Dose by the right scalar, position before you induce, and assume the sats fall twice as fast.
Top concerns
1.Rapid desaturation: FRC falls dramatically supine — full preoxygenation in the ramped position (consider CPAP/HFNO adjuncts)
2.Dosing scalars matter: propofol induction by lean body weight, maintenance infusion by total body weight; succinylcholine by TBW; nondepolarizing NMBDs by ideal/lean weight; opioids by lean weight
3.Mask ventilation is more often the problem than laryngoscopy — plan a two-hand/two-person technique and an oral airway from the start
4.OSA until proven otherwise — screen (STOP-Bang) and extend postop monitoring accordingly
5.VTE risk: mechanical prophylaxis on the table, early mobilization
6.Comorbidity cluster: HTN, T2DM, NAFLD, pulmonary hypertension in the severest phenotypes
Drug do's and don'ts
AVOIDPropofol induction dosed by TBW— Overdose — induce by lean body weight, then titrate.
CAUTIONLong-acting opioids / sedative stacking— OSA physiology; prefer multimodal, short-acting, regional where possible.
PREFERRamped positioning + full preO₂— Ear-to-sternal-notch alignment buys the minutes the FRC took away.
Airway & positioning
Ramp until external auditory meatus aligns with sternal notch — build it before induction