4-Anesthesia and Obese Patients[1]

7/29/2019 4-Anesthesia and Obese Patients[1]

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Anesthesia and

Obese Patients

Abdullah Halawani, MBChB, FRCPC.Department of Anesthesiology

KFSH & RC , Riyadh


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Obesity is a relatively common condition,

that can have a profound impact on

morbidity/mortality and anesthesia.

Physiological derangements, difficult

airway management, and alterations in

pharmacokinetics & dose/response

relationships can all be part of thepicture.


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Twenty Years of Increasing Obesity

30.5%

22.9%

15%14.5%13.4%

0%

10%

20%

30%

40%

1960 1974 1980 1994 2000

%O

bes

ity

Source NCHS -- JAMA 2002:14:1723-27.


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All-cause mortality versus

BMI for each sex in the

range 15 to 50 kg/m2

(excluding the first fiveyears of follow-up)


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Dr. Tushar Chokshi 5


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Definitions

- Overweight is defined as weight abovethe normal range.- Obesity is defined as an abnormally high

percentage of body weight as fat.- Body mass index (BMI) is used todistinguish between the two terms andalso determines the degree of excess

weight

BMI = body weight (in kg) height (in meters) squared


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Classification of BMI

* Underweight BMI


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Equations

Ideal body weight in Kg (IBW)

(Brocas Index)

Height in centimeters - 100 for men Height in centimeters - 105 for women

-----------------------------------------------------

Body mass index (BMI) weight in Kg / height (m) 2


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Causes of Obesity

Complex and multifactorial Genetic predisposition

Socialization

Age

Sex

Race

Economic status

Psychological

Cultural

Emotional

Environmental factors

Cessation of smoking


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Diseases Linked to Obesity

Diabetes Coronary Heart Disease

High Blood Pressure ( Hypertension is about 6 timesmore frequent in obese subjects than in lean men and

women ) Stroke

Arthritis

Gastroesophageal reflux

Cancer

High cholesterol

Endocrine disease


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Diseases Linked to Obesity

Hypertrophic Cardiomyopathy Infertility

Depression

Obstructive sleep apnea

Gallstones

Fatty liver

Stress incontinence

Venous ulcers end-stage kidney failure

Sudden death


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Physical Complications of Obesity

Heart disease Type II diabetes mellitus

Hypertension

Stroke

Cancer (endometrial, breast, prostrate, colon)

Gallbladder disease

Sleep apnea

Osteoarthritis Reduced fertility

increased risk of morbidity and mortality as wellas reduced life expectancy


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9.2prevalence is2Diabetes Mellitus Type

times higher in the obese than in non-obesefor those 20-75 years of age.

hasCardiovascular diseasesMorbidity due tobeen reported to be almost 90 % in those withsevere obesity.


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Psychological Complications

of Obesity

Emotional distress

Discrimination

Social stigmatization

Anxiety, Fear, Hostility and Insecurity


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PathophysiologyCardiovascular

in Obesity

Excess body mass

metabolic demand CO

For every 13.5 kg of fat gained: 25 miles of neovascularization occurs

Increased CO of 0.1 L/min for each kg of fat.

workload

LVH

pulmonary blood flow and HPV

Pulmonary HTN cor pulmonale right heart

failure


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in Obesity

Stroke volume index and stroke work indexare the same as non-obese

SV and SW must

Proportion to body weight

SV and SW

LVH dilatation


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Risk of arrhythmias

Hypertrophy

Hypoxemia Fatty infiltration of cardiac conduction system

Catecholamines

Sleep apnea Dyslipidemia

Glucose intolerance


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Cardiac Evaluation:

Assess For

Prior MI

HTN

Angina

PVD


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Cardiac Evaluation

Indications of LV dysfunction

Limitations in exercise tolerance

History of orthopnea

Paroxysmal nocturnal dyspnea


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Cardiac Evaluation: ECG

Determination of

resting rate

Rhythm

Ventricular hypertrophy or strain


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ECG Changes That May Occur in Obese Individuals

Heart rate

PR interval

QRS interval

or QRS voltage

QTc interval

QT dispersion

SAECG (late potentials)

ST-T abnormalities

ST depression

Left-axis deviation

Flattening of the T wave (inferolateral leads)

Left atrial abnormalities

False-positive criteria for inferior myocardialinfarction


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Investigate ischemic changes or evidence

of coronary artery disease

Low voltage ECG

Excess overlying tissue

Underestimate LVH


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Axis deviation and atrial tachyarrhythmias

Sudden cardiac death is more prevalent

with

LVH

Ventricular ectopy


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Vascular Access

Challenging at best

Excessive fat obscures blood vessels

Central line placement

Vessels impeded by distortions of the

underlying anatomy by adipose tissue


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Volume Replacement

Adult total body water percentage is 60%to 65%.

