Neuroanaesthesia in traumatic brain injury with morbid obesity: Perioperative strategy

Traumatic brain injury in morbidly obese patients (body mass index ⩾ 35 kg/m²) presents complex perioperative challenges due to compounded respiratory, cardiovascular, and metabolic dysfunctions. Reduced functional residual capacity, obstructive sleep apnoea, and increased thoracoabdominal pressures impair oxygenation and elevate intracranial pressure. Cardiovascular comorbidities such as hypertension and arrhythmias further compromise cerebral perfusion. Altered pharmacokinetics in obesity demand weight-adjusted anaesthetic dosing to avoid over- or under-sedation. This narrative review highlights the need for a structured, evidence-based approach involving preoperative optimisation, advanced airway planning, lung-protective ventilation, and invasive haemodynamic monitoring to maintain cerebral perfusion pressure. Postoperative strategies should include cautious extubation, continuous positive airway pressure or high-flow nasal oxygen, multimodal analgesia, and close neurological monitoring. Dexmedetomidine offers neuroprotective advantages with minimal respiratory depression. Multidisciplinary collaboration among anaesthesia, neurosurgery, and intensive care teams is critical to minimising perioperative risks and improving outcomes in this high-risk population.