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Obesity > Apex- Obesity > Flashcards

Apex- Obesity Flashcards

1
Q

Each gram of the following produces how many calories:

-Fat:
-Carbs:
-Protein:

A

-Fat: 9
-Carbs & Protein = 4

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2
Q

T/F: childhood obesity is more common than diabetes, cystic fibrosis, and all cancers

A

TRUE! yikes

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3
Q

what % of children and adolescents are overweight or obese?

adults?

A

over 30%

adults - over 33%

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4
Q

2 genetic disorders associated with obesity

A
  1. Prader-Willi syndrome
  2. Bardet-Biedl syndrome
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5
Q

Where does obesity rank in the cause of preventable deaths in America?

A

Second (smoking first)

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6
Q

Which is worse: Android obesity or gynecoid obesity?

which is more common in men vs women

which one is apple vs pear shaped

A

Android obesity worse

men

apple

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7
Q

waist size > what for men vs women is associated with increased risk of ischemic heart disease, HTN, HLD, insulin resistance, and death?

A

> 40” for men
35” for women

women of course have to have the smaller waist

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8
Q

Metabolic syndrome parameter:

Fasting Plasma Glucose

A

> 110

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9
Q

Metabolic syndrome parameter:
Abdominal obesity (men vs women)

A

> 40” wasit in men
35” waist in women

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10
Q

Metabolic syndrome parameter:
Serum HDL (men vs women)

A

Men < 40g/dL
Women < 50g/dL

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11
Q

Metabolic syndrome parameter:
Serum triglycerides

A

> 150mg/dL

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12
Q

Metabolic syndrome parameter:
Blood pressure

A

> 135/85

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13
Q

People with metabolic syndrome have what % greater CV risk compared to the general population

metabolic syndome AKA

A

50-60%

syndrome X

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14
Q

T/F: diagnosis of metabolic syndrome requires at least 2 of the parmaters

A

fasle 3

out of 5

fasting glucose > 110

waist > 40” men >35” females

HDL < 40 men, > 50 women

Tris > 150

BP > 135/85

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15
Q

BMI ranges

A

*just focus on memorizing what each one starts at , starting with normal

normal = 18.5
overweight = 25
class 1= 30
class 2= 35
class 3 >/0 40

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16
Q

Kid %tiles for overweight, obese, vs severely obese

A

overweight - 85th
obese 95th
severely obese 99th

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17
Q

BMI calculation and the tricky part to it

A

Weight (kg)/ Height (m2)

tricky part is finding the meters squared
your going to want to convert height from inches to cm ( in x 2.54) - you know this part
then convert cm to meters (cm/100)
*i thinki get tripped up here bc i think i wanan x it but just think dividing will get you a smaller number and meters is a smaller number compared to cm
-then times the cm by itself to square it

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18
Q

BMI of a patient who weights 176lbs and 74 inches tall

A

22.64

    1. convert pounds to kg (lb/2.2)
  2. convert height to cm (in x 2.54)
  3. convert cm to m (cm/100)
  4. square the m (mxm)
  5. KG / m squared

*avoid rounding until you get final answer

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19
Q

BMI of a patient who weights 176lbs and 74 inches tall

A

22.64

    1. convert pounds to kg (lb/2.2)
  2. convert height to cm (in x 2.54)
  3. convert cm to m (cm/100)
  4. square the m (mxm)
  5. KG / m squared

*avoid rounding until you get final answer

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20
Q

Normal child body weight percentile

A

< 85%

overweight = > 85%
obse = > 95%
severely obse 99%

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21
Q

Ideal body weight calculation men vs women

A

Men = height (cm) - 100
Women = height (cm) - 105

think 100 = ideal and men are always first
then minus an extra 5 bc women are generally shorter

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22
Q

What measurement of weight describes the optimal weight for a given height

A

ideal body weight

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23
Q

IBW of a 5’4” man

A

62.56kg

64 inches x 2.54cm = 162.56cm - 100

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24
Q

you always hate when the height is written in CM for the anesthesia post op- how can you use this to your benifit?

A

easy way to find out IBW!!!

-100 for men
- 105 for females

wow it took me almost 2 years of clinical to figure that out
i even bought a badge with IBW for all heights - dear god

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25
Q

pt’s height is 170cm (man)
what range do you want their tidal volumes?

A

IBW = 70kg
tidal volumes = 6-8ml/kg
420-560mls

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26
Q

what’s the IBW of a 5’10” woman ?

A

72.8kg

70inches x 2.54cm = 177,8cm
177.8 - 105 = 72.8kg

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27
Q

Which factors are reduced by obesity? (select 2):

-vital capacity
-ERV
-closing volume
-residual volume

A

vital capacity and ERV

obesity creates a RESTRICTIVE ventilatory deffect
–> lungs are compressed and therefore lung volumes are reduced (VC, ERV)

-FRC decreases (bc of ERV)
-RV remains constant
-closing volume increases (collapsing of alvoli)
-vital capacity decreases (decreased ERV)

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28
Q

how does obsity affect FRC, ERV, and RV?

