Anesthesia management for patients with Prader-Willi syndrome undergoing bariatric surgery: a single-center retrospective case series study

Anesthesia management for patients with Prader-Willi syndrome undergoing bariatric surgery: a single-center retrospective case series study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anesthesia management for patients with Prader-Willi syndrome undergoing bariatric surgery: a single-center retrospective case series study Juan Tan, Haibei Liu, Huawu Yang, Dan Luo, Qiang Fu, Qiang Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4481847/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Apr, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 4 You are reading this latest preprint version Abstract Background Prader-Willi syndrome (PWS) is a rare neurodevelopmental disease caused by abnormalities on chromosome 15q11.2-q13. Due to the characteristics of this syndrome, there are many difficulties in the anesthetic management of PWS patients undergoing bariatric surgery. Methods We reported five times anesthetic management in three patients with PWS undergoing bariatric surgery under general anesthesia combined with nerve block in the Third People’s Hospital of Chengdu. Results Obesity, sleep apnea, airway ventilatory dysfunction and hypotonia were the main challenge for patients with PWS in our study. We took some special measures, mainly including reverse Trendelenburg position, gradually deepening sedation, multimode analgesia and perioperative progressive respiratory exercise. Only in case1a, respiratory obstruction occurred during mask ventilation, which improved through the oropharynx and nasopharyngeal ventilation tract. In addition, delayed awakening occurred in case1a after surgery, and the respiratory condition did not improve significantly after the use of neostigmine and atropine. Her tracheal tube was removed on the first postoperative day. When she came in the second time (case1b), we used sugammadex as the antagonistic muscle relaxants and successfully removed the tracheal tube 10 minutes after the procedure. Conclusions We recommend choosing sugammadex as the antagonistic muscle relaxant, progressive respiratory exercise and multimode analgesia in PWS patients undergoing bariatric surgery. Besides, the oropharyngeal and nasopharyngeal ventilatory tract should be prepared before the anesthesia induction. Prader-Willi syndrome anesthesia airway management bariatric surgery Figures Figure 1 Figure 2 Introduction Prader-Willi syndrome (PWS) is a rare neurodevelopmental disease resulting from the absence of imprinted genes at 15q11.2–q13 through paternal deletion of this region (65– 75% of individuals), maternal uniparental disomy 15 (20– 30%), or an imprinting defect (1–3%) 1 . The prevalence of PWS is 1 in 10,000–30,000 2 . The most characteristic clinical feature is a gradual change in eating disorders according to age 3 . And they develop obesity because of hyperphagia related to hypothalamic dysfunction and gain weight easily as a result of decreased satiety and limited physical activity 4 , 5 . However, lung volume remains stable independent of increasing fat masses in weight gaining adults 6 . The risk of pulmonary complications such as respiratory failure, hypoxia, and apnea is markedly higher in morbidly obese patients, especially those with obstructive sleep apnea (OSA) 7 . The incidence of difficult tracheal intubation has been reported to be 13–24%, whereas difficult face mask ventilation is seen in 79% of obesity patients 8 , 9 . Due to the reduction in lung compliance and functional residual capacity (FRC), work of breathing, oxygen consumption, and carbon dioxide production are increased, thus leading to a considerably impaired tolerance of hypoxia 6 . A high incidence of atelectasis even 24 h after general anesthesia predisposes to arterial desaturation in the postoperative course 10 . Patients with PWS have hypotonia, characteristic orofacial dysmorphic features (e.g. poor dentition, micrognathia, palatal abnormalities), viscous saliva and airway secretions 11 – 13 . Thus, patients with PWS combined with obesity are more challenging in perioperative airway management than other obese patients. In addition, patients with PWS also have cardiovascular complications, hypothalamic dysfunction (e.g. temperature dysregulation, endocrine dysfunctions), high pain threshold, mental retardation, temper tantrums and compulsive traits, short stature and skin picking 3 , 11 , 12 , 14 . It brings a great risk to perioperative anesthesia management. Here, we reported a case series with PWS who underwent bariatric surgery under general anesthesia combined with nerve block, in order to provide a reference for the anesthesia management of such cases. Method Patient collection This was a single-center retrospective study. The institutional review board of the Third People’s Hospital of Chengdu approved this study. We obtained informed consent from the patients and guardians of the patients. All the patients were confirmed with PWS by genetic testing. We collected three cases of PWS patients undergoing successful weight loss surgery in the Third People’s Hospital of Chengdu, and two patients underwent twice surgery, with a total of five times perioperative anesthesia management experience. The patients from these five surgeries were sequentially named case1a, case1b, case2a, case2b, case3 (case1b was due to the gastroesophageal reflux after surgery in case1a, case2b was due to weight rebound after surgery in case2a). Data collection Patient information was extracted from the case information system (Union Digital Medical Record browser, version 2012.4) and the surgical anesthesia information management system (Docare Anesthesia Clinical Information System, version 5.0). Data extraction included demographics (including gender, age, height, weight, body mass index (BMI), diagnosis), auxiliary examination, anesthesia preoperative evaluation, anesthesia management records, postoperative complications, and patients figures. Results Preoperative evaluation and therapy All the patients had obesity, OSA, hypotonia, mental development disorder and metabolic syndrome. Some patients had hypertension, diabetes, bronchitis, arhythmia and other diagnosis. The demographic characteristics and clinical features were shown in Table 1 . Preoperative evaluation found that all of them had airway ventilatory dysfunction, characteristic orofacial dysmorphic features, short and thickened neck, Mallampati class III, short stature. The preoperative characteristics of the patients were shown in Fig. 1. They were given lung function training and non-invasive ventilator-assisted ventilation before surgery. All the patients had prophylactic antithrombotic therapy with low molecular weight heparin (LMWH). Table 1 Demographic characteristics and clinical features Patient Gender Age (years) Height (m) Weight (kg) BMI (kg/m 2 ) Other diagnosis Challenge during anesthesia management Case1a female 16 141 97 48.79 Bronchitis, diabetes, arhythmia, abnormal liver function, hiatal hernia, hypoplasia of uterus, hyperuricemia, hyperlipidemia Hypotonia, airway secretions, small airway ventilatory dysfunction, poor blood glucose control Case1b female 18 141 73.9 37.7 Reflux esophagitis, gallstone with cholestasis, mild regurgitation of tricuspid valve, sinus arrhythmia, hypoplasia of uterus Hypotonia, airway ventilatory dysfunction Case2a female 22 154 137 57.8 Restrictive ventilation dysfunction, gallstone, hyperuricemia, sinus tachycardia Hypotonia, restrictive ventilatory dsyfunction, small airway ventilatory dysfunction Case2b female 23 154 139 57.85 Diabetes, heart enlargement, liver insufficiency, sleep disorders, hyperuricemia, gallstones Hypotonia, poor blood glucose control, moderate pulmonary arterial hypertension, small airway ventilatory dysfunction Case3 male 17 160 120 46.8 Bronchitis, diabetes, hypertension, left atrial enlargement, reflux esophagitis, hyperlipidemia, lung nodules and cyst Hypotonia, airway secretions, poor blood glucose control, small airway ventilatory dysfunction Figure1 PWS patients before surgery Note There was severe obesity, orofacial dysmorphic features (micrognathia, narrow bifrontal diameter, almond-shaped palpebral fissures, downturned corners of the mouth), short and thickened neck, short stature. Table 1 Demographic characteristics and clinical features Monitoring In the operating room, electrocardiogram, oxygen saturation, invasive blood pressure (in the radial artery) and bispectral index (BIS) were monitored. However, the arterial puncture catheterization of case1a failed because of the difficulty in puncture and limited vascular selection (after the surgeon disinfected and placed the sterile drape). In addition, case1a had difficulty in venipuncture and failed peripheral vein puncture, central venous catheterization (CVC) was performed for her. Anesthesia induction and artificial airway establishment They were placed in a reverse Trendelenburg position (a high head and low foot position) for improving ventilation conditions and reducing the risk of reflux aspiration. Meanwhile they were given a high flow of oxygen (6–10 L/min) for inhalation through the face mask. The oropharyngeal and nasopharyngeal ventilatory tract were prepared before the anesthesia induction. A 0.5 µg/kg loading dose of dexmedetomidine was completed within 10 minutes, administration weight was given according to the standard weight (female standard weight = height-105 cm, male standard weight = height-100 cm) and breathing was closely observed. 