Awake endotracheal intubation and prone patient self-positioning: Anesthetic and positioning considerations during percutaneous nephrolithotomy in obese patients

Background and Purpose: Obesity is associated with adverse outcomes with certain urologic procedures and may make patient positioning more difficult. We describe our technique of awake intubation and prone patient self-positioning before percutaneous nephrolithotomy (PCNL), and review the literature regarding prone positioning in obese patients and the impact of obesity on PCNL. Methods: Patient preparation begins with detailed preoperative counseling regarding the procedure. Premedication with a sedative and antisialagogue is followed by airway topicalization to suppress gag reflex and pain. Fiberoptic bronchoscope intubation is then carried out. The patient then positions himself/herself comfortably before induction of general anesthesia. Results: We have successfully performed awake intubation and patient prone self-positioning followed by PCNL, most recently in a 58-year-old (body mass index 51.3kg/m ²) man with a history of gastric bypass, diabetes mellitus, and hypertension, without added morbidity. Adverse effect on patient cardiopulmonary dynamics can be minimized in the prone position. Conclusions: The technique of awake intubation with prone patient self-positioning can be helpful for positioning morbidly obese patients before PCNL and has been safe and effective in properly selected patients. Efficacy of PCNL should not be impacted by obesity or prone positioning and morbidity minimized provided that surgical and anesthesia teams understand and safeguard against potential complications.