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REFERAT
September 2011
ANESTESI PADA OBESITY
Oleh
MULYONO
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Klas!"as obesity #l$%&%e'"er(
200)* BMI #"&+m2* Des"rps Kelas obesity
, 1)(- Under
weight
1)(-.2/( Normal
2-(0.2( Over weight
0(0./( Obesity I
-(0.( Morbid
obesity
II
/0 Extreme
obesity
III
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Tpe 3ar $bestas a3a 2
14 Tpe a%3r$3 # $bestas se%tral*
Pa3a tpe % 3strb5s lema" 3$m%a% 3 t5b5h ba&a% atas #3strb5s tr5%"al* 3a%
berh5b5%&a% 3e%&a% pe%%&"ata% "$ms5ms $"s&e% 3a% %s3e% pe%6a"t
"ar3$7as"5ler4
2. Tpe &%e"$3 # $bestas per!er*
Pa3a tpe % 8ar%&a% a3p$se 3$m%a% l$"as 3 paha( pa%tat 3a% p%&&5l #lema"
se'ara metab$l" "5ra%& a"t! seh%&&a "5ra%& berh5b5%&a% erat 3e%&a% pe%6a"t
"ar3$7as"5ler*
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Pat$!s$l$& $best6Sstem respras 91. Work of breathing Pase% $bestas m$rb3 me%%&"at
mer5pa"a% a"bat 3ar compliance 3%3%& 3a3a me%5r5%
24 T$tal $"s&e% "$ms5ms 3a% pr$35"s "arb$%3$"s3a me%%&"at
pa3a pase% obese saat strahat
4 :p$;a "r$%s me%6ebab"a% p$l6'6thema( 3ma%a ber"$%trb5s
3alam pe%%&"ata% 7$l5me 3arah4 Ter8a3%6a :p$"sema "r$%s
3apat me%6ebab"a% hperte%s p5lm$%al 3a% "$rp5lm$%ale4
#L$%&%e'"er( 200)*
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OBSTRUKTIF SLEEP APNEU 33e!%s"a% seba&a berhe%t%6a alra% 53ara
selama 10 3et"( ter8a3 - "al ata5 lebh setap 8am
saat t35r( <ala5p5% 5saha ber%a!as mela<a%
pe%5t5pa% &l$ts tetap ter8a3( 3"$mb%as 3e%&a%
pe%5r5%a% sat5ras $"s&e% lebh 3ar /=4
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Obstrksi sleep hypopne t5r5%%6a alra% 53ara -0= 3alam <a"t510 3et"
ter8a3 lebh 3ar 1- "al setap 8am selama t35r4
Basa%6a berh5b5%&a% 3e%&a% s%$r%& 3a%
3esat5ras $"s&e% /= 4
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Ap%ea.:p$p%ea %3e; > A:I A:I a3alah 85mlah t$tal 3ar ap%e5 3a% hp$p%e5 per8am 3a% 3&5%a"a%
5%t5" me%&etah5 "5a%ttas 3ar berat%6a OSA4 A:I 0 mer5pa"a%
OSA se7ere( A:I -.1- $sa ml3 3a% A:I 1?.0 seba&a OSA m$3erate4
I%3e"s t$tal ar$5sal # Ar$5sal %3e;>AI* a3alah 85mlah t$tal %3735
terba%&5% per 8am4 Kesmp5la% 3ar A:I 3a% t$tal A:I 3 "e%al seba&a
respiratory distrbance index #RDI*4
#L$%&%e'"er( 200)*
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syndrome hipoventilsi o!esity 33e!%s"a% seba&a "$mb%as a%tara $bestas
#BMI0 "&+m2* 3a% hper"ap%a arter "et"a
sa3ar #Pa'$2/- mmh&* 3e%&a% t3a" a3a%6a
pe%6ebab la% 3ar hp$7e%tlas
S%3r$ma P'"<'"a% 3ta%3a 3e%&a% obesity (
me%&a%t5" berlebha%( hp$"sa( hper"ap%a(
&a&al 7e%tr"el "a%a%( 3a% p$lsthema ( % a3alah
a"hr 3ar O:S4
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E"m# Orophryn"Patient With the Crowded Oropharynx
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Physi$l E"m
Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. iss! "#$%.