10mg dexamethasone, 2 mg midazolam, 1 mg/kg lidocaine, 50 mg flurbiprofen axetil, 0.1–0.3 µg/kg sufentanil were given (administration weight was according to the standard weight). With gradual increase sedation levels, only case1a developed ventilation obstruction and improved through the oropharynx and nasopharyngeal ventilation tract. No airway obstruction was in others cases. The controlled plasma infusion concentrations of propofol and remifentanil were set to 1–4 µg/ml, 2–6 ng/ml (it was adjusted according to the hemodynamics and the depth of anesthesia). Meanwhile, rocuronium 0.6 mg/kg were intravenously injected to complete anesthesia induction, the administration weight was given according to the adjusted weight, the adjusted weight = standard weight + 0.4× (real weight-standard weight). All the tracheal intubation was completed with a video laryngoscope without difficulty. Patients after the endotracheal intubation were shown in Fig. 2. The sizes of the tracheal tube were shown in Table 2 . Mechanical ventilation used lung protective ventilation strategies, including low tidal volume (6–8 ml/kg, standard weight), intermittent pulmonary recurrent ventilation, individualized positive end expiratory pressure (PEEP) and low inspired oxygen concentration (< 60%). Table 2 Intraoperative ventilation, surgical details and antagonistic muscle relaxants condition Patient Mask ventilation Tracheal intubation Procedure Agonist drug Tracheal extubation Case1a Difficult The oropharynx and nasopharyngeal airway were used 7.5 enhanced tracheal tube Laparoscopic sleeve gastrectomy and esophageal hiatal hernia repair and abdominal wall plastic surgery 1mg neostigmine 0.5mg atropine Bring the tracheal intubation to the ICU Case1b Not difficult 7.5 enhanced tracheal tube Laparoscopic gastric bypass and cholecystectomy 100mg sugammadex Ten minutes after the procedure, the tracheal tube was removed Case2a Not difficult 8.0 enhanced tracheal tube laparoscopic sleeve gastrectomy and jejunojejunostomy 2mg neostigmine 0.5mg atropine Fifteen minutes after the procedure, the tracheal tube was removed Case2b Not difficult 8.0 enhanced tracheal tube laparoscopic gastric volume reduction and double-channel anastomosis 1mg neostigmine 0.5mg atropine 0.5mg flumazenil Seventeen minutes after the procedure, the tracheal tube was removed Case3 Not difficult 7.5 enhanced tracheal tube Laparoscopic sleeve gastrectomy and jejunojejunostomy and bowel arrangement 2mg neostigmine 0.5mg atropine 0.25mg flumazenil Twelve minutes after the procedure, the tracheal tube was removed Figure 2 PWS patients during the surgery Note There were severe obesity, orofacial dysmorphic features, short and thickened neck, microcheiria and skin picking. Maintenance of anesthesia and intraoperative details Bilaterally transverse abdominal fascia plane (TAP) and rectus sheath nerve block were performed with ultrasound guidance after endotracheal intubation. Sulfentanyl 5–10 µg or esketamine 0.2 mg/kg, and rocuronium 0.3 mg/kg were added before the incision (according to the standard weight). Anesthesia was maintained by intravenous combined inhalational anesthesia with propofol, remifentanil, dexmedetomidine and sevoflurane. BIS was maintained at 40–60 by adjustment of anesthetic agents in real time. Prior to gastric resection, 0.15 mg/kg oxycodone (according to the standard weight) and 5mg tropisetron were given. The performance of the surgery was shown in Table 2 . Anesthesia recovery After the end of the surgery, the patient's position was adjusted back to reverse Trendelenburg position. After the procedure. the patient was observed for spontaneous breathing and recovery of consciousness, and muscle relaxant antagonism was given. After their consciousness and autonomous respiration were recovered completely, case1b, case2a, case2b, case3 both successfully extracted the tracheal tube. Case1a had shown a delay in awakening, her autonomous respiration recovered 150 min after entering the PACU, the breathing was shallow and fast (breathing rate was 38 breaths per minute). After intravenous antagonistic muscle relaxants administration of neostigmine and atropine, her spontaneous breathing was still not improved obviously. She was admitted to the intensive care unit (ICU) with endotracheal intubation. On the first postoperative day, her consciousness and breathing were recovered completely, and the tracheal tube was removed successfully. When she came to the surgery for the second time (case1b), we used sugammadex as the antagonistic muscle relaxants and successfully removed the tracheal tube 10 minutes The use of muscle relaxant antagonism and the removal time of the tracheal catheter are shown in Table 2 . All the patients had used a patient controlled intravenous analgesia (PCIA). All of them underwent aggressive pulmonary toilet with chest physiotherapy and other respiratory adjuncts to prevent atelectasis and pulmonary infection after returning to the ward. They had no complications after the surgery, and they were all discharged smoothly. Table 2 Intraoperative ventilation, surgical details and antagonistic muscle relaxants condition Discussion For patients with PWS combined with obesity, airway management is a major challenge for anesthesiologists. But neither obesity itself nor the BMI is predictive factor for difficult intubation in obese patients. Instead, reduced mobility of the lower jaw, male sex, OSA, snoring, and a thickened neck are predictive of a difficult airway 15 . Some studies recommended performing sleep breathing monitoring before surgery 16 , 17 . During the preoperative evaluation, we fully evaluated the airway conditions of patients, mainly including: mouth opening, Mallampati class, mobility of the lower jaw, neck circumference, OSA, hypotonia, cervical mobility, respiratory infections, airway secretions, dental condition. The reverse Trendelenburg position is recommended as the standard position for patients with obesity and can significantly improve conditions for intubation 18 and provide the longest safe apnea period 19 , 20 . During the induction, patients may have a risk of airway obstruction and difficult ventilation. The airway potency was evaluated by gradual increase sedation levels together with manual positive ventilation test. Only case1a had airway obstruction during mask ventilation and had improved ventilation after the use of the oropharyngeal and nasopharyngeal ventilatory tract. Meanwhile, volatile anesthetics with more lipophilic properties accumulate in fat tissue causing delayed emergence after anesthesia longer than 2–4 h 21 . Rapid awaking and fast recovery of protective airway reflexes are essential. If inhaled anesthetics are needed, substances with relatively low lipid solubility such as sevoflurane or desflurane should be preferred in morbidly obese patients 22 . Many studies suggested a multimodal analgesia to reduce the total amount of opioid use to prevent postoperative respiratory complications 6 , 7 , 18 . We applied TAP and rectus sheath block, PCIA to provide analgesia for reducing the opioid use. No anesthesiologists applied this combined anesthesia method in the published reports of patients with PWS. Active measures to improve the respiratory status should be taken throughout the perioperative period. All the patients underwent continuous positive airway pressure (CPAP) to improve ventilation status before the surgery in our study (Nixon et al recommended CPAP for the treatment of OSA 23 ). Adequate pre-oxygenation with 100% oxygen was essential before the anesthesia induction. Some researchers suggested that during pre-oxygenation, it is better to use CPAP of 10 cm H 2 O enabling higher PaO 2 after intubation and reducing atelectasis formation 7 . And some researchers recommended incentive spirometry or chest physiotherapy to improve pulmonary function and decrease complications after the surgery 24 , 25 . All the patients we reported had hypotonia associated with a higher risk of reflux aspiration and delayed recovery. The obese patients with a limited lung reserve, which may make the consequences of aspiration more severe 26 . Body position to utilize gravity, secure the airway rapidly and gastrointestinal decompression can reduce the surgical morbidity and mortality associated with inhalation of gastric contents 26 . By these methods, none of our patients developed reflux aspiration. Muscle relaxants