Pulse 2 Anesthesia for the Bariatric Patient: Optimizing Safety and Managing Complications oximetry is used for the monitoring of oxygenation during the perioperative period and should be maintained as long as patients remain at increased risk for airway compromise [24]. Capnography is used to monitor ventilation intraoperatively. End-tidal carbon dioxide (ETCO2) may not accurately reflect arterial carbon dioxide tension (PaCO2) due to ventilation–perfusion mismatch in severely obese patients. Transcutaneous CO2 (TcCO2) monitoring may provide an alternative to end-tidal carbon dioxide monitoring, and has been shown to be more accurate than ETCO2 at estimating PaCO2 [25, 26].

Patients with severe and chronic psychiatric disorders, such as adjustment disorders, personality disorders, or major depression, may have more difficulties accepting the behavioral changes imposed by surgery and thus be less likely to achieve successful weight loss [14, 15]. Ultimately, psychological distress secondary to obesity is highly likely to decrease with weight loss, which may contribute to better long-term weight maintenance and a better quality of life. Compared to the general population, bariatric patients suffer from an increased risk of suicide and lifetime substance abuse.

Bilateral TAP block in the nonobese patient has shown efficacy with midline incisions [47]. It can be used as a rescue option in situations of failed/difficult epidural analgesia in open bariatric surgery patients. Ultrasound guidance may reduce the challenge of performing TAP block in morbidly obese patients. Infusion of local anesthetic at the surgical wound site is another convenient analgesia option for bariatric surgery. Both continuous flow devices and patient controlled pumps can be used. A bupivacaine pump has been found to reduce the use of opioids in morbidly obese undergoing laparoscopic bariatric surgery although its use is somewhat controversial [48].