Laparoscopic colectomy in a morbidly obese patient with sleep apnea and diabetes on a GLP-1 agonist
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The stem
A 58-year-old woman, 142 kg, 163 cm (BMI 53), is scheduled for laparoscopic sigmoid colectomy for a biopsy-proven adenocarcinoma. The surgeon expects about four hours in steep Trendelenburg.
She has obstructive sleep apnea diagnosed two years ago (apnea-hypopnea index 38) and uses her CPAP "most nights." She has type 2 diabetes, hypertension and knee osteoarthritis. She climbs one flight of stairs slowly and denies chest pain. She completed a clear-liquid bowel preparation yesterday. This week she has felt bloated and full after small meals.
Medications: semaglutide 1 mg subcutaneously weekly (same dose for eight months, last injection four days ago), insulin glargine 40 units nightly (she took 32 units last night), metformin 1000 mg twice daily, empagliflozin 25 mg daily (last dose four days ago), lisinopril 20 mg, amlodipine 10 mg, and oxycodone 5 mg occasionally for knee pain.
Allergies: none known.
Airway: Mallampati III, neck circumference 46 cm, thyromental distance 7 cm, good mouth opening, full neck extension.
- BP 152/90 (large-adult cuff), HR 88, RR 18, SpO2 93% on room air, temperature 36.7 °C
- Hemoglobin 12.8 g/dL, platelets 268,000/µL
- Sodium 139, potassium 4.1, chloride 101, bicarbonate 30 mmol/L, creatinine 0.9 mg/dL
- Fingerstick glucose 194 mg/dL; A1c 7.8%
- ECG: sinus rhythm, rate 86, low voltage, no ischemic changes
- Transthoracic echo (six months ago): normal LV size and function, RV normal, estimated RV systolic pressure 38 mmHg
- Chest radiograph: low lung volumes, no infiltrate