Perioperative analgesia in obese patients


  • S.I. Vorotyntsev Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine



obesity, morbid obesity, perioperative analgesia, review


Obesity in general and morbid obesity (MO) in particular are becoming more common around the world. MO is associated with altered physiology of the body and increased number of comorbidities, which can make perioperative pain control particularly difficult in such patients. Given the higher incidence of respiratory disorders, traditional opioid-oriented treatment of pain in patients with MO can often lead to ventilation disorders and increased morbidity and/or mortality. Multimodal analgesia strategies based on a step-by-step, according to the pain severity, opioid-sparing approach can improve patient safety and treatment outcomes. Further progress in understanding the mechanisms of acute pain forces doctors to actively detect and treat both its nociceptive and pro-nociceptive components (hyperalgesia, etc.). Such multimodal analgesia protocols should be standardized and implemented in perioperative care of patients with MO. In addition to standardizing the treatment of postoperative pain, regardless of used regimen of anesthesia and analgesia, some patients with MO require enhanced respiratory monitoring to prevent possible airway side effects. This review briefly describes the physiological changes in obese patients, the pathophysiology of pain, and the evidence-based clinical updates for pain management in MO. Also, the role of opioid-sparing pharmacological adjuvants is discussed and future directions of research in the field of perioperative pain management in patients with MO are highlighted.


Download data is not yet available.


Hales C.M., Carroll M.D., Fryar C.D., Ogden C.L. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS Data Brief. 2017. 288. 1-8.

Schug S.A., Palmer G.M., Scott D.A. et al. and Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientifc Evidence. 2015. 4th edn. P. 558-562.

Thorell A., MacCormick A.D., Awad S. et al. Guidelines for Perioperative Care in Bariatric Surgery: enhanced recovery after surgery (ERAS) Society recommendations. World J. Surg. 2016. 40. 2065-83.

Okifuji A., Hare B.D. The association between chronic pain and obesity. J. Pain Res. 2015. 8. 399-408.

Thomazeau J., Perin J., Nizard R. et al. Pain management and pain characteristics in obese and normal weight patients before joint replacement. J. Eval. Clin. Pract. 2014. 20. 611-6.

King W.C., Chen J., Belle S.H. et al. Use of prescribed opioids before and after bariatric surgery: prospective evidence from a U.S. multicenter cohort study. Surg. Obes. Rel. Dis. 2017. 13. 1337-46.

Raebel M.A., Newcomer S.R., Reifer L.M. et al. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013. 310. 1369-76.

Severino A.L., Shadfar A., Hakimian J.K. et al. Pain therapy guided by purpose and perspective in light of the opioid epidemic. Front. Psych. 2018. 9. 119.

Budiansky A.S., Margarson M.P., Eipe N. Acute pain mana­gement in morbid obesity — an evidence based clinical update. Surg. Obes. Rel. Dis. 2017. 13. 523-32.

Gan T.J. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J. Pain Res. 2017. 10. 2287-98.

World Health Organization. International statistical classifcation of diseases and related health problems (11th Revision), 2018. y/ 302680255. Accessed Apr 2019.

Liu S.S., Buvanendran A., Rathmell J.P. et al. Predictors for moderate to severe acute postoperative pain after total hip and knee replacement. Int. Orthop. 2012. 36. 2261-7.

Mei W., Seeling M., Franck M. et al. Independent risk factors for postoperative pain in need of intervention nearly after awake­ning from general anaesthesia. Eur. J. Pain. 2010. 14(149). e1-7.

Yen C.R., Tsou M.Y., Mandell M.S. et al. An analysis of patient variables that infuence intravenous patient-controlled analgesic use of morphine with quantile regression. Anesthesiology. 2010. 112. 688-95.

Zeidan A., Al-Temyatt S., Mowaf H., Ghattas T. Gender-related difference in postoperative pain after laparoscopic Roux-En-Y gastric bypass in morbidly obese patients. Obes. Surg. 2013. 23. 1880-4.

Weingarten T.N., Sprung J., Flores A. et al. Opioid requirements after laparoscopic bariatric surgery. Obes. Surg. 2011. 21. 1407-12.

