Anästhesie bei Patienten mit Adipositas – Besonderheiten des perioperativen Managements

Zusammenfassung

Die Zahl adipöser Patienten steigt ständig, dieser Trend macht sich auch in der operativen Medizin bemerkbar. Bei der präoperativen Evaluation sollte der Patient hinsichtlich der adipositasassoziierten Begleiterkrankungen untersucht werden. Gleichzeitig muss man sich vergewissern, dass die OP–Ausrüstung eine ausreichende Belastbarkeit aufweist. Obwohl eine generelle Tendenz zu einer erhöhten Rate schwieriger Intubationen oder Aspirationen bei der Narkoseeinleitung nicht besteht, sollte eine sorgfältige Untersuchung erfolgen. Die Funktion des kardiovaskulären Systems ist eingeschränkt, ebenso die Toleranz gegenüber der chirurgischen Belastung. Die Lungenfunktion wird durch eine Anästhesie weiter eingeschränkt, diese Effekte sind noch 48 Stunden nach einem Eingriff nachweisbar. Weitere Einschränkungen betreffen die renale und hepatische Funktion, die Gerinnung und Stoffwechselhomöostase. Die Pharmakokinetik zahlreicher Anästhetika ist verändert hinsichtlich Verteilung, Elimination und Wirkdauer. Adipöse Patienten ohne wesentliche Einschränkungen sind für ambulante Operationen geeignet.

Abstract

The prevalence of obesity is increasing and a growing number of people with overweight present for surgery. For preoperative evaluation, the patients have to be checked for obesity–related diseases. The assurance whether the equipment can stand the increased stress needs a thorough check up. Although there is no general tendency for a higher rate of difficult intubation or increased rates of aspiration, there is a need of particular consideration. Cardiovascular function as well as tolerance to surgical stress is diminished. Pulmonary function is deterioated and impaired for at least 48 hours after surgery, which also applies to renal, hepatic function and to coagulation and glucose hemostasis. The pharmacokinetics of most anaesthetics is altered in view of initial distribution, elimination and duration of effects. Obese people without significant impairments are suitable for ambulatory surgery.

Schlüsselwörter

Adipositas - Anästhesie - Begleiterkrankungen - Pharmakokinetik

Key words

obesity - anaesthesia - concomitant disease - pharmacokinetics

Kernaussagen

• Mehr als die Hälfte der Menschen in Deutschland ist übergewichtig – Tendenz steigend.

• Die Ausgaben für adipositasassoziierte Begleiterkrankungen haben die Höhe der Krebstherapie–Ausgaben erreicht.

• Bei Adipositas besteht – neben der Häufung von bestimmten Krebserkrankungen – eine verschlechterte Funktion von Herz, Lunge, Leber, Niere, Stoffwechsel und Gerinnung.

• Bei adipösen Patienten ist mit erheblichen kardiovaskulären Einschränkungen zu rechnen. Die Patienten sind hyperton, das Herz weist eine exzentrische Hypertrophie auf.

• Bei adipösen Patienten finden sich Einschränkungen statischer und dynamischer Lungenfunktionsparameter. Diese werden durch eine Anästhesie weiter verschlechtert.

• Die Anlage einer Regionalanästhesie kann bei adipösen Patienten erschwert sein, ist aber die Grundlage für eine suffiziente Schmerztherapie.

• Der BMI allein ist kein eindeutiger Hinweis auf eine erschwerte Intubation oder eine erhöhte Aspirationsgefahr bei Narkoseeinleitung.

• Je nach Substanz muss die Einleitungs– oder Erhaltungsdosis auf Basis des realen oder idealen Körpergewichts berechnet werden.

• Ein erhöhter BMI ist per se keine Kontraindikation für eine ambulante Anästhesie.

