Adrian Alvarez

Total Intravenous Anesthesia with Midazolam, Remifentanil, Propofol and Cisatracurium in Morbid Obesity

Background: According to physical impairments of massive obesity, cardiac, respiratory and gastrointestinal physiology must be considered as much as pharmacokinetic behavior. Anesthetic management of morbidly obese patients has to be carefully planned, in order to minimize the increased risks of aspirative pneumonitis, hemodynamic instability and delay in recovery.The ideal anesthesia should provide a smooth and quick induction, allowing rapid airway control, prominent hemodynamic stability, and rapid emergence from anesthesia.To approach these ideal conditions,aTotal Intravenous Anesthesia (TIVA) with midazolam, remifentanil, propofol and cisatracurium was designed and analyzed. Methods: 10 consenting morbidly obese patients scheduled for elective Laparoscopic Adjustable Gastric Banding participated in the study.TIVA with midazolam, remifentanil, propofol and cisatracurium was used in all cases.Time to loss of consciousness, tracheal intubation, perianesthetic physiological parameters and complications, incidence of awareness with recall, recovery times, postoperative analgesia and costs of drugs were evaluated. Results:The analyzed data showed adequate time and physiological conditions for induction and tracheal intubation, stable maintenance with easy handling of deepness, low incidence of perianesthetic complications, excellent recovery performance and institutional efficiency. Conclusions: TIVA with midazolam, remifentanil, propofol and cisatracurium was found to be effective, secure, predictable and economic for the anesthetic management of morbidly obese patients.

Postoperative analgesia in morbid obesity.

Morbidly obese patients due to high incidence of obstructive sleep apnea (OSA) are predisposed to opioid induced airway obstruction and thus frontline high ceiling analgesics (opioids) have concerns based on safety in their liberal use. Although surgical techniques over the last two decades have seen a paradigm shift from open to laparoscopic procedures for morbidly obese patients; optimally titrated yet safe analgesic management still remains a challenge. The present review sums up the analgesic options available for management of morbidly obese patients undergoing surgery. We highlight the utility of multimodal approach for analgesia with combinations of agents to decrease opioids requirements. Pre-emptive analgesia may be additionally used to improve the efficacy of postoperative pain relief while allowing further reductions in opioid requirements.

Practical considerations in the development of a nonoperating room anesthesia practice

Purpose of review More than 25% of the procedures necessitating an anesthesia providers involvement are performed outside the operating room. As a result, it is imperative that the expansion of anesthesia services to any new nonoperating room anesthesia (NORA) location takes into account the challenges and safety considerations associated with such a transformation. Recent findings Although the adverse events encountered in the NORA suite are similar to those met in the operating room, the frequency and implications are different. In addition, many adverse events are site specific. Hypoxemia events, including cardiac arrest continue to dominate all areas of NORA practice. Challenges posed by new minimally invasive procedures continue to grow. Electronic documentation is rapidly expanding into the NORA suite, which brings both advantages and challenges. Summary Involvement of anesthesia providers at the development stage and an understanding of the administrative and clinical challenges are essential elements in the building of a NORA practice.

Enhanced recovery after bariatric surgery.

Purpose of review Enhanced recovery after surgery (ERAS) methodology has demonstrated consistent benefits in patients undergoing colorectal, urological and thoracic surgeries. Principles of these protocols and their advantages are expected to extend into other surgical specialties such as bariatric surgery. In this review, we summarize the components of ERAS protocols for bariatric surgery and present the evidence on the emerging role of ERAS principles in obese patients. Recent findings Many recent trials have evaluated ERAS protocols for bariatric surgery. Most of these protocols originate from modifications within the individual hospital-based conventional perioperative care strategies. Studies demonstrate that ‘ERAS based’ care requires evidence-based modifications in all preoperative, intraoperative and postoperative phase. Despite a lack of standardization in protocols at present, benefits such as decreased length of hospital stay, rapid patient turnover, shorter operating room times and lower healthcare costs have been well demonstrated repeatedly. Summary ERAS for bariatric surgery is in its early phase. Nevertheless, literature supports its role in improving perioperative outcomes compared with conventional care in this scenario. Evidence-based protocols, multidisciplinary teamwork and meticulous audit seem to be the key factors for success in ERAS methodology.

