Research Article

The incidence of hemodynamic and respiratory adverse events in morbidly obese presenting for Bariatric surgery

Tomi Myrberg*, Veronica Atterhem and Magnus Hultin

Published: 25 July, 2018 | Volume 2 - Issue 1 | Pages: 009-017

Context: Perioperative management of morbidly obese patients undergoing bariatric surgery is challenging. Lacking standardized perioperative protocols, complication rates may be high. This retrospective study aims to quantify the incidence of significant blood pressure decreases on induction of anesthesia and intraoperative hypoxemia, before implementation of a standardized protocol designed for bariatric surgery.

Design: Retrospective, observational study.

Setting: A 250-bed county hospital in northern Sweden.

Subjects: 219 morbidly obese patients (body mass index > 35 kg/m2) who underwent bariatric surgery between 2003 and 2008.

Main outcome measures: Incidence of systolic blood pressure (SAP) falls to less than 70% of the preoperative baseline during induction of anesthesia and incidence of perioperative hypoxemia.

Results: The incidence of confirmed SAP falls to below 70% of baseline at induction of anesthesia was 56.2% (n = 123/219). This incidence rose with increasing age (p < 0.001) but not with body mass index (BMI). 3.7% (n = 8/219) of cases were marked as difficult intubations. A transient period of hypoxemia was observed in 6.8% (n = 15/219) and was more common with increasing BMI (p = 0.005). Fourteen different drug combinations were used in the study population. Of those administered an induction anesthetic drug, 72.6% (n = 159/193) were given an overdose when calculated by lean body weight, but this did not correlate significantly to SAP falls (p = 0.468).

Conclusion: The incidence of a significant blood pressure fall upon induction of anesthesia was common. The incidence of airway and ventilation problems were low. Overdosing of anesthetics and excessive variation in applied anesthesia methods were found.

Read Full Article HTML DOI: 10.29328/journal.ijcar.1001006 Cite this Article Read Full Article PDF


Morbid obesity; Bariatric surgery; Desaturation; Hypoxemia; Anaesthesia; Venous return; Anesthesia methods


