We need to be ready to resuscitate any patient that comes to our EDs and ICUs. Being Resus Ready for bariatric patients requires forethought and planning. Let's discuss some resuscitation strategies for the obese patient.
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Bibliography
Barletta, Jeffrey F. “Drug Dosing in Special Populations: Obesity and Geriatrics,” 2020, 24.
Brown III, Calvin A. “Emergency Airway Management in the Morbidly Obese Patient.” UpToDate, June 2022.
Dargin, James, and Ron Medzon. “Emergency Department Management of the Airway in Obese Adults.” Annals of Emergency Medicine 56, no. 2 (August 1, 2010): 95–104. https://doi.org/10.1016/j.annemergmed.2010.03.011.
De Jong, A., N. Molinari, Y. Pouzeratte, D. Verzilli, G. Chanques, B. Jung, E. Futier, et al. “Difficult Intubation in Obese Patients: Incidence, Risk Factors, and Complications in the Operating Theatre and in Intensive Care Units.” British Journal of Anaesthesia 114, no. 2 (February 2015): 297–306. https://doi.org/10.1093/bja/aeu373.
De Jong, Audrey, Hermann Wrigge, Goran Hedenstierna, Luciano Gattinoni, Davide Chiumello, Jean-Pierre Frat, Lorenzo Ball, Miet Schetz, Peter Pickkers, and Samir Jaber. “How to Ventilate Obese Patients in the ICU.” Intensive Care Medicine 46, no. 12 (2020): 2423–35. https://doi.org/10.1007/s00134-020-06286-x.
Domi, Rudin, and Haki Laho. “Anesthetic Challenges in the Obese Patient.” Journal of Anesthesia 26, no. 5 (October 1, 2012): 758–65. https://doi.org/10.1007/s00540-012-1408-4.
Levin, Nicholas M., Megan L. Fix, Michael D. April, Allyson A. Arana, Calvin A. Brown, and on behalf of the NEAR Investigators. “The Association of Rocuronium Dosing and First-Attempt Intubation Success in Adult Emergency Department Patients.” Canadian Journal of Emergency Medicine 23, no. 4 (July 1, 2021): 518–27. https://doi.org/10.1007/s43678-021-00119-6.
Nestler, C., P. Simon, D. Petroff, S. Hammermüller, D. Kamrath, S. Wolf, A. Dietrich, et al. “Individualized Positive End-Expiratory Pressure in Obese Patients during General Anaesthesia: A Randomized Controlled Clinical Trial Using Electrical Impedance Tomography.” British Journal of Anaesthesia 119, no. 6 (December 1, 2017): 1194–1205. https://doi.org/10.1093/bja/aex192.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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great stuff. Better than trying to tape the pannus, which can be a mess, and break your sterility when it rips…. use wrist restraints. take two of them, unroll that little padded part, and buckle each side to each other. then tie the straps to the upper handrail of the bed, and sinch them down. the padding *i think* causes a little less trauma to the skin… and they WILL hold. also works well for breast tissue when doing chest tubes… but you MUST mark out landmarks before doing this. it shifts the tissue a significant amount and if you… Read more »
i will give this a shot!
Love this. im always trying to remember the dosing of paralytics and sedatives. Seems like there is a lack of clarity or agreement on some drugs.
I believe you said lean was higher than ideal but I think it is generally the other way around? no ? what dose bento do you use in obese patients for initial? what is see is TBW but jeez that could be a lot?
LBW is confusing, but is above IBW in obese pts
Weight comparison
Give the TBW if you need immediate effect, and use short acting, i.e. midazolam
If you don’t need immediate effect, you can give smaller doses of titratable benzos–midaz or diazepam
As an anesthesiologist, great episode – I usually need to extend the neck more than shown in the position photos, so I ramp the shoulders and then remove some of the linens under the head. The combined technique for intubation is great, but they desaturate so fast that I usually will opt to paralyze for my first attempt as long as external airway anatomy looks normal – the vast majority of the time I do not find that the airway is more difficult than normal weight patients. I do not worry about recall because the risk of death from inadequate… Read more »
great comments!!!
DSI was studied (by us) with no secretion or tachycardia issues. Hypersalivation is a remnant of the 2-4 mg/kg dosing. When you dose as low as possible, it is rare. Tachycardia is usually mild, or not present–these patients are usually maximally catechol released even before the ketamine.
yep, I mentioned my anticipation of my anesthesia comrades will spurning my 20 g rec
Hey Scott. Great pod… tough topic. My thoughts on bariatric spinal / LP mainly from doing Obstetric anaesthesia in this area. I do like to use US to get the midline. My best technique is: position the patient in best possible sitting position if tolerated. Use curvilinear to locate a spinous process at the estimated level, slide up and down to ensure the space is adequate and then if the spinous process is on the screen in the centre, then the space is usually just at the edge of the probe. USe a long spinal needle to inject local in… Read more »
Thanks a lot for another great episode. In Switzerland we use a “ramping device” that’s quite usefull: https://www.nizell.ch/product/na-609-keil-rampenkissen-mit-kopflagerungsteil/
I don’t know if it is available in the US. When the patient claims that she/he is lying uncomfortably, then you know that the positioning is right.
Some great trouble shooting techniques here! Regarding USG-PIV, I find that preserving lines in the upper arms become more challenging with more habbitus. On one of the first shaodwboxing episodes, there was a statistic thrown out along the lines of “50% of above the elbow PIV’s fail within a certain amount of time”. Can you link to this statistic or study?
I really like you’re view on compassion, technique points awesome too