Literatur

• 1 Mokdad AH, Ford ES, Bowman BA. et al. . Prevalence of obesity, diabetes, and obesity–related health risk factors, 2001.  Jama. 2003;  289 76-9
• 2 Allison DB, Fontaine KR, Manson JE. et al. . Annual deaths attributable to obesity in the United States.  Jama. 1999;  282 1530-8
• 3 Bundesamt für Statistik Gd: Durchschnittliche Körpermaße der Bevölkerung.  www.gbebund.de/oowa921install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/325187357 2007
• 4 Dindo D, Muller MK, Weber M. et al. . Obesity in general elective surgery.  Lancet. 2003;  361 2032-5
• 5 Yap CH, Zimmet A, Mohajeri M. et al. . Effect of Obesity on Early Morbidity and Mortality Following Cardiac Surgery.  Heart Lung Circ. 2007;  16 31-6
• 6 Alban RF, Lyass S, Margulies DR. et al. . Obesity does not affect mortality after trauma.  Am Surg. 2006;  72 966-9
• 7 Brown CV, Neville AL, Rhee P. et al. . The impact of obesity on the outcomes of 1,153 critically injured blunt trauma patients.  J Trauma. 2005;  59
• 8 Neville AL, Brown CV, Weng J. et al. . Obesity is an independent risk factor of mortality in severely injured blunt trauma patients.  Arch Surg. 2004;  139 983-7
• 9 Cabrera MA, Gebara OC, Diament J. et al. . Metabolic syndrome, abdominal obesity, and cardiovascular risk in elderly women.  Int J Cardiol. 2007;  114 224-9
• 10 Church TS, Kuk JL, Ross R. et al. . Association of cardiorespiratory fitness, body mass index, and waist circumference to nonalcoholic fatty liver disease.  Gastroenterology. 2006;  130 2023-30
• 11 Lemmens HJ, Bernstein DP, Brodsky JB.. Estimating ideal body weight – new formula.  Obesity Surgery. 2005;  15 1082-3
• 12 Rosenbaum M, Leibel RL, and J. Hirsch. Obesity.  N Engl J Med. 1997;  337 396-407
• 13 National IoH. . Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults––The Evidence Report. National Institutes of Health.  Obes Res. 1998;  6
• 14 Lauer MS, Anderson KM, Kannel WB. et al. . The impact of obesity on left ventricular mass and geometry. The Framingham Heart Study.  Jama. 1991;  266 231-6
• 15 Christou DD, Jones PP, Pimentel AE. et al. . Increased abdominal–to–peripheral fat distribution contributes to altered autonomic–circulatory control with human aging.  Am J Physiol Heart Circ Physiol. 2004;  287 1530-7
• 16 Ward KD, Sparrow D, Landsberg L. et al. . Influence of insulin, sympathetic nervous system activity, and obesity on blood pressure: the Normative Aging Study.  J Hypertens. 1996;  14 301-8
• 17 Mattsson E, Larsson UE, Rossner S.. Is walking for exercise too exhausting for obese women?.  Int J Obes Relat Metab Disord. 1997;  21 380-6
• 18 Stelfox HT, Ahmed SB, Ribeiro RA. et al. . Hemodynamic monitoring in obese patients: the impact of body mass index on cardiac output and stroke volume.  Crit Care Med. 2006;  34 1243-6
• 19 Messerli FH, Nunez BD, Ventura HO. et al. . Overweight and sudden death. Increased ventricular ectopy in cardiopathy of obesity.  Arch Intern Med. 1987;  147 1725-8
• 20 Lemmens HJ, Bernstein DP, Brodsky JB.. Estimating blood volume in obese and morbidly obese patients.  Obes Surg. 2006;  16 773-6
• 21 Fleisher LA, Beckman JA, Brown KA. et al. .ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2007
• 22 Kaw R, Michota F, Jaffer A. et al. . Unrecognized sleep apnea in the surgical patient: implications for the perioperative setting.  Chest. 2006;  129 198-205
• 23 Biring MS, Lewis MI, Liu JT. et al. . Pulmonary physiologic changes of morbid obesity.  Am J Med Sci. 1999;  318 293-7
• 24 Sharp JT, Henry JP, Sweany SK. et al. . Effects of Mass Loading the Respiratory System in Man.  J Appl Physiol. 1964;  19 959-66
• 25 Ochs–Balcom HM, Grant BJ, Muti P. et al. . Pulmonary function and abdominal adiposity in the general population.  Chest. 2006;  129 853-62
• 26 Koenig SM.. Pulmonary complications of obesity.  Am J Med Sci. 2001;  321 249-79
