Dans ce travail, nous décrivons les conséquences physiologiques et physiopathologiques de l'obésité, ainsi que les difficultés techniques et logistiques de la prise en charge clinique. Puis, nous étudions les caractéristiques de la prise en charge des patients obèses et obèses morbides aux urgences, au bloc opératoire et en réanimation, ainsi que les modifications de la fonction respiratoire liées à l'obésité morbide et à la perte de poids. Aux urgences, nous démontrons que les patients obèses (IMC et#8805; 30 kg/m²) ont un capital veineux moins accessible et sont plus difficiles à perfuser que les non obèses. En physiologie clinique, nous avons pu confirmer l'absence de variation de la CRF en position couchée et démontrer pour la première fois l'effet de la perte de poids et de la position couchée sur les variations de la CRF. Au bloc opératoire, nous montrons que la préoxygénation des obèses morbides est optimisée par la ventilation non invasive (VNI), qui permet une augmentation rapide et importante de la fraction expirée en oxygène (FEo2) que la préoxygénation classique. Nous montrons aussi que la position assise à 45° associée à la VNI n'améliore pas la préoxygénation chez l'obèse morbide comparé à la VNI seule. Enfin, nous rapportons que les patients obèses médicaux en réanimation se caractérisent par une surmortalité, qui persiste un an après la sortie de l'hôpital, alors que les patients obèses chirurgicaux bénéficient d'un effet protecteur qui persiste jusqu'à un an. Nos travaux proposent la mise en place de nouvelles techniques afin d'optimiser les conditions de prise en charge spécifiques des patients obèses aux urgences, au bloc opératoire et en réanimation. / To specifically address arising issues in managing obese patients, we have developed a physiological and a clinical approach. We first describe the physiological and pathophysiological consequences of obesity, as well as the technical and logistic difficulties in obese patient management. We then underline respiratory alterations in morbid obesity and study characteristics of obese and morbidly obese patients' care in the emergency department (ED), the operating room (OR) and the intensive care unit (ICU).In the ED, we demonstrate that obese patients (BMI ³ 30 kg/m2) are more difficult to perfuse than normal weight patients. In clinical physiology, as for alterations in respiratory function induced by obesity, we confirm the maintained functional residual capacity (FRC) in morbidly obese patients adopting a supine position and we further demonstrate for the first time, the effect of weight loss on postural changes in FRC, from the sitting to the supine position in a same individual.In the OR, we show that obese patient's pre-oxygenation can be optimized by using non-invasive ventilation (NIV), thus allowing a better and faster FeO2 increase than classical pre-oxygenation with spontaneous ventilation. We also demonstrate that combining a upright position at 45° to non invasive ventilation (NIV) does not improve pre-oxygenation in the morbidly obese patients. In the ICU, we show that medical obese patients show a higher mortality, whereas surgical obese patients benefit from a protective effect of obesity up to one year after hospital leave. In light of our data, we propose new techniques to specifically optimize obese patient management in the ED, OR and in the ICU.

Bakgrund: Studier visar att patienten, framför allt kvinnor, upplevde sig utlämnade, nervös, ångestfyllda och oroliga inför och under det korta mötet med anestesisjuksköterskan innan operation. Syftet: är att undersöka patientens upplevelse av obehag och delaktighet i mötet med anestesisjuksköterskan inför en nedsövning och om patientens kön har någon betydelse för detta. Metod: En kvantitativ tvärsnittsstudie med ett deskriptivt förhållningssätt där enkät valts som datainsamlingsmetod med totalt 44 respondenter. Resultat: Majoriteten av respondenterna upplevde ingen obehagskänsla inför en anestesi, av de få som upplevde påtaglig med obehag var samtliga kvinnor. Medan en majoritet av respondenter kände sig delaktiga i vårdarbetet inför en nedsövning, var en fjärdedel inte tillfredsställda. En fjärdedel av respondenterna önskade större delaktighet, medan övriga inte ville eller inte visste ifall de ville vara delaktiga. Männen kände sig mindre delaktiga i vårdarbetet än kvinnorna samtidigt som de inte hade en större önskan om att vara delaktiga. Kvinnor däremot kände sig mer delaktiga, än män, och hade dessutom en önskan om att vara delaktiga. Ingen signifikant skillnad fanns mellan kvinnor och mäns svar. Slutsats: Även om en majoritet av de patienter som genomgick en operation som krävde generell anestesi antingen kände sig delaktiga eller inte eftersökte mer delaktighet i sjuksköterskan vårdarbetet så var det fortfarande en fjärdedel som inte kände sig delaktiga. En tredjedel av respondenterna hade en positiv inställning till att med egna händer hålla i syrgasmasken under preoxygeneringen. När det kommer till patientens upplevelse av obehag inför en anestesi så visar denna studie att en tydlig majoritet inte upplever någon form av obehag, av dem få som upplevde påtagligt med obehag var samtliga kvinnor.   Nyckelord: Obehagskänsla, preoxygenering, delaktighet, patientcentrerad vård. / Background: Studies have shown that patients, especially women, feel themselves vulnerable, nervous, anxious and apprehensive before and during the brief meeting with the nurse anesthetist before surgery. Aim: The purpose of this study is to examine the patient's experience of uneasiness, participation in the meeting with the nurse anesthetist, before a general anesthetic, and if the patient's gender has bearing   Method: A quantitative cross-sectional study with a descriptive approach where survey was selected as data collection method, with a total of 44 participants. Results: The majority of respondents experienced no uneasiness before an anesthesia, the few who experienced significantly uneasiness were all women. The study showed that the majority of respondents already felt a sense of involvement involved in the care work before a general anesthetic, but still 25% did not ensure patients needs. 25 % of the respondents expressed a desire for greater involvement, while rest of the respondents did not want to, or did not know whether they wanted to be more involved. Male respondents felt less involved currently, but also expressed least interest for greater involvement. Female respondents, on the other hand, felt more involved than men, and at the same time also expressed a desire to be involved. No significant difference was found between women's and men's responses. Conclusion: A majority of the patients who underwent a surgery requiring general anesthesia did feel a level of involvement in the care work performed by nurses. While a majority did not want to be involved at all in the care work, 25% did not feel, but wished to be involved. One way to accommodate and increase involvement would be to offer the patients to hold the oxygen mask with their own hands during preoxygenation. Nearly a third of the respondents would have agreed to do so if they had been given the option. When it comes to patient’s uneasiness before an anesthesia does this study shows that a clear majority does not experience any kind of uneasiness, those who experienced significantly uneasiness with were all women.   Keywords: Uneasiness, preoxygenation, participation, patient-centered care.