This ongoing column is authored by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient.
Column Editor: Stephanie B. Jones, MD
Dr. Jones is Associate Professor, Harvard Medical School and Vice Chair for Education, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
In this month’s installment of Anesthetic Aspects of Bariatric Surgery, we feature an interview with Dr. Stephanie Jones, Column Editor and new president of the International Society for the Perioperative Care of the Obese Patient (ISPCOP). ISPCOP’s mission is to promote excellence in clinical management, education and research regarding the care of the morbidly obese patient during the perioperative period.
BT: What role does anesthesia play in the bariatric surgery process? How does anesthesia work in the human body?
Dr. Jones: Simply put, our job is to render the patient insensate to surgical pain, maintain physiologic homeostasis while the surgeon does his or her best to alter it, and return the patient to a conscious and comfortable state once surgery is completed. This is most typically accomplished with a combination of intravenous and inhalational anesthetics; pain may be treated with intravenous narcotic and/or non-narcotic medication or with neuraxial (spinal or epidural) administration of local anesthetics.
Bariatric anesthesia comes with the additional responsibility of managing patients with often multiple comorbid conditions and positioning them optimally while they undergo complex abdominal procedures. They require postoperative pain management in the setting of known or likely obstructive sleep apnea (OSA), and attention to fluid management that varies depending upon surgical procedure and patient factors. Some anesthetic medications are dosed based upon ideal body weight, some on lean body weight, and others approaching total body weight. Research by bariatric anesthesiologists has yielded successful management strategies, such as the use of multimodal analgesia, including dexmedetomidine and ketamine to facilitate outpatient laparoscopic gastric banding, and positioning and preoxygenation strategies to increase the safe apnea period post-induction.
BT: Please provide a brief background of the International Society for the Perioperative Care of the Obese Patient. When, where, why, and how did it begin?
Dr. Jones: The International Society for the Perioperative Care of the Obese Patient (ISPCOP) was founded in 2006 as an international organization based in the United States by two anesthesiologists with well-established careers in bariatric anesthesia: Dr. Jay Brodsky (Stanford University) and Dr. Adrian Alvarez (Italian Hospital, Buenos Aires). The governance structure was revised in 2010 at the American Society of Anesthesiologists (ASA) meeting in San Diego, California and subsequently ratified at the ASA meeting in 2011 in Chicago, Illinois. The mission of ISPCOP is to promote excellence in clinical management, education, and research regarding the care of the morbidly obese patient during the perioperative period. At this time, the membership is comprised primarily of anesthesiologists and anesthesia trainees, with a small number of industry and nursing members.
BT: How did you get involved in this field? How did you become involved in ISPCOP?
Dr. Jones: One could say I married into it. Early in my career, my husband, Dr. Daniel B. Jones, and his partner at the University of Texas Southwestern Medical Center, Dr. David Provost, began developing their technique for laparoscopic Roux-en-Y gastric bypass (RYGB). It wasn’t the most popular anesthesia assignment in 1998 as the surgical times were long and Dr. Provost’s operating room music of choice was loud heavy metal. I took one for the team, but then happily found myself in an interesting and rapidly expanding clinical niche as bariatric surgery became more popular.
Shortly after I moved to Boston, Massachusetts in 2003, the Betsy Lehman Center for Patient Safety and Medical Error Reduction was founded by the Office of Health and Human Services of Massachusetts. As its first task, the Center convened a Weight Loss Surgery Expert Panel in response to a spate of serious bariatric surgery complications in the state. I co-chaired the Anesthesia Task Force along with fellow ISPCOP member Dr. Roman Schumann (Tufts University). As a group, we published best practice recommendations for anesthetic perioperative care in 2005, and updated our findings in 2009. During the same time period, ISPCOP was working hard to establish itself as the go-to organization for bariatric anesthesia so it made complete sense to join their efforts.
BT: How does the care of patients with obesity differ from care of normal weight patients in terms of anesthesia? What are the challenges?
