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• The WHO estimates that as of 2005
• 1.6 billion people were overweight(defined as BMI 25–30 kg/m2) and
400 million obese (BMI > 30 kg/m2).
• 2.3 billion people will be overweight and 700 million will be obese.

Ingrande, 2009
Influence of obesity on regional anesthesia
• peripheral nerve blockade technically difficult.
• BMI of more than 25 kg/m2 was an independent risk factor for block
failure although the success rate was still relatively high (94.3 vs.
• The rate of block failure increased incrementally with BMI.
• paravertebral and continuous epidural, continuous supraclavicular,
and superficial cervical plexus blocks had the highest failure rates

Ingrande, 2009
• there may be difficulty in palpating bony landmarks or even
identifying the midline
• landmarks may be concealed by excess body tissue
• the sitting position can facilitate location of the midline
• the presence of fat pockets may result in false-positive loss of
resistance during needle placement.
• Longer spinal and epidural needles may be necessary
• Drug distribution may also be altered

Ingrande, 2009; Fenton, 2007; Brown, 2010

• The sitting position may improve respiratory mechanics and may aid
the anesthetist in identifying anatomic landmarks, particularly in the
obese patient. In addition, obese patients may be more comfortable
in the sitting position
• The sitting position may aid in successful identification of the epidural
space because the midline is more readily identified and the skin-to-
epidural space distance is less in the sitting position
• Some have suggested that, because there is a lower volume of CSF in
obese patients, there may have been higher concentrations of local
anesthetic in these patients
Raj, 2002
• Obese patients require less local anesthetic in their epidural and
subarachnoid spaces as much as 20% less in order to achieve the
same level of block when compared with nonobese control.
• lower spinal anesthetic dose requirement may be explained by the
fact that obese patients have smaller cerebrospinal fluid volumes
than do nonobese individuals
• lower epidural anesthetic dose requirement presumably because of
fatty infiltration and vascular engorgement from increased
intraabdominal pressure, which decreases the volume of the epidural
Ingrande, 2009 ; Stoelting’s, 2012
• Obese patients had similar pain scores (at rest), opioid requirements,
incidence of PONV, PACU length of stay, and rate of unplanned
hospital admission when compared with normal weight individuals.
• the rate of block failure and acute block complications were
statistically greater in obese patients compared with nonobese

Ingrande, 2009
Advantage of RA over GA for Obese
• reduction in the need for airway intervention
• fewer drugs with less cardiopulmonary depression
• decreased need for opioid and other sedatives
• decreased PONV
• provides postoperative analgesia

Ingrande, 2009 ; Fenton, 2007

• The skin-epidural, skin-supraspinous, and supraspinous-epidural distances
were measured and correlated with height, weight, shoe size, body mass
index (BMI), neck circumference, waist circumference, and the ratios of
weight/height, waist/neck, waist/height, and weight/neck of these
• The value of the supraspinous-epidural distance was found to be
independent of any physical measurement. A significant correlation was
found between the skin-supraspinous distance and physical measurements
that were related to obesity.
• The waist circumference/neck circumference ratio and BMI resulted in a
higher predictive value of epidural depth than the traditional weight or
weight/height ratio.

Raj, 2002