61-year-old male for THR
- BMI 56
- OSA – severe AHI 86, can’t tolerate CPAP
- Chronic back pain
- Hiatus hernia
- HCO3 normal, unlikely to have obesity hypoventilation syndrome
- SpO2 on RA 97%
- Patient cannot tolerate mask
- Limited scope for optimisation apart from weight loss
- BMI 56
- Likelihood of preoperative weight-loss small.
- Evidence for weight loss strategies points to gastro-reductive surgery, but extremely limited public availability (especially with absence of metabolic syndrome) and expensive in the private sector.
- There is merit at face value for preoperative weight loss, but no clear evidence to suggest improved outcomes.
- Unusual that patient was offered surgery at this BMI. See table below, obesity and smoking only co-morbidities with RCT evidence to support increased perioperative risk.
- Reviewed by cardiologist. Sestamibi normal. TTE showed diastolic dysfunction (diuretics commenced)
- SOB thought to be multifactorial – diastolic dysfunction, obesity, deconditioning.
- Nil further cardiac investigations thought necessary by cardiologist
- Proceed with surgery
- Encourage compliance, where possible, with CPAP
- ICU level 3
- Neuraxial technique and minimal sedation recommended.