Feld J.M., Hofman W.E., Stechert M.M., Hofman I.W., Ananda R.C. Fentanyl or dexmedetomidine combined with desfurane for bariatric surgery. J. Clin. Anesth. 2006. 18. 24-8.

Bouhassira D., Attal N., Alchaar H. et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005. 114. 29-36.

Clarke H., Bonin R.P., Orser B.A. et al. The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis. Anesth. Analg. 2012. 115. 428-42.

Eipe N., Budianski A.S. Analgesic techniques. In: Bouch C., Cousins J., editors. Core topics in anaesthesia and perioperative care of the morbidly obese surgical patient. Cambridge: Cambridge University Press. 2018. P. 137-44.

Rivat C., Bollag L., Richebe P. Mechanisms of regional anaes­thesia protection against hyperalgesia and pain chronicization. Curr. Opin. Anaesthesiol. 2013. 26. 621-5.

Nightingale C.E., Margarson M.P., Shearer E. et al. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia. 2015. 70. 859-76.

De Raaf, Gorter-Stam M.A.W., de Vries N. et al. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg. Obes. Relat. Dis. 2017. 13. 1095-109.

Tufanogullari B., White P.F., Peixoto M.P. et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the efect on recovery outcome variables. Anesth. Analg. 2008. 106. 1741-8.

Theunissen M., Peters M.L., Bruce J. et al. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin. J. Pain. 2012. 28. 819-41.

Schug S.A. Acute pain management in the opioid-tolerant patient. Pain Manag. 2012. 2. 581-91.

Ziemann-Gimmel P., Hensel P., Koppman J., Marema R. Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery. Surg. Obes. Relat. Dis. 2013. 9. 975-80.

Saurabh S., Smith J.K., Pedersen M. et al. Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand & requirement after laparoscopic Roux-en-Y gastric bypass. Surg. Obes. Relat. Dis. 2015. 11. 424-30.

Jibril F., Sharaby S., Mohamed A., Wilby K.J. Intravenous versus oral acetaminophen for pain: systematic review of current evidence to support clinical decision-making. Can. J. Hosp. Pharm. 2015. 68. 238-47.

Govindarajan R., Ghosh B., Sathyamoorthy M.K. et al. Efcacy of ketorolac in lieu of narcotics in the operative management of Laparoscopic surgery for morbid obesity. Surg. Obes. Relat. Dis. 2005. 1. 530-5.

Klein M., Stockel M., Rosenberg J., Gogenur I. Intraoperative ketorolac and bleeding after laparoscopic Roux-en-Y gastric bypass surgery. Acta Chir. Belg. 2012. 112. 369-73.

Moore R.A., Derry S., McQuay H.J. et al. Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database Syst. Rev. 2011. 9. CD008659.

Hegi T.R., Bombeli T., Seifert B. et al. Efect of rofecoxib on platelet aggregation and blood loss in gynaecological and breast surgery compared with diclofenac. Br. J. Anaesth. 2004. 92. 523-31.

Lin J., Zhang L., Yang H. Perioperative administration of selective cyclooxygenase-2 inhibitors for postoperative pain management in patients after total knee arthroplasty. J. Arthroplasty. 2013. 28(207-13). e2.

Zhang J., Ding E.L., Song Y. Adverse efects of cyclooxyge­nase 2 inhibitors on renal and arrhythmia events: meta-analysis of randomized trials. JAMA. 2006. 296. 1619-32.

Bhala N., Emberson J., Merhi A. et al. Vascular and upper gastrointestinal efects of non-steroidal anti-infammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013. 382. 769-79.

Ng J.J., Leong W.Q., Tan C.S. et al. A Multimodal analgesic protocol reduces opioid-related adverse events and improves patient outcomes in laparoscopic sleeve gastrectomy. Obes. Surg. 2017. 27. 3075-81.

Bamgbade O.A., Oluwole O., Khaw R.R. Perioperative analgesia for fast-track laparoscopic bariatric surgery. Obes. Surg. 2017. 27. 1828-34.