should be careful in PWS patient with hypotonia. Studies have shown that the effects of nondepolarizing muscle relaxants were prolonged in these patients, particularly in infants 27 . There have been case reports of delayed recovery in these patients and decreased or no use of muscle relaxants because of this problem 28 – 31 . However, several reports demonstrated the safe use of various nondepolarizing muscle relaxants agents including pancuronium, atracurium, vecuronium, and rocuronium without evidence of prolonged effects 26 , 32 – 34 . Some cases have reported that neuromuscular blockade with good reversal is possible 35 , 36 . In our study, delayed recovery of muscle strength occurred in case1a, and the improvement was not remarkable after administration of neostigmine and atropine. Therefore, in her second surgery, we chose sugammadex as the agonist drug. At 10 minutes after the surgery, she recovered the muscle strength and the tracheal tube was removed. Neostigmine takes effect by inhibiting cholinesterase competitively and is not suitable for deep blocks due to the ceiling effect 37 . However, sugammadex can encapsulate and inactivate unbound aminosteroid muscle relaxants; thus, it has better effects in reversing muscle relaxant and lowering the risk of residual paralysis 38 . The advantage of sugammadex was more than shortening neuromuscular recovery duration regardless of the degree of the blockade 39 . Studies have shown that immediate reversal of neuromuscular blockade can be achieved by using suggamadex with 2 mg/kg་40% (according to the standard weight) 40 regardless of the depth of neuromuscular blockage 41 Besides, we recommend tracheal intubation should be removed only after assessing the patient's complete recovery of consciousness and muscle strength. Conclusion Due to the low incidence and inexperience, PWS patients undergoing weight loss surgery create anesthesia challenges. The risk of developing a difficult airway should be carefully assessed during the preoperative evaluation. The oropharyngeal and nasopharyngeal ventilatory tract should be prepared before the anesthesia induction. Besides, we recommend choosing sugammadex as a antagonistic muscle relaxant, progressive respiratory exercise, and general anesthesia combined with nerve block, PCIA to reduce opioid use. And we recommend tracheal intubation should be removed only after assessing the patient's complete recovery of consciousness and muscle strength. Declarations Ethics approval and consent to participate The institutional review board of the Third People’s Hospital of Chengdu approved this study. Consent for publication We obtained informed consent from the patients and guardians of the patients. Availability of data and materials Please contact the corresponding author if necessary. Competing interests None. Funding None. Authors' contributions Juan Tan was responsible for ethical approval, data collation, writing and revision of the article. Haibei Liu assisted with the revision of the article. Huawu Yang assisted with data collation, and obtained informed consent. Dan Luo assisted with data collation, and obtained informed consent. Qiang Fu was responsible for the revision of the article. Qiang Li assisted with the revision of the article. Acknowledgements No applicable. References Cassidy SB, Schwartz S, Miller JL, Driscoll DJ. Prader-Willi syndrome. Genet medicine: official J Am Coll Med Genet. 2012;14(1):10–26. 10.1038/gim.0b013e31822bead0 . Powis L, Oliver C. The prevalence of aggression in genetic syndromes: a review. Res Dev Disabil. 2014;35(5):1051–71. 10.1016/j.ridd.2014.01.033 . Miller JL, Driscoll LC, Goldstone DC, Gold AP, Kimonis JA. Nutritional phases in prader-willi syndrome. Am J Med Genet A. 2011;155A:1040–9. MG B. Prader-Willi syndrome: current understanding of cause and diagnosis. Am J Med Genet A. 1990;35:319–32. JD LR, a. T. Anesthesia and Prader-Willi syndrome: preliminary experience with regional anesthesia. Pediatr Anesth. 2006;16:712–22. Huschak G, Busch T, Kaisers UX. Obesity in anesthesia and intensive care. Best Pract Res Clin Endocrinol Metab. 2013;27(2):247–60. 10.1016/j.beem.2013.02.001 . Hardt K, Wappler F. Anesthesia for Morbidly Obese Patients. Deutsches Arzteblatt Int. 2023;120(46):779–85. 10.3238/arztebl.m2023.0216 . Buckley FP, Robinson NB, Simonowitz DA, Dellinger EP. Anaesthesia in the morbidly obese. A comparison of anaesthetic and analgesic regimens for upper abdominal surgery. Anaesthesia. 1983;38(9):840–51. 10.1111/j.1365-2044.1983.tb12249.x . Domínguez-Cherit G, Gonzalez R, Borunda D, Pedroza J, Gonzalez-Barranco J, Herrera MF. Anesthesia for morbidly obese patients. World J Surg. 1998;22(9):969–73. 10.1007/s002689900501 . Eichenberger A, Proietti S, Wicky S, Frascarolo P, Suter M, Spahn DR, Magnusson L. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg. 2002;95(6):1788–92. 10.1097/00000539-200212000-00060 . table of contents. Cassidy SB, Miller SS. Driscoll DJ Prader-Willi syndrome. Genet Med. 2012;14:10–26. Whittington J. H. A., Neurobehavioral phenotype in prader-willi syndrome. Am J Med Genet C Semin Med Genet 2010, 154C , 438 – 47. Bailleul-Forestier I, Fryns VV, Vinckier JP, Declerck F, Vogels D. The oro-dental phenotype in prader-willi syndrome: A survey of 15 patients. Int J Paediatr Dent. 2008;18:40–7. McAllister CJ, Holland WJ. Development of the eating behaviour in prader-willi syndrome: Advances in our understanding. Int J Obes (Lond). 2011;35:188–97. Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, Ludwig TA. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885–91. 10.1097/00000542-200611000-00007 . Miller J, Wagner M. Prader-Willi syndrome and sleep-disordered breathing. Pediatr Ann. 2013;42(10):200–4. 10.3928/00904481-20130924-10 . Nixon GM, Rodda CP, Davey MJ. Longitudinal association between growth hormone therapy and obstructive sleep apnea in a child with Prader-Willi syndrome. J Clin Endocrinol Metab. 2011;96(1):29–33. 10.1210/jc.2010-1445 . Nottelmann K, Menzen A, Röding T, Grünewald M, Kehl F. [Anesthesia in obesity surgery: Recommendations from the practice for the practice]. Die Anaesthesiologie. 2023;72(2):89–96. 10.1007/s00101-022-01240-6 . Hassan EA, Baraka AAE. The effect of reverse Trendelenburg position versus semi-recumbent position on respiratory parameters of obese critically ill patients: A randomised controlled trial. J Clin Nurs. 2021;30(7–8):995–1002. 10.1111/jocn.15645 . Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13(1):4–9. 10.1381/096089203321136511 . Cork RC, Vaughan RW, Bentley JB. General anesthesia for morbidly obese patients–an examination of postoperative outcomes. Anesthesiology. 1981;54(4):310–3. 10.1097/00000542-198104000-00010 . De Baerdemaeker LE, Jacobs S, Den Blauwen NM, Pattyn P, Herregods LL, Mortier EP, Struys MM. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Obes Surg. 2006;16(6):728–33. 10.1381/096089206777346691 . Nixon GM, Brouillette RT. Sleep and breathing in Prader-Willi syndrome. Pediatr Pulmonol. 2002;34(3):209–17. 10.1002/ppul.10152 . Sharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020;38(1):197–212. 10.1016/j.anclin.2019.10.008 . Legrand R, Tobias JD. Anesthesia and Prader-Willi syndrome: preliminary experience with regional anesthesia. Paediatr Anaesth. 2006;16(7):712–22. 10.1111/j.1460-9592.2006.01968.x . Sloan TB, Kaye CI. Rumination risk of aspiration of gastric contents in the Prader-Willi syndrome. Anesth Analg. 1991;73(4):492–5. 10.1213/00000539-199110000-00023 . Dearlove OR, Dobson A, Super M. Anaesthesia and Prader-Willi syndrome. Paediatr Anaesth. 1998;8(3):267–71. 10.1046/j.1460-9592.1998.00689.x . Meco BC, Alanoglu Z, Cengiz OS, Alkis N. Anesthesia for a 16-month-old patient with Prader-Willi syndrome. J Anesth. 2010;24(6):949–50. 10.1007/s00540-010-1005-3 . Kim JY, Lee JH, Kim EJ, Lee SK, Ban JS, Min BW. Anesthetic management in a pediatric patient with infantile phase Prader-Willi Syndrome: A case report. Korean J anesthesiology. 2009;57(2):259–63. 10.4097/kjae.2009.57.2.259 . Lee JY, Cho KR, Kim MH, Lee KM, Kim HJ. General anesthetic management of Prader-Willi syndrome patient undergoing middle cerebral artery-superficial temporal artery anastomosis. Korean J anesthesiology. 2012;63(1):85–6. 10.4097/kjae.2012.63.1.85 . Aravindan A, Singh AK, Kurup M, Gupta S. Anaesthetic management of paediatric patient with Prader-Willi syndrome for bariatric surgery. Indian J Anaesth. 2020;64(5):444–5. 10.4103/ija.IJA_22_20 . Yamashita M, Koishi K, Yamaya R, Tsubo T, Matsuki A, Oyama T. Anaesthetic considerations in the Prader-Willi syndrome: report of four cases. Can Anaesth Soc J. 1983;30(2):179–84. 10.1007/bf03009349 . Mayhew JF, Taylor B. Anaesthetic considerations in the Prader-Willi syndrome. Can Anaesth Soc J. 1983;30(5):565–6. 10.1007/bf03007103 . Lirk P, Keller C, Colvin J, Rieder J, Wulf K. Anaesthetic management of the Prader-Willi syndrome. Eur J Anaesthesiol. 2004;21(10):831–3. 