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Morbid obesity (MO) is becoming increasingly prevalent worldwide and is associated with both altered physiology and increased co-morbidities. Together, these can render the perioperative pain management in patients with MO particularly challenging. With the higher incidence of sleep-disordered breathing in this patient population, traditional opioid-centric pain management can often result in opioid-induced ventilatory impairment and increased morbidity and/or mortality. Multimodal analgesia strategies based on a step-wise, severity-based, opioid-sparing approach can improve patient safety and outcomes. These protocols should be standardized and implemented in the perioperative care of patients with MO. Further advancements in acute pain management have sought to identify and treat nociceptive and pro-nociceptive components (hyperalgesia, etc.) with both pharmacologic and non-pharmacologic measures. In addition to standardizing postoperative pain management, irrespective of the anesthetic and analgesic regimen used, some patients with MO will need extended monitoring for potential respiratory adverse events. In this review, we briefly describe the obesity-associated changes in physiology and their impact on the pharmacology of pain, and provide an evidence-based clinical update on the perioperative pain management in MO. We discuss the role of opioid-sparing pharmacological adjuvants and implementation of standardized protocols, and highlight future areas of research in perioperative pain management in this patient population.

Background: Physicians need global health competencies to provide effective care to culturally and linguistically diverse patients. Medical schools are seeking innovative approaches to support global health learning. This pilot study evaluated e-learning versus peer-reviewed articles to improve conceptual knowledge of global health., Methods: A mixed methods study using a randomized-controlled trial (RCT) and qualitative inquiry consisting of four post-intervention focus groups. Outcomes included pre/post knowledge quiz and self-assessment measures based on validated tools from a Global Health CanMEDS Competency Model. RCT results were analyzed using SPSS-21 and focus group transcripts coded using NVivo-9 and recoded using thematic analysis., Results: One hundred and sixty-one pre-clerkship medical students from three Canadian medical schools participated in 2012-2013: 59 completed all elements of the RCT, 24 participated in the focus groups. Overall, comparing pre to post results, both groups showed a significant increase in the mean knowledge (quiz) scores and for 5/7 self-assessed competencies (p < 0.05). These quantitative data were triangulated with the focus groups findings that revealed knowledge acquisition with both approaches. There was no statistically significant difference between the two approaches. Participants highlighted their preference for e-learning to introduce new global health knowledge and as a repository of resources. They also mentioned personal interest in global health, online convenience and integration into the curriculum as incentives to complete the e-learning. Beta version e-learning barriers included content overload and technical difficulties., Conclusions: Both the e-learning and the peer reviewed PDF articles improved global health conceptual knowledge. Many students however, preferred e-learning given its interactive, multi-media approach, access to links and reference materials and its capacity to engage and re-engage over long periods of time.