Lam K.K.Y., Mui W.L.M. Multimodal analgesia model to achieve low postoperative opioid requirement following bariatric surgery. Hong Kong Med. J. 2016. 22(22). 428-34.

Murphy J.D., Yan D., Hanna M.N. et al. Comparison of the postoperative analgesic efcacy of intravenous patient-controlled analgesia with tramadol to intravenous patient-controlled analgesia with opioids. J. Opioid Manag. 2010. 6. 141-7.

Hollingshead J., Duhmke R.M., Cornblath D.R. Tramadol for neuropathic pain. Cochrane Database Syst. Rev. 2006. 3. CD003726.

Tarkkila P., Tuominen M., Lindgren L. Comparison of respiratory efects of tramadol and oxycodone. J. Clin. Anesth. 1997. 9. 582-5.

Stamer U.M., Lehnen K., Hothker F. et al. Impact of CYP2D6 genotype on postoperative tramadol analgesia. Pain. 2003. 105. 231-8.

Avila C., Holloway A., Hahn M. et al. An overview of links between obesity and mental health. Curr. Obes. Rep. 2015. 4. 303-10.

Radbruch L., Grond S., Lehmann K.A. A risk-beneft assessment of tramadol in the management of pain. Drug. Saf. 1996. 15. 8-29.

Ahmad S., Nagle A., McCarthy R.J. et al. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth. Analg. 2008. 107. 138-43.

De Baerdemaeker L.E., Jacobs S., Pattyn P. et al. Infuence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid obesity. Br. J. Anaesth. 2007. 99. 404-11.

Bidgoli J., Delesalle S., De Hert S.G. et al. A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient. Eur. J. Anaesthesiol. 2011. 28. 120-4.

Gaszynski T.M., Strzelczyk J.M., Gaszynski W.P. Post-anesthesia recovery after infusion of propofol with remifentanil or alfentanil or fentanyl in morbidly obese patients. Obes. Surg. 2004. 14. 498-503.

Machado F.C., Palmeira C.C.D.A., Torres J.N.L. et al. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study. J. Pain Res. 2018. 11. 2123-9.

Cabrera Schulmeyer M., Maza J., Ovalle C. et al. Analgesic efects of a single preoperative dose of pregabalin after laparoscopic sleeve gastrectomy. Obes. Surg. 2010. 20. 1678-81.

Alimian M., Imani F., Faiz S.H. et al. Efect of oral pregabalin premedication on post-operative pain in laparoscopic gastric bypass surgery. Anesthesiol. Pain Med. 2012. 2. 12-6.

Hassani V., Pazouki A., Nikoubakht N. et al. The efect of gabapentin on reducing pain after laparoscopic gastric bypass surgery in patients with morbid obesity: a randomized clinical trial. Anesth. Pain Med. 2015. 5. e22372.

Chaparro L.E., Smith S.A., Moore R.A. et al. Pharmacothe­rapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst. Rev. 2013. 7. CD008307.

Laskowski K., Stirling A., McKay W.P. et al. A systematic review of intravenous ketamine for postoperative analgesia. Can. J. Anaesth. 2011. 58. 911-23.

Mathews T.J., Churchhouse A.M., Housden T. et al. Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain? Interact. Cardiovasc. Thorac. Surg. 2012. 14. 194-9.

Tawfc Q.A. A review of the use of ketamine in pain management. J. Opioid Manag. 2013. 9. 379-88.

Kamal H.M. Ketamine as an adjuvant to morphine for patient controlled analgesia in morbidly obese patients. J. Med. Sci. 2008. 8. 364-70.

Hasanein R., El-Sayed W., Nashwa N., Elsayed G. The efect of combined remifentanil and low dose ketamine infusion in patients undergoing laparoscopic gastric bypass. Egypt. J. Anaesthesiol. 2011. 27. 255-60.

Barreveld A., Witte J., Chahal H. et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013. 116. 1141-61.

Vigneault L., Turgeon A.F., Cote D. et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-ana­lysis of randomized controlled trials. Can. J. Anaesth. 2011. 58. 22-37.

