Perioperative pain management of the patient with morbid obesity in bariatric surgery. Clinical report and literature review

Background. Anesthetic management of patients with morbid obesity during bariatric surgery presents a number of problems, including “difficult” vascular access, “difficult” airways, increased risk of aspiration, changes in the pharmacokinetics of anesthetics, and an increased risk of postoperative respiratory depression associated with opioids. Methods. Case description Patient 32 years old, height 162 cm, body weight 200 kg (body mass index 76.2 kg/m²) underwent surgical treatment for morbid obesity (gastroentero bypass) using combined anesthesia (general anesthesia with desflurane combined with epidural analgesia ropivacaine 2 mg/ml). Results. Ultrasound navigation was used to catheterize the peripheral vein and insert an epidural catheter. Also, due to the high risk of difficult airways (according to the MOSCOW TD scale — 4 points), the patient underwent fiberoptic orotracheal intubation with in consciousness with sedation by dexmedetomidine to level –1 on the Richmond excitation-sedation scale. Early activation of the patient was achieved by controlled anesthesia and multimodal analgesia in the postoperative period. Analgesia after surgery using prolonged epidural administration of 0.2 % ropivacaine at a rate of 4–8 ml/h, intravenous paracetamol 1 gram every 8 hours. 2 hours after the end of the operation, the patient sat down on the bed with her legs down and got up for the first time after 6 hours. On the second day, she was transferred to a specialized department with prolonged epidural analgesia, the duration of which was 72 hours. Complications were not observed in the postoperative period. The patient was discharged from the clinic on the eighth day after surgery in a satisfactory condition without active complaints. Conclusion. In this clinical case, the chosen tactics of postoperative analgesia made it possible to achieve good analgesia, conduct early activation of the patient, and begin early rehabilitation procedures.