10.1017/s0265021504230137 . Jain A, Bala I, Makkar JK. Anesthetic management of Prader-Willi syndrome: what if neuromuscular relaxants could not be avoided? J Anesth. 2012;26(2):304–5. 10.1007/s00540-011-1304-3 . Kim KW, Kim SH, Ahn EJ, Kim HJ, Choi HR, Bang SR. Anesthetic management with a neuromuscular relaxant and sugammadex in a patient with Prader-Willi syndrome: A case report. SAGE open Med case Rep. 2020;8:2050313x20927616. 10.1177/2050313x20927616 . Caldwell JE. Clinical limitations of acetylcholinesterase antagonists. J Crit Care. 2009;24(1):21–8. 10.1016/j.jcrc.2008.08.003 . Brueckmann B, Sasaki N, Grobara P, Li MK, Woo T, de Bie J, Maktabi M, Lee J, Kwo J, Pino R, Sabouri AS, McGovern F, Staehr-Rye AK, Eikermann M. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015;115(5):743–51. 10.1093/bja/aev104 . Liu H, Luo R, Cao S, Zheng B, Ye L, Zhang W. Superiority of sugammadex in preventing postoperative pulmonary complications. Chin Med J. 2023;136(13):1551–9. 10.1097/cm9.0000000000002381 . Van Lancker P, Dillemans B, Bogaert T, Mulier JP, De Kock M, Haspeslagh M. Ideal versus corrected body weight for dosage of sugammadex in morbidly obese patients. Anaesthesia. 2011;66(8):721–5. 10.1111/j.1365-2044.2011.06782.x . Horrow JC, Li W, Blobner M, Lombard J, Speek M, DeAngelis M, Herring WJ. Actual versus ideal body weight dosing of sugammadex in morbidly obese patients offers faster reversal of rocuronium- or vecuronium-induced deep or moderate neuromuscular block: a randomized clinical trial. BMC Anesthesiol. 2021;21(1):62. 10.1186/s12871-021-01278-w . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Apr, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 05 Jun, 2024 Submission checks completed at journal 04 Jun, 2024 Editor assigned by journal 04 Jun, 2024 First submitted to journal 26 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4481847","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":310756889,"identity":"1bd971ea-efe2-4755-8870-1a164264d97f","order_by":0,"name":"Juan Tan","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Tan","suffix":""},{"id":310756890,"identity":"d45635d7-2aad-49d3-bf8e-33431c43a8eb","order_by":1,"name":"Haibei Liu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Haibei","middleName":"","lastName":"Liu","suffix":""},{"id":310756891,"identity":"b299e35e-ae90-44d7-9145-a74dfd001c98","order_by":2,"name":"Huawu Yang","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Huawu","middleName":"","lastName":"Yang","suffix":""},{"id":310756892,"identity":"e496160e-e1f4-4459-bb97-858dbdbc73aa","order_by":3,"name":"Dan Luo","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Luo","suffix":""},{"id":310756893,"identity":"39f0edee-95c2-4185-9eef-1b39143caf33","order_by":4,"name":"Qiang Fu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIie3PvQrCMBDA8UihLidZE/DjFTJ1EnyVlkInhY4dqhSUOIi7j6G4OKYU4hJ3R0Vwc3DTQTAi4tZmFMwfjiz3OwhCNtsPVs8QEvoF3DnlBz9JqwmIN2nSLArZQUkz8qrLRN+jx4ljQEi4EvfNEGgmoyTIXISnM7+CRHE+V1vAtbHcB5smImq3LCU90meiwSXQsRvtA+UiRgblBDTJH5owCV4ccMeMFA2eAlPgITMC57hocQF04YbEVxIq/wL1cH298FEPEye/3pK0jafzcqJjeorvjar1DxmZLNpsNtu/9gS530wP1WQIIgAAAABJRU5ErkJggg==","orcid":"","institution":"The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University","correspondingAuthor":true,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Fu","suffix":""},{"id":310756894,"identity":"b8ce0f79-d3ad-495a-ad83-02b6951f8016","order_by":5,"name":"Qiang Li","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-05-27 02:38:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4481847/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4481847/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-025-03013-1","type":"published","date":"2025-04-17T15:57:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59048613,"identity":"49c2efd7-4ec4-4557-9c50-6a951af0b617","added_by":"auto","created_at":"2024-06-25 19:29:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":653261,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePWS patients before surgery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4481847/v1/cf38ed211b31683f33f8953c.jpg"},{"id":59048612,"identity":"843b8ecb-ac14-4f96-8c76-8aab95624ba3","added_by":"auto","created_at":"2024-06-25 19:29:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":592512,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePWS patients during the surgery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4481847/v1/e6b5e1c567119e51b82ac41f.jpg"},{"id":81050928,"identity":"14f42b0e-79c4-466b-8452-fa0430b3260b","added_by":"auto","created_at":"2025-04-21 16:07:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2071043,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4481847/v1/d617cf92-85f0-47a6-ae35-1f96cac46a04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anesthesia management for patients with Prader-Willi syndrome undergoing bariatric surgery: a single-center retrospective case series study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrader-Willi syndrome (PWS) is a rare neurodevelopmental disease resulting from the absence of imprinted genes at 15q11.2\u0026ndash;q13 through paternal deletion of this region (65\u0026ndash; 75% of individuals), maternal uniparental disomy 15 (20\u0026ndash; 30%), or an imprinting defect (1\u0026ndash;3%)\u003csup\u003e1\u003c/sup\u003e. The prevalence of PWS is 1 in 10,000\u0026ndash;30,000\u003csup\u003e2\u003c/sup\u003e. The most characteristic clinical feature is a gradual change in eating disorders according to age\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. And they develop obesity because of hyperphagia related to hypothalamic dysfunction and gain weight easily as a result of decreased satiety and limited physical activity\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, lung volume remains stable independent of increasing fat masses in weight gaining adults\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The risk of pulmonary complications such as respiratory failure, hypoxia, and apnea is markedly higher in morbidly obese patients, especially those with obstructive sleep apnea (OSA)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The incidence of difficult tracheal intubation has been reported to be 13\u0026ndash;24%, whereas difficult face mask ventilation is seen in 79% of obesity patients\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Due to the reduction in lung compliance and functional residual capacity (FRC), work of breathing, oxygen consumption, and carbon dioxide production are increased, thus leading to a considerably impaired tolerance of hypoxia\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. A high incidence of atelectasis even 24 h after general anesthesia predisposes to arterial desaturation in the postoperative course\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Patients with PWS have hypotonia, characteristic orofacial dysmorphic features (e.g. poor dentition, micrognathia, palatal abnormalities), viscous saliva and airway secretions\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Thus, patients with PWS combined with obesity are more challenging in perioperative airway management than other obese patients.\u003c/p\u003e \u003cp\u003eIn addition, patients with PWS also have cardiovascular complications, hypothalamic dysfunction (e.g. temperature dysregulation, endocrine dysfunctions), high pain threshold, mental retardation, temper tantrums and compulsive traits, short stature and skin picking\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. It brings a great risk to perioperative anesthesia management. Here, we reported a case series with PWS who underwent bariatric surgery under general anesthesia combined with nerve block, in order to provide a reference for the anesthesia management of such cases.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient collection\u003c/h2\u003e \u003cp\u003eThis was a single-center retrospective study. The institutional review board of the Third People\u0026rsquo;s Hospital of Chengdu approved this study. We obtained informed consent from the patients and guardians of the patients. All the patients were confirmed with PWS by genetic testing. We collected three cases of PWS patients undergoing successful weight loss surgery in the Third People\u0026rsquo;s Hospital of Chengdu, and two patients underwent twice surgery, with a total of five times perioperative anesthesia management experience. The patients from these five surgeries were sequentially named case1a, case1b, case2a, case2b, case3 (case1b was due to the gastroesophageal reflux after surgery in case1a, case2b was due to weight rebound after surgery in case2a).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003ePatient information was extracted from the case information system (Union Digital Medical Record browser, version 2012.4) and the surgical anesthesia information management system (Docare Anesthesia Clinical Information System, version 5.0). Data extraction included demographics (including gender, age, height, weight, body mass index (BMI), diagnosis), auxiliary examination, anesthesia preoperative evaluation, anesthesia management records, postoperative complications, and patients figures.