Severely obese total body water is 40%.

Estimated blood volume in obese patient is45 to 55 mL/kg actual body weight

70 mL/kg for the non-obese


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Volume Replacement

Avoid rapid rehydration

Lessen cardiopulmonary compromise.

Administer Hetastarch at recommended

volumes per kilogram of IBW 20 mL/kg

Albumin 5% and 25% used as indicated

Support circulatory volume and oncoticpressure.

Replace blood loss with crystalloid

3:1 ratio


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PathophysiologyRespiratory

There is a clear association between dyspnea andobesity. Obesity increases the work of breathingbecause of the reductions in both chest wall

compliance and respiratory muscle strength

Excess metabolically active adipose + workload onsupportive respiratory muscle

CO2 production

Hypercarbia

O2 consumption

Hypoxia


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Time to desaturation


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FRC.FRC..FRC..FRC. F RC

Obesity in anaesthesia and intensive care

J. P. Adams and P. G. Murphy British Journal of Anaesthesia, 2000, Vol. 85, No. 1 91-108
http://www.bja.oupjournals.org/content/vol85/issue1/images/large/aed004f1.jpeg


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PathophysiologyRespiratory

Restrictive lung disease

Decreased chest wall compliance

Diaphragm forced cephalad Decreased lung volumes

Accentuated by supine and Trendelenbergpositions

FRC may fall below closing capacity Alveolar collapse

Ventilation / perfusion mismatch


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Changes in Pulmonary

Volumes and Function Tests Tidal volume

Normal or decreased

Inspiratory reserve volume

Decreased

Expiratory reserve volume

Greatly decreased


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Changes in Pulmonary

Volumes and Function Tests

FRC

Greatly decreased

Direct inverse relationship between BMI

and FRC

FEV1

Normal or slightly decreased


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PathophysiologyRespiratory Relatively hypoxemic

Occasionally hypercapnic

Obesity-hypoventilation (Pickwickian syndrome)

Obesity usually extreme

Hypercapnia

Cyanotic / hypoxemia

Polycythemia

Pulmonary HTN

Biventricular failure

Somnolence

Obstructive sleep apnea syndrome (OSAS)


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Obesity alters upper airway anatomy

Increased fat deposition in pharyngeal

tissues increases the likelihood of

pharyngeal wall collapse, which can

complicate the performance of rapidsequence intubation


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OSAS

Definition

10 seconds or more of total cessation of

airflow despite respiratory efforts

Clinically relevant

5 episodes per hour

30 episodes per night


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OSAS

Snoring

Dry mouth and short arousal during sleep

Partners report apnea pauses during sleep


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OSAS

More vulnerable to airway obstruction

Opioids

Sedatives

More vulnerable in supine or Trendelenberg

position
http://www.cmaj.ca/content/vol174/issue9/images/large/21ffb1.jpeg


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http://www.cmaj.ca/content/vol174/issue9/images/large/21ffb1.jpeghttp://www.cmaj.ca/content/vol174/issue9/images/large/21ffb1.jpeg


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Detecting OSAS

Nocturnal polysomnography


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PathophysiologyGI

incidence

Gastroesophageal reflux

Hiatal hernia

abdominal pressure

Severe risk of aspiration


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PathophysiologyGI

After 8 hour fast

85 90% of morbidly obese patients

have

Gastric volumes > 25 ml

Gastric pH < 2.5

A th ti C id ti


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Anesthetic Considerations:

Preoperative

risk for aspiration pneumonitis if reflux history

Consider H2 antagonist ( pre, intra and post )

Metoclopramide, Ranitidine or Ondansetron

Sleep apnea, asthma, smoking

Avoid unnecessary respiratory depressants

BHT (breath holding time)

Assess for

Cardiopulmonary reserve

ECG & X-ray Chest, if necessary echocardiography

LFT & RFT

ABG

PFTs


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Preoperative

BP with appropriate size cuff

Plan / examine for venous / arterial

access Possible regional anesthesia


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AIRWAY ASSESSMENT

Obesity and airway difficulty

The goal of airway assessment is to identifyclinical features that predict difficulty in any

of the following areas of emergency airway

management:- Ventilation with bag-mask or extraglottic

device

- Laryngoscopy and endotracheal intubation

- Surgical airway performance


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Preoperative Airway Assessment

Limited TM joint mobility

Limited atlanto-occipital mobility

Narrow upper airway

Small space between mandible and sternal

fat pads


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The Mallampati classification fordifficult laryngoscopy and intubation


