You can deliver quality anesthesia care to overweight and obese patients if you think through the challenges these patients present with and develop solutions in advance of the day of surgery.

1. Airway maintenance. The first consideration is the patient's ability to maintain a stable, protected airway. Obese patients may have a large chin, a large neck or extra soft tissue that can cause the airway to collapse if the patient is over-sedated. They're also prone to hypoxia, which severely limits the time allowed to secure the airway during induction of anesthesia. Have a good set of alternate airway devices close at hand when starting anesthesia. An airway cart lets you store these supplies together, and move them easily wherever they're needed.

Optimize the position of the head, neck and chest by using blankets or special pillows to make intubation as easy as possible. These maneuvers result in a "ramp" position, with the head, shoulders and upper back elevated off the table. Awake or lightly sedated intubation may be required in some circumstances.

2. Respiratory concerns. Extra abdominal weight can press onto the chest and diaphragm when the patient is supine, making ventilation and oxygenation difficult. The reverse Trendelenburg position (head-up) will help to alleviate this. Use reverse Trendelenburg during anesthesia induction, emergence and extubation after surgery, and the immediate post-anesthesia recovery phase.

Screen all obese patients with BMI above 35kg/m2 for obstructive sleep apnea. OSA is often found in conjunction with obesity, but may exist as a separate issue. Treatment may require continuous positive airway pressure or special oral devices, which should be brought to the surgery center the day of surgery. The Frederick (Md.) Surgical Center described a wonderful program to identify, manage and track these patients through outpatient surgery (see "How to Handle the Risks of Obstructive Sleep Apnea," Outpatient Surgery Magazine, December 2005).

The combination of morbid obesity, severe sleep apnea and a procedure requiring general anesthesia may be a "triple whammy" that could make staff of a freestanding outpatient surgery center uncomfortable with handling these patients safely.

3. Cardiovascular issues. Extra tissue bulk may make IV access problematic. If possible, identify potential IV sites before the day of surgery during the pre-op evaluation. Hypertension, congestive heart failure and pulmonary hypertension are more likely in these patients, adding to the challenge of managing safe anesthesia delivery.

4. Metabolic considerations. Obese patients are more likely to have diabetes and require oral hypoglycemics, insulin or both to control their blood glucose levels. Close monitoring of blood glucose levels in the perioperative period will help to minimize problems. Keep blood glucose levels in a normal range as much as possible. The obese may also be at higher risk for aspiration due to the pressure from increased abdominal mass. Administer prophylaxis medications to all patients with a BMI > 35kg/m2.

5. Nerve injuries. Positioning can be extremely problematic for obese patients, especially if their bulk exceeds the capacity of the support device. While some studies suggest that extra tissue acts as protection against nerve injury, most experts recommend careful padding of sensitive areas and repeated visual checks to prevent intraoperative problems.

6. Pharmacologic effects. Because of the excess fat and lean mass, the pharmacologic effects of different anesthetic agents may be altered when administered to obese patients. This is especially true for those drugs that are lipophilic.

7. Intravenous agents. Dose induction agents such as propofol or thiopental based on total body weight. Base loading doses of opioids and benzodiazepines on total body weight, but reduce additional doses because of the potential depressant effects. Dose muscle relaxants based on ideal body weight, as they're not distributed into fat tissue.

8. Inhalation agents. Low lipid-solubility inhalation agents, such as desflurane or sevoflurane, are ideal for maintenance of anesthesia in a balanced technique (using a combination of inhalation anesthetics, narcotic and non-narcotic analgesics, and local anesthesia). While some studies suggest desflurane may allow for more rapid awakening, head-to-head comparison in patients for laparoscopic gastric bypass didn't show any clinically significant advantage for one over the other (Journal of Clinical Anesthesia. 2007;19:3??"8).

9. Facility planning. Equip your ORs with items that match the physical characteristics of obese patients. The OR beds must hold patients weighing up to 500 pounds. Different sized blood pressure cuffs will be needed to accommodate larger and conical-shaped arms. Gowns, gurneys, chairs and wheelchairs should be available in sizes and capacities that allow a comfortable experience. Trained personnel should be dedicated to professional, dignified and respectful service. Your patients will notice and deeply appreciate these considerations.

10. Pre-op preparation. Planning is the key to successful outcomes. Surgeons and their office staff should be informed of the need to refer patients to the surgery center well in advance of the date of service. This will provide time for review of the medical records by the anesthesia provider and additional testing or consultations. Pre-op evaluations should be performed in person before the day of surgery. Some patients will be judged as unsuitable for outpatient surgery, a decision you should make before the patient arrives at your facility. Comprehensive communication between the surgeon, anesthesia providers, nurses and facility personnel is critical.

11. Extra time. It may be helpful to allow extra time for cases involving obese patients, both in the OR and in PACU. Anesthetic plans may include MAC, regional or general, with the focus on minimizing long-term effects of sedation. Surgeons should be reminded to use enough local anesthetic so that post-operative narcotic use is reduced. PACU nurses will need to carefully observe patients for deleterious cardiorespiratory responses and be prepared to aggressively treat any problems they observe.