Structural Abnormalities
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Pthophysiolo%y o& Apne
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Pthophysiolo%y o& SleepApne
oss o& neuromus'ular
'ompensation
()e'reased pharyn*eal
mus'le a'ti+ity
Sleep Onset
,yper+entilate: 'orre't
hypoxia - hyper'apnia
Airway opens
Airway 'ollapses
Pharyn*eal mus'le
a'ti+ity restored
Apnea Arousal &rom sleep
,ypoxia -
,yper'apnia
n'reased +entilatory
e&&ort
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PICKWICKIAN SYNDROME OR
OHS
8% of obese patients
Alveolar hypoventilation, somnolence and
morbid obesity
↑ Soft tissue mass of oropharynx→Intermittent obstruction of airway
during sleep
Hypoxemia, hypercarbiaPolycythemia, pulmonary hypertension
and right ventricular failure
Pulmonary embolism and pneumonia
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+- V/+01 23#-14 I- /"14I56
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FR2 $12R1#414 I53 I-2R1#4I-
"0I
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sitting supine
Normal Obese
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Sstem "ar3$7as"5ler
Pe%%&"ata% m$rb3tas 3a% m$rtaltas pa3a pase% obese a3alah hasl 3ar pr$blem "ar3$7as"5ler sepert hperte%s( pe%6a"t 8a%t5%& s"em"( &a&al
8a%t5%&( "ar3$m$pat( artma( 3slp3ema( 3a% me%%&&al me%3a3a" "are%a
pe%6a"t 8a%t5%&4
@ar%&a% a3p$se berlebha% 9
14 $l5me 3arah24 Car3a' $5tp5t
4 ater$s"ler$ss
/4 Dsrtma
-4 Sstem RAA
?4 Resste%s %s5l%
4 Dslp3ema
)4 :p$!br%$lt" 3a% hper"$a&5las
#L$%&%e'"er( 200*
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a&al 8a%t5%& %tra $perat! 3apat ter8a3 "are%a pe%bera% 'ara% %tra 7e%a 6a%& 'epat
#mer5pa"a% %3"as 3s!5%&s 3ast$l" 7e%tr"el
"r*( %$tr$p" %e&at! 3ar a&e%t a%estes(
hperte%s p5lm$%al 6a%& 3presptas $leh
hp$"sa 3a% hper"ap%a4#Barash( 200*
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Sstem &astr$ %test%al 3a% hepat"
$l5me &aster 3a% "easama% me%%&"at( &a%&&5a% !5%s
hepar 3a% metab$lsme $bat
Pe%&$s$%&a% lamb5%& me%8a3 lebh lambat pa3a pase%
$bese( "are%a pe%%&"ata% massa ab3$me% 3a% 3ste%sa%tr5m4 Release &astr%( 3a% pe%5r5%a% p: 3e%&a%
hperse"res sel paretal4
Pe%%&"ata% %s3e% hat5s her%a 3a% re!l5"s
&astr$es$pha&eal
ab%$rmaltas m$r!$l$& 3a% b$"emstr 3ar hepar
seh5b5%&a% 3e%&a% $bestas termas5" %!ltras lema"(
%!lamas( %e"r$ss !$"al 3a% sr$ss4
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Sstem metab$l"( re%al( 3a% e%3$"r% a%&&5a% t$lera%s &l5"$sa
:p$tr$3sm s5b"l%" ter8a3 se"tar 2-= 3ar sem5a pase% m$rb34
Le7el TS: ser%& me%%&&4
Obestas mer5pa"a% res"$ ma6$r terha3ap end stage renaldisease #ESRD* 3a% hperte%s esse%sal4
Obestas ter"at &l$mer5l$pat 3 3e!%s"a% seba&
&l$mer5l$s"ler$ss !$"al se"me%tal 3a% &l$mer5l$pat ata5
&l$mer5l$pat sa8a4
#Barash 200( L$%&%e'"er 200)*
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S%3r$me metab$l"
mer5pa"a% hasl 3ar %tera"s a%tara !a"t$r.!a"t$r &e%et"( h$rm$%al 3a% l!est6le Me%5r5t !nternational "iabetes #ederation( sese$ra%& 33a&%$ss s%3r$me
metab$l" har5s memp5%6a $bestas se%tral #l%&"ar p%&&a%& - 'm 5%t5" la".