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Neck Circumference

Normal neck circumference in cm is

weight in kg / 2

Normal neck cir. at 7o kg is 35 cm

If it increase by 13 % then difficultintubation is counted


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Bag-mask ventilation

Obesity makes bag-mask ventilation more difficult Redundant upper airway soft tissue coupled with

increased body mass results in increased airwayresistance

Higher pressures are required to ventilateeffectively, and this can lead to difficulty

maintaining a mask seal

The MOANS mnemonic for difficult bag


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The MOANS mnemonic for difficult bag

mask ventilation

Mask seal

Obesity/obstruction

Aged (over 55 years)

No teeth

Stiff lungs

d h l b


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Endotracheal intubation

Studies assessing emergency airway management in obese patients are

scarce. Nevertheless, multiple studies performed in the operating roomhave found an association between obesity and difficult laryngoscopy andendotracheal intubation :

19 Lundstrm, LH, Mller, AM, Rosenstock, C, et al. High body mass indexis a weak predictor for difficult and failed tracheal intubation: a cohort

study of 91,332 consecutive patients scheduled for direct laryngoscopyregistered in the Danish Anesthesia Database. Anesthesiology 2009;110:266.

20 Juvin, P, Lavaut, E, Dupont, H, et al. Difficult tracheal intubation is morecommon in obese than in lean patients. Anesth Analg 2003; 97:595.

21 Lavi, R, Segal, D, Ziser, A. Predicting difficult airways using theintubation difficulty scale: a study comparing obese and non-obesepatients. J Clin Anesth 2009; 21:264.

22 Brodsky, JB, Lemmens, HJ, Brock-Utne, JG, et al. Morbid obesity andtracheal intubation. Anesth Analg 2002; 94:732

The LEMON mnemonic for predicting the
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The LEMON mnemonic for predicting the

difficult emergency airway

Look externally

Evaluate 3-3-2

Mallampati

Obstruction/Obesity

Neck mobility


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Endotracheal Intubation

Position

Preoxygenation

Equipments

Backup plan

Help


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RAMP position

A) In the supine patient,access to the airway isobstructed.

B) With the patient

propped on linens in theRAMP position, access tothe airway is improved. Inthis position, an imaginary

horizontal line can bedrawn from the externalauditory meatus to the

sternal notch.


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Airway

Airtraq optical laryngoscope

Endotracheal tube introducer ("bougie")

video laryngoscope

The laryngeal mask airway (LMA) allows flexible


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The laryngeal mask airway (LMA) allows flexiblebronchoscopy and ventilation to be performedunder general anesthesia. The device can also

serve as an excellent rescue airway.


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Surgical airway

Excessive soft tissue in the anterior necklimits access to the cricothyroid

membrane and makes it difficult to

identify the anatomic landmarks neededto perform a cricothyrotomy

The SHORT mnemonic for assessing


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g

difficult cricothyrotomy

Surgery (or other airway disruption)

Hematoma (or infection or abscess)

Obesity (or other access problem)

Radiation (or other tissue deformity)

Tumor


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Induction Airway Equipment

Light Stylet

Gum elastic bougie

Oral airway, Nasopharyngeal Airway

LMAs

ETT with stylet



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Induction

Consider awake intubation

Avoids airway collapse

Minimal to no sedation LMA is good alternative for temporary

mechanical ventilation in grossly and morbidobese patient

Consider tracheotomy kit and surgeon

standing by



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Intraoperative

Awake fiberoptic intubation if difficult airwaysuspected

Breath sounds distant

ETCO2 more important

Relatively high FIO2 may be needed in:

Lithotomy

Trendelenberg Prone


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VENTILATION

In morbidly obese patients, the best strategy forventilation is to deliver TV according to IBW (8-10ml/kg )

Apply 5 cm H2O PEEP in order to decrease theincidence of atelectasis.

Minute ventilation and ETCO2 need to be monitored

closely Usually use pressure control ventilation

The metabolism and pharmacokinetics


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The metabolism and pharmacokinetics

of Drugs

Lipophilic drugs have a larger volume of distribution (Vd),since the Vd is dependent upon the amount of adiposetissue

Obese patients are known to have higher glomerular

filtration rates, and renally excreted drugs may haveshorter half-lives since their elimination is directlyproportional to creatinine clearance

Obesity does not generally affect the clearance of drugs

that are metabolized by the liver

Because of the complexity of obesity-relatedpharmacokinetic changes and because detailed data arelacking for many drugs, individual drug dosing for obese

patients remains controversial

Obesity: Pharmacology


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Overdosing of pre medication and anesthesia drugsin obese patient is very common

doses should be calculated on predicted lean

body weight Lean body weight = body weight - fat weight

Avoid IM injection due to unpredictableabsorption

If possible, avoid narcotics and sedation in obesepatient



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Propofol at TBW

Thiopental at IBW

Midazolam at IBW

Scolene at TBW Vcuronium at IBW

Atracurium at TBW

Rocuronium at IBW

Fentanyl & Sufentanyl at TBW

Remifentanil at IBW

Ideal body weight and approximate lean


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y g pp

body weight in obesity (adult)

