Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients

A Systematic Review of Clinical Studies

Zahid Hussain, Colin Curtian, Corinne Mirkazmi, Syed Tabish R Zaidi

Research output: Contribution to journalArticle

Abstract

Background: Despite the increasing numbers of obese patients undergoing elective surgery, there is a lack of evidence-based dosing guidelines for peri-operative medications in obesity. Objective: The objective was to systematically review the dosing and outcomes of peri-operative medications used in obese elective surgical patients. Methods: Medical subject headings and general keywords were used to systematically search multiple databases (PubMed, EMBASE, Cochrane Library and CINAHL). Studies of medications in obese surgical patients were included if they had a non-obese control or comparative dosing scalar group. The National Health and Medical Research Council GRADE tool was used to assess quality of evidence for each drug. Results: Thirty-three studies of six drug classes were identified: anaesthetics (n = 6), muscle relaxants (n = 10), neuromuscular reversal agents (n = 3), analgesics (n = 2), antibiotics (n = 5) and anticoagulants (n = 7). A variety of dose scalars and/or recommendations was observed for various medications. Lean body weight was proposed as a suitable weight scalar for induction of anaesthesia with propofol whereas total body weight for maintenance of anaesthesia with propofol and depolarizing muscle relaxants. Ideal body weight was reported as an appropriate dosing scalar for non-depolarizing muscle relaxants and neuromuscular reversal agents. Both corrected body weight 40% and ideal body weight were reported as suitable weight scalars for post-operative analgesia with morphine. The standard 2-g dose of cefazolin appeared effective in the prevention of surgical site infection. Body mass index stratified dosing of enoxaparin was effective for venous thromboembolism prevention. Conclusion: No drug recommendation achieved an “Excellent” quality of evidence. Limited data suggest that clinicians should consider each individual class of medication when selecting a dose for obese surgical patients. Routine use of fixed-dosing regimens is likely to under- or overdose obese patients thus predisposing them to adverse drug events or treatment failure leading to patient harm.
Original languageEnglish
Pages (from-to)673-693
Number of pages21
JournalClinical Drug Investigation
Volume38
Issue number8
DOIs
Publication statusPublished - Aug 2018
Externally publishedYes

Fingerprint

Neuromuscular Agents
Ideal Body Weight
Propofol
Neuromuscular Depolarizing Agents
Anesthesia
Neuromuscular Nondepolarizing Agents
Body Weight
Medical Subject Headings
Pharmaceutical Preparations
Patient Harm
Surgical Wound Infection
Enoxaparin
Weights and Measures
Cefazolin
Venous Thromboembolism
Drug-Related Side Effects and Adverse Reactions
Treatment Failure
PubMed
Analgesia
Anticoagulants

Cite this

Hussain, Zahid ; Curtian, Colin ; Mirkazmi, Corinne ; R Zaidi, Syed Tabish. / Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients : A Systematic Review of Clinical Studies. In: Clinical Drug Investigation. 2018 ; Vol. 38, No. 8. pp. 673-693.
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abstract = "Background: Despite the increasing numbers of obese patients undergoing elective surgery, there is a lack of evidence-based dosing guidelines for peri-operative medications in obesity. Objective: The objective was to systematically review the dosing and outcomes of peri-operative medications used in obese elective surgical patients. Methods: Medical subject headings and general keywords were used to systematically search multiple databases (PubMed, EMBASE, Cochrane Library and CINAHL). Studies of medications in obese surgical patients were included if they had a non-obese control or comparative dosing scalar group. The National Health and Medical Research Council GRADE tool was used to assess quality of evidence for each drug. Results: Thirty-three studies of six drug classes were identified: anaesthetics (n = 6), muscle relaxants (n = 10), neuromuscular reversal agents (n = 3), analgesics (n = 2), antibiotics (n = 5) and anticoagulants (n = 7). A variety of dose scalars and/or recommendations was observed for various medications. Lean body weight was proposed as a suitable weight scalar for induction of anaesthesia with propofol whereas total body weight for maintenance of anaesthesia with propofol and depolarizing muscle relaxants. Ideal body weight was reported as an appropriate dosing scalar for non-depolarizing muscle relaxants and neuromuscular reversal agents. Both corrected body weight 40{\%} and ideal body weight were reported as suitable weight scalars for post-operative analgesia with morphine. The standard 2-g dose of cefazolin appeared effective in the prevention of surgical site infection. Body mass index stratified dosing of enoxaparin was effective for venous thromboembolism prevention. Conclusion: No drug recommendation achieved an “Excellent” quality of evidence. Limited data suggest that clinicians should consider each individual class of medication when selecting a dose for obese surgical patients. Routine use of fixed-dosing regimens is likely to under- or overdose obese patients thus predisposing them to adverse drug events or treatment failure leading to patient harm.",
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Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients : A Systematic Review of Clinical Studies. / Hussain, Zahid; Curtian, Colin; Mirkazmi, Corinne; R Zaidi, Syed Tabish.

In: Clinical Drug Investigation, Vol. 38, No. 8, 08.2018, p. 673-693.

Research output: Contribution to journalArticle

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T1 - Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients

T2 - A Systematic Review of Clinical Studies

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AU - Curtian, Colin

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AU - R Zaidi, Syed Tabish

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AB - Background: Despite the increasing numbers of obese patients undergoing elective surgery, there is a lack of evidence-based dosing guidelines for peri-operative medications in obesity. Objective: The objective was to systematically review the dosing and outcomes of peri-operative medications used in obese elective surgical patients. Methods: Medical subject headings and general keywords were used to systematically search multiple databases (PubMed, EMBASE, Cochrane Library and CINAHL). Studies of medications in obese surgical patients were included if they had a non-obese control or comparative dosing scalar group. The National Health and Medical Research Council GRADE tool was used to assess quality of evidence for each drug. Results: Thirty-three studies of six drug classes were identified: anaesthetics (n = 6), muscle relaxants (n = 10), neuromuscular reversal agents (n = 3), analgesics (n = 2), antibiotics (n = 5) and anticoagulants (n = 7). A variety of dose scalars and/or recommendations was observed for various medications. Lean body weight was proposed as a suitable weight scalar for induction of anaesthesia with propofol whereas total body weight for maintenance of anaesthesia with propofol and depolarizing muscle relaxants. Ideal body weight was reported as an appropriate dosing scalar for non-depolarizing muscle relaxants and neuromuscular reversal agents. Both corrected body weight 40% and ideal body weight were reported as suitable weight scalars for post-operative analgesia with morphine. The standard 2-g dose of cefazolin appeared effective in the prevention of surgical site infection. Body mass index stratified dosing of enoxaparin was effective for venous thromboembolism prevention. Conclusion: No drug recommendation achieved an “Excellent” quality of evidence. Limited data suggest that clinicians should consider each individual class of medication when selecting a dose for obese surgical patients. Routine use of fixed-dosing regimens is likely to under- or overdose obese patients thus predisposing them to adverse drug events or treatment failure leading to patient harm.

U2 - 10.1007/s40261-018-0662-0

DO - 10.1007/s40261-018-0662-0

M3 - Article

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SP - 673

EP - 693

JO - Drug Investigation

JF - Drug Investigation

SN - 1173-2563

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