What are the recommendations for imaging morbidly obese patients undergoing peripheral nerve or neuraxial procedures?

From the Guidelines

For morbidly obese patients undergoing peripheral nerve or neuraxial procedures, fluoroscopy-guided imaging is recommended as a valuable adjunct to improve success rates and reduce complications, as evidenced by the use of intermittent-pulse fluoroscopy to identify the appropriate site and monitor needle position 1. When using fluoroscopy, it is essential to consider the operator's experience, as the success rate can vary significantly depending on the operator's skill level 1. Additionally, the use of 3D fluoroscopy can be beneficial in guiding procedures, especially in cases where bedside attempts are challenging 1. While ultrasound guidance is also a valuable tool, the provided evidence suggests that fluoroscopy-guided imaging can be particularly useful in morbidly obese patients, especially when combined with proper patient positioning and technique. Some key considerations for imaging morbidly obese patients include:

• Using advanced imaging technologies, such as 3D fluoroscopy, to improve visualization and guidance
• Optimizing patient positioning to improve imaging windows and reduce complications
• Considering the use of "phantoms" or virtual simulations as training aids to increase confidence and skill in less experienced healthcare providers 1
• Being aware of the potential risks and challenges associated with imaging in morbidly obese patients, such as increased signal attenuation and scattering, and taking steps to mitigate these issues. It is also important to note that regional anesthesia is preferred to general anesthesia in morbidly obese patients, and that appropriate patient counseling and consent are essential due to the higher risk of failure of regional techniques in this population 1.

From the Research

Peripheral Nerve Imaging and Neuraxial Imaging in Morbidly Obese Patients

To improve peripheral nerve imaging and neuraxial imaging in morbidly obese patients, several guidelines and tips can be considered:

• Use of ultrasound guidance for peripheral nerve blocks, as it can help improve the accuracy and safety of the procedure 2
• Consideration of the patient's body mass index (BMI) and its potential impact on the difficulty of block placement and the effectiveness of analgesia 3
• Use of alternative imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI), if ultrasound guidance is not feasible
• Careful planning and modification of the imaging protocol to accommodate the patient's body habitus and potential comorbidities

Recommendations for Imaging Morbidly Obese Patients

Some key recommendations for imaging morbidly obese patients undergoing peripheral nerve or neuraxial procedures include:

• Use of a dual-head camera and attenuation correction to improve image quality 4
• Consideration of the patient's weight and BMI when selecting the imaging modality and protocol
• Use of high-dose contrast agents and optimized imaging parameters to improve image quality
• Careful monitoring of the patient's vital signs and potential complications during the imaging procedure

Challenges and Considerations

Morbidly obese patients pose unique challenges for peripheral nerve imaging and neuraxial imaging, including:

• Poor image quality due to attenuation and scatter 4
• Increased risk of complications, such as deep venous thrombosis and pulmonary embolism 5
• Difficulty with patient positioning and access to the imaging site
• Potential need for modified imaging protocols and equipment to accommodate the patient's body habitus 6