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A 15-year-old adolescent male presents with a history of morbid obesity, fatty liver, and severe obstructive sleep apnea (OSA). He is on nocturnal continuous positive airway pressure (CPAP) at home and comes to the operating room for a laparoscopic adjustable gastric banding.

  • Height 167 cm; weight 192 kg; body mass index (BMI) 68.8

  • Sleep study: Severe obstructive sleep apnea

  • Electrocardiogram and echocardiogram: Normal


Obesity is classified according to body mass index (BMI = weight in kilograms divided by square of the height in meters). Children and adolescents with BMI >95th percentile or BMI >30 are defined as obese. Those with BMI >99th percentile or BMI >35 are classified as morbidly obese. The rate of obesity among children and adolescents in the United States increased from 5% in the early 1980s to 17% in 2010.

A comprehensive preoperative evaluation is important, since a variety of comorbidities, such as type 2 diabetes mellitus, insulin resistance, hypertension, asthma, cardiac abnormalities, fatty liver, the metabolic syndrome, and depression, are found during childhood in obese individuals.

Obstructive sleep apnea and obesity hypoventilation syndrome are common among obese children and adolescents. The prevalence of OSA is ∼55%, with up to 20% of these having moderate-to-severe OSA. The definite diagnosis of OSA is made by a sleep study. The results of a sleep study are reported as Apnea-Hypopnea Index and define the severity of OSA. Patients with moderate to severe OSA are at higher risk of developing pulmonary hypertension and require preoperative cardiac evaluation.

An obese patient with a history of snoring or a diagnosis of OSA may be difficult to ventilate by mask and may be more difficult to intubate. Although the incidence of difficult laryngoscopy in obese children is much lower than that in obese adults, 1.3% versus 15%, difficult intubation equipment should always be immediately available. Anesthetics and opioids may cause airway obstruction and a poor ventilatory response to hypoxemia and hypercapnia in obese patients.

Lower functional residual capacity, reduced chest wall compliance, lung derecruitment, and airway obstruction predispose patients to hypoxemia and rapid desaturation after induction of anesthesia.

Peripheral line placement is more challenging in these patients.

Morbidly obese patients are at increased risk for compression neurologic injuries. At particular risk are the sciatic and ulnar nerves and the brachial plexus.

Highly lipophilic drugs such as barbiturates, benzodiazepines, fentanyl, and sufentanil have an increased volume of distribution in obese children and adolescents.


  • Place your patient in the reverse Trendelenburg position.

  • Build a ramp beneath the upper body and head and carefully pad all the pressure points.

  • Preoxygenate with 100% oxygen and CPAP of 10 cm H2O for at least 3 minutes prior to induction.

  • Obtain noninvasive cuff ...

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