How should anesthesia be managed for a patient undergoing Nissen fundoplication, including pre‑operative assessment, rapid‑sequence induction, lung‑protective ventilation, intra‑operative monitoring, and multimodal postoperative analgesia, with adjustments for obesity, obstructive sleep apnea, or severe pulmonary disease?

Anesthesia Management for Nissen Fundoplication

For Nissen fundoplication, use rapid-sequence induction with full aspiration precautions, implement lung-protective ventilation with low tidal volumes (4-8 ml/kg predicted body weight) and PEEP 7-10 cm H₂O, employ multimodal opioid-sparing analgesia, and ensure complete neuromuscular reversal with awake extubation in semi-upright position—with mandatory postoperative CPAP for obese patients or those with OSA. 1

Pre-operative Assessment

Aspiration Risk Evaluation:

• All Nissen fundoplication patients have documented gastroesophageal reflux disease with abnormal 24-hour pH monitoring, placing them at high aspiration risk 2, 3, 4
• Identify patients with reflux-induced pulmonary disease (present in up to 43% of cases), as these patients have compromised baseline respiratory function 2
• Screen aggressively for obstructive sleep apnea, particularly in obese patients, and ensure CPAP equipment is immediately available for postoperative use 1, 5

Airway and Vascular Access:

• Establish two large-bore IV cannulae pre-operatively; use ultrasound guidance for obese patients and consider unusual sites (upper arm, anterior chest wall) if standard access is difficult 5

Induction Strategy

Rapid-Sequence Induction Protocol:

• Position the patient head-up 20-30 degrees during intubation to optimize respiratory mechanics and reduce aspiration risk 6
• Use full rapid-sequence technique with cricoid pressure given the universal presence of active reflux disease in these patients 1
• Employ short-acting agents exclusively (propofol for induction, desflurane or sevoflurane for maintenance) to enable rapid emergence and neurological assessment 6, 7
• Desflurane is preferred over sevoflurane for faster return of airway reflexes 6, 5

Intraoperative Ventilation Management

Lung-Protective Ventilation Parameters:

• Use tidal volumes of 4-8 ml/kg predicted body weight to minimize ventilator-induced lung injury 1
• Apply PEEP of 7-10 cm H₂O continuously throughout the procedure to prevent atelectasis and maintain alveolar recruitment 1, 6
• Consider pressure-controlled ventilation rather than volume-controlled, as this achieves greater tidal volumes for a given peak pressure 6
• Maintain the patient in slight head-up/sitting position throughout surgery to improve respiratory mechanics and reduce airway pressures 6, 5

FiO₂ Management:

• During maintenance, use the lowest FiO₂ that maintains adequate oxygenation
• **During emergence, reduce FiO₂ to <0.4 if clinically appropriate** to minimize atelectasis formation, as FiO₂ >0.8 significantly increases atelectasis 1

Recruitment Maneuvers:

• While routine alveolar recruitment maneuvers after intubation lack strong consensus (only 57% expert agreement), consider them based on individual risk-benefit assessment, particularly during pneumoperitoneum when respiratory compliance changes rapidly 1

Anesthetic Technique Selection

Balanced Anesthesia Approach:

• Implement multimodal balanced anesthesia combining hypnotic (desflurane/sevoflurane or propofol), opioid (remifentanil or fentanyl), and optional benzodiazepine to minimize individual drug doses and side effects 7
• Use depth of anesthesia monitoring to limit total anesthetic load and reduce awareness risk 6, 5
• Employ continuous neuromuscular monitoring to maintain appropriate block level and ensure complete reversal 6, 5

Multimodal Opioid-Sparing Analgesia:

• Implement aggressive opioid-sparing strategies using local anesthetics, regional techniques (consider transversus abdominis plane blocks for laparoscopic approach), and non-opioid analgesics 6, 7
• This reduces total opioid requirements by 30-50% and minimizes postoperative respiratory depression 7
• Avoid long-acting opioids given the risk of postoperative respiratory compromise 6
• Avoid intramuscular injections in obese patients due to unpredictable pharmacokinetics 5

Emergence and Extubation Protocol

Pre-Extubation Requirements:

• Verify complete reversal of neuromuscular blockade using quantitative monitoring before attempting extubation, as any residual weakness significantly increases aspiration risk in these patients 1, 6, 5
• Ensure patient is fully awake with complete return of airway reflexes and breathing with adequate tidal volumes 1, 6, 5
• Extubate only when patient is awake unless there is a compelling medical or surgical contraindication 1

Extubation Positioning:

• Perform extubation with patient in lateral, semi-upright, or sitting position—never supine—to maintain optimal respiratory mechanics and reduce aspiration risk 1, 6, 5
• Have a nasopharyngeal airway immediately available before emergence to mitigate partial airway obstruction 6, 5

Post-Extubation Oxygen Therapy:

• Administer supplemental oxygen to maintain SpO₂ ≥94%, but investigate underlying causes if desaturation occurs 1

Special Considerations for High-Risk Populations

Obese Patients:

• Apply CPAP immediately upon extubation in obese patients, as this reduces atelectasis, improves oxygenation and pulmonary function, and minimizes postoperative pulmonary complications 1
• Early postoperative NIPPV promotes more rapid recovery of lung function compared to standard oxygen therapy 1
• Position head-up throughout the perioperative period 6, 5

Obstructive Sleep Apnea:

• Reinstate CPAP therapy immediately in the PACU for patients with pre-existing OSA 1, 5
• Consider prophylactic postoperative CPAP (7.5-10 cm H₂O) even for patients not previously on CPAP, as this reduces reintubation rate, pneumonia, and ICU length of stay after major abdominal surgery 1
• Maximize opioid-sparing techniques and multimodal analgesia 1, 5

Severe Pulmonary Disease:

• Implement all lung-protective strategies rigorously 1
• Consider postoperative CPAP prophylactically, as CPAP of 10 cm H₂O after thoracoabdominal surgery reduces pulmonary complications and hospital stay 1

Postoperative Monitoring

PACU Monitoring:

• Monitor continuously for signs of hypoventilation, apnea, hypopnea, and oxygen desaturation 6, 5
• Observe for respiratory depression, particularly on postoperative days 3-4 when REM rebound may occur 1
• Continue supplemental oxygen and pulse oximetry monitoring 6

Discharge Criteria:

• Transfer to ward only when routine discharge criteria are met, respiratory rate is normal, and oxygen saturation returns to pre-operative baseline values 5
• Consider level-2 care if long-acting opioids are required or patient-controlled analgesia is needed, particularly for high-risk patients 5

Common Pitfalls to Avoid

• Never extubate in supine position—this dramatically increases aspiration risk in patients with reflux disease 1
• Never use high FiO₂ (>0.8) during emergence—this significantly increases atelectasis formation 1
• Never skip quantitative neuromuscular monitoring—residual paralysis is catastrophic in aspiration-prone patients 1, 6, 5
• Do not rely on single-agent anesthesia—balanced multimodal approach reduces individual drug toxicity 7
• Do not discharge OSA patients from PACU without ensuring adequate spontaneous ventilation and return to baseline oxygen saturation 1, 5