6 5
J U N E 2 0 1 4 | O R E X C E L L E N C E. C O M S U P P L E M E N T T O O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
in the waiting area to special wheelchairs and OR tables that can safely handle
patients in the 400- to 600-pound range, and perhaps even heavier.
• The importance of a plan. The best way to manage the obese patient is
to have plans B, C and D ready to go in the event something goes wrong. If dif-
ficult airway warning signs are apparent during pre-op assessments, ask an
airway expert to assist during the procedure. Use short-acting drugs and dose
slowly — don't paralyze patients if you can't ventilate and intubate them. Have
a supraglottic airway device readily available. It doesn't have to be opened and
lubed, but you shouldn't be slamming drawers trying to find it during emer-
gent situations.
• Pain management. Overweight patients have difficulty metabolizing
medications, which makes pain control challenging. Avoid using narcotics in
order to lower the risk of respiratory depression. The obese have smaller
functional reserve capacity and larger metabolic demand, so whatever reserve
they have is used up very quickly. A multimodal pain control plan is best in
patients with a small margin of safety.
• So how heavy is too heavy? The cutoff shouldn't be based on total
weight or BMI. It depends on the comorbidities the patient has and the care
plan you have in place. Is your surgical team expert in caring for obese patients?
Do you have the proper equipment? Do you have quick access to a hospital?
• The new normal. Is caring for obese patients a matter of taking unneces-
sary risks and being lucky? When we've successfully managed obese patients 75
times before running into an issue during the 76
th
case, was it a disaster waiting
to happen or a lightning strike?
• Being kind and considerate. You must be sensitive to the emotional
state of obese patients. These patients have feelings, and have probably been
K I C K E R
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