Anesthesia Student Survival Guide.pdf - Index of

PhysioloGy And AnesthesiA for GenerAl And BAriAtriC surGery ● 339
anesthetic plan, you may choose to use a consciousness monitor such as
BIS, particularly if you choose to use TIVA during any part of the case.
Temperature monitoring availability is an ASA standard, and morbidly
obese patients generally do not lose heat as quickly as thin patients in the
OR. However, a large portion of the body will be exposed and the insufflating
gas is relatively cool, so she may become hypothermic. Since this is a risk
factor for wound infection, you should monitor temperature continuously.
How will you induce and maintain anesthesia?
Although any combination of general anesthetics are possible, you may
consider short acting, nonlipophilic drugs to avoid excessive somnolence
and respiratory problems at the end of the case. You may choose to avoid
nitrous oxide to maximize oxygen delivery, but, conversely, it is rapidly
eliminated and thus may facilitate a rapid wakeup. You will have to weigh
its use against other adverse effects such as bowel distention in laparoscopic
surgery. Some anesthesiologists have advocated TIVA at least at the end
of the procedure to allow you to fully wash out inhalation anesthetics.
Dexmedetomidine and remifentanil can provide excellent analgesia and
sedation with minimal postoperative respiratory depression and is one
attractive option. You should avoid large doses of long-acting opioids until
her respiratory status can be assessed postoperatively. You will fully reverse
neuromuscular blockade prior to emergence to avoid hypoventilation due
to even subtle weakness.
How will you manage postoperative pain? Would your plan differ if the
procedure were an open Roux-en-Y?
It is important to have good pain control but not oversedate the patient.
Pain control is important to avoid splinting and hypoventilation that can
cause atelectasis and hypoxemia. Patient-controlled analgesia has been
successfully used following bariatric surgery. Some advocate increased
vigilance for hypoventilation such as continuous pulse oximetry or
frequent respiratory rate monitoring. The surgeon can also infiltrate the
laparoscopy incisions with long-acting local anesthetic such as bupivacaine
with epinephrine to augment the analgesia. If the procedure were an open
laparotomy, placement of a thoracic epidural for postoperative pain control
should be strongly considered. This technique allows minimization of
systemic opioids and may improve pulmonary outcomes.