Advanced | Obesity and Anesthesia in Bariatric Surgery Flashcards
A 40 year old male, classified as Obese class II is scheduled for Laparoscopic cholecystectomy. Which of the following ventilatory parameter will MOST likely improve his respiratory function perioperatively?
A. PEEP
B. TV
C. Pressure support
D. SIMV
A. PEEP
Is the only ventilatory parameter that has consistently been shown to improve respiratory function in obese patients.
It is the weight associated with the lowest mortality rate for a given height and gender:
A. IBW
B. LBW
C. Actual body weight
D. Total body weight
A. IBW
Mr. John came in for pre-operative screening. His BMI is 38. Which of the following category should he belong?
A. Obese Class II
B. Super obese
C. Obese Class III
D. Super-super obese
A. Obese Class II
Mr. Smith, a known Obese Class II claimed to have had several visits to his primary care physician for the management of his obesity. He mentioned that his appetite significantly decreased after taking a prescribed medication for several weeks. While he did experience occasional tachycardia and hypertension, he noted that his appetite remained notably reduced. Which medication did he took?
A. Phentermine (Adipex-P)
B. topiramate (Topamax)
C. Lorcaserin
D. Bupropion
A. Phentermine (Adipex-P)
Is primarily a noradrenergic and possibly dopaminergic sympathomimetic amine that decreases appetite. Although it is only approved for 3 months’ use, it can induce, tachycardia, palpitations, and hypertension, as well as dependence, abuse, and withdrawal symptoms.
Is combined with naltrexone and is a dopamine and norepinephrine reuptake inhibitor which stimulates pro-opiomelanocortin neurons.
A. Phentermine (Adipex-P)
B. topiramate (Topamax)
C. Lorcaserin
D. Bupropion
D. Bupropion
Which of the following parameters is most commonly reported as abnormal in the pulmonary function of obese patients?
A. Decreased IRV
B. Decreased ERV
C. Decreased TLC
D. Decreased closing capacity
B. Decreased ERV
Decreased FRC and Decreased ERV are the two most commonly altered pulmonary function.
____ is the reduction of FRC occurring in obese patients during general anesthesia?
A. 50%
B. 70%
C. 30%
A. 50%
Anesthesia and supine positioning worsen this situation such that up to a 50% reduction in FRC occurs in the obese anesthetized patient compared with * 20% in the nonobese individual
It is the most sensitive indicator of the effect of obesity on pulmonary function:
A. ERV
B. FRC
C. TLC
A. ERV
This is the gold standard technique for diagnosing OSA:
A. STOB-BANG questionnaire
B. Overnight polysomnography
C. Clinical diagnosis
D. Apnea–hypopnea index
B. Overnight polysomnography
A 30 year old female is scheduled for elective surgery. She is Obese class II without hypertension. During pre-op rounds, she mentioned that she underwent polysomnography abroad with a AHI (apnea–hypopnea index) of 12 events per hour. This means that her OSA is:
A. Mild
B .Moderate
C. Severe
D. Normal
A. Mild
The diagnosis of OSA can only be made in patients who undergo polysomnography, or a home sleep study.
Results of polysomnography are reported as the apnea–hypopnea
index (AHI), which is derived from the total number of apneas and hypopneas divided by the total sleep time or the respiratory disturbance index (RDI).
Most sleep centers commonly use an AHI between 5 and 10 events per hour as a normal limit.
Mild Disease: AHI of 5 to 15 events per hour
Moderate Disease: AHI of 15 to 30 events per hour
Severe Disease: AHI of greater than 30 events per hour
Which of the following is NOT a component of Obesity Hypoventilation (Pickwickian) Syndrome?
A. BMI >30
B. Awake arterial hypercapnia (>45 paco2)
C. No known causes of hypoventilation
D. Asleep O2 sats 92% or less
D. Asleep O2 sats 92% or less
- Obesity Hypoventilation (Pickwickian) Syndrome Is a combination of obesity and chronic hypoventilation that is frequently misdiagnosed and untreated, resulting in pulmonary hypertension and cor-pulmonale, increased risk of postoperative complications, and death.
The following clotting factors are consistently increased in obese patients EXCEPT?