la" 3a% )0 'm 5%t5" <a%ta* 3 tambah 35a 3ar empat !a"t$r 3 ba<ah % 9
14 Pe%%&"ata% le7el tr&lser3a # 14 mm$l+L*
24 Ka3ar :DL ser5m ber"5ra%& # 140 mm$l+L pa3a la".la" 3a% 142 mm$l+L pa3a˂ ˂
<a%ta*
4 Pe%%&"ata% te"a%a% 3arah # SBP 10 mmh& ata5 DBP )- mmh& * ata5 se3a%&
3alam terap hperte%s4
/4 Ka3ar &l5"$sa 3arah p5asa -(? mm$l+L* ata5 sebel5m6a 33a&%$ss DM tpe 2
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Me%e8eme% per$perat!E7al5as pre a%estes
P$ss
Ar<a6 me%e8eme%
Preparas
M$%t$r%&
I%35"s( %t5bas 3a% pemelharaa%
Plha% te"%" a%estes
Me%e8eme% pas'a $peras
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!reanesthetic 1valuation!reanesthetic 1valuation
IncludesIncludes
– MedicationsMedications
– Laboratory TestsLaboratory Tests
– Cardiac AssessmentCardiac Assessment
– Respiratory EvaluationRespiratory Evaluation
– Airway EvaluationAirway Evaluation
– Vascular AccessVascular Access
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!reanesthetic 1valuation !atient!reanesthetic 1valuation !atient
1ducation1ducation
menjelaskan keadaan yan munkinmenjelaskan keadaan yan munkin
terjadi selama preparasi pre operati! terjadi selama preparasi pre operati! ""pemasanan cateter in!us berulanpemasanan cateter in!us berulan##
venavena central and arterial linescentral and arterial linesinsertions# awake intubation# paininsertions# awake intubation# pain
manaement$manaement$ dan pencea%andan pencea%an
cemas berlebi%ancemas berlebi%an
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preparasipreparasi 17uipment17uipment
operatin room tables can accommodateoperatin room tables can accommodateup to )** pounds o! wei%t+up to )** pounds o! wei%t+
E(tra lare cu!!s can be used onE(tra lare cu!!s can be used onupper,lower e(tremity+upper,lower e(tremity+
warmin devices# !luid warms andwarmin devices# !luid warms and
warm air!low blankets s%ould bewarm air!low blankets s%ould beemployed to prevent %ypot%ermiaemployed to prevent %ypot%ermia
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monitoringmonitoring
monitorinmonitorinIntraoperativeIntraoperative sesuai kebutu%ansesuai kebutu%anpasienpasien
E-. di atur aar dapat mendeteksiE-. di atur aar dapat mendeteksi myocardialmyocardialisc%emia and pat%oloy "leads II and V/$+isc%emia and pat%oloy "leads II and V/$+
0lacement o! an arterial cat%eter is appropriate0lacement o! an arterial cat%eter is appropriate!or t%e monitorin %emodynamic status!or t%e monitorin %emodynamic status++
1se o! central venous and pulmonary artery1se o! central venous and pulmonary arterycat%eters s%ould be consider in patientscat%eters s%ould be consider in patients
underoin e(tensive or seriousunderoin e(tensive or seriouscardiorespiratory disease+cardiorespiratory disease+
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#irway 17uipment #irway 17uipment
preparation o! e'uipment and personnelpreparation o! e'uipment and personnelnecessary to ventilate and intubate t%e morbidlynecessary to ventilate and intubate t%e morbidlyobese patientobese patient
5TATIC55TATIC5
Laryneal mask airways "LMAs$# !iberoptic andLaryneal mask airways "LMAs$# !iberoptic andbronc%oscopic devices# emerency trac%eotomybronc%oscopic devices# emerency trac%eotomyand cricot%yrotomy kits must be available in t%eand cricot%yrotomy kits must be available in t%eevent t%at ventilation by mask or endotrac%ealevent t%at ventilation by mask or endotrac%ealtube is unsuccess!ul+tube is unsuccess!ul+
A di!!icult airwayA di!!icult airway !low!lowcartcart
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0aintenance0aintenance
maintenance consist o!&maintenance consist o!&
– IntubationIntubation
– E!!ects o! .eneral Anest%esia on RespirationE!!ects o! .eneral Anest%esia on Respiration
– C%oice o! Anest%etic Tec%ni'ueC%oice o! Anest%etic Tec%ni'ue– Volume ReplacementVolume Replacement
– Intraoperative 0ositioninIntraoperative 0ositionin
– E(tubationE(tubation
– Reional Anest%esiaReional Anest%esia
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IntubationIntubation
7or airway manaement to be !acilitated# t%e7or airway manaement to be !acilitated# t%eobese patient s%ould be positioned wit% t%e %eadobese patient s%ould be positioned wit% t%e %eadelevated "reverse Trendelenbur position$ on t%eelevated "reverse Trendelenbur position$ on t%eoperatin room table+operatin room table+
