What is the argument against admitting a patient with a body mass index (BMI) of 43 after general endotracheal anesthesia (GETA) for a scleral buckle procedure?

From the Guidelines

I would not recommend routine admission for a patient with a BMI of 43 after general endotracheal anesthesia (GETA) for a scleral buckle procedure based solely on their BMI. While obesity (BMI >30) and especially morbid obesity (BMI >40) are risk factors for postoperative complications, the decision to admit should be based on multiple factors beyond BMI alone, as suggested by the Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia 1. If the patient has stable vital signs, adequate pain control, no significant respiratory compromise, no postoperative nausea or vomiting, and can ambulate safely, they may be appropriate for discharge. The patient should be monitored in the post-anesthesia care unit (PACU) for a sufficient period (typically 1-2 hours) to ensure respiratory stability, as obese patients have higher risks of obstructive sleep apnea and airway complications.

Key Considerations

• The use of low tidal volumes (6-8 mg/kg of predicted body weight) and low positive end-expiratory pressure (PEEP) levels can help reduce pulmonary complications in obese patients, as recommended by the Enhanced Recovery After Surgery (ERAS) Society 1.
• The patient's airway management, oxygen requirements, and pain control should be carefully evaluated, and admission for observation would be appropriate if there are any concerns in these areas.
• The Obesity Surgery Mortality Risk Stratification score (OS-MRS) may be useful in identifying patients at high risk of peri-operative complications, although it has only been validated for bariatric surgical patients 1.
• A clear pathway for referral for specialist sleep studies should be identified, as sleep-disordered breathing is a common comorbidity in obese patients.

Monitoring and Discharge Criteria

• The patient should be monitored in the PACU for a sufficient period to ensure respiratory stability.
• Discharge criteria should include stable vital signs, adequate pain control, no significant respiratory compromise, no postoperative nausea or vomiting, and the ability to ambulate safely.
• If the patient has been extubated without difficulty, maintains good oxygen saturation on room air or minimal supplemental oxygen, and has no other complications from surgery, admission may not provide additional benefit.

From the Research

Argument Against Admitting a Patient with a BMI of 43

• The patient's high BMI may increase the risk of perioperative complications, particularly obstructive sleep apnea, which can lead to respiratory problems during anesthesia and recovery 2.
• Although the study suggests that patients with a BMI between 40-50 kg/m² can undergo ambulatory surgery with caution, it emphasizes the importance of individualized evaluations considering patient-related, surgery-related, and anesthesia-related factors 2.
• The scleral buckle procedure itself may not be directly related to the patient's BMI, but the patient's overall health and potential comorbidities associated with obesity could impact the surgery and recovery process 3, 4, 5.
• The patient's BMI of 43 falls within the range where careful consideration of other factors, such as obstructive sleep apnea, is necessary to determine suitability for ambulatory surgery 2.
• It is essential to assess the patient's individual risk factors and optimize their comorbidities before proceeding with the scleral buckle procedure to minimize potential complications 2, 6.