight 433 kg, body mass index 110 kg·m–2) was 200 mg and initial muscle relaxation was achieved with admitted for bariatric surgery. He had been hospitalized 10 mg of vecuronium iv. The patient’s lungs were ven- and bedridden over the past ten months because of an tilated with a tidal volume (TV) of 1200 mL, 10 –1 inability to perform basic daily activities. His obesity breaths·min , 10 cm H2O of positive end-expiratory was complicated with OSA, pulmonary hypertension, pressure (PEEP), using FIO2 of 0.6; the peak inspirato- massive lower extremity lymphedema, and gastroe- ry pressure (PIP) was 38 cm H2O. Isoflurane was sophageal reflux. The preoperative electrocardiogram administered at an end-tidal concentration of 0.9%. A showed a normal sinus rhythm with non specific ST-T right subclavian, four-lumen central venous catheter wave abnormalities. Chest radiography was normal; was placed without difficulty (initial central venous results of pulmonary function tests showed a severe pressure was 19 mmHg). Immediately after anesthetic restrictive pattern: forced vital capacity (FVC) of 2 L = induction, we initiated the administration of iv 31% predicted; forced expiratory volume in one second dexmedetomidine: 1.4 µg·kg–1 as a loading dose –1 (FEV1) was 1.2 L·min = 24% predicted, FEV1/FVC (Precedex, Abbot Laboratories Inc., Abbot Park, IL, 60%). Arterial blood gases on room air were: pHa 7.39, USA) over ten minutes (dosing weight was based on an arterial partial oxygen tension (PaO2) 69 mmHg; oxy- estimated lean body mass of 175 kg) followed by a con- –1 –1 hemoglobin saturation (SaO2) 91%, bicarbonate 30 tinuous infusion of 0.7 µg·kg ·hr . This rate was main- –1 mEq·L , and arterial partial CO2 tension (PaCO2) 51 tained uninterrupted throughout the operation until mmHg. All other laboratory values were within normal the end of the first postoperative day. No narcotics were limits. Transthoracic echocardiography (described as given pre- or intraoperatively. technically challenging with suboptimal images) After anesthetic induction, we inserted a kink resis- revealed normal left ventricular size with normal global tant polyurethane right radial artery catheter (Cook systolic function (estimated ejection fraction 60%). The Pressure Monitoring Catheter, Cook, Critical Care, right ventricle was mildly enlarged, however the cardi- Bloomington, IN, USA). We used a continuous blood ologist was unable to estimate right ventricular systolic gas-monitoring system (Trend Care Satellite TMC pressure. The rest of the examination appeared within 6000, Diametrics Medical LTD., Buckinghamshire, normal limits. Preoperative oral medications included England, UK), with a thin electrode inserted through ranitidine 150 mg three times daily, trazodone 50 mg the existing arterial line, to continuously monitor PaO2, every
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