A. Fibrinogen
B. X
C. VIII
D. vWf
B. X
FACTORS ELEVATED in OBESE patient:
Fibrinogen
VII
VIII
vWf
PAI-1
- Von Willy is riding his new F-78 jet!:)
Among obese patients, which clotting factor is highly correlated with increased cardiovascular mortality.
A. Factor I (Fibrinogen)
B. Factor II (Prothrombin)
C. Factor VIII (Anti-hemophilic A)
D. Factor IV (calcium)
C. Factor VIII (Anti-hemophilic A)
An increase of more than ___ kg/m2 in BMI is associated with a 2.7-fold increase in risk for developing new reflux symptoms.
A. 3.5
B. 10
C. 5
D. 1.5
A. 3.5
In general, this is the most common biochemical abnormality in obese patients?
A. Elevated ALT
B. Elevated AST
C. Elevated APTT
D. Elevated Creatinine
A. Elevated ALT
TRUE or FALSE
A drug that is mainly distributed to lean tissues should have the loading dose calculated based on LBW.
TRUE
The following are physiologic abnormalities resulting from OSA EXCEPT:
A. Hypoxemia
B. Hypercapnia
C. Pulmonary hypertension
D. Polycythemia
E. Respiratory Alkalosis
E. Respiratory Alkalosis
Barash | 9th Edit
The following pulmonary physiology is altered in Obese patients EXCEPT:
A. Increased pulmonary blood volume
B. Decreased closing capacity
C. Decreased ERV
D. Decreased lung compliance
B. Decreased closing capacity
Which of the following drug metabolism is ENHANCED among obese patients?
A. Oxidation
B. Reduction
C. Hydrolysis
D. Sulfation
**D. Sulfation **
Drugs that undergo phase I metabolism (oxidation, reduction, hydrolysis) are generally unaffected by changes induced by obesity, whereas phase II reactions (glucuronidation, sulfation) are enhanced.
Barash | 9th Edit
Compounds that are less lipophilic typically show little or no change in their volume of distribution (VD) with obesity. However, highly lipophilic drugs are exception to this rule. Which of the following drug follows this rule?
A. Remifentanil
B. Succinylcholine
C. Tetracaine
D. Rocuronium
E. Thiopental
A. Remifentanil
Less lipophilic compounds have little or no change in VD with obesity. Exceptions to this rule include the highly lipophilic drugs:
- Procainamide
- Remifentanil
- Digoxin
PPRD (Tatay Digong is exceptional).:)
Among obese patients, Sugammadex when used as reversal agent must be based on:
A. Actual body weight
B. Lean body weight
C. Total body weight
A. Actual body weight
A recent study evaluated recovery times after reversal of neuromuscular blockade with sugammadex in obese (BMI >30 kg/m) and nonobese (BMI <30 kg/m) patients, and found that recovery time did not correlate with BMI.
- Sugammadex dosing can therefore be based on actual
body weight in both obese and nonobese patients.
Which of the following anesthetic drugs, when given thru parenteral route, must be based on TOTAL BODY WEIGHT?
A. Rocuronium
B. Neostigmine
C. Fentanyl
D. Sugammadex
E. Thiopental
B. Neostigmine
Drugs wherein the dosing should be based on TOTAL BODY WEIGHT are the following:
- Propofol (maintenance)
- Succinylcholine (pseudocholinesterase activity increases)
- Dexmedetomidine
- Neostigmine
IV bolus of benzodiazepine in obese patients must be based on:
A. Actual body weight
B. Ideal body weight
C. Total body weight
B. Ideal body weight
- Continuous IV infusion should be based on actual body weight
In combination with clinical findings, which of the following is the most common echocardiographic finding that can clinically help confirm pulmonary hypertension?
A. Tricuspid regurgitation
B. Mitral regurgitation
C. borderline low ejection fraction
A. Tricuspid regurgitation
Tricuspid regurgitation on echocardiography is the most useful confirmatory
test of pulmonary hypertension but should be combined with clinical
evaluation.