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative evaluation and therapy\u003c/h2\u003e \u003cp\u003eAll the patients had obesity, OSA, hypotonia, mental development disorder and metabolic syndrome. Some patients had hypertension, diabetes, bronchitis, arhythmia and other diagnosis. The demographic characteristics and clinical features were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Preoperative evaluation found that all of them had airway ventilatory dysfunction, characteristic orofacial dysmorphic features, short and thickened neck, Mallampati class III, short stature. The preoperative characteristics of the patients were shown in Fig.\u0026nbsp;1. They were given lung function training and non-invasive ventilator-assisted ventilation before surgery. All the patients had prophylactic antithrombotic therapy with low molecular weight heparin (LMWH).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics and clinical features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeight\u003c/p\u003e \u003cp\u003e(m)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeight\u003c/p\u003e \u003cp\u003e(kg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOther diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChallenge during anesthesia management\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBronchitis, diabetes, arhythmia, abnormal liver function, hiatal hernia, hypoplasia of uterus, hyperuricemia, hyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypotonia, airway secretions, small airway ventilatory dysfunction, poor blood glucose control\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eReflux esophagitis, gallstone with cholestasis, mild regurgitation of tricuspid valve, sinus arrhythmia, hypoplasia of uterus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypotonia, airway ventilatory dysfunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e57.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRestrictive ventilation dysfunction, gallstone, hyperuricemia, sinus tachycardia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypotonia, restrictive ventilatory dsyfunction, small airway ventilatory dysfunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e57.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDiabetes, heart enlargement, liver insufficiency, sleep disorders, hyperuricemia, gallstones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypotonia, poor blood glucose control, moderate pulmonary arterial hypertension, small airway ventilatory dysfunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBronchitis, diabetes, hypertension, left atrial enlargement, reflux esophagitis, hyperlipidemia, lung nodules and cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypotonia, airway secretions, poor blood glucose control, small airway ventilatory dysfunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFigure1 PWS patients before surgery\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eThere was severe obesity, orofacial dysmorphic features (micrognathia, narrow bifrontal diameter, almond-shaped palpebral fissures, downturned corners of the mouth), short and thickened neck, short stature.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003eDemographic characteristics and clinical features\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMonitoring\u003c/h2\u003e \u003cp\u003eIn the operating room, electrocardiogram, oxygen saturation, invasive blood pressure (in the radial artery) and bispectral index (BIS) were monitored. However, the arterial puncture catheterization of case1a failed because of the difficulty in puncture and limited vascular selection (after the surgeon disinfected and placed the sterile drape). In addition, case1a had difficulty in venipuncture and failed peripheral vein puncture, central venous catheterization (CVC) was performed for her.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAnesthesia induction and artificial airway establishment\u003c/h2\u003e \u003cp\u003eThey were placed in a reverse Trendelenburg position (a high head and low foot position) for improving ventilation conditions and reducing the risk of reflux aspiration. Meanwhile they were given a high flow of oxygen (6\u0026ndash;10 L/min) for inhalation through the face mask. The oropharyngeal and nasopharyngeal ventilatory tract were prepared before the anesthesia induction. A 0.5 \u0026micro;g/kg loading dose of dexmedetomidine was completed within 10 minutes, administration weight was given according to the standard weight (female standard weight\u0026thinsp;=\u0026thinsp;height-105 cm, male standard weight\u0026thinsp;=\u0026thinsp;height-100 cm) and breathing was closely observed. 10mg dexamethasone, 2 mg midazolam, 1 mg/kg lidocaine, 50 mg flurbiprofen axetil, 0.1\u0026ndash;0.3 \u0026micro;g/kg sufentanil were given (administration weight was according to the standard weight).\u003c/p\u003e \u003cp\u003eWith gradual increase sedation levels, only case1a developed ventilation obstruction and improved through the oropharynx and nasopharyngeal ventilation tract. No airway obstruction was in others cases. The controlled plasma infusion concentrations of propofol and remifentanil were set to 1\u0026ndash;4 \u0026micro;g/ml, 2\u0026ndash;6 ng/ml (it was adjusted according to the hemodynamics and the depth of anesthesia). Meanwhile, rocuronium 0.6 mg/kg were intravenously injected to complete anesthesia induction, the administration weight was given according to the adjusted weight, the adjusted weight\u0026thinsp;=\u0026thinsp;standard weight\u0026thinsp;+\u0026thinsp;0.4\u0026times; (real weight-standard weight).\u003c/p\u003e \u003cp\u003eAll the tracheal intubation was completed with a video laryngoscope without difficulty. Patients after the endotracheal intubation were shown in Fig.\u0026nbsp;2. The sizes of the tracheal tube were shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Mechanical ventilation used lung protective ventilation strategies, including low tidal volume (6\u0026ndash;8 ml/kg, standard weight), intermittent pulmonary recurrent ventilation, individualized positive end expiratory pressure (PEEP) and low inspired oxygen concentration (\u0026lt;\u0026thinsp;60%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative ventilation, surgical details and antagonistic muscle relaxants condition\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMask ventilation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTracheal intubation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAgonist drug\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTracheal extubation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifficult\u003c/p\u003e \u003cp\u003eThe oropharynx and nasopharyngeal airway were used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5 enhanced tracheal tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparoscopic sleeve gastrectomy and esophageal hiatal hernia repair and abdominal wall plastic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1mg neostigmine\u003c/p\u003e \u003cp\u003e0.5mg atropine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBring the tracheal intubation to the ICU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot difficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5 enhanced tracheal tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparoscopic gastric bypass and cholecystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100mg sugammadex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTen minutes after the procedure, the tracheal tube was removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot difficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0 enhanced tracheal tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003elaparoscopic sleeve gastrectomy and jejunojejunostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2mg neostigmine\u003c/p\u003e \u003cp\u003e0.5mg atropine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFifteen minutes after the procedure, the tracheal tube was removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot difficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0 enhanced tracheal tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003elaparoscopic gastric volume reduction and double-channel anastomosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1mg neostigmine\u003c/p\u003e \u003cp\u003e0.5mg atropine\u003c/p\u003e \u003cp\u003e0.5mg flumazenil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSeventeen minutes after the procedure, the tracheal tube was removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot difficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5 enhanced tracheal tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparoscopic sleeve gastrectomy and jejunojejunostomy and bowel arrangement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2mg neostigmine\u003c/p\u003e \u003cp\u003e0.5mg atropine\u003c/p\u003e \u003cp\u003e0.25mg flumazenil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTwelve minutes after the procedure, the tracheal tube was removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2 PWS patients during the surgery\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eThere were severe obesity, orofacial dysmorphic features, short and thickened neck, microcheiria and skin picking.