Background:Obesity is one reason which will make central venous catheterization a difficult procedure. Ultrasound will help in locating the veins but in some patients because of short neck, internal jugular approach will be technically difficult. Supraclavicular approach to subclavian cannulation has been described as being less dependent on anatomical land marks and associated with comparatively less complications even in inexperienced hands. Literature does not show the effectiveness of this method in morbidly obese patients. Our aim of this study was to investigate the rates of success and complications of supraclavicular subclavian central venous catheterization in the morbidly obese. Methods:From amongst the morbidly obese patients who presented for FOBI gastric pouch bypass surgery, supraclavicular approach to subclavian venous cannulation was attempted by an anaesthetic registrar who was relatively new to this technique. Closed questionaire was used to gather data such as age, gender, weight, height, BMI, attempts with seeker needle and proper needle. Immediate and late complications were noted till catheter removal. Results:Catheterization was attempted in 48 patients with mean weight 131.29+/-29.89kg and mean BMI of 47.60+/-9.80. Overall success rate was 97.9% (47 out of 48 patients) with average attempts 1.44 (68 in 47 successful cannulations) of seeker needle and with average attempts 1.40 (66 in 47 successful cannulations) of proper needle. There was 01 pneumothorax, 01 catheter malposition and 01 catheter related infection. Conclusion:Supraclavicular approach is a reliable way of obtaining central venous access with less complications in obese, even in less experienced hand.

Background: Not like in general population, in obese siting the epidural catheter is a time consuming process and needs high level of nursing care during the postoperative period. In our institution we have done more than 1000 gastric bypasses over the last decade, most of them with postoperative epidural analgesia. Because of draw backs with epidural technique, recently we changed our practice to continuous infiltration/PCA technique. This is an attempt to see whether new technique is offering the same quality of analgesia to our gastric bypass patients during their postoperative stay. Methods: All the patients who had either epidural or PCA/continuous infiltration as their primary mode of analgesia, following gastric bypass surgery during the period of 1st June 2008 and 28th February 2009 were taken in to consideration. Pain was rated by the patient using VAS score at 0,2,6,12,24,36,48,72,96 hours and overall patient satisfaction at end of 96 hours. Side effects were also noted. Results: Out of 98 patients, only 87 patients (epidural 62, continuous infiltration / PCA 25) were considered in this study. Rest had either PCA alone (8 patients) or combination of epidural / PCA (intentionally-1,convertion of epidural to PCA-2). Epidural group consisted of 21 (33.9%) males, 41 (66.1) females, age 48.2+/-10.4 (23-69 years), BMI 48.9+/-9.66 (34-86) and PCA/infiltration group 3 (12%) males, 22 (88%) females, age 47.36 + /-12.08 (19-71) BMI 46.6 + /-7. 65 (36-65). Continuous infiltration / PCA provided same degree of pain relief as epidural infusion. Except for nausea and vomiting (60%), other side effects were less with continuous infiltration/PCA (pruritus, urinary retention, wound infection). 11.3% of epidurals group developed hypotension and 36% of infiltration / PCA group mentioned oozing as a side effect. In epidural group 13% rated it as excellent, 37% as very good, 50% as good while in infiltration/PCA group 36% related as excellent ,48% as very good and 16% as good. Conclusion: Continuous infiltration/PCA technique provides equally effective postoperative analgesia after gastric bypass surgery, compared to epidural infusion, with comparatively less side effects and more patient satisfaction.