The following are important risk factors in developing post-operative DVT among obese patients EXCEPT:
A. Venous stasis disease
B. BMI ≥60
C. Central obesity
D. OSA
E. Male
E. Male
Four important risk
factors, namely venous stasis disease, BMI ≥60, central obesity, and OHS and/or OSA, are significant in the development of postoperative DVT, and if present, preoperative prophylactic placement of an inferior vena cava filter should be considered.
When a patient is obese, succinylcholine dosage must be based on which of the following:
A. TBW
B. IBW
C. Actual body weight
A. TBW
Pseudocholinesterase activity increases linearly with
increasing weight and large extracellular fluid compartment.
Dose of succinylcholine should be INCREASED
____ is the total body weight (TBW) minus the adipose tissue. It is a combination of body cell mass, extracellular water, and nonfat connective tissue:
A. Lean body weight
B. Ideal body weight
C. Predicted body weight
A. Lean body weight
LBW is the total body weight (TBW) minus the
adipose tissue. It is a combination of body cell mass, extracellular water, and nonfat connective tissue.
It approximates 80% and 75% of TBW for
males and females, respectively,
TRUE or FALSE
Increasing the IBW by 20% gives an estimate of LBW.
TRUE
In morbidly obese patients, increasing the IBW by 20% to 30% gives an estimate of LBW.
In non-obese and non-muscular individuals, TBW approximates IBW
In an obese patient, induction with Propofol is ideally based on which parameter?
A. TBW
B. LBW
C. Actual body weight
D. Predicted body weight
B. Lean body weight
If used for maintenance of general anesthesia or TIVA, the dose should be based on TBW.
Increased VD at steady state and increased clearance
prevent increases in elimination half-life.
Total clearance and VD at steady state correlate with body weight during maintenance infusion.
Negative cardiovascular effects.
High affinity for fat and well-perfused organs.
High hepatic extraction and conjugation relate to TBW.
TRUE or FALSE
The pharmacokinetics and pharmacodynamics of ROCURONIUM is not altered in obese female patients
TRUE
In an obese patient, induction with Thiopental is ideally based on which of the following?
A. TBW
B. LBW
C. Actual body weight
D. Predicted body weight
Lean body weight
Increased initial dose due to increased blood volume,
CO, muscle mass.
- Rapid distribution from plasma to periphery
Ideal IV analgesic adjuvant in the morbidly obese patient:
A. Dexmedetomidine
B. Remifentanil
C. Alfentanil
A. Dexmedetomidine
In Obese patient, Neostigmine should be based on ____ when used for the reversal of vecuronium.
A. TBW
B. IBW
C. LBW
Total body weight
Prompt early reversal but delayed full recovery during
neostigmine-induced reversal of vecuronium dosed
according to TBW.
TRUE or FALSE
A drug that is mainly distributed to lean tissues should have the loading dose calculated based on LBW
TRUE
In contrast, If the drug is equally distributed between adipose and lean tissues, dosing should be calculated based on TBW.
Which of the following physiologic changes in obesity is MOST ACCURATE?
A. increased total body water
B. decreased lean body mass
C. decreased cardiac output
D. increased α1-acid glycoprotein
D. increased α1-acid glycoprotein
Volume of distribution in Obese is affected by these changes:
reduced total body water
increased total body fat
increased lean body mass
altered protein binding
increased blood volume
increased cardiac output
increased blood concentrations of free fatty acids, triglycerides, cholesterol, and α1-acid glycoprotein, lipophilicity of the drug
Plasma albumin and total plasma protein concentrations and binding among obese patients is:
A. Increased
B. Decreased
C. Unchanged
C. Unchanged
TRUE or FALSE
In obese patients, phase II reactions (glucuronidation and sulfation) are ENHANCED.
TRUE
Phase I is unaffected while Phase II is enhanced.
Remifentanil when given in a continuous infusion should be based on:
A. LBW
B. TBW
C. Actual body weight
Lean body weight
High lipid solubility = LEAN BODY WEIGHT
Highly lipophilic substances such as barbiturates and benzodiazepines show significant increases in VD for obese
individuals.
These drugs have a more selective distribution to fat stores and therefore a longer elimination half-life but with comparable clearance values to normal individuals.
aminoglycoside dosing in obese patients should be:
A. Increased
B. Decreased
Increased
As a result of the increases in glomerular filtration rate and tubular secretion, drugs such as cimetidine and aminoglycoside antibiotics that depend on renal excretion
may require increased dosing.
