Prise en charge anesthésique des patients obèses soumis à une chirurgie bariatrique

Morbid obesity is defined by a body mass index (BMI) higher than 35 kg m−2. Bariatric surgery includes all the surgical techniques aiming to achieve weight loss by changing nutritional behaviour or decreasing food absorption. Surgery is usually performed under laparoscopy. These curative surgical procedures are performed by trained teams, including a multidisciplinary care network. Evaluation of the obese patient at the preoperative consultation is very important. Besides respiratory and cardiovascular impairments, sleep apnoea obstructive syndrome and gastro-oesophageal reflux must be systematically detected. Clinical examination estimates the risks of difficult facemask ventilation or intubation. Proclive position must be maintained as long as possible during anaesthesia. Preoxygenation in proclive position allows delaying oxygen desaturation. Anaesthetic induction is performed by two staffs, one of them being experienced for the procedure. A crush induction is mandatory only in case of gastro-oesophageal reflux symptoms. Controlled ventilation aims at maintaining the lung “opened” during the respiratory cycle, with a positive end expiratory pressure greater or equal to 10 cmH2O and using alveolar recruitment manoeuvres. Tidal volume is calculated based on the ideal weight. Extubation is performed as soon as possible after the end of surgery, in proclive position. Postoperative thromboprophylaxis combines mechanical contention, anticoagulation and deambulation.