ESA Chair Scientific Committee
1. Q: 1. An important target for anaesthesia providers should be the sharing of good practices from Centers of Excellence throughout the network of non specialist hospitals where morbidly obese patients seek assistance.
Do you envisage any specific way in which ESA or ESPCOP could make a contribution to the standardization of the good practices related to the perioperative care of the morbidly obese?
A: ESA is dedicated to improve patient safety and promote good clinical practice all over Europe. Obesity is a growing problem all over Europe and significantly increases perioperative risk. Perioperative care of obese patients is a challenge for every anesthesiologist; Just think about the important anticipated difficulties of vessel access, difficult intubation, ventilation, patient positioning and many others. This highlights the need for a well-developed program of teaching and training skills for this particular subset of patients. Needless to say that such training should be standardized.
Designing such standardized education and training programs should include the input of all centers of excellence dealing with this type of pathology. As such it is only logical that a scientific organization like ESA works in close collaboration with a specialist society, and in this particular case with ESPCOP.
2. Q: What in your opinion are the main areas that should be investigated as research under ESA auspices? Is there a place for topics related to the morbidly obese?
A: ESA promotes and supports of all types of research related to the field of perioperative medicine, critical care medicine and pain medicine. In addition Multicentre European Research in the broader field of Anesthesiology is stimulated and supported through the Clinical Trial Network.
Of course there is a place for topics related to the morbidly obese. As stated before, the morbidly obese represents a very specific and challenging patient population. One cannot simply and unequivocally translate the known pharmacological and physiological principles of a normally shaped adult and /or child to those of their morbidly obese counterpart. There is certainly a need for specific research in this patient population.
Actually if you review the literature of the last few years you can see that this topic is increasingly being addressed. When looking at applications for research grants, it can be noted that a number of them specifically target the obese patient. Finally, the PROBESE multicenter study proposal is in its final stage of design and will soon be launched. I think this is a perfect example of how specific research questions in the obese patients can be addressed and studied in close collaboration between scientific and specialist societies.
3. Q: ESPCOP, as an ESA Specialist Society, holds sessions within Euroanaesthesia Congresses.
In your opinion should these sessions offer basic learning in the anaesthetic management of the obese or should they focus on specific problematic areas (e.g. Obstructive sleep apnoea)?
Do you think there would be scope for both types of sessions within Euroanaesthesia?
A: The Scientific Subcommittees of ESA are intended to provide a European platform for contact and exchange of ideas and scientific initiatives within their specific field of interest. Among others, this translates in an exchange of ideas and initiatives at the different ESA annual meetings. EPSCOP is a good example of how input of a specialist society may result in a common program with different scientific subcommittees or in the development of symposiums on anesthesiology-related topics in the particular subset of the obese patient population.
If you look at the program of Euroanaesthesia 2014, you will notice that joint meetings with ESPCOP are organized and that members of ESPCOP are involved in the scientific program of Euroanaesthesia. In addition we can observe that over the years there is an increasing number of submitted and accepted abstracts on obesity-related issues at Euroanaesthesia.
Moreover, the ESA Autumn meetings will focus on perioperative medicine in particular patient populations. This year the pediatric patient is the topic and the scientific program of this meeting is established in close collaboration with the European pediatric specialist societies and presented as a joint meeting. The obese patient will be the target of one of the upcoming meetings and it is beyond discussion that this meeting will be organized in close cooperation with ESPCOP.
With regard to the second part of your question, I would like to say the following. There is probably place for the two types of sessions: basic and more problem-oriented. Our experience however is that clinical anesthesiologists benefit most of clinically-oriented presentations in which problems are addressed that they may encounter in their daily practice. This does of course not preclude that on a regular base the more basic physiological and pharmacological aspects of the perioperative care of obese patients can be addressed in a refresher course.
4. Q: ESA has released or endorsed guidelines for different practices aspects Do you think the same should be done for the anaesthetic management of the obese? And if yes, in what way could ESA get involved?
A: Up to now, guidelines on the perioperative care of obese patients were covered in the global guidelines on the adult patients. If you have a look at the ESA guidelines on the preoperative assessment of the adult patient undergoing non-cardiac surgery published in the EJA 2011; 28: 684- 722, you will see that a substantial part is related to the problems encountered in the obese patient. For sure, input of ESPCOP in any update of such guidelines will be very much appreciated. Personally, I am not convinced that there is at this moment a real need for specific guidelines on the perioperative care of the obese patients. Basically, recommendations on safe and evidence-based perioperative care are very similar for the obese and non-obese patient. As you know the ESA guidelines committee selects each year from a list of proposals which proposal will be developed to an ESA guideline. If ESPCOP considers that perioperative management of the obese patient would warrant separate guidelines, I would suggest that such a proposal is submitted to the ESA Guidelines Committee. Anyway, the scope of such guidelines should – in my opinion – encompass the entire perioperative period and not just be limited to the anesthetic management.
5. Q: After the successful 4th ESPCOP meeting held in Brugge last December ESPCOP has an increasing membership, with more than 100 members now. What would be your message to them?
