What are the pre-surgical clearance recommendations for a 32-year-old female with a body mass index (BMI) of 46, who vapes, and is on Adderall (amphetamine and dextroamphetamine)?

Pre-Surgical Clearance Recommendations for Obese Patient Who Vapes and Takes Adderall

For a 32-year-old female with BMI 46 who vapes and takes Adderall, pre-surgical clearance should include smoking cessation at least 4 weeks before surgery, Adderall management, and thorough cardiorespiratory assessment to reduce perioperative complications.

Initial Assessment and Risk Stratification

Medical History and Physical Examination

• Document height, weight, BMI (46), and calculate lean and adjusted body weight to guide medication dosing 1
• Assess for obesity-related comorbidities:
  • Metabolic syndrome
  • Obstructive sleep apnea (OSA)
  • Cardiovascular disease
  • Respiratory dysfunction
  • Diabetes

Respiratory Assessment

• Evaluate respiratory function and exercise tolerance 1
• Check arterial oxygen saturation (concerning if <95% on room air)
• Consider spirometry to assess pulmonary function
• Evaluate for signs of respiratory compromise:
  • Arterial saturation <95% on air
  • Forced vital capacity <3L or FEV1 <1.5L
  • Respiratory wheeze at rest
  • Serum bicarbonate >27 mmol/L

Cardiovascular Assessment

• Assess exercise tolerance as indicator of cardiovascular fitness 1
• Consider cardiopulmonary exercise testing (CPET) if exercise tolerance is limited
• Evaluate for features of metabolic syndrome which increase cardiac morbidity

Specific Interventions

Smoking/Vaping Cessation

• Smoking/vaping should be stopped at least 4 weeks before surgery to reduce respiratory and wound-healing complications 1
• Implement intense counseling and nicotine replacement therapy 1
• Even shorter periods of cessation may provide some benefit 1
• For patients who vape cannabis, consider reduction or suspension at least 7 days before surgery if consumption is significant 2

Medication Management (Adderall)

• Adderall (amphetamine/dextroamphetamine) management:
  • Document dosage and frequency
  • Consider discontinuation 24-48 hours before surgery to avoid interactions with anesthetics
  • Discuss with prescribing physician regarding perioperative management plan
  • Monitor for potential withdrawal symptoms if discontinued

Nutritional Assessment

• Screen for malnutrition despite high BMI 1
• Consider "liver shrinking" diet for 2-6 weeks before surgery to improve respiratory function and facilitate laparoscopic access 1

Airway Assessment

• Measure neck circumference (>60 cm associated with 35% probability of difficult laryngoscopy) 1
• Assess for predictors of difficult intubation
• If facial hair present, recommend trimming/removal before surgery 1

Preoperative Optimization

Prehabilitation

• Consider preoperative exercise program to improve functional capacity 1
• Even short but intensive 7-day programs may be beneficial 1
• Focus on:
  • Aerobic exercise
  • Respiratory muscle training
  • Education on postoperative breathing exercises

Patient Education and Counseling

• Provide detailed information about surgical and anesthetic procedures 1
• Explain importance of:
  • Early mobilization
  • Thromboprophylaxis
  • Respiratory exercises
  • Pain management expectations
• Instruct to bring personal CPAP machine if used at home 1

Thromboprophylaxis Planning

• Obesity is an independent risk factor for venous thromboembolism (VTE) 1
• Plan for appropriate pharmacological prophylaxis
• Consider mechanical prophylaxis (compression devices)
• Ensure proper sizing of TED stockings if used

Postoperative Planning

Respiratory Support

• Determine need for postoperative monitoring based on:
  • Presence of untreated OSA
  • Need for parenteral opioids
  • Degree of obesity (BMI 46)
• Consider level 2 care if significant respiratory concerns exist 1

Pain Management Strategy

• Plan multimodal analgesia to minimize opioid requirements
• Consider regional anesthesia techniques when appropriate
• If patient-controlled analgesia (PCA) is required in a patient with suspected sleep-disordered breathing, plan for increased monitoring 1

Common Pitfalls and Caveats

• Do not delay surgery solely for weight loss unless specifically indicated
• Avoid intramuscular medication administration due to unpredictable pharmacokinetics 1
• Be aware that standard target-controlled infusion (TCI) pumps may be unreliable for patients >140-150 kg 1
• Remember that obesity increases the risk of difficult bag-mask ventilation and intubation 1
• Consider depth of anesthesia monitoring for patients with BMI >35 kg/m² 1

By implementing these recommendations, you can optimize this patient's perioperative course and minimize the risk of complications related to her obesity, vaping habit, and Adderall use.