Dr. Jones: The first thing an anesthesiologist tends to think about when caring for a morbidly obese patient is the airway. Will I be able to intubate the patient without difficulty? If not, will I be able to mask ventilate? Will I need any special equipment? Those of us who take care of obese patients regularly recognize that weight or BMI alone is not predictive of a difficult airway. However, if difficulty is unexpectedly encountered, time is of the essence as oxygen reserve is significantly decreased. Therefore, a back-up plan should be in place prior to induction of anesthesia. OSA is a common comorbid condition. Extra care must be taken with extubating the OSA patient to ensure that airway obstruction does not occur. They are also more sensitive to the sedating effects of narcotics, necessitating thoughtful planning of postoperative pain regimens and monitoring. Safely moving and positioning the patient in the operating room can become a challenge, with risk of injury to provider and patient.
BT: Is it important to communicate these differences to all anesthetists and caregivers in other fields? Does ISPCOP work to educate beyond membership? If so, through what methods?
Dr. Jones: Absolutely! We continually seek out opportunities to convey our message at major anesthesiology meetings and other specialty conferences. Individual ISPCOP members are also hard at work at their home institutions establishing care guidelines and educating nurses and other physicians. We also have our regular column in Bariatric Times.
BT: Have you seen increased interest in caring for patients with obesity among non-ISPCOP members?
Dr. Jones: Yes and no. Obesity is such a widespread problem that providing anesthesia for patients with obesity has nearly become routine for most anesthesiologists. So we may have become a bit inured to obesity in the operating room until patients reach extremely high BMI levels. That being said, anesthesiology is in real need of evidence-based guidelines for perioperative care of the obese patient. Many of the currently published guidelines applicable to the obese patient consist largely of expert opinion. This is valuable, but less powerful than data-driven recommendations. There has been a considerable increase in the amount of research on obesity applicable to the perioperative period over the past decade or so, particularly involving issues such as obstructive sleep apnea and appropriate dosing of anesthetic medications. But other questions need to be addressed. For example, which procedures on which patients can be safely performed in ambulatory surgery centers? Is there an upper limit of BMI for which outpatient surgery is never appropriate? How do we prospectively differentiate the “healthy” obese patient from the “nonhealthy” and adjust our perioperative plan appropriately? How do we decide who needs more intensive postoperative monitoring in an era of cost containment?
BT: What has ISPCOP accomplished since its inception?
Dr. Jones: We held our first symposium at the American Society of Anesthesiologists annual meeting in Washington, DC, in 2012, and our second this past Fall in San Francisco, California. There we were able to provide CME credit and a scientific session. The 2014 symposium is in the planning stages and will include a formal call for abstracts and research award, in addition to lectures by an international panel of experts. We have had wider exposure with well-attended panel presentations by ISPCOP members at the ASA, European Society of Anesthesiologists, and The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) meetings. We organized a full-day session at the 2012 World Congress of Anaesthesia (WCA) in Buenos Aires and are in discussions regarding the WCA 2016 in Hong Kong.
BT: As President for the 2014-2015 term, what do you hope to accomplish?
Dr. Jones: ISPCOP increasingly serves a networking function to gather anesthesiologists from around the world performing research and educating others on the perioperative care of the obese patient. I would like to see a significant increase in membership as a way to consolidate existing expertise and brainstorm research priorities. We have already decided to offer free membership to medical students and residents to attract the next generation of bariatric anesthesiologists at the earliest level of training. We are excited to partner with our surgical colleagues at ASMBS and have applied for Level 2 Partnership for Obesity Week 2014, with the intent of sponsoring a symposium tailored to a multispecialty audience. Perioperative care of the obese patient extends far beyond the operating room—surgeons, internists, endocrinologists, and others must be thoroughly engaged as well. With a cohesive multidisciplinary team, bariatrics might enjoy the same success as other team-based specialties, such as transplant and cardiac surgery. Finally, we plan to use the symposium as a basis for a white paper, enabling wide dissemination via journal publication and our website (www.ispcop.org).
BT: Dr. Jones, thank you for taking the time to talk with us. Good luck with the ISPCOP.
Funding: No funding was provided.
Disclosures: The author does not have any conflicts of interest relevant to the content of this article.