A: Obesity is a growing health problem in our European society. As a consequence, we will increasingly have to face the fact that we will have to deal with such patients in the perioperative period. Everyone involved in the perioperative care of these patients knows that they present with very specific problems and challenges that require dedicated and skilled care if surgical procedures are performed.
Insights in the specifics of this patient population and experience on how to treat problems of difficult vascular and airway access, specific ventilation problems etc can only improve patient care and safety.
Such insights are obtained primarily by anesthesiologists who are frequently treating this patient population and have specific interest in this pathology. Dissemination of the essential knowledge and skills necessary to treat these patients is of prime importance if we want to provide these patients the best and the most safe treatment throughout their perioperative course. EPSCOP can play a key role in this process and the cooperation between EPSCOP and ESA allows us to extend this expertise beyond the core group of anesthesiologists who treat obese patients in their routine daily practice.
I would therefore encourage EPSCOP and its members to further investigate the pathophysiological and pharmacological specifics of the obese patients, further explore and design safe peri-operative treatment strategies for these patients and share these new insights with their fellow anesthesiologists.
Prof. Dr. Stefan De Hert
Chair Scientific Committee ESA
Director of Research
Department of Anesthesiology
Ghent University Hospital, Belgium
From Rome, Jan Mulier ESPCOP president:
Decision Making in Bariatric and Metabolic Surgery -The First International Congress
Held in Rome, Italy between 24-26 October 2013 on behalf of the International Federation for the Surgery of Obesity and metabolic disorders (IFSO) and the Italian Society of Bariatric and Metabolic Surgery (SICOB).
This was aimed to be a forum for debates and discussions on selected topics, through the “what I did and/or what I should have done” methodology..
In a special session dedicated to the peri-operative care of the high risk obese patient, a prestigious international faculty debated specific challenging topics. .
The take home messages that emerged were:.
- That cardiovascular risk is reduced after bariatric surgery, with a greater reduction in the highest risk cardiovascular patients.
- Only symptomatic coronary disease requires preoperative angiography .
- Pre-operative arterial oxygen saturation is the simplest indicator for lung function
- Intra-operative ventilation management using recruitment maneuvers, small tidal volume and PEEP, can prevent postoperative respiratory complications.
- For an enhanced recovery after surgery an opioid sparing anaesthetic technique (e.g. adding dexmedetomidine, ketamine, magnesium sulphate) is the first step, with no routine postoperative opioid use for analgesia.
- Xenon used as an inhalational anaesthetic reduces opioid need, is probably the best agent for the obese, but still far too expensive today.
- Abdominal muscles are more resistant to neuromuscular blockade and have earlier reversal, therefore to achieve paralysis a deep neuromuscular block, utilizing continuous infusion and close monitoring, is needed.
- Pre-operative weight reduction reduces postoperative risk, and can be achieved using a ketogenic diet or an intragastric balloon.
- The prevention of deep vein thrombosis is a key component of peri-operative care, and should include pharmacological and mechanical methods, pneumatic compression being very effective.
- Extreme BMI only is never a contra-indication to surgery, but end stage organ dysfunction can be, like for other surgeries.
Certainly, it is worthwhile to keep in mind other ten golden rules for morbidly obese perioperative care…
The 4th ESA Autumn Meeting took place from 8-9 November 2013 in Timisoara, Romania. With a total of more than 600 attendees, the 4th Autumn Meeting was definitely the best attended Autumn Meeting yet.
The topic of obesity was rediscovered in the problem-based learning course for anaesthesia in bariatric surgery. The discussions focused on the key steps when anaesthetizing obese patients, preoperative evaluation, positioning and intubation, intraoperative ventilation, extubation and postoperative care.
The interest of both anaesthetists and trainees in the airway management of morbidly obese was underlined by the full bookings for both airway workshops held during the Congress. The interactive theoretical session, based on pro cons approaches ranked by the audience, clarified the myths and truths regarding airway challenges in the obese.
Consequently the key learning points emerged were included in the ten airway golden rules:
- Obesity per se is not a risk factor for difficult intubation
- The distribution of the fat around the head, neck and chest could really increase the risk mostly for difficult mask ventilation but also for difficulties with tracheal intubation.
- Preoperative evaluation of the patients airway needs to take into account the additional risk factors for morbidly obese as neck circumference, obstructive sleep apnoea, in order to deem the airway management.
- The positioning of the patient (ramped position and beach chair ) is very important for the airway management at induction as well as at extubation
- In accordance with ASA guidelines, videolaryngoscopy should be considered in the morbidly obese with suspected difficulties as an initial approach to intubation, or following failed intubation as a rescue technique when face mask ventilation is adequate.
- The most familiar and intuitive Videolaryngoscope (VL) types are the MacIntosh –type videoassisted direct laryngoscopes with the same insertion technique, a better and magnified view of the larynx, a narrow blade and a simple tube passage.
- The VL evidence based issues are higher success rates of intubation comparing with DL, especially for the trainees due to a steep learning curve , as well as in emergency medicine and critical care (where the airway disasters in the obese are most frequently)
- Awake VL with topical anaesthesia with the same comfort as FOI, and high success rate can be an alternative in morbidly obese
- In morbidly obese with anticipated difficult airway AFOI remains the gold standard –this skill requires a renewed educational emphasis so anesthesiologists can and will use this technique when indicated.