Height (in) Height (cm) IBW* (kg)ApproximateLBW in classIII obesity

(kg)

Female(adult)

60 152 46 52

65 165 57 60

70 178 68 70

75 191 80 80

Male (adult)

60 152 50 63

65 165 62 73

70 177 76 85

75 191 89 97

80 203 103 112



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Intraoperative

Morbidly obese patient should never lie flat

Semi-Fowlers position

Upper body elevated 30 40

Semi-recumbent position

Best position during post-operative

period

PositionTrendelenburgReverse


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g

RTP is bestintraoperative position

Can amelioratedeleterious effects ofsupine position

RTP is 30 degree head upposition

RTP

pulmonarycompliance

FRC

Returned P(A-a)O2 tobaseline

RTP may be a bettersolution than

Large TV and PEEP


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monitoring

ECG

Pulse Oxymeter

Blood pressure

Temperature

Inspired oxygen concentrationCapnography

Arterial catheter to continuously measure BPand blood gases ( if medically indicated )

CVP catheter

Urinary catheter

Advance monitoring according to Surgery



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Intraoperative

Regional anesthesia

Technically more difficult

Require 20 25% less LA for Spinal or Epiduralanesthesia because of

(Epidural fat and distended epidural veins)

Combined epidural/general(GA) preferred to

decrease GA requirement Epidural anesthesia may postoperative

respiratory complications



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Intraoperative

Pulmonary compliance and FRC Worsened by GETA and high intraabdominal

pressure

Opening the abdomen or lifting thepanniculus FRC

Improves oxygenation

G l f f h


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Goals for Maintenance of Anesthesia

Strict maintenance of airway Adequate skeletal muscle relaxation

Optimum oxygenation

Maintenance of anesthesia with inhalation andintravenous agents

Avoid residual effects of muscle relaxants

Appropriate intraoperative and postoperative tidal

volume

Effective postoperative analgesia.


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Postoperative Respiratory failure risk increased by

Preoperative hypoxia

Thoracic or upper abdominal surgery Vertical incision

Delayed extubation until Complete reversal of muscle relaxation

Patient fully awake

Follows commands



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Postoperative

Supplemental O2 after extubation

Transport from OR to Recovery room

45 degree head up position

Unload diaphragm

Improves oxygenation

Improves ventilation

CPAP and BiPAP should available


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Postoperative PCA

Can provide good pain relief

Dose based on IBW

NSAIDs, Local anesthetic infiltration

Epidural route is preferred

Administration of smaller dose than IV

route


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The first intubation attempt should be by the most experiencedintubator

If the first best attempt determines difficult or impossiblelaryngoscopy or intubation, change to either Rescue Airway plan (ifpatient condition is critical), or earlyFiberoptic Intubation beforeairway trauma worsens the situation

Large breasts may get in the way of the laryngoscope handle (half-size handles are available).

Response to induction agents is less predictable for intubation

Confirmation of endotracheal intubation should be by three ormore methods including either capnometry or capnography

Obese patients will desaturate oxygen rapidly

All obese patients with airway problems or impending intubationshould have 100% oxygen

In failed Intubation by all methods, in emergency Percutaneouscricothyrotomy or surgical tracheostomy


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Message

The anesthetic management of the clinicallysevere obese patient requires meticulouspreoperative, perioperative and postoperativecare. Careful planning is essential before taking

the patient in the operating room. To haveexcellent outcome, a multidisciplinary approach,including the primary care physician,anesthesiologist, surgeon, nursing staff andsocial worker is necessary.


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L f A h i Th E i l


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Laws of Anesthesia: The Essentials

Air goes in and out. Blood goes round and round.

Numb is good.

Numb and hemodynamically stable is better.

Numb, hemodynamically stable and amnestic isbest.

Numb, hemodynamically stable, amnestic andwarm is better yet.

Dead meat dont beat.

Evidence-based medicine and the critically

ll b


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ill bariatric patient

Subject Study Weight exclusion criteria

Early goal-directed thrapyin patients with sepsis

Rivers, 2001 N/A

Low tidal volumes in ARDS ARDSnet, 2000Excluded if weight >1kg/cm of height

Low-dose corticosteroidsfor refractory shock

Annane, 2002 N/A

Intensive insulin therapy van den Berghe, 2001N/A; mean body massindex = 26

Activated protein C Bernard, 2001 Excluded if weight >135 kg

Daily dialysis in renalfailure

Schiffl, 2002 N/A

Effect of PA catheterSandham, 2003 N/A

Richard, 2003 N/A

Clinical and laboratory data for the evaluation


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y

of overweight patients

4-Anesthesia and Obese Patients[1]

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