Anesthesia for a 228-kg patient (body mass index, 90.6) undergoing laparoscopic sleeve gastrectomy

We undertook anesthesia of a 40-year-old woman with body weight of 228 kg and body mass index (BMI) of 90.6 kg/m(2) who was undergoing laparoscopic sleeve gastrectomy. This case may be the largest known patient undergoing general anesthesia in our country. Anesthesia was induced in a 30° head-up position with midazolam, fentanyl, droperidol, and inhalation of sevoflurane and nitrous oxide without muscle relaxants, and maintained with propofol, remifentanil, and pancuronium under pressure-controlled ventilation. The Airway Scope could not be inserted into her mouth, but her trachea was successfully intubated with a Macintosh laryngoscope. Dosages of anesthetics and fluid infusion rate were calculated first per ideal body weight. Then, infusion of propofol and remifentanil and administration of muscle relaxant were controlled by bispectral index, hemodynamics, and train-of-four response, respectively. Postoperative 12-h pressure-controlled ventilation and pain management by subcutaneous infusion of fentanyl and droperidol were successful. Subcutaneous heparin 5,000 units twice per day postoperatively did not induce thromboembolism.