The Essentials of Bariatric and Metabolic Surgery: Course Applications for Members of the Multidisciplinary Care Team
Bariatric Times. 2017;14(2):22–23.
An Interview with:
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.
Dr. Jones, thank you for taking the time to discuss the Essentials of Bariatric & Metabolic Surgery App. The Essentials App contains a full sub-section dedicated to “Preanesthesia Evaluation.” What are issues of specific concern to anesthesiologists while caring for patients with obesity?
Dr. Jones: The patient with obesity poses a unique challenge to the anesthesia team. These challenges can be mitigated with proper planning. The preanesthetic evaluation is extremely important, particularly with respect to airway evaluation. The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4), published in 2011,[1,2] clearly states that poor airway assessment contributes to poor airway outcomes. This is even more critical for the patient with obesity, where poor planning combined with early oxygen desaturation leads to rapid development of a critical situation. Multiple comorbidities are associated with obesity, including diabetes mellitus, hypertension, coronary artery disease, and obstructive sleep apnea (OSA). Optimization of these conditions preoperatively, including diagnosis and treatment of OSA, will improve perioperative outcomes. Planning for the possibility of difficult intravenous access will prevent unnecessary preoperative delay and use of expensive operating room time.
What are the dangers of treating a patient with obesity WITHOUT this knowledge/training?
Dr. Jones: The average anesthesiologist is well-trained for the technical aspects of taking care of the patient with severe obesity—preoxygenation, endotracheal intubation, and obtaining intravenous access. What the occasional bariatric anesthetist might miss are the more subtle points, such as the benefits of multimodal analgesia to avoid the complications of perioperative opioids or the risks of OSA after ambulatory surgery. Most patients will do just fine without the extra consideration, but significant complications can and do occur.
Do you feel that the majority of anesthesiologists are aware of considerations in treating patients with obesity? Does this course help fill a need for educating this community?
Dr. Jones: The majority of anesthesiologists do quite well taking care of the vast majority of patients with obesity, but there is always room for improvement and education can fill the gaps needed to eliminate rare but significant instances of patient harm.
The use of actual closed malpractice claims in Essentials really helps drive important points home. For example, in the Intraoperative Considerations section, a case is presented of a 51-year-old woman who underwent an open Roux-en-Y gastric bypass. She had several of the comorbidities commonly associated with obesity, including severe obstructive sleep apnea treated with CPAP therapy. Several hours postoperatively, she suffered a near respiratory arrest, which resulted in emergent tracheotomy.
The complication may have been prevented with an opioid-sparing, multimodal analgesic strategy, including thoracic epidural analgesia for this open procedure. Additionally, earlier communication by PACU personnel when pain was not being effectively managed by escalating doses of fentanyl and morphine may have occurred if the risks of opioids in this patient were appreciated. These knowledge gaps can be filled with the material contained in Essentials.
What else do readers need to know about accessing and using this resource?
Dr. Jones: The app is available online at http://essentials.asmbs.org/ and also for free download in the Apple App Store. While registration is free, fees will apply should you elect to redeem continuing education credits. I encourage readers to share the app with everyone in practice.
1. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth. 2011;106(5):617–631.
2. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011;106(5):632–642.
Funding: No funding was provided in the preparation of this interview.
Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.