Sun Y., Li T., Wang N. et al. Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: a meta-analysis of randomized controlled trials. Dis. Colon. Rectum. 2012. 55. 1183-94.

Dunn L.K., Durieux M.E. Perioperative use of intravenous lidocaine. Anesthesiology. 2017. 126. 729-37.

Feld J.M., Laurito C.E., Beckerman M. et al. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can. J. Anaesth. 2003. 50. 336-41.

De Oliveira G.S., Duncan K., Fitzgerald 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. 212-8.

Blaudszun G., Lysakowski C., Elia N. et al. Efect of periope­rative systemic alpha2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomi­zed controlled trials. Anesthesiology. 2012. 116. 1312-22.

Singh P.M., Panwar R., Borle A. et al. Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis. Surg. Obes. Relat. Dis. 2017. 13. 1434-46.

Dholakia C., Beverstein G., Garren M. et al. The impact of perioperative dexmedetomidine infusion on postoperative narcotic use and duration of stay after laparoscopic bariatric surgery. J. Gastrointest. Surg. 2007. 11. 1556-9.

Buckley F.P., Robinson N.B., Simonowitz D.A., Dellinger E.P. Anaesthesia in the morbidly obese: a comparison of anaesthetic and analgesic regimens for upper abdominal surgery. Anaesthesia. 1983. 38. 840-51.

Fox G.S., Whalley D.G., Bevan D.R. Anaesthesia for the morbidly obese: experience with 110 patients. Br. J. Anaesth. 1981. 53. 811-6.

Sharma M., Mehta Y., Sawhney R. et al. Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m2 for of pump coronary artery bypass surgery. Ann. Card. Anaesth. 2010. 13. 28-33.

Saumier N., Gentili M., Dupont H., Aubrun F. Postoperative intravenous morphine titration in PACU after bariatric laparoscopic surgery. Ann. Fr. Anesth. Reanim. 2013. 32. 850-5.

Cottam D.R., Fisher B., Atkinson J. et al. A randomized trial of bupivicaine pain pumps to eliminate the need for patient controlled analgesia pumps in primary laparoscopic Roux-en-Y gastric bypass. Obes. Surg. 2007. 17. 595-600.

Von Ungern-Sternberg B.S., Regli A., Reber A., Schneider M.C. Efect of obesity and thoracic epidural analgesia on periope­rative spirometry. Br. J. Anaesth. 2005. 94. 121-7.

Regli A., von Ungern-Sternberg B.S., Reber A. et al. Impact of spinal anaesthesia on perioperative lung volumes in obese and morbidly obese female patients. Anaesthesia. 2006. 6. 215-21.

Panni M.K., Columb M.O. Obese parturients have lower epidural local anaesthetic requirements for analgesia in labour. Br. J. Anaesth. 2006. 96. 106-10.

McCulloch W.J., Littlewood D.G. Infuence of obesity on spinal analgesia with isobaric 0.5% bupivacaine. Br. J. Anaesth. 1986. 58. 610-4.

Taivainen T., Tuominen M., Rosenberg P.H. Infuence of obesity on the spread of spinal analgesia after injection of plain 0.5% bupivacaine at the L3-4 or L4-5 interspace. Br. J. Anaesth. 1990. 64. 542-6.

Hogan Q.H., Prost R., Kulier A. et al. Magnetic resonance imaging of cerebrospinal fuid volume and the infuence of body habitus and abdominal pressure. Anesthesiology. 1996. 84. 1341-9.

Lee Y., Balki M., Parkes R., Carvalho J.C. Dose requirement of intrathecal bupivacaine for cesarean delivery is similar in obese and normal weight women. Rev. Bras. Anestesiol. 2009. 59. 674-83.

Carvalho B., Collins J., Drover D.R. et al. ED (50) and ED (95) of intrathecal bupivacaine in morbidly obese patients undergoing cesarean delivery. Anesthesiology. 2011. 114. 529-35.