  1. Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013; 273: 219-234. Ref.: https://tinyurl.com/yctwa5xr
  2. Marshall NS, Delling L, Grunstein RR, Peltonen M, Sjöström CD, et al. Self-reported sleep apnoea and mortality in patients from the Swedish Obese Subjects study. Eur Respir J. 2011; 38: 1349-1354. Ref.: https://tinyurl.com/ycfl8rck
  3. Sjoholm K, Anveden A, Peltonen M, Jacobson P, Romeo S, et al. Evaluation of current eligibility criteria for bariatric surgery: diabetes prevention and risk factor changes in the Swedish obese subjects (SOS) study. Diabetes Care. 2013; 36: 1335-1340. Ref.: https://tinyurl.com/ybk8msyp
  4. Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth. 2000; 85: 91-108. Ref.: https://tinyurl.com/y9o54rth
  5. Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005; 241: 219-226. Ref.: https://tinyurl.com/y7rlb5hr
  6. Brodsky JB. Positioning the morbidly obese patient for anesthesia. Obes Surg. 2002; 12: 751-758. Ref.: https://tinyurl.com/yca5m66m
  7. Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997; 87: 979-982. Ref.: https://tinyurl.com/ybm38zab
  8. Murphy C, Wong DT. Airway management and oxygenation in obese patients. Can J Anaesth. 2013; 60: 929-945. Ref.: https://tinyurl.com/y8ap5rmz
  9. Poso T, Kesek D, Aroch R, Winso O. Rapid weight loss is associated with preoperative hypovolemia in morbidly obese patients. Obes Surg. 2013; 23: 306-313. Ref.: https://tinyurl.com/yczubse2
  10. Talab HF, Zabani IA, Abdelrahman HS, Bukhari WL, Mamoun I, et al. Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesth Analg. 2009; 109: 1511-1516. Ref.: https://tinyurl.com/ycjrdub3
  11. Reich DL, Hossain S, Krol M, Baez B, Patel P, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg. 2005; 101: 622-628. Ref.: https://tinyurl.com/y9orsbsk
  12. Alecu C, Cuignet-Royer E, Mertes PM, Salvi P, Vespignani H, et al. Pre-existing arterial stiffness can predict hypotension during induction of anaesthesia in the elderly. Br J Anaesth. 2010; 105: 583-588. Ref.: https://tinyurl.com/y9l8cfwz
  13. Alpert MA, Omran J, Mehra A, Ardhanari S. Impact of obesity and weight loss on cardiac performance and morphology in adults. Prog Cardiovasc Dis. 2014; 56: 391-400. Ref.: https://tinyurl.com/ycer82c8
  14. Poso T, Kesek D, Aroch R, Winso O. Morbid obesity and optimization of preoperative fluid therapy. Obes Surg. 2013; 23: 1799-1805. Ref.: https://tinyurl.com/ybcnvlvz
  15. Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth. 2010; 105: i16-23. Ref.: https://tinyurl.com/y9pgh7ds
  16. Lemmens HJ. Perioperative pharmacology in morbid obesity. Curr Opin Anaesthesiol. 2010; 23: 485-491. Ref.: https://tinyurl.com/y8kd6sfp
  17. Poso T, Winso O, Aroch R, Kesek D. Perioperative Fluid Guidance with Transthoracic Echocardiography and Pulse-Contour Device in Morbidly Obese Patients. Obes Surg. 2014; 24: 2117-2125. Ref.: https://tinyurl.com/y9czf5h7
  18. Anderin C, Gustafsson UO, Heijbel N, Thorell A. Weight Loss Before Bariatric Surgery and Postoperative Complications: Data From the Scandinavian Obesity Registry (SOReg). Ann Surg. 2015; 261: 909-913. Ref.: https://tinyurl.com/ychqk4oc
  19. Poso T, Kesek D, Winso O, Andersson S. Volatile rapid sequence induction in morbidly obese patients. Eur J Anaesthesiol. 2011; 28: 781-787. Ref.: https://tinyurl.com/yc2e2spw
  20. Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG, et al. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology. 2007; 107: 213-220. Ref.: https://tinyurl.com/y8wttpj5
  21. Miller RDE. Miller's Anaesthesia. 8th ed. Philadelphia: Churchill Livingstone. 2014; 1713.
  22. Gragasin FS, Bourque SL, Davidge ST. Vascular aging and hemodynamic stability in the intraoperative period. Front Physiol. 2012; 3: 74. Ref.: https://tinyurl.com/y6udfpk6
  23. Acree LS, Montgomery PS, Gardner AW. The influence of obesity on arterial compliance in adult men and women. Vasc Med. 2007; 12: 183-188. Ref.: https://tinyurl.com/ydx3y9k5
  24. Katkhouda N, Mason RJ, Wu B, Takla FS, Keenan RM, et al. Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery. Surg Obes Relat Dis. 2012; 8: 634-640. Ref.: https://tinyurl.com/yd3gaubx
  25. Wani S, Azar R, Hovis CE, Hovis RM, Cote GA, et al. Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc. 2011; 74: 1238-1247. Ref.: https://tinyurl.com/ydefrwxe
  26. Reinius H, Jonsson L, Gustafsson S, Sundbom M, Duvernoy O, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology. 2009; 111: 979-987. Ref.: https://tinyurl.com/ybdd5pa6
  27. O'Neill T, Allam J. Anaesthetic considerations and management of the obese patient presenting for bariatric surgery. Current Anaesthesia Critical Care. 2010; 21: 16-23. Ref.: https://tinyurl.com/ybsm5aof
  28. Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, et al. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008; 106: 1132-1136. Ref.: https://tinyurl.com/yd6vnrtz
  29. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002; 94: 732-736. Ref.: https://tinyurl.com/ych7g5fb
  30. Leykin Y, Pellis T, Del Mestro E, Marzano B, Fanti G, et al. Anesthetic management of morbidly obese and super-morbidly obese patients undergoing bariatric operations: hospital course and outcomes. Obes Surg. 2006; 16: 1563-1569. Ref.: https://tinyurl.com/ycj48qug
  31. Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005; 102: 1110-1115. Ref.: https://tinyurl.com/y9a8hg7g
  32. Dhonneur G, Abdi W, Ndoko SK, Amathieu R, Risk N, et al. Video-assisted versus conventional tracheal intubation in morbidly obese patients. Obes Surg. 2009; 19: 1096-1101. Ref.: https://tinyurl.com/yd5smrz2
  33. Sundqvist J, Walldén J. PONV in bariatric surgery: 1AP5-2. Eur J Anaesthesiology. 2014; 31: 16-17. Ref.: http://bit.ly/2XHKnzQ
  34. Thorell A, Mac Cormick AD, Awad S, Reynolds N, Roulin D, et al. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg. 2016; 40: 2065-2083. Ref.: https://tinyurl.com/y8d9bdzb
  35. Sinha A, Jayaraman L, Punhani D, Chowbey P. Enhanced Recovery after Bariatric Surgery in the Severely Obese, Morbidly Obese, Super-Morbidly Obese and Super-Super Morbidly Obese Using Evidence-Based Clinical Pathways: a Comparative Study. Obes Surg. 2017; 27: 560-568. Ref.: https://tinyurl.com/yc5p96m4


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