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Anesthesia implications for obesity Flashcards

1
Q

Factors that influence obesity

A

Influenced by;
metabolic factors,
hormones,
neural regulation and
pathologic syndromes in addition to behavioral, cultural, and
socioeconomic factors

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2
Q

BMI equation

A

Patient weight (kg)/ height2 in meters = kg/m2

created by insurance companies to calculate risk

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3
Q

What does BMI not differentiate between

A

Overweight and overfat

Waist circumference, waist-hip ration, age

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4
Q

Android fat distribution

A

“central” obesity
Upper body (truncal)
Associated with ↑ oxygen consumption/cardiovascular dz

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5
Q

Gynecoid Fat distribution

A

“peripheral” obesity
Hips, buttocks, thighs
Less metabolically active
Not really associated with CV disease (genetics)

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6
Q

Total blood volume ____ in obesity

A

increases

On a volume-to-weight ratio is lower 50ml/kg

Most distributed to adipose tissue

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7
Q

CO is ____ in obesity because of ______

A

increased
d/t LV dilation and ↑ stroke volume

20-30ml/kg of excess body fat

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8
Q

Increase in cardiac dysrhythmias is due to____

A

d/t fatty infiltrates of conduction system, CAD,

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9
Q

EKG changes with obesity

A

Low QRS voltage; because of increased impedence,

LVH,
left axis

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10
Q

Hematologic changes with obesity

A

↑er levels of fibrinogen, factor VII, VIII, von Willebrand —-> Hypercoagulability

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11
Q

Endothelial dysfunction in obesity is due to_____

A

higher levels of factor VIII and von Willebrand

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12
Q

Gastric considerations for obesity

A

Gastric volume and acidity are increased -> Intragastric pressure increases -> Relaxation of LES and hiatal hernia formation (increased)

Delayed gastric emptying

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13
Q

Gastric levels and ph for risk of pneumonititis

A

Volume > 25 ml and pH < 2.5…levels for aspiration pneumonitis

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14
Q

Hepatic changes with obesity

A

Hepatic function/drug metabolism is altered
decreased albumin in circulation

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15
Q

RBF _____ with obesity

A

increases (Glomerular hyperfiltration)

will then have a drop off as the kidneys dont perfuse as well

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16
Q

Increased renal tubular reabsorption results in what? (2)

A

Impairs natriuresis

Activates renin-angiotensin system

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17
Q

Increased level of SNS activity in obesity results in what? (4)

A

Insulin resistance…impaired glucose metabolism

Enhanced pressor activity of norepi and angiotensin II

Sodium retention

Thyroid hormone resistance

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18
Q

Hypothyroidism prevalence in obesity

A

Hypothyroidism in 25% of morbidly obese patients

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19
Q

Metabolic syndrome (8)

A

*Abdominal obesity; (Uses waist circumference (not BMI))

*Decreases levels of HDL

*Hypertriglyceridemia

Hyperinsulinemia

*Glucose intolerance

*Hypertension

Proinflammatory state

Prothrombotic state

  • at least 3 must be present for diagnosis
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20
Q

Risk factors for metabolic syndrome (3)

A

Increased age

Men > women

Hispanics and South Asians

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21
Q

Metabolic syndrome may result from ____, ____,_____,____

A

May result from chronic corticosteroids, antidepressants, antipsychotics, protease inhibitors

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22
Q

Metabolic syndrome results in increased risk of ________ (5)

A

Cardiovascular disease

Type 2 diabetes mellitus

Polycystic ovary syndrome

Nonalcoholic fatty liver disease

Improper immune responses

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23
Q

OSA dx (4)

A

Complete cessation of breathing

Lasting 10 seconds or >

5x or > each hour of sleep

Decreased sat 4%

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24
Q

Hypopnea dx (4)

