70: Safer Surgeries for All: Expert Tips on Anesthesia and Obesity with Dr. Sarah Bodin

If you are overweight or obese and planning to have surgery, it's important to understand how excess weight can put you at risk for certain side effects and complications, whether from the surgery itself or the anesthesia you need. 

To help me explore the unique challenges people with obesity face when undergoing surgery, I recently interviewed Dr. Sarah Bodin, a double board-certified physician in obesity medicine and anesthesia, who shared some valuable insights into how we can make surgical experiences safer and more inclusive for all patients.

Holding GLP-1 Agonists Prior to Elective Procedures

If you're taking GLP-1 medications and getting ready for surgery, it’s important to be aware of the guidelines around holding these medications before surgery.

GLP-1 medications are able to manage weight and diabetes by slowing down how quickly your stomach empties. But during surgery, this can cause problems. When you're under anesthesia, you can't control your swallowing or coughing reflexes well, so there's a risk of stomach contents getting into your lungs, which is called aspiration.

To avoid this risk, it's important to stop taking GLP-1s before surgery. For people on weekly injectable GLP-1s like Ozempic, Wegovy, or Mounjaro, it's advised to stop them for at least seven days before surgery. Dr. Bodin recommends erring on the side of caution and stopping them for two weeks ahead of surgery to be safe. Even after you stop, there can still be a lot of the drug in your body, affecting your stomach and raising the risk of aspiration.

For those on daily injectable GLP-1s or oral semaglutide (Rybelsus), it's recommended to stop them for 24 hours before surgery but Dr. Bodin says doubling that time could be better for safety.  We know the elimination half life for these drugs and that's what the hold time recommendations are, but that doesn't necessarily correspond exactly with the clinical half lives.

The use of gastric ultrasound is also likely to become more common in the future. This will help determine how much is in the stomach more accurately, rather than relying solely on how long ago the medication was taken.

Navigating Clinical Challenges Posed by Obesity

In clinical practice, managing obesity poses various challenges that need careful consideration, especially where anesthesia is concerned. One of the most common issues Dr. Bodin encounters is obstructive sleep apnea (OSA). This condition, characterized by interrupted breathing during sleep due to upper airway obstruction, can significantly impact patients undergoing surgery.

Alongside OSA, several other conditions frequently accompany obesity, including hypertension, heart disease, and type 2 diabetes. Managing these conditions, particularly blood sugar control and ensuring adequate IV access, can be challenging in patients with severe obesity.

Airway management becomes particularly complex in individuals with OSA, as sedation and opioids can exacerbate breathing difficulties. In Dr. Bodin’s pain management practice, where breathing tubes aren't always used during sedation, she regularly encounters patients with undiagnosed OSA. Identifying these individuals is crucial, as certain medications and positioning can further compromise their airway.

Given the intricate relationship between obesity and OSA, screening for sleep apnea is an integral part of Dr. Bosin’s practice. Using tools like the Stop Bang questionnaire, she assesses patients for their likelihood of having OSA. This screening not only helps in perioperative settings but also informs weight management strategies. By identifying and treating OSA, we can not only improve surgical outcomes but also address a crucial aspect of obesity management.

Surgical Safety: Outpatient vs. Hospital Setting

In a hospital, everything needed for treatment is readily available, including ICU facilities for emergencies. This means patients can feel confident that any unexpected complications can be dealt with promptly.

However, outpatient centers operate differently. These centers aren't connected to hospitals, so if a major issue occurs during surgery, like a heart attack or breathing problems, an ambulance would have to transfer the patient to a hospital. This delay in treatment can be risky, especially for those with severe obesity and other health issues.

To ensure safety, patients are often screened for BMI. While we know it is an imperfect measure, it's an easy screening tool and is actually very well correlated with complications in terms of higher body mass index. At the centers where Dr. Bodin works, they use a BMI of 50 as the cutoff for outpatient procedures. Above this limit, they advise patients to have surgery in a hospital for better access to advanced care.

While some patients may prefer the convenience of outpatient centers, safety has to come first. Being in a hospital ensures immediate access to advanced medical care in emergencies, which can make a huge difference in outcomes.

Prepping for Surgery: Proactive Measures for a Successful Outcome

Before undergoing elective surgery, Dr. Bodin recommends these proactive steps to optimize your health and minimize the risk of complications:

• Blood Sugar Control:

Keeping blood sugar levels well-controlled before surgery is crucial as high blood sugars can lead to various complications, including infections and impaired wound healing. Aim to keep blood sugars under 200 mg/dL, ideally under 180 mg/dL, especially for inpatient surgeries.

• Nutrition:

Ensure a balanced diet with adequate protein intake to support healing. Protein is essential for wound healing, so focus on consuming enough protein-rich foods.

• Blood Pressure Management:

If you have high blood pressure, continue taking your medications as prescribed to maintain optimal blood pressure levels.

• Exercise:

Engage in prehabilitation exercises to build strength and endurance before surgery. Improved cardiovascular fitness can help your body better tolerate the stress of surgery and anesthesia.

• Hydration:

Stay hydrated by drinking plenty of fluids leading up to surgery. Avoid coming into the hospital dehydrated as adequate hydration is crucial for optimal recovery. 

• Smoking Cessation: 

If you smoke, consider quitting or at least abstaining from smoking for 24 hours before surgery. Even short-term smoking cessation can improve wound healing and oxygen delivery to tissues.

• Thrombotic Risk Management:

People with obesity have a higher risk of blood clots, particularly during surgery. Sequential compression devices are often used on the lower extremities before surgery to prevent blood clots. Depending on the surgery and individual risk factors, your doctor may prescribe blood thinners to decrease the risk of blood clots.

By integrating these insights into our approach, we can work towards ensuring safer and more inclusive surgical experiences for all patients, regardless of weight.