Obesity and Anesthesia: Challenges in the Perioperative Period.

The obesity epidemic has significant implications for all aspects of healthcare. The physiological changes of obesity affect every area of perioperative medicine. In this article, we discuss several anesthetic concerns regarding obesity. We will specifically discuss preoperative evaluation, perioperative challenges, and postoperative pain control and monitoring.

Dexmedetomidine and ketamine for sedation during spinal anesthesia in children.

STUDY OBJECTIVE: To evaluate the combination of dexmedetomidine and ketamine for sedation during lumbar puncture and sedation for spinal anesthesia in children. DESIGN: Retrospective analysis of quality assurance data sheets and anesthetic records. SETTING: Developing countries with the humanitarian group, Kids First. PATIENTS: 12 infants and children, ranging in age from two to 9 years. INTERVENTIONS: A bolus dose of ketamine (two mg/kg) and dexmedetomidine (one µg/kg) was given over three minutes followed by a continuous infusion of dexmedetomidine (two µg/kg/hr for the first 30 min, followed by one µg/kg/hr for the duration of the case). Supplemental analgesia/sedation was provided by ketamine (0.5 mg/kg) as needed. MEASUREMENTS: The need for supplemental ketamine, the ability to complete the procedure, and heart rate (HR), blood pressure, end-tidal carbon dioxide (ETCO(2)), and oxygen saturation values were recorded. MAIN RESULTS: Effective sedation for lumbar puncture and performance of spinal anesthesia were achieved in all patients. One patient required a supplemental dose of ketamine (0.5 mg/kg). Following the bolus dose of ketamine and dexmedetomidine, HR increased by 11 ± 4 bpm. The greatest HR increase was 20 bpm. No patient had a HR increase ≥ 20% from baseline. The HR decrease was ≤ 30 bpm in 10 of the 12 patients, and the greatest HR decrease was 58 bpm. Systolic blood pressure (SBP) increased from baseline by 10 ± 3 mmHg after administration of the bolus dose of ketamine and dexmedetomidine. During the subsequent dexmedetomidine infusion, SBP decreased by 11 ± 9 mmHg. No patient's respiratory rate decreased to less than 10 breaths/min or increased above 24 breaths/min during the procedural sedation. The highest ETCO(2) was 45 ± 2 mmHg (P < 0.0001). Oxygen saturation remained ≥ 95% during the procedure in all patients. CONCLUSION: A combination of ketamine and dexmedetomidine provides effective sedation during spinal anesthesia in infants and children, with limited effects on cardiovascular and ventilatory function.