- A minimum standard of skill is required for all clinicians who manage the airway rather than one technique for placing a tracheal tube.
Following the discussions, the hands on section, where all the workshop participants practiced the different airway techniques, ended the session with vivid and active interactions between attendees and trainers.
Center of Excellence in Bariatric and Metabolic Surgery, Bucharest
Bariatric Anaesthesia 2013
Early December 2013 saw the Annual Scientific Meeting of SOBA, the UK Society for Obesity and Bariatric Anaesthesia. This was the sixth consecutive year that SOBA has run its scientific session, and this year the meeting returned to Central London.
The day preceding this event we ran our “Key Issues in Obesity Anaesthesia” study day, covering core topics and featuring a group of truly expert speakers, each giving short, highly clinically-orientated talks of 8-12 minutes duration. This was a repeat of the very successful format devised and run in April last year at the Royal College of Anaesthetists, where 140 people attended and the event sold out. This “Key Issues” meeting is aimed primarily at revalidation and reinforcement of the known and accepted best practices in Obesity Anaesthesia.
The Second day was the true scientific meeting and attracted around 120 attendees, including eleven from overseas, including delegates from Norway, Germany, Belgium, Canada, Malta , Romania and Poland.
The topics were more contentious, with talks from a host of International speakers, followed by some hotly-contested pro-con debates and oral presentations of the best of the submitted original research.
- An US view on Standards and Excellence in Bariatric surgery, from Prof Sinha from Philadelphia;
- The current understanding of how to dose TIVA in the super-obese, from Prof. Absalom of Groningen;
- A superb and fascinating talk about the origins and development of Sugammadex from the inventor and developer of the drug, Anton Bom;
- And a further thought-provoking explanation of opioid-free Anaesthesia in gastric bypass surgery from Prof. Jan Mulier
The prize-winning oral presentation was from the York group, who showed that pre-operative Cardiopulmonary Exercise Testing (CPET) has no useful role in predicting outcome in the morbidly obese. In the Pro-Con debates, the roles of routine Sleep Studies, and of routine Sugammadex, were hotly debated (for what its worth, the swing was against both)
The SOBA meetings have become a regular fixture in the UK Anaesthesia calendar, and both days of this conference booked out some 4 weeks in advance. Feedback from delegates was again excellent. The Core topics days will run again on May the 7th, and then again on Friday December 5th, with this year’s Annual Scientific Meeting taking place the next day on Saturday the 6th at the Royal College of Physicians in central London – see www.sobaconference.com for details. Come see for yourselves what its all about!
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Mike Margarson, Secretary
UK Society for Obesity and Bariatric Anaesthesia
Sugammadex Neuromuscular Blockade Dosage Schemes on BIS and EMG Measurements
The effect of Neuromuscular Blockade (NMB) on depth of anaesthesia monitors is an important and multidirectional question that has been addressed by various authors in a rather inconsistent manner, fact reflected by the repeatedly inconsistent results. Such controversy ranges from induction to reversal of NMB, although the latter has recently received more clinical attention.The not so recently introduced cyclodextrin-derived drug Sugammadex, has made reversal of even deep NMB by steroidal NMB agents possible in periods as short as 3 minutes. Its fast pharmacodynamic profile allied to case-reports and clinical experience of Sugammadex-induced awakening made the investigation of the potential arousal-inducing profile of this drug attractive.Such investigations have been carried out more frequently with resort to Bispectral Index Scale (BIS) measurements as end-points. As a practical and simple EEG-based awareness monitor, it has been widely used in clinical practice. Nonetheless, it has not been exempt from critique, and its signal overlap with EMG measurements in the 10-50Hz frequency range has been forwarded as a critical limitation needed to take into consideration when evaluating the regain of arousal during the NMB reversal period.
Several explanations have been forwarded both to support and refute the effect of NMB reversal on the regain of consciousness. The “afferent muscle spindle” theory states that the rise in BIS values after decurarization might be the result of NMB reversal-induced return of proprioceptive signals, which cause cortical arousal and a consequent rise in BIS values. However, other studies propose that an EMG contamination of BIS due to the above-stated frequency overlap is the most probable culprit of the reported BIS increase, thus, falsely suggesting cortical arousal.
TThis discussion has also been related to depth of anaesthesia, and the influence of NMB agents on BIS values has been referred as anaesthesia depth-dependent, with reversal of NMB probably having a minor effect in the return of arousal only during light anaesthesia.
One of the missing links in existing literature is not only the lack of an approach based on reversal agent dosage, but also the investigation of the (morbidly) obese population.
Thus, the aim of this retrospective study was to assess the effects of different Sugammadex doses on BIS and EMG readings in morbidly obese patients, but also to compare them to a control group of non-obese patients without reversal of NMBA.
Read the full article
Luc De Baerdemaeker
Join us at Euroanaesthesia in Stockholm on 2nd of June 14:00-15:30
Key points that are different when giving anaesthesia for morbidly obese patients!
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