What special equipment does the anesthesiologist require to anesthetize patients for bariatric surgery?

What special equipment does the anesthesiologist require to anesthetize patients for bariatric surgery?

Most operating room tables are rated for 250 pounds (115 kg). Placing patients whose weight exceeds this limit on a standard table risks collapse and harm to the patient. Specially designed operating room tables that support heavier patients are recommended. The operating room table should also be equipped with a motor to change table positions. Traditional hand cranks do not offer enough mechanical advantage to adjust table positions and frequently break under heavier loads.

Ramps are recommended to achieve optimal sniffing position. These ramps are created by placing folded blankets under the patient’s shoulders, neck, and occiput. The idea is to bring the patient’s chin to a higher point than the chest. Without ramps, a MO patient lying supine will often be positioned with the chin in close proximity to the chest, creating two problems. First, the mouth opening is reduced, thereby limiting space in the mouth for a laryn-goscope blade and tracheal tube. Also, the assistant’s hand providing cricoid pressure takes up space needed to open the mouth and exacerbates the problem. Second, as the laryngoscope is placed in the mouth and directed over the chin, it contacts the chest. In other words, the chest occupies space needed to position the laryngoscope and becomes an obstruction to laryngoscope placement. Ramps allow the chest to fall below the space needed to place a laryngoscope, thereby avoiding this problem.

Previously, large blood pressure cuffs were recom-mended for all MO patients. These often gave inconsistent measurements necessitating intra-arterial blood pressure monitoring. Additionally, MO patients frequently have conical-shaped arms that prevent proper positioning of the blood pressure cuff. When deflated, the cuff tends to slip distally, covering the elbow and forearm. More recently, normal-sized blood pressure cuffs have been used on the forearm for MO patients. This technique generally gives consistent readings that are closely matched to those of indwelling arterial catheters.

A wide range of airway equipment is required. Among the numerous supraglottic airway devices that exist, several should be available. Although medium facemasks fit most patients, some MO patients will require large facemasks. It is best to have several sizes of oral airways. Available models include single hard plastic molded types, tradi-tional Guedel types, and adjustable Chou airways. LMAs and esophageal-tracheal Combitubes are the more tradi-tional fallback supraglottic devices. Newer devices include pharyngeal airways, EZ tubes, Cobras, laryngotracheal tubes (LTs), and many more. Although tracheostomy sets come within the surgeon’s purview, they should be read-ily available also. Numerous laryngoscope blades and sizes may be applicable to MO patients, but in this author’s expe-rience almost everyone can be intubated with a Macintosh 3 or Miller 2 blade. Additional possibilities include a Bullard laryngoscope, Wu Scope, Glidescope, and flexible fiberoptic laryngoscope. Stylets help guide tracheal tubes into the lar-ynx. Although semirigid models are the most commonly used in the United States, specially designed malleable stylets that extend beyond the tracheal tube tip are helpful. They include the ‘Reusch’ stylet and gummed elastic bougie.

Neuromuscular blockade monitors guide administra-tion of muscle relaxants and help determine extubation cri-teria at the end of surgery. Anesthesia machines equipped with air are important to avoid using nitrous oxide, which distends the bowel. One hundred percent oxygen predis-poses to oxygen toxicity, which is avoided by diluting oxygen in air. Continuous infusion pumps are optional, depending on the anesthetic technique planned. Orogastric tubes are needed to decompress the stomach prior to inser-tion of trochars and to evacuate the stomach prior to surgi-cal manipulation. Warming blankets help prevent heat loss to the environment during laparotomy and to cold gases that are insufflated into the peritoneum during laparoscopy.

Following surgery, patients who are unable to move themselves to the next bed need to be transported to it. Several people working together can lift the patient, but using an inflatable air mattress makes the job much easier. The bed to which they are moved must be extra large and rated for the patient’s weight. The bed’s back should be capable of rising, allowing for the sitting or semi-Fowler’s position. For the postanesthesia care unit, large chairs rated for the patient’s weight are also desirable.