Preface

When an anesthesiologist is asked to provide care for a patient there are usually two major areas that must be considered in planning the actual approach to management. The first concern is ‘‘what are the specific requirements for the procedure?’’ Obviously the anesthetic management of a patient undergoing a laparotomy is quite different from the management of the same patient undergoing a craniotomy. The second area of concern is potentially far more complicated since each patient is different. ‘‘What are the physical and medical conditions of the specific patient that the anesthesiologist must know which will affect the actual management?’’ In other words, ‘‘how will I tailor my choice of agents and their doses, the positioning and monitoring of the patient, and essentially all other aspects of anesthetic management for this specific patient undergoing this specific procedure?’’ In clinical anesthetic practice, there is probably no other group of patients in which these major areas of concern coincide and who present a greater challenge than the patient with extreme or morbid obesity (MO). The management of a MO patient is never simple. Extreme obesity always alters physiology, particularly cardiac, respiratory, and metabolic functions. MO patients almost invariably have significant associated medical comorbidities, which can include hypertension, Type-2 diabetes, obstructive sleep apnea, coronary and cerebrovascular disease, liver problems, and many types of cancer; all of which must be considered when planning the anesthetic. A subset of obese patients, those with the metabolic syndrome (MetS), is at even greater risk for having serious associated medical problems and perioperative complications. Even in young, otherwise healthy MO patients, their extreme weight makes them susceptible to neurologic and pressure injuries during routine intraoperative positioning. Every MO patient, including those undergoing the least invasive operations and with a minimum of anesthesia, can present a challenge for safe management. The worldwide obesity epidemic we have experienced during the past 20 years means that thousands of MO patients undergo anesthesia and surgery daily for every type of operation. Given this high volume of cases it is logical to think that every area of the perioperative care of the obese patient has been evaluated, studied, and the data then published in the medical literature. By now every practicing anesthesiologist should be familiar with every aspect of the