The dosing of sugammadex should be based on:
A. actual body weight
B. IBW
C. TBW
A. actual body weight
Sugammadex dosing can therefore be based on actual
body weight in both obese and non-obese patients.
TRUE or FALSE
a neck circumference of ≥40 cm is the biggest predictor of difficult mask ventilation, difficult laryngoscopy, and difficult endotracheal intubation.
TRUE
It is the weight associated with the lowest mortality rate for a given height and gender:
A. Ideal body weight
B. Total Body weight
C. Lean body weight
D. Predicted body weight
A. Ideal body weight
Which of the following is NOT a risk factors for developing DVT among obese patients?
A. venous stasis disease
B. BMI ≥60
C. central obesity
D. OHS and/or OSA
E. Male
E. Male
Four important risk factors, namely venous stasis disease, BMI ≥60, central obesity, and OHS and/or OSA, are significant in the development of postoperative DVT, and if present, preoperative prophylactic placement of an inferior vena cava filter should be considered.
Intra-abdominal pressure of more than ___ causes caval compression thereby decreasing cardiac output
A. 20 mmHg
B. 30 mmHg
C. 45 mmHg
A. 20 mmHg
Pneumoperitoneum should not be increased above 15 mmHg since intra-abdominal pressures of 20 mmHg
or greater can cause caval compression and decrease cardiac output
Fluid management among obese patients should be ideally based on:
A. IBW
B. Total body weight
C. PBW
D. Actual body weight
A. IBW
Rapid infusion of intravenous fluids should be avoided because pre-existing congestive cardiac failure is common in the obese patient.
The use of IBW estimates and appropriate monitoring can help to avoid potential hyperhydration in morbidly obese patients.
This is the only ventilator parameter that has consistently been shown to improve respiratory function in obese
subjects:
A. FiO2 1.0
B. CPAP
C. APRV
D. PEEP
D. PEEP
Positive PEEP is the only ventilatory parameter that has consistently
been shown to improve respiratory function in obese subjects, although the
ideal PEEP value is still unknown.
Which is responsible for the decreased
effective dose of spinal local anesthetic
in obese patients?
A. Decreased CSF volume
B. Increased CSF volume
C. Exaggerated lordosis of lumbar spine
D. Exaggerated kyphosis of thoracic spine
A. Decreased CSF volume
The decreased spinal fluid volume results from displacement of the cerebral spinal fluid by soft tissue movement into the intervertebral foramen caused by an increase in abdominal pressure.
The maximum safe dose of local anesthetic for any type of PNB or local infiltration should be based on:
A. IBW
B. Actual body weight
C. TBW
IBW
The maximum safe dose of local anesthetic for a peripheral nerve block or local infiltration should be based on IBW rather than actual weight due to the risk of local anesthetic systemic toxicity.
TRUE or FALSE
A patient is using a PCA post-operatively should avoid using the continuous background infusions.
TRUE
If patient-controlled systemic opioids are used, continuous background infusions should be avoided or used with extreme caution.
Reduction in FRC among obese patients is primarily a result of reduced _________
A. Tidal volume
B. Inspiratory capacity
C. Residual volume
D. Expiratory reserve volume (ERV)
D. Expiratory reserve volume (ERV)
Morbid obesity is defined as
a BMI _____
A. >30 kg/m2
B. >35 kg/m2
C. >40 kg/m2
D. >45 kg/m2
C. >40 kg/m2
This has been identified as the single
biggest predictor of problematic
intubation in morbidly obese patients.
A. Neck circumference
B. Mallampati score
C. Thyromental distance
D. Degree of mouth opening
A. Neck circumference
A BMI of 34 kg/m2 is:
A. Overweight
B. Obese I
C. Obese II
Obese I
An increased dose of succinylcholine is
necessary because of _______
A. Decrease in activity of pseudocholinesterase
B. Increase in activity of pseudocholinesterase
C. Increased volume of distribution
D. Decreased volume of distribution
B. Increase in activity of pseudocholinesterase