Kim H.J., Kim W.H., Lim H.W. et al. Obesity is independently associated with spinal anesthesia outcomes: a prospective observational study. PLoS One. 2015. 10. e0124264.

Lamon A.M., Einhorn L.M., Cooter M., Habib A.S. The impact of body mass index on the risk of high spinal block in parturients undergoing cesarean delivery: a retrospective cohort study. J. Anesth. 2017. 31. 552-8.

Mittal T., Dey A., Siddhartha R. et al. Efcacy of ultrasoundguided transversus abdominis plane (TAP) block for postoperative anal­gesia in laparoscopic gastric sleeve resection: a randomized single blinded case control study. Surg. Endosc. 2018. 32. 4985-9.

Johns N., O’Neill S., Ventham N.T. et al. Clinical efectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a syste­matic review and meta-analysis. Colorecta.l Dis. 2012. 14. e635-42.

Wassef M., Lee D.Y., Levine J.L. et al. Feasibility and analgesic efcacy of the transversus abdominis plane block after singleport laparoscopy in patients having bariatric surgery. J. Pain Res. 2013. 6. 837-41.

De Oliveira G.S., Jr. Fitzgerald P., Ahmad S. et al. Transversus abdominis plane infltration for laparo- scopic gastric banding: a pilot study. World J. Gastrointest. Surg. 2014. 6. 27-32.

Albrecht E., Kirkham K.R., Endersby R.V. et al. Ultrasound-guided transversus abdominis plane (TAP) block for laparoscopic gastric- bypass surgery: a prospective randomized controlled double-blinded trial. Obes. Surg. 2013. 23. 1309-14.

Said A.M., Balamoun H.A. Continuous Transversus Abdomi­nis Plane Blocks via Laparoscopically Placed Catheters for Bariatric Surgery. Obes. Surg. 2017. 27. 2575-82.

Conn R.A., Cofeld R.H., Byer D.E. et al. Interscalene block anesthesia for shoulder surgery. Clin. Orthop. Relat. Res. 1987. 216. 94-8.

Schwemmer U., Papenfuss T., Greim C. et al. Ultrasound-guided interscalene brachial plexus anaesthesia: diferences in success between patients of normal and excessive weight. Ultraschall. Med. 2006. 27. 245-50.

Schroeder K., Andrei A.C., Furlong M.J. et al. The perioperative efect of increased body mass index on peripheral nerve blockade: an analysis of 528 ultrasound guided interscalene blocks. Rev. Bras. Anestesiol. 2012. 62. 28-38.

Melton M.S., Monroe H.E., Qi W. et al. Efect of interscalene brachial plexus block on the pulmonary function of obese patients: a prospective. Observational Cohort. Study. Anesth. Analg. 2017. 125. 313-9.

Carles M., Pulcini A., Macchi P. et al. An evaluation of the brachial plexus block at the humeral canal using a neurostimulator (1417 patients): the efcacy, safety, and predictive criteria of failure. Anesth. Analg. 2001. 92. 197-8.

Cotter J.T., Nielsen K.C., Guller U. et al. Increased body mass index and ASA physical status IV are risk factors for block failure in ambulatory surgery—an analysis of 9,342 blocks. Can. J. Anaesth. 2004. 51. 810-6.

Franco C.D., Gloss F.J., Voronov G. et al. Supraclavicular block in the obese population: an analysis of 2020 blocks. Anesth. Analg. 2006. 102. 1252-4.

Rau R.H., Chan Y.L., Chuang H.I. et al. Dyspnea resulting from phrenic nerve paralysis after interscalene brachial plexus block in an obese male — a case report. Acta Anaesthesiol. Sin. 1997. 35. 113-8.

Parra M.C., Loftus R.W. Obesity and regional anesthesia. Int. Anesthesiol. Clin. 2013. 51. 90-112.

Nielsen K.C., Guller U., Steele S.M. et al. Infuence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks. Anesthesiology. 2005. 102. 181-7.



How to Cite

Vorotyntsev, S. (2022). Perioperative analgesia in obese patients. EMERGENCY MEDICINE, 17(5), 18–26.



Scientific Review