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMaintenance of anesthesia and intraoperative details\u003c/h2\u003e \u003cp\u003eBilaterally transverse abdominal fascia plane (TAP) and rectus sheath nerve block were performed with ultrasound guidance after endotracheal intubation. Sulfentanyl 5\u0026ndash;10 \u0026micro;g or esketamine 0.2 mg/kg, and rocuronium 0.3 mg/kg were added before the incision (according to the standard weight). Anesthesia was maintained by intravenous combined inhalational anesthesia with propofol, remifentanil, dexmedetomidine and sevoflurane. BIS was maintained at 40\u0026ndash;60 by adjustment of anesthetic agents in real time. Prior to gastric resection, 0.15 mg/kg oxycodone (according to the standard weight) and 5mg tropisetron were given. The performance of the surgery was shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAnesthesia recovery\u003c/h2\u003e \u003cp\u003eAfter the end of the surgery, the patient's position was adjusted back to reverse Trendelenburg position. After the procedure. the patient was observed for spontaneous breathing and recovery of consciousness, and muscle relaxant antagonism was given. After their consciousness and autonomous respiration were recovered completely, case1b, case2a, case2b, case3 both successfully extracted the tracheal tube. Case1a had shown a delay in awakening, her autonomous respiration recovered 150 min after entering the PACU, the breathing was shallow and fast (breathing rate was 38 breaths per minute). After intravenous antagonistic muscle relaxants administration of neostigmine and atropine, her spontaneous breathing was still not improved obviously. She was admitted to the intensive care unit (ICU) with endotracheal intubation. On the first postoperative day, her consciousness and breathing were recovered completely, and the tracheal tube was removed successfully. When she came to the surgery for the second time (case1b), we used sugammadex as the antagonistic muscle relaxants and successfully removed the tracheal tube 10 minutes The use of muscle relaxant antagonism and the removal time of the tracheal catheter are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All the patients had used a patient controlled intravenous analgesia (PCIA). All of them underwent aggressive pulmonary toilet with chest physiotherapy and other respiratory adjuncts to prevent atelectasis and pulmonary infection after returning to the ward. They had no complications after the surgery, and they were all discharged smoothly.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003eIntraoperative ventilation, surgical details and antagonistic muscle relaxants condition\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor patients with PWS combined with obesity, airway management is a major challenge for anesthesiologists. But neither obesity itself nor the BMI is predictive factor for difficult intubation in obese patients. Instead, reduced mobility of the lower jaw, male sex, OSA, snoring, and a thickened neck are predictive of a difficult airway\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Some studies recommended performing sleep breathing monitoring before surgery\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. During the preoperative evaluation, we fully evaluated the airway conditions of patients, mainly including: mouth opening, Mallampati class, mobility of the lower jaw, neck circumference, OSA, hypotonia, cervical mobility, respiratory infections, airway secretions, dental condition. The reverse Trendelenburg position is recommended as the standard position for patients with obesity and can significantly improve conditions for intubation\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e and provide the longest safe apnea period\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. During the induction, patients may have a risk of airway obstruction and difficult ventilation. The airway potency was evaluated by gradual increase sedation levels together with manual positive ventilation test. Only case1a had airway obstruction during mask ventilation and had improved ventilation after the use of the oropharyngeal and nasopharyngeal ventilatory tract.\u003c/p\u003e \u003cp\u003eMeanwhile, volatile anesthetics with more lipophilic properties accumulate in fat tissue causing delayed emergence after anesthesia longer than 2\u0026ndash;4 h\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Rapid awaking and fast recovery of protective airway reflexes are essential. If inhaled anesthetics are needed, substances with relatively low lipid solubility such as sevoflurane or desflurane should be preferred in morbidly obese patients\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Many studies suggested a multimodal analgesia to reduce the total amount of opioid use to prevent postoperative respiratory complications\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. We applied TAP and rectus sheath block, PCIA to provide analgesia for reducing the opioid use. No anesthesiologists applied this combined anesthesia method in the published reports of patients with PWS.\u003c/p\u003e \u003cp\u003eActive measures to improve the respiratory status should be taken throughout the perioperative period. All the patients underwent continuous positive airway pressure (CPAP) to improve ventilation status before the surgery in our study (Nixon et al recommended CPAP for the treatment of OSA\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e). Adequate pre-oxygenation with 100% oxygen was essential before the anesthesia induction. Some researchers suggested that during pre-oxygenation, it is better to use CPAP of 10 cm H\u003csub\u003e2\u003c/sub\u003eO enabling higher PaO\u003csub\u003e2\u003c/sub\u003e after intubation and reducing atelectasis formation\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. And some researchers recommended incentive spirometry or chest physiotherapy to improve pulmonary function and decrease complications after the surgery\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAll the patients we reported had hypotonia associated with a higher risk of reflux aspiration and delayed recovery. The obese patients with a limited lung reserve, which may make the consequences of aspiration more severe\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Body position to utilize gravity, secure the airway rapidly and gastrointestinal decompression can reduce the surgical morbidity and mortality associated with inhalation of gastric contents\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. By these methods, none of our patients developed reflux aspiration.\u003c/p\u003e \u003cp\u003eMuscle relaxants should be careful in PWS patient with hypotonia. Studies have shown that the effects of nondepolarizing muscle relaxants were prolonged in these patients, particularly in infants\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. There have been case reports of delayed recovery in these patients and decreased or no use of muscle relaxants because of this problem\u003csup\u003e\u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. However, several reports demonstrated the safe use of various nondepolarizing muscle relaxants agents including pancuronium, atracurium, vecuronium, and rocuronium without evidence of prolonged effects\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Some cases have reported that neuromuscular blockade with good reversal is possible\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, delayed recovery of muscle strength occurred in case1a, and the improvement was not remarkable after administration of neostigmine and atropine. Therefore, in her second surgery, we chose sugammadex as the agonist drug. At 10 minutes after the surgery, she recovered the muscle strength and the tracheal tube was removed. Neostigmine takes effect by inhibiting cholinesterase competitively and is not suitable for deep blocks due to the ceiling effect\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. However, sugammadex can encapsulate and inactivate unbound aminosteroid muscle relaxants; thus, it has better effects in reversing muscle relaxant and lowering the risk of residual paralysis\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. The advantage of sugammadex was more than shortening neuromuscular recovery duration regardless of the degree of the blockade\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Studies have shown that immediate reversal of neuromuscular blockade can be achieved by using suggamadex with 2 mg/kg་40% (according to the standard weight)\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e regardless of the depth of neuromuscular blockage\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e Besides, we recommend tracheal intubation should be removed only after assessing the patient's complete recovery of consciousness and muscle strength.