A

Reduction in airflow 50% or >

Lasting 10 seconds or >

15 x or more/hour of sleep

Decreased sat 4%

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25
name for Sleep study
polysomnography
26
apnea/hypopnea index (AHI)= total # of events/total sleep time ranking for mild, moderate, severe
Mild: 5-15/hr Moderate: 15-30/hr Severe: > 30/hr
27
Treatment (CPAP, weight loss) required for mod/severe disease OSA d/t risk of (4)
Systemic/Pulmonary hypertension LVH Cardiac dysrhythmias Cognitive impairment
28
Obesity hypoventilation syndrome other name
Pickwickian syndrome
29
Obesity hypoventilation syndrome results from _____
Results from long-term OSA…5-10% of morbidly obese
30
Obesity hypoventilation syndrome results in______(2)
Pulmonary hypertension Cor pulmonale
31
Dx of Obesity hypoventilation syndrome (2)
BMI > 30 kg/m2 Awake hypercapnia
32
Phentermine factors (4)
Sympathomimetic which ↓ appetite FDA approved for only 3 months Tachycardia, palpitations, hypertension, dependence, abuse No longer in combo with Fenfluramine (caused valvular disorders)
33
Orlistat factors (4)
Blocks absorption of dietary fat Liquid stool, oily spotting, fecal urgency, flatulence, abdominal cramps Fat soluble vitamin deficiencies with chronic use Possible Vit K deficiency…prolonged PT
34
when to stop taking Phentermine and what are the side effects if not
tachycardia and hypotension stay off for 2 weeks
35
OTC Herbals on obesity factors (4)
Pancreatic lipase inhibitors…caffeine, green tea Appetite suppressors…ginseng, ephedra, sunflower oil Energy stimulants…acai berry Regulate lipid metabolism…soybean, fish oil, oolong tea
36
GLP-1 Agonists
Results in delayed gastric emptying
37
Glucagon-like Peptide-1 Receptor Agonists for Adults names
Dulaglutide Exenatide (IR) Liraglutide(1.2 mg1.8mg) Semaglutide Semaglutide
38
Trulicity
Dulaglutide
39
Byetta
Exenatide (IR)
40
Victoza
Liraglutide
41
Ozempic, Wegovy
Semaglutide
42
Rybelsus
Semaglutide
43
When to hold GLP1-agonists
For patients on daily dosing consider holding GLP-1 agonists on the day of the procedure/surgery. For patients on weekly dosing consider holding GLP-1 agonists a week prior to the procedure/surgery
44
If GLP1 - agonists are presceibed for dm management are held ______
If GLP-1 agonists prescribed for diabetes management are held for longer than the dosing schedule, consider consulting an endocrinologist for bridging the antidiabetic therapy to avoid hyperglycemia.
45
If pt shows up day of with these symptoms you should delay the case
severe nausea/vomiting/retching, abdominal bloating, or abdominal pain are present
46
If the patient has no GI symptoms, but the GLP-1 agonists were not held as advised_____
rsi for full stomach US to eval gastric volume
47
Gastric volume scanning with obese pts
depth of 7 instead of 3 cm CSA of gastric antrum may be bigger but still 1.5 ml/kg (useIBW)
48
Preoperative evaluation focuses on evidence of ______ (4)
-Hypertension -Diabetes -Heart failure -Hypoventilation syndrome
49
If they use cpap ________ suggest difficult mask ventilation
CPAP usage of > 10cm H2O suggests difficult mask ventilation consider doing awake intubation
50
Surgical history with obesity to consider
-Compare past/current weight -Ease/difficult intubations -Intravenous access -Need for ICU admission -Surgical outcomes
51
Medications to dc with obese pts
antihypertensives, insulin, oral hypoglycemics
52
Respiratory volumes changes with obesity
⬇️ vital capacity ⬇️ inspiratory capacity ⬇️ expiratory reserve volume ⬇️ functional residual capacity Low compliance Closing capacity is close to or within tidal breathing (especially when supine/recumbent)
53
Supine considerations for obesity
Ventilatory impairment Compression of IVC and Ao Reports of rhabdomyolysis on gluteal muscles (Leads to renal failure/death)
54
Prone considerations for obesity
Cushioning pads may have excessive pressure Skin breakdown, tissue necrosis/infections
55
Lateral decubitus considerations with obesity
Dependent hip pressure ulcers Impossible or unnecessary to place axillary rolls Favored over prone
56
Lithotomy considerations with obesity
Regular stirrups may not support weight Tissue compression/compartment syndrome
57
Airway assessment in obesity can have increased adipose depositing into ______ (6)
Uvula Tonsils Tonsillar pillars Tongue Aryepiglottic folds Lateral pharyngeal walls
58
The oropharynx can change into an _____ in obestiy
Changes oropharynx into an ellipse Short transverse/long AP axis
59
Inverse relationship between degree of obesity and_______ area
pharyngeal
60
Predictors of difficult intubation (4)
Small mouth opening Large/protuberant teeth Limited neck mobility Retrognathia BMI not necessarily an independent predictor
61
Desaturation to 90% with Normal vs obese
Normal BMI: 6 minutes Morbidly obese BMI: less than 3 minutes
62
In an effort to prevent atelectasis and desaturation you should _______
CPAP during preoxygenation… 10cm (close apl) Positioning 25-30 degrees head up for obese patients.30 degrees reverse Trendelenburg even better Recruitment maneuvers then PEEP 10cm Mechanical ventilation after induction
63
Aspiration Prophylaxis with identifiable risk factors in Obesity (4)
Histamine receptor agonists Proton pump inhibitors RSI Awake fiberoptic intubation
64
Advantages of regional anesthesia in obesity
Less airway manipulation Fewer cardiopulmonary depressants ↓ chance of PONV Better postop pain control (at least initially)
65
Technical difficulties with regional anesthesia in obesity
Longer needles Different ultrasound probes Smaller doses (epidurals) d/t smaller space…cephalad spread Higher rates of block failure Higher rates of hypotension after block d/t IVC/Ao compression
66
BP falsely ____ if cuff is too small
elevated
67
Bp cuff bladder should circle at least ____ of circumference
75%
68
Opioids, Propofol, Benzodiazepines on obese pts
Exaggerated responses (especially in pts with OSA) Decrease pharyngeal musculature Decreased airway patency
69
Meds favored for OSA
Short acting…remi/fentanyl most favored α2 agonists…dexmedetomidine
70
Volatiles on obesity
Diminish ventilatory response to CO2 Nitrous not favored d/t high oxygen demand in pts
71
Drugs based on IBW
Propofol Vecuronium Rocuronium Remifentanil
72
Drugs based on TBW (hydrohilic)
Midazolam Succinylcholine Cisatracurium Fentanyl Sufentail
73
Drug dosing is based on _____ of the drug
lipid solubility
74
Favored volatile for Obesity
Based on tissue solubility Desflurane probably favored
75
Obese are more likely to becomes what temperature?
hypothermic (larger body habitus exposed)
76
Postoperative management for obese pts
-sit up -fully reverse nmB -Pressure support mode during emergence -Continue home levels of CPAP -Non-opioid or opioid sparing -Consider when/where cases are done
77
non opioid analgesia for obese pts
Tramadol, dexmedetomidine, ketamine, clonidine

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