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IntubationIntubation
preo(yenated wit% 8**9 mask o(yenpreo(yenated wit% 8**9 mask o(yen!or at least : to / minutes+!or at least : to / minutes+
T%e patients %ead# neck and s%ould beT%e patients %ead# neck and s%ould becare!ully moved into ;sni!!in position<care!ully moved into ;sni!!in position<
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$ifficult to
"ag90as:
Ventilate
#ssistant holds
bac: breasts,
applies cricoid
pressure
/RAC,0A
N/12A/ON in the
S1PN0 POS/ON
Rapid SpO3
)esaturation
4hort
laryngo;scope
handle
!oor view
with direct
laryngoscopy
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S1PN0 POS/ON
Reduced lung volumes
Increased V9<
mismatch
n'reased intra4
a5dominal pressure
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/R0N)00N21RG POS/ON
8 Improved surgical exposure1ngorged nec: veins (central line placement)
;$ecreased pulmonary compliance and lung volumes
;$ecreased Intra;abdominal volume (I#V)
;(!otential) advancement of 155 into bronchus
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S/AN)NG AN) S//NG
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IntubationIntubation
5ome practitioners advocate t%e use o! an5ome practitioners advocate t%e use o! an ;awake look< to visuali=e t%e di!!iculty o! ;awake look< to visuali=e t%e di!!iculty o!t%e airway+t%e airway+
Care!ul administration o! sedative drusCare!ul administration o! sedative drusand application o! topical anest%esia to t%eand application o! topical anest%esia to t%eorop%aryneal structuresorop%aryneal structures
6asal o(yen is used as a supplement6asal o(yen is used as a supplement
durin awake larynoscopy+durin awake larynoscopy+
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IntubationIntubation
>ika>ika epilottic and laryneal anatomyepilottic and laryneal anatomymuda% di li%atmuda% di li%at# intuba# intubasi denan sedasisi denan sedasidapat di lakukandapat di lakukan## jika tidak jika tidak# intuba# intubasisidenandenan LMA or awake !iberoptic intubationLMA or awake !iberoptic intubation
dapat di unakandapat di unakan++ 7iksasi7iksasi endotrac%eal tubeendotrac%eal tube denan amandenan aman++ re'uires one person to support t%e mask andre'uires one person to support t%e mask and
airway w%ile anot%er person ba ventilates t%eairway w%ile anot%er person ba ventilates t%e
patient+patient+ In t%e case o! inability to ventilate,intubate# t%eIn t%e case o! inability to ventilate,intubate# t%e
American 5ociety o! Anest%esioloist di!!icultAmerican 5ociety o! Anest%esioloist di!!icultairway alorit%m s%ould be !ollowed+airway alorit%m s%ould be !ollowed+
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mene=emen ventilasimene=emen ventilasi
.eneral anest%esia depresses respiration +.eneral anest%esia depresses respiration + T%e type o! surery# positionin and underlyinT%e type o! surery# positionin and underlyin
diseasedisease .eneral anest%esia causes a /*9 reduction in 7RC in.eneral anest%esia causes a /*9 reduction in 7RC in
t%e obese anest%esia# as compared wit% a 3*9t%e obese anest%esia# as compared wit% a 3*9reduction in anest%eti=ed non obese patientsreduction in anest%eti=ed non obese patients 7RC can be increased by ventilatin wit% lare7RC can be increased by ventilatin wit% lare
tidal volumes "8/ to 3* ml,k$tidal volumes "8/ to 3* ml,k$ 0EE00EE0 dilakukan untuk memperbaikidilakukan untuk memperbaiki 7RC and7RC and
0a?30a?3 Current ventilation recommendations includeCurrent ventilation recommendations include
usin tidal volumes o! 8* to 83 ml,k to avoidusin tidal volumes o! 8* to 83 ml,k to avoidbarotrauma+barotrauma+
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2hoice of #nesthetic 5echni7ue2hoice of #nesthetic 5echni7ue
?bjective !or maintenance o! anest%esia in?bjective !or maintenance o! anest%esia in
t%e obese include&t%e obese include&
– 5trict maintenance o!5trict maintenance o! airwayairway
– Ade'uate skeletalAde'uate skeletal muscle rela(ationmuscle rela(ation– ?ptimum?ptimum o(yenationo(yenation
– Avoidance o! t%eAvoidance o! t%e residual e!!ectsresidual e!!ects o! muscleo! muscle
rela(antsrela(ants
– appropriate intraoperative and postoperativeappropriate intraoperative and postoperativetidal volumetidal volume
– E!!ectiveE!!ective postoperative analesiapostoperative analesia