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDue to the low incidence and inexperience, PWS patients undergoing weight loss surgery create anesthesia challenges. The risk of developing a difficult airway should be carefully assessed during the preoperative evaluation. The oropharyngeal and nasopharyngeal ventilatory tract should be prepared before the anesthesia induction. Besides, we recommend choosing sugammadex as a antagonistic muscle relaxant, progressive respiratory exercise, and general anesthesia combined with nerve block, PCIA to reduce opioid use. And we recommend tracheal intubation should be removed only after assessing the patient's complete recovery of consciousness and muscle strength.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe institutional review board of the Third People\u0026rsquo;s Hospital of Chengdu approved this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained informed consent from the patients and guardians of the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlease contact the corresponding author if necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJuan Tan was responsible for ethical approval, data collation, writing and revision of the article. Haibei Liu assisted with the revision of the article. Huawu Yang assisted with data collation, and obtained informed consent. Dan Luo assisted with data collation, and obtained informed consent. Qiang Fu was responsible for the revision of the article. Qiang Li assisted with the revision of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCassidy SB, Schwartz S, Miller JL, Driscoll DJ. Prader-Willi syndrome. Genet medicine: official J Am Coll Med Genet. 2012;14(1):10\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/gim.0b013e31822bead0\u003c/span\u003e\u003cspan address=\"10.1038/gim.0b013e31822bead0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowis L, Oliver C. The prevalence of aggression in genetic syndromes: a review. Res Dev Disabil. 2014;35(5):1051\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ridd.2014.01.033\u003c/span\u003e\u003cspan address=\"10.1016/j.ridd.2014.01.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller JL, Driscoll LC, Goldstone DC, Gold AP, Kimonis JA. Nutritional phases in prader-willi syndrome. Am J Med Genet A. 2011;155A:1040\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMG B. Prader-Willi syndrome: current understanding of cause and diagnosis. Am J Med Genet A. 1990;35:319\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJD LR, a. T. Anesthesia and Prader-Willi syndrome: preliminary experience with regional anesthesia. Pediatr Anesth. 2006;16:712\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuschak G, Busch T, Kaisers UX. Obesity in anesthesia and intensive care. Best Pract Res Clin Endocrinol Metab. 2013;27(2):247\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.beem.2013.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.beem.2013.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHardt K, Wappler F. Anesthesia for Morbidly Obese Patients. Deutsches Arzteblatt Int. 2023;120(46):779\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3238/arztebl.m2023.0216\u003c/span\u003e\u003cspan address=\"10.3238/arztebl.m2023.0216\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuckley FP, Robinson NB, Simonowitz DA, Dellinger EP. Anaesthesia in the morbidly obese. A comparison of anaesthetic and analgesic regimens for upper abdominal surgery. Anaesthesia. 1983;38(9):840\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1365-2044.1983.tb12249.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2044.1983.tb12249.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDom\u0026iacute;nguez-Cherit G, Gonzalez R, Borunda D, Pedroza J, Gonzalez-Barranco J, Herrera MF. Anesthesia for morbidly obese patients. World J Surg. 1998;22(9):969\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s002689900501\u003c/span\u003e\u003cspan address=\"10.1007/s002689900501\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEichenberger A, Proietti S, Wicky S, Frascarolo P, Suter M, Spahn DR, Magnusson L. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg. 2002;95(6):1788\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000539-200212000-00060\u003c/span\u003e\u003cspan address=\"10.1097/00000539-200212000-00060\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. table of contents.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassidy SB, Miller SS. Driscoll DJ Prader-Willi syndrome. Genet Med. 2012;14:10\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhittington J. H. A., Neurobehavioral phenotype in prader-willi syndrome. \u003cem\u003eAm J Med Genet C Semin Med Genet\u003c/em\u003e 2010, \u003cem\u003e154C\u003c/em\u003e, 438\u0026thinsp;\u0026ndash;\u0026thinsp;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailleul-Forestier I, Fryns VV, Vinckier JP, Declerck F, Vogels D. The oro-dental phenotype in prader-willi syndrome: A survey of 15 patients. Int J Paediatr Dent. 2008;18:40\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAllister CJ, Holland WJ. Development of the eating behaviour in prader-willi syndrome: Advances in our understanding. Int J Obes (Lond). 2011;35:188\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, Ludwig TA. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000542-200611000-00007\u003c/span\u003e\u003cspan address=\"10.1097/00000542-200611000-00007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller J, Wagner M. Prader-Willi syndrome and sleep-disordered breathing. Pediatr Ann. 2013;42(10):200\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3928/00904481-20130924-10\u003c/span\u003e\u003cspan address=\"10.3928/00904481-20130924-10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNixon GM, Rodda CP, Davey MJ. Longitudinal association between growth hormone therapy and obstructive sleep apnea in a child with Prader-Willi syndrome. J Clin Endocrinol Metab. 2011;96(1):29\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1210/jc.2010-1445\u003c/span\u003e\u003cspan address=\"10.1210/jc.2010-1445\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNottelmann K, Menzen A, R\u0026ouml;ding T, Gr\u0026uuml;newald M, Kehl F. [Anesthesia in obesity surgery: Recommendations from the practice for the practice]. Die Anaesthesiologie. 2023;72(2):89\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00101-022-01240-6\u003c/span\u003e\u003cspan address=\"10.1007/s00101-022-01240-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan EA, Baraka AAE. The effect of reverse Trendelenburg position versus semi-recumbent position on respiratory parameters of obese critically ill patients: A randomised controlled trial. J Clin Nurs. 2021;30(7\u0026ndash;8):995\u0026ndash;1002. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jocn.15645\u003c/span\u003e\u003cspan address=\"10.1111/jocn.15645\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13(1):4\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1381/096089203321136511\u003c/span\u003e\u003cspan address=\"10.1381/096089203321136511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCork RC, Vaughan RW, Bentley JB. General anesthesia for morbidly obese patients\u0026ndash;an examination of postoperative outcomes. Anesthesiology. 1981;54(4):310\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000542-198104000-00010\u003c/span\u003e\u003cspan address=\"10.1097/00000542-198104000-00010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Baerdemaeker LE, Jacobs S, Den Blauwen NM, Pattyn P, Herregods LL, Mortier EP, Struys MM. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Obes Surg. 2006;16(6):728\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1381/096089206777346691\u003c/span\u003e\u003cspan address=\"10.1381/096089206777346691\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNixon GM, Brouillette RT. Sleep and breathing in Prader-Willi syndrome. Pediatr Pulmonol. 2002;34(3):209\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ppul.10152\u003c/span\u003e\u003cspan address=\"10.1002/ppul.10152\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020;38(1):197\u0026ndash;212. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.anclin.2019.10.008\u003c/span\u003e\u003cspan address=\"10.1016/j.anclin.2019.10.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLegrand R, Tobias JD. Anesthesia and Prader-Willi syndrome: preliminary experience with regional anesthesia. Paediatr Anaesth. 2006;16(7):712\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1460-9592.2006.01968.