Two-day hospital stay after laparoscopic colorectal surgery, is enhanced recovery program a healthcare system specific issue? Reply.

We greatly appreciate the opportunity to reply to the letter from Wang et al. asking whether an enhanced recovery after surgery (ERAS) program is a healthcare systemspecific issue. According to the comparison they made with our patients and Asian customs in terms of postoperative recovery, we consider that there are a few points to discuss. First, we certainly agree with Wang et al. that our findings in terms of morbidity and readmission rates were within our ERAS group. We also agree that our findings may not be the same as in other countries. In fact, they may even be different for the other institutions of our country. Secondly, as it has been previously reported, length of stay (LOS) is an indicator of healthcare efficiency and may be useful in assessing healthcare quality [1, 2], while laparoscopy has shown to impact favorably on this postoperative outcome [3]. However, Wang et al. not only did not find any significant difference in terms of LOS between patients operated on by laparoscopy versus open surgery under a fast track program, but also their overall LOS was around 13 days. This seems to show that in West China Hospital, patients are generally admitted several days before surgery. These two findings reflect the likelihood that the compliance with the various components of ERAS in their institution was not so high, as expected. Moreover, the delay in discharging the patient from the hospital until stitch removal conspires against the essence of ERAS. In fact, if we should wait for stitch removal in all our surgical patients, our institution would collapse (logistically and economically speaking). On the other hand, it seems that there are at least two key factors that suggest higher chances of success with ERAS. Firstly, the greater the adherence to the guidelines, the better the outcome. Two, we must know what we are doing. This means that we need to audit the whole process. Very frequently, the amount of single ‘‘therapeutic measures’’ (removal of tubes and drains, opioid-free analgesia, minimally invasive approach, etc.,) is overestimated. In other words, it is very common to believe that ‘‘we are doing ERAS’’ but that is not really the truth. With reference to this, a group from Canada recently reported that the main barriers to the implementation of an ERAS program include the need for patient education, the optimization of communication, and, finally, better evidence for ERAS interventions [4]. Another important aspect of perioperative care is related to cost. It has also been reported that with decreasing hospital resources and increasing medical costs, a safe reduction in postoperative hospital stays has become a major concern to optimize utilization of healthcare resources including the availability of beds [5]. Because of that, despite every medical institution (public health or private) has different economic needs, effort should also be focused on a rational use of economic resources. There is no doubt that each country has its own idiosyncrasies that will surely influence postoperative care. However, whenever any surgical group intends to implement an ERAS program, these issues need to be addressed. Returning to the initial question posed by the G. Rossi (&) H. Vaccarezza Section of Colorectal Surgery, Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina e-mail: gustavo.rossi@hospitalitaliano.org.ar

Analgesia in the Obese Patient

Obese patients pose unique challenges to the anesthesiologist for optimal perioperative management. The perioperative universal goal of comfortable yet safe surgery is no less than a double-edged sword in the morbidly obese. In order to achieve high patient satisfaction (directly related to quality of recovery and analgesia), the anesthesiologist has to strike a delicate balance between the life-threatening adverse events and analgesic potential of opioids. Further to compound the issue, the interindividual pharmacokinetic variations in opioid effects make this job almost next to impossible. Despite these safety hurdles and pharmacological barriers, a postsurgical obese patient in pain cannot be ethically or morally justified! Over the years, gradual progress has been made in analgesic management of the morbidly obese that not only resorts to alternative analgesic regimens but also strikes a safety balance for the use of “dangerous” opioids. The “danger” here is not by any standards a misrepresentation as it can be adjudged by the fact that as per the American Society of Anesthesiologists (ASA) closed claim data, highest perioperative complications/mortality in obese occurs due to opioid-related airway complications [1].