• 27 Damia G, Mascheroni D, Croci M. et al. . Perioperative changes in functional residual capacity in morbidly obese patients.  Br J Anaesth. 1988;  60 574-8
• 28 von Ungern–Sternberg BS, Regli A, Schneider MC. et al. . Effect of obesity and site of surgery on perioperative lung volumes.  Br J Anaesth. 2004;  92 202-7
• 29 Eichenberger A, Proietti S, Wicky S. et al. . Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem.  Anesth Analg. 2002;  95
• 30 Dixon BJ, Dixon JB, Carden JR. et al. . Preoxygenation is more effective in the 25 degrees head–up position than in the supine position in severely obese patients: a randomized controlled study.  Anesthesiology. 2005;  102
• 31 Sprung J, Whalley DG, Falcone T. et al. . The impact of morbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy.  Anesth Analg. 2002;  94 1345-50
• 32 El–Solh AA.. Clinical approach to the critically ill, morbidly obese patient.  Am J Respir Crit Care Med. 2004;  169 557-61
• 33 Gaszynski T.. Anesthetic complications of gross obesity.  Curr Opin Anaesthesiol. 2004;  17 271-6
• 34 Ogunnaike BO, Jones SB, Jones DB. et al. . Can the morbidly obese have the same "standard of care"?–answer to a letter to the editor.  Anesth Analg. 2003;  97 603-4
• 35 Pieracci FM, Barie PS, Pomp A.. Critical care of the bariatric patient.  Crit Care Med. 2006;  34 1796-804
• 36 Coussa M, Proietti S, Schnyder P. et al. . Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients.  Anesth Analg. 2004;  98
• 37 Ezri T, Hazin V, Warters D. et al. . The endotracheal tube moves more often in obese patients undergoing laparoscopy compared with open abdominal surgery.  Anesth Analg. 2003;  96
• 38 Burns SM, Egloff MB, Ryan B. et al. . Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites.  Am J Crit Care. 1994;  3 102-6
• 39 Smetana GW.. Preoperative pulmonary evaluation.  N Engl J Med. 1999;  340 937-44
• 40 Smetana GW.. Preoperative pulmonary evaluation: identifying and reducing risks for pulmonary complications.  Cleve Clin J Med. 2006;  73 36-41
• 41 Peiser J, Lavie P, Ovnat A. et al. . Sleep apnea syndrome in the morbidly obese as an indication for weight reduction surgery.  Ann Surg. 1984;  199 112-5
• 42 Gross JB, Bachenberg KL, Benumof JL. et al. . Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea.  Anesthesiology. 2006;  104 1117-8
• 43 American Society of Anesthesiologists Task Force on Management of the Difficult A. . Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.  Anesthesiology. 2003;  98 1269-77
• 44 Schulte H, Cullen P, Assmann G.. Obesity, mortality and cardiovascular disease in the Munster Heart Study (PROCAM).  Atherosclerosis. 1999;  144 199-209
• 45 Frayn KN, Williams CM, Arner P.. Are increased plasma non–esterified fatty acid concentrations a risk marker for coronary heart disease and other chronic diseases?.  Clin Sci (Lond). 1996;  90 243-53
• 46 Adams JP, Murphy PG.. Obesity in anaesthesia and intensive care.  Br J Anaesth. 2000;  85 91-108
• 47 Hans P, Vanthuyne A, Dewandre PY. et al. . Blood glucose concentration profile after 10 mg dexamethasone in non–diabetic and type 2 diabetic patients undergoing abdominal surgery.  Br J Anaesth. 2006;  97 164-70
• 48 Juhan–Vague I, Alessi MC.. PAI–1, obesity, insulin resistance and risk of cardiovascular events.  Thromb Haemost. 1997;  78 656-60
• 49 Juhan–Vague I, Alessi MC.. Regulation of fibrinolysis in the development of atherothrombosis: role of adipose tissue.  Thromb Haemost. 1999;  82 832-6
• 50 Hamad GG, Choban PS.. Enoxaparin for thromboprophylaxis in morbidly obese patients undergoing bariatric surgery: findings of the prophylaxis against VTE outcomes in bariatric surgery patients receiving enoxaparin (PROBE) study.  Obes Surg. 2005;  15 1368-74
• 51 Blouin RA, Warren GW.. Pharmacokinetic considerations in obesity.  J Pharm Sci. 1999;  88 1-7