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1460-9592.2006.01968.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSloan TB, Kaye CI. Rumination risk of aspiration of gastric contents in the Prader-Willi syndrome. Anesth Analg. 1991;73(4):492\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1213/00000539-199110000-00023\u003c/span\u003e\u003cspan address=\"10.1213/00000539-199110000-00023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDearlove OR, Dobson A, Super M. Anaesthesia and Prader-Willi syndrome. Paediatr Anaesth. 1998;8(3):267\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1046/j.1460-9592.1998.00689.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1460-9592.1998.00689.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeco BC, Alanoglu Z, Cengiz OS, Alkis N. Anesthesia for a 16-month-old patient with Prader-Willi syndrome. J Anesth. 2010;24(6):949\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00540-010-1005-3\u003c/span\u003e\u003cspan address=\"10.1007/s00540-010-1005-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JY, Lee JH, Kim EJ, Lee SK, Ban JS, Min BW. Anesthetic management in a pediatric patient with infantile phase Prader-Willi Syndrome: A case report. Korean J anesthesiology. 2009;57(2):259\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4097/kjae.2009.57.2.259\u003c/span\u003e\u003cspan address=\"10.4097/kjae.2009.57.2.259\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee JY, Cho KR, Kim MH, Lee KM, Kim HJ. General anesthetic management of Prader-Willi syndrome patient undergoing middle cerebral artery-superficial temporal artery anastomosis. Korean J anesthesiology. 2012;63(1):85\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4097/kjae.2012.63.1.85\u003c/span\u003e\u003cspan address=\"10.4097/kjae.2012.63.1.85\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAravindan A, Singh AK, Kurup M, Gupta S. Anaesthetic management of paediatric patient with Prader-Willi syndrome for bariatric surgery. Indian J Anaesth. 2020;64(5):444\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ija.IJA_22_20\u003c/span\u003e\u003cspan address=\"10.4103/ija.IJA_22_20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamashita M, Koishi K, Yamaya R, Tsubo T, Matsuki A, Oyama T. Anaesthetic considerations in the Prader-Willi syndrome: report of four cases. Can Anaesth Soc J. 1983;30(2):179\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/bf03009349\u003c/span\u003e\u003cspan address=\"10.1007/bf03009349\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayhew JF, Taylor B. Anaesthetic considerations in the Prader-Willi syndrome. Can Anaesth Soc J. 1983;30(5):565\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/bf03007103\u003c/span\u003e\u003cspan address=\"10.1007/bf03007103\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLirk P, Keller C, Colvin J, Rieder J, Wulf K. Anaesthetic management of the Prader-Willi syndrome. Eur J Anaesthesiol. 2004;21(10):831\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/s0265021504230137\u003c/span\u003e\u003cspan address=\"10.1017/s0265021504230137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain A, Bala I, Makkar JK. Anesthetic management of Prader-Willi syndrome: what if neuromuscular relaxants could not be avoided? J Anesth. 2012;26(2):304\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00540-011-1304-3\u003c/span\u003e\u003cspan address=\"10.1007/s00540-011-1304-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim KW, Kim SH, Ahn EJ, Kim HJ, Choi HR, Bang SR. Anesthetic management with a neuromuscular relaxant and sugammadex in a patient with Prader-Willi syndrome: A case report. SAGE open Med case Rep. 2020;8:2050313x20927616. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2050313x20927616\u003c/span\u003e\u003cspan address=\"10.1177/2050313x20927616\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaldwell JE. Clinical limitations of acetylcholinesterase antagonists. J Crit Care. 2009;24(1):21\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jcrc.2008.08.003\u003c/span\u003e\u003cspan address=\"10.1016/j.jcrc.2008.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrueckmann B, Sasaki N, Grobara P, Li MK, Woo T, de Bie J, Maktabi M, Lee J, Kwo J, Pino R, Sabouri AS, McGovern F, Staehr-Rye AK, Eikermann M. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015;115(5):743\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/bja/aev104\u003c/span\u003e\u003cspan address=\"10.1093/bja/aev104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Luo R, Cao S, Zheng B, Ye L, Zhang W. Superiority of sugammadex in preventing postoperative pulmonary complications. Chin Med J. 2023;136(13):1551\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/cm9.0000000000002381\u003c/span\u003e\u003cspan address=\"10.1097/cm9.0000000000002381\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Lancker P, Dillemans B, Bogaert T, Mulier JP, De Kock M, Haspeslagh M. Ideal versus corrected body weight for dosage of sugammadex in morbidly obese patients. Anaesthesia. 2011;66(8):721\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1365-2044.2011.06782.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2044.2011.06782.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorrow JC, Li W, Blobner M, Lombard J, Speek M, DeAngelis M, Herring WJ. Actual versus ideal body weight dosing of sugammadex in morbidly obese patients offers faster reversal of rocuronium- or vecuronium-induced deep or moderate neuromuscular block: a randomized clinical trial. BMC Anesthesiol. 2021;21(1):62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12871-021-01278-w\u003c/span\u003e\u003cspan address=\"10.1186/s12871-021-01278-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prader-Willi syndrome, anesthesia, airway management, bariatric surgery","lastPublishedDoi":"10.21203/rs.3.rs-4481847/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4481847/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrader-Willi syndrome (PWS) is a rare neurodevelopmental disease caused by abnormalities on chromosome 15q11.2-q13. Due to the characteristics of this syndrome, there are many difficulties in the anesthetic management of PWS patients undergoing bariatric surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe reported five times anesthetic management in three patients with PWS undergoing bariatric surgery under general anesthesia combined with nerve block in the Third People\u0026rsquo;s Hospital of Chengdu.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eObesity, sleep apnea, airway ventilatory dysfunction and hypotonia were the main challenge for patients with PWS in our study. We took some special measures, mainly including reverse Trendelenburg position, gradually deepening sedation, multimode analgesia and perioperative progressive respiratory exercise. Only in case1a, respiratory obstruction occurred during mask ventilation, which improved through the oropharynx and nasopharyngeal ventilation tract. In addition, delayed awakening occurred in case1a after surgery, and the respiratory condition did not improve significantly after the use of neostigmine and atropine. Her tracheal tube was removed on the first postoperative day. When she came in the second time (case1b), we used sugammadex as the antagonistic muscle relaxants and successfully removed the tracheal tube 10 minutes after the procedure.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe recommend choosing sugammadex as the antagonistic muscle relaxant, progressive respiratory exercise and multimode analgesia in PWS patients undergoing bariatric surgery. Besides, the oropharyngeal and nasopharyngeal ventilatory tract should be prepared before the anesthesia induction.\u003c/p\u003e","manuscriptTitle":"Anesthesia management for patients with Prader-Willi syndrome undergoing bariatric surgery: a single-center retrospective case series study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 19:29:46","doi":"10.21203/rs.3.rs-4481847/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-05T06:58:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-04T13:12:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-04T13:12:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2024-05-27T02:36:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ebc713d-5771-4733-a287-5be653871768","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T16:02:12+00:00","versionOfRecord":{"articleIdentity":"rs-4481847","link":"https://doi.org/10.1186/s12871-025-03013-1","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-04-17 15:57:57","publishedOnDateReadable":"April 17th, 2025"},"versionCreatedAt":"2024-06-25 19:29:46","video":"","vorDoi":"10.1186/s12871-025-03013-1","vorDoiUrl":"https://doi.org/10.1186/s12871-025-03013-1","workflowStages":[]},"version":"v1","identity":"rs-4481847","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4481847","identity":"rs-4481847","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}