What is the recommended anesthetic plan for this patient?

Anesthetic Plan for This Patient

Without specific patient details provided, I will outline a comprehensive, evidence-based anesthetic approach that prioritizes patient safety, morbidity reduction, and optimal recovery based on current guidelines.

Pre-operative Assessment and Optimization

Patient Risk Stratification

• Assume all obese patients have some degree of sleep-disordered breathing (SDB) and modify the anesthetic technique accordingly, even without formal testing 1
• Ensure preoperative medical optimization is completed, including cessation of smoking and alcohol (for abusers) at least four weeks before surgery 1
• Provide dedicated preoperative counseling to set realistic expectations and improve outcomes 1

Specific Pre-operative Preparations

• Avoid long- or short-acting sedative premedication as it delays immediate postoperative recovery 1
• Administer thromboembolism prophylaxis with well-fitting compression stockings, intermittent pneumatic compression, and LMWH 1
• Give antimicrobial prophylaxis 30-60 minutes before surgery with additional doses during prolonged operations 1
• Allow clear fluids up to 2 hours and solids up to 6 hours prior to induction, with preoperative oral carbohydrate treatment 1

Anesthetic Technique Selection

Primary Recommendation: Regional Anesthesia

Regional anesthesia should be prioritized whenever possible as it reduces morbidity, mortality, and improves recovery 1

• For colonic surgery: mid-thoracic epidural blocks using local anesthetics and low-dose opioids for open procedures 1
• For laparoscopic surgery: spinal analgesia or morphine PCA is an acceptable alternative to epidural 1
• Spinal anesthesia with an opioid adjunct (using fentanyl in preference to morphine or diamorphine) is recommended for lower extremity procedures 1, 2
• Regional analgesia and infiltration techniques should be considered to minimize systemic drug requirements 1

When General Anesthesia is Required

Induction Strategy

For standard adult patients (ASA I-II, <55 years):

• Titrate propofol approximately 40 mg every 10 seconds (total 2-2.5 mg/kg) until clinical signs show onset of anesthesia 3
• Avoid rapid bolus administration 3

For elderly, debilitated, or ASA III-IV patients:

• Reduce induction dose to 1-1.5 mg/kg (approximately 20 mg every 10 seconds) and avoid rapid bolus to prevent cardiorespiratory depression including hypotension, apnea, airway obstruction, and oxygen desaturation 3

For obese patients with suspected OSA:

• Position patient in ramped position with tragus of ear level with sternum before induction 1
• Consider rocuronium over suxamethonium to minimize apnea time, with sugammadex pre-calculated and immediately available 1
• Use video laryngoscopy by the most experienced provider 1, 4
• Site two intravenous cannulae while in theatre, using ultrasound guidance if needed, considering unusual sites (upper arm, anterior chest wall) 1, 2

Maintenance Strategy

Use short-acting agents and drug-sparing strategies:

• Prefer desflurane or sevoflurane over isoflurane for faster onset and offset 1, 2
• Desflurane provides faster return of airway reflexes compared with sevoflurane in obese patients 1
• Implement depth of anesthesia monitoring to limit anesthetic load, particularly with neuromuscular blocking drugs or total intravenous anesthesia 1
• Use neuromuscular monitoring to maintain appropriate block level and ensure complete reversal before waking 1

Ventilation management:

• Use pressure-controlled ventilation with sufficient PEEP and recruitment maneuvers to reduce intra- and postoperative atelectasis 1
• Maintain head-up/sitting position throughout to improve respiratory mechanics 1, 2
• Maintain normothermia >36°C using warming devices and warmed intravenous fluids 1

Analgesia:

• Implement maximal use of local anesthetic and multimodal opioid-sparing analgesia 1
• Avoid intramuscular route due to unpredictable pharmacokinetics in obesity 1, 2

Emergence and Extubation Plan

Critical Safety Steps

An extubation plan must be in place in accordance with Difficult Airway Society guidelines 1

• Reverse neuromuscular blockade guided by nerve stimulator with aim to restore motor capacity before waking 1
• Ensure patients have return of airway reflexes and are breathing with good tidal volumes before extubation 1
• Perform extubation with patient awake and in sitting position 1, 2
• For confirmed OSA patients, insert nasopharyngeal airway before waking to mitigate partial airway obstruction 1, 2
• Maintain head-up position throughout recovery 1

Postoperative Management

Immediate PACU Care

For patients with OSA or on home CPAP:

• Reinstate CPAP therapy immediately on return to ward or even in PACU if oxygen saturation cannot be maintained by inhaled oxygen alone 1, 2
• Supplemental oxygen can be given via CPAP machine or nasal specula under CPAP mask 1

Monitoring requirements:

• Observe all obese patients while unstimulated for signs of hypoventilation, apnea, or hypopnea with associated oxygen desaturation 1
• Monitor oxygen saturations continuously until mobile postoperatively 1

Discharge criteria from PACU:

• Routine discharge criteria are met 1
• Respiratory rate is normal with no periods of hypopnea or apnea for at least one hour 1
• Arterial oxygen saturation returns to pre-operative values with or without oxygen supplementation 1

Ward Care and Recovery

Enhanced recovery protocol is essential:

• Early mobilization is vital—most patients should be out of bed on day of surgery 1, 2
• Avoid restricting patients with urinary catheters (remove after 1-2 days), intravenous infusions, or other devices where possible 1
• Discontinue intravenous fluids as soon as enteral route is tolerated 1

Analgesia considerations:

• If long-acting opioids are required and patient not stabilized on CPAP pre-operatively, use level-2 care 1
• PCA systems need careful consideration due to increased risk of respiratory depression in undiagnosed SDB—consider level-2 monitoring if PCA required 1, 5
• Continue multimodal opioid-sparing analgesia 1, 2

Special Considerations

COVID-19 Context (if applicable)

• Prioritize outpatient management when safety conditions are met 1
• Favor regional anesthesia to reduce exposure of healthcare professionals to contamination risk 1
• For COVID+ patients requiring general anesthesia: limit staff present, avoid face mask ventilation during preoxygenation, use video laryngoscope by most experienced senior, connect ventilator only after inflating tube balloon 1

Drug-Sparing Strategies

• In context of drug shortages, prefer drug-saving anesthetic strategies for propofol, midazolam, and myorelaxants 1
• Morphine premedication (0.15 mg/kg) with nitrous oxide decreases necessary propofol maintenance infusion rates compared to non-narcotic premedication 3

Common Pitfalls to Avoid

• Never use rapid bolus induction in elderly, debilitated, or ASA III-IV patients 3
• Do not routinely use nasogastric tubes postoperatively; if inserted during surgery, remove before reversal of anesthesia 1
• Avoid routine mechanical bowel preparation in colonic surgery 1
• Do not routinely drain peritoneal cavity after colonic anastomosis as it impairs mobilization 1