• 52 Cheymol G.. Effects of obesity on pharmacokinetics implications for drug therapy.  Clin Pharmacokinet. 2000;  39 215-31
• 53 Bolinder J, Kerckhoffs DA, Moberg E. et al. . Rates of skeletal muscle and adipose tissue glycerol release in nonobese and obese subjects.  Diabetes. 2000;  49 797-802
• 54 Wasan KM, Lopez–Berestein G.. The influence of serum lipoproteins on the pharmacokinetics and pharmacodynamics of lipophilic drugs and drug carriers.  Arch Med Res. 1993;  24 395-401
• 55 Hsu CY, McCulloch CE, Iribarren C. et al. . Body mass index and risk for end–stage renal disease.  Ann Intern Med. 2006;  144 21-8
• 56 Eger EI, Saidman LJ.. Illustrations of inhaled anesthetic uptake, including intertissue diffusion to and from fat.  Anesth Analg. 2005;  100 1020-33
• 57 Arain SR, Barth CD, Shankar H. et al. . Choice of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane.  J Clin Anesth. 2005;  17 413-9
• 58 Jung D, Mayersohn M, Perrier D. et al. . Thiopental disposition in lean and obese patients undergoing surgery.  Anesthesiology. 1982;  56 269-74
• 59 Wada DR, Bjorkman S, Ebling WF. et al. . Computer simulation of the effects of alterations in blood flows and body composition on thiopental pharmacokinetics in humans.  Anesthesiology. 1997;  87 884-99
• 60 Servin F, Farinotti R, Haberer JP. et al. . Propofol infusion for maintenance of anesthesia in morbidly obese patients receiving nitrous oxide. A clinical and pharmacokinetic study.  Anesthesiology. 1993;  78 657-65
• 61 Albertin A, Poli D, La L Colla. et al. . Predictive performance of 'Servin's formula' during BIS–guided propofol–remifentanil target–controlled infusion in morbidly obese patients.  Br J Anaesth. 2007;  98 66-75
• 62 Shibutani K, Inchiosa MA, Jr., Sawada K. et al. . Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients: derivation of dosing weight ("pharmacokinetic mass").  Anesthesiology. 2004;  101 603-13
• 63 Slepchenko G, Simon N, Goubaux B. et al. . Performance of target–controlled sufentanil infusion in obese patients.  Anesthesiology. 2003;  98 65-73
• 64 Egan TD, Huizinga B, Gupta SK. et al. . Remifentanil pharmacokinetics in obese versus lean patients.  Anesthesiology. 1998;  89 562-73
• 65 Greenblatt DJ, Abernethy DR, Locniskar A. et al. . Effect of age, gender, and obesity on midazolam kinetics.  Anesthesiology. 1984;  61 27-35
• 66 Weinstein JA, Matteo RS, Ornstein E. et al. . Pharmacodynamics of vecuronium and atracurium in the obese surgical patient.  Anesth Analg. 1988;  67 1149-53
• 67 Lebrault C, Berger JL, D'Hollander AA. et al. . Pharmacokinetics and pharmacodynamics of vecuronium (ORG NC 45) in patients with cirrhosis.  Anesthesiology. 1985;  62 601-5
• 68 Puhringer FK, Keller C, Kleinsasser A. et al. . Pharmacokinetics of rocuronium bromide in obese female patients.  Eur J Anaesthesiol. 1999;  16 507-10
• 69 Leykin Y, Pellis T, Lucca M. et al. . The pharmacodynamic effects of rocuronium when dosed according to real body weight or ideal body weight in morbidly obese patients.  Anesth Analg. 2004;  99
• 70 Lemmens HJ, Brodsky JB.. The dose of succinylcholine in morbid obesity.  Anesth Analg. 2006;  102 438-42
• 71 Rose JB, Theroux MC, Katz MS.. The potency of succinylcholine in obese adolescents.  Anesth Analg. 2000;  90 576-8
• 72 Juvin P, Lavaut E, Dupont H. et al. . Difficult tracheal intubation is more common in obese than in lean patients.  Anesth Analg. 2003;  97
• 73 Collins JS, Lemmens HJ, Brodsky JB.. Obesity and difficult intubation: where is the evidence?.  Anesthesiology. 2006;  104 618-9
• 74 Brodsky JB, Lemmens HJ, Brock–Utne JG. et al. . Morbid obesity and tracheal intubation.  Anesth Analg. 2002;  94 732-6
• 75 Hampel H, Abraham NS, El–Serag HB.. Meta–analysis: obesity and the risk for gastroesophageal reflux disease and its complications.  Ann Intern Med. 2005;  143 199-211
