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Intravenous anesthetic drug dosing for obese patients[1-20]

Intravenous anesthetic drug dosing for obese patients[1-20]
Drug Weight for dosing Notes
Sedative/hypnotics
Propofol bolus doses AdjBW  
Propofol maintenance infusions AdjBW Titrate to clinical endpoint.
Etomidate AdjBW  
Ketamine AdjBW  
Thiopental AdjBW Doses should be adjusted for high or low cardiac output, and rapid redistribution may result in more rapid awakening after a single bolus dose than in lean patients.
Midazolam (and other benzodiazepines) bolus doses TBW For sedation, usually dosed in small increments (eg, midazolam 1 mg IV) titrated to effect. Caution should be exercised as patients with OSA may have increased central sensitivity to the sedative and respiratory effects of benzodiazepines. TBW is used for induction of anesthesia, due to high lipophilicity and thus increased volume of distribution in obese patients.
Midazolam (and other benzodiazepines) continuous infusions AdjBW Titrate to effect.
Dexmedetomidine TBW Titrate to effect. Dose adjustments may be required for comorbidities or other sedative or anesthetic drugs used concomitantly.
Opioids
Synthetic opioids (fentanyl, sufentanil, alfentanil, and remifentanil) TBW When possible, titrate to effect.
Morphine IBW Initial dosing should be based on IBW and further administration titrated to effect.
Hydromorphone IBW As with morphine, initial dosing is based on IBW and then further titrated to effect.
Lidocaine, systemic
Bolus AdjBW  
Infusion AdjBW  
Neuromuscular blocking agents
Nondepolarizing agents (eg, vecuronium, rocuronium) IBW versus TBW The dosing scalar will depend on the clinical circumstance. In general, a higher (ie, closer to TBW) intubating dose will result in faster onset and shorter time to complete NMB, but a longer duration of action. An IBW-based dosing will prolong the time to ideal intubating conditions, but assure a faster recovery from NMB.
Succinylcholine TBW  
Reversal agents
Sugammadex AdjBW  
Neostigmine AdjBW  
The optimal method for calculating weight based doses of many medications in obese patients is unclear, with limited available literature. When possible and appropriate, anesthetic medications should be titrated to effect with incremental doses or incrementally adjusted infusions. The dosing strategy in this table is based on available pharmacokinetic and pharmacodynamic data in obesity, such data in non-obese patients, clinical experience, and the clinical use of the drug.
AdjBW: adjusted body weight; TBW: total body weight; IV: intravenous; OSA: obstructive sleep apnea; IBW: ideal body weight; NMB: neuromuscular blockade.
References:
  1. Wada DR, Björkman S, Ebling WF, et al. Computer simulation of the effects of alterations in blood flows and body composition on thiopental pharmacokinetics in humans. Anesthesiology 1997; 87:884.
  2. Ingrande J, Brodsky JB, Lemmens HJ. Lean body weight scalar for the anesthetic induction dose of propofol in morbidly obese subjects. Anesth Analg 2011; 113:57.
  3. Echevarria GC, Elgueta MF, Donosoto MT, et al. The effective effect-site propofol concentration for induction and intubation with two pharmacokinetic models in morbidly obese patients using total body weight. Anesth Analg 2012; 115:823.
  4. Greenblatt DJ, Abernethy DR, Locniskar A, et al. Effect of age, gender, and obesity on midazolam kinetics. Anesthesiology 1984; 61:27.
  5. Feld J, Hoffman WE. Response entropy is more reactive than bispectral index during laparoscopic gastric banding. J Clin Monit Comput 2006; 20:229.
  6. Bakhamees HS, El-Halafawy YM, El-Kerdawy HM, et al. Effects of dexmedetomidine in morbidly obese patients undergoing laparoscopic gastric bypass. Middle East J Anesthesiol 2007; 19:537.
  7. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg 2008; 106:1741.
  8. Ramsay MA. Bariatric surgery: The role of dexmedetomidine. Seminars in Anesthesia, Perioperative Medicine and Pain 2006; 25:51.
  9. Leykin Y, Pellis T, Lucca M, et al. The effects of cisatracurium on morbidly obese women. Anesth Analg 2004; 99:1090.
  10. Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102:438.
  11. Abernethy DR, Greenblatt DJ. Lidocaine disposition in obesity. Am J Cardiol 1984; 53:1183.
  12. Schwartz AE, Matteo RS, Ornstein E, et al. Pharmacokinetics of sufentanil in obese patients. Anesth Analg 1991; 73:790.
  13. Scholz J, Steinfath M, Schulz M. Clinical pharmacokinetics of alfentanil, fentanyl and sufentanil. An update. Clin Pharmacokinet 1996; 31:275.
  14. Egan TD, Huizinga B, Gupta SK, et al. Remifentanil pharmacokinetics in obese versus lean patients. Anesthesiology 1998; 89:562.
  15. Schwartz AE, Matteo RS, Ornstein E, et al. Pharmacokinetics and pharmacodynamics of vecuronium in the obese surgical patient. Anesth Analg 1992; 74:515.
  16. Pühringer FK, Keller C, Kleinsasser A, et al. Pharmacokinetics of rocuronium bromide in obese female patients. Eur J Anaesthesiol 1999; 16:507.
  17. Rose JB, Theroux MC, Katz MS. The potency of succinylcholine in obese adolescents. Anesth Analg 2000; 90:576.
  18. Jung D, Mayersohn M, Perrier D, et al. Thiopental disposition in lean and obese patients undergoing surgery. Anesthesiology 1982; 56:269.
  19. De Oliveira GS Jr, Duncan K, Fitzgeral P, et al. Systemic Lidocaine to Improve Quality of Recovery after Laparoscopic Bariatric Surgery: A Randomized Double-Blinded Placebo-Controlled Trial. Obes Surg 2014; 24:212.
  20. Carabalona JF, Delwarde B, Duclos A, et al. Serum Concentrations of Lidocaine During Bariatric Surgery. Anesth Analg 2020; 130:e5.
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