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2hoice of #nesthetic 5echni7ue2hoice of #nesthetic 5echni7ue
@ependin on t%e patients condition@ependin on t%e patients condition epidural anest%etic wit% ;li%t< eneral anest%esiaepidural anest%etic wit% ;li%t< eneral anest%esia
is !re'uently c%osen+is !re'uently c%osen+ A li%t eneral anest%etic can !acilitateA li%t eneral anest%etic can !acilitate
manaement o! t%emanaement o! t%e airway# ventilation# and t%eairway# ventilation# and t%epatients level o! consciousnesspatients level o! consciousness# w%ere as t%e# w%ere as t%eepidural provides surical analesia andepidural provides surical analesia andanest%esia+anest%esia+
Epidural cat%eter can be used !or postoperativeEpidural cat%eter can be used !or postoperativeanalesic administration and will en%ance earlieranalesic administration and will en%ance earlierreturn o!return o! deep breat%in and cou%indeep breat%in and cou%inmaneuvers+maneuvers+
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Volume ReplacementVolume Replacement
T%eT%e normal adultnormal adult percentae o! totalpercentae o! total
body water isbody water is )*9 to )/9)*9 to )/9T%ere!ore calculation o! estimatedT%ere!ore calculation o! estimatedblood volume s%ould beblood volume s%ould be B/ to //B/ to //ml,kml,k o! actual body wei%t rat%ero! actual body wei%t rat%er
t%ant%an *ml,k*ml,k apportioned inapportioned in nonnonobese adults+obese adults+Accurate volume replacementAccurate volume replacement
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Volume ReplacementVolume Replacement
Dlood loss replacement o! :&8 ratioDlood loss replacement o! :&8 ratio": ml o! crystalloid to 8 ml o! blood": ml o! crystalloid to 8 ml o! bloodlossloss$ is applicable in severely obese$ is applicable in severely obese
patients+patients+Dlood products a!ter care!ulDlood products a!ter care!ul
identi!icationidenti!ication
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1xtubation1xtubation
Criteria !or e(tubation consist o!&Criteria !or e(tubation consist o!&– Awake state# tidal volume andAwake state# tidal volume and
respiratory rate at preoperative levelsrespiratory rate at preoperative levels
– Ability to sustainAbility to sustain %ead li!t or le li!t !or%ead li!t or le li!t !orat least / secondsat least / seconds
– ConstantConstant %and rip%and rip
– E!!ective cou%E!!ective cou%
– Ade'uateAde'uate vital capacityvital capacity o! at leasto! at least8/ml,k8/ml,k
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1xtubation1xtubation
0atients must be placed wit% t%e0atients must be placed wit% t%e
%ead up%ead up or in aor in a sittin positionsittin position++
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!ostoperative 2are!ostoperative 2are
0ostoperative Care includes&0ostoperative Care includes&
0ain Manaement0ain Manaement
0ostoperative Complication0ostoperative Complication
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!ain 0anagement!ain 0anagement
0ili%an analesik &0ili%an analesik & oral analesics#oral analesics#nonsteroidal antiin!lammatory aents#nonsteroidal antiin!lammatory aents#narcotics# patient2controlled analesia#narcotics# patient2controlled analesia#local in!iltration o! surical site andlocal in!iltration o! surical site and
epidural anest%esiaepidural anest%esia 4ati2%ati &4ati2%ati &?bese patients are more?bese patients are more
sensitive to t%e respiratory depressantsensitive to t%e respiratory depressante!!ects o! opioide!!ects o! opioid analesics t%ere!oreanalesics t%ere!ore
caution and close monitorincaution and close monitorin
5upplemental o(yen and pulse o(imetry5upplemental o(yen and pulse o(imetrymonitorin are mandated+monitorin are mandated+
8/10/2019 Ppt. Obesity
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8/10/2019 Ppt. Obesity
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!ostoperative 2omplications!ostoperative 2omplications
Early ambulation and maintenance o!Early ambulation and maintenance o!
vascular volumevascular volume !urt%er reduces t%e!urt%er reduces t%e
likeli%ood t%atlikeli%ood t%at clotsclots will develop+will develop+
Found in!ections and pulmonaryFound in!ections and pulmonary
embolism are /*9 %i%erembolism are /*9 %i%er in obesein obese
patients t%an non obese patients+patients t%an non obese patients+
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