• 76 Harter RL, Kelly WB, Kramer MG. et al. . A comparison of the volume and pH of gastric contents of obese and lean surgical patients.  Anesth Analg. 1998;  86 147-52
• 77 Sprung J, Bourke DL, Grass J. et al. . Predicting the difficult neuraxial block: a prospective study.  Anesth Analg. 1999;  89 384-9
• 78 Buckley FP, Robinson NB, Simonowitz DA. et al. . Anaesthesia in the morbidly obese. A comparison of anaesthetic and analgesic regimens for upper abdominal surgery.  Anaesthesia. 1983;  38 840-51
• 79 Hamza J, Smida M, Benhamou D. et al. . Parturient's posture during epidural puncture affects the distance from skin to epidural space.  J Clin Anesth. 1995;  7 1-4
• 80 Watts RW.. The influence of obesity on the relationship between body mass index and the distance to the epidural space from the skin.  Anaesth Intensive Care. 1993;  21 309-10
• 81 McCulloch WJ, Littlewood DG.. Influence of obesity on spinal analgesia with isobaric 0.5 % bupivacaine.  Br J Anaesth. 1986;  58 610-4
• 82 Hodgkinson R, Husain FJ.. Obesity, gravity, and spread of epidural anesthesia.  Anesth Analg. 1981;  60 421-4
• 83 Carles M, Pulcini A, Macchi P. et al. . An evaluation of the brachial plexus block at the humeral canal using a neurostimulator (1417 patients): the efficacy, safety, and predictive criteria of failure.  Anesth Analg. 2001;  92 194-8
• 84 Conn RA, Cofield RH, Byer DE. et al. .Interscalene block anesthesia for shoulder surgery. Clin Orthop Relat Res 1987: 94-8
• 85 Nielsen KC, Guller U, Steele SM. et al. . Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks.  Anesthesiology. 2005;  102 181-7
• 86 Schwemmer U, Papenfuss T, Greim C. et al. . Ultrasound–guided interscalene brachial plexus anaesthesia: differences in success between patients of normal and excessive weight.  Ultraschall Med. 2006;  27 245-50
• 87 Sanchez NC, Tenofsky PL, Dort JM. et al. . What is normal intra–abdominal pressure?.  Am Surg. 2001;  67 243-8
• 88 Nguyen NT, Lee SL, Anderson JT. et al. . Evaluation of intra–abdominal pressure after laparoscopic and open gastric bypass.  Obes Surg. 2001;  11 40-5
• 89 Nguyen NT, Ho HS, Fleming NW. et al. . Cardiac function during laparoscopic vs open gastric bypass.  Surg Endosc. 2002;  16 78-83
• 90 Nguyen NT, Anderson JT, Budd M. et al. . Effects of pneumoperitoneum on intraoperative pulmonary mechanics and gas exchange during laparoscopic gastric bypass.  Surg Endosc. 2004;  18 64-71
• 91 Salihoglu Z, Demiroluk S, Dikmen Y.. Respiratory mechanics in morbid obese patients with chronic obstructive pulmonary disease and hypertension during pneumoperitoneum.  Eur J Anaesthesiol. 2003;  20 658-61
• 92 Sprung J, Whalley DG, Falcone T. et al. . The effects of tidal volume and respiratory rate on oxygenation and respiratory mechanics during laparoscopy in morbidly obese patients.  Anesth Analg. 2003;  97
• 93 Nguyen NT, Braley S, Fleming NW. et al. . Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass.  Am J Surg. 2003;  186 40-4
• 94 Nguyen NT, Wolfe BM.. The physiologic effects of pneumoperitoneum in the morbidly obese.  Ann Surg. 2005;  241 219-26
• 95 Friedman Z, Chung F, Wong DT.. Ambulatory surgery adult patient selection criteria – a survey of Canadian anesthesiologists.  Can J Anaesth. 2004;  51 437-43
• 96 WHO. .Ernährung und Versorgungssicherheit.  www.euro.who.int/nutrition/20030507_1?language=German 2004
• 97 Casati A, Putzu M.. Anesthesia in the obese patient: pharmacokinetic considerations.  J Clin Anesth. 2005;  17 134-45
• 98 Schwartz AE, Matteo RS, Ornstein E. et al. . Pharmacokinetics of sufentanil in obese patients.  Anesth Analg. 1991;  73 790-3
• 99 Schwartz AE, Matteo RS, Ornstein E. et al. . Pharmacokinetics and pharmacodynamics of vecuronium in the obese surgical patient.  Anesth Analg. 1992;  74 515-8
• 100 Leykin Y, Pellis T, Lucca M. et al. . The effects of cisatracurium on morbidly obese women.  Anesth Analg. 2004;  99 1090-4