A

FRC is reduced primarily due to a reduction in ERV
RV remains constant

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29
Q

General Anesthesia causes FRC to fall by what % in obsese vs non-obese population

A

50% obese
20% non-obese

*obesity = higher o2 consumption + smaller FRC + 50% reduction in FRC with induction = reapid desat

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30
Q

Okay so you know that for fat people, their tidal volume needs to be based on IBW - bc just bc they are fat, doesnt mean their lungs are bigger; however, what else do you need to be aware of with vent settings?

A

that you will need to increase RR to compensate for increased O2 consummption and CO2 production since fat is a metabolically active organ

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31
Q

What lung volumes (1) and lung capacities (3) are affected by obesity?

A

decreased ERV

decreased: FRC, VC, TLC

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32
Q

does obesity created an obstructive or restrictive ventilatory effect?

A

restrictive

lungs are compressed by chest fat and abdominal contents - reduced compliance

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33
Q

T/F: although the abese patient may experience hypoxemia, the PaCO2 is usually normal

A

True

elevated CO2 signals impending resp failure

explained by the high diffusing capacity of Co2 and the favorabile characteristics of the Co2 dissociation curve
sure….
so i guess they are saying that more alvoli may be compressed and o2 may not be able to diffuse into the blood bc of it, however, bc they have an increased co2 production + it’s ability to diffuse - it balances out

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34
Q

What kind of breathing pattern is good for an obese person and why?

A

rapid and shallow breaths

they have increased o2 requirements bc fat is metabolically active
& increased weight on the chest increases work of breathing, so rapid shallow breaths provides the most energy- efficent way to achieve this goal

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35
Q

How should you preoxygenate the obese patient?

A

CPAP 10cm H20

+100% fio2 - duh; until eto2 > 90%

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36
Q

How should you breathe for the obese patient

A

rapid , shallow breaths

TV 6-8ml/kg IBW

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37
Q

Is it better to manage PaCO2 in the obese patient by increasing the respiratory rate or tV?

A

respiratory rate

general population is tidal volume bc increasing RR just increases dead space ventilation
however, fat is a metabolically active organ with higher o2 consumption, and the most metabolically efficient way to do this in the obese patient is to increase RR

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38
Q

How to decrease risk of post-induction atelectasis in the obese patient

A

lower fio2 < 80%
ARMs and PEEP

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39
Q

Optimal positioning of an obese person during induction and why

A

HELP positon - Head Elevated Laryngoscopy Position
Reverse T & ramp until sternal notch in line with external auditory meatus

*Goal is to elevate the head, shoulder,s and upperbody above the chest
*sternal notch in line with external auditory meatus

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40
Q

You induce anesthesia on an obese patient and sucessfully intubate them and confirm placement - what should you do before putting them on the vent

A

recruit collapsed alveoli by giving a breath to 40cm h20 and holding for 10 seconds

then apply PEEP to keep them held open

*may reduce venous return and bp (and hr during valsalva)

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41
Q

T/F: increased BMI increases the incidence of pulmonary aspiration in a linerar fashion

A

false- no solid evidence that BMI alone increases risk of aspriation

RSI can be considered if other factors such as GERD or DM are present (gastroporesis)

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42
Q

When is postop hypoxemia most likely to occur in the obese patient?

A

immediately postop and upt o 2-5 days following surgery

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43
Q

5 ways to maximize postop oxygenation in the obese patient

A
  1. hob up 30 degrees
  2. cpap or bipap
  3. IS
  4. early ambulation
  5. pain control with non-opioid analgesics/regional
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44
Q

Considerations for the CV effects of the morbidly obese patient: select 2:

-increased baseline HR
-increased EKG voltage
-diastolic dysfunction
-increased venous return

A

diastolic dysfunction and increased venous return

  • increased intravascular volume = increased wall stress
  • –> heart compensates by becoming thicker; thicker = unable to relax

-HR is usually unchanged bc an increased SV is responsible for the increased CO

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45
Q

How much does cardiac output increase for every extra kg of fat?

A

100mls/min

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46
Q

T/F- increased HR in obese population is expected

A

false- usually no change - increased SV accounts for increased CO

47
Q

Why would an obese patients heart be dilated?

A

Venous return must match cardiac output, so the heart dilates to accept the larger incoming volume.

then also becomes thicker to compensate for increased wall stress
-> reduces ventricular compliance and causes diastolic dysfunction
*makes them less tolerant of excessive fluids, putting them at risk for fluid overload (pulm edema)

*use LBW to calculate periop fluid requirements

48
Q

Concerns with fluid managment if you dont have an echo to tell you their heart function- what can you assume

A

well they have this increased circulating intravascular volume in order to perfuse all this extra fat:

-venous return must match CO, so the heart will dilate to accept more volume

-this increased volume makes the heart work harder and overtime it becomes stiffer to compensate at the expense of it being able to relax (diastolic dysfunction)

-so they dont handle excessive fluid administration very well - at risk for fluid overload nad pulm edema

calculate fluid requirements based on LBW

49
Q

What are some common EKG changes in the obese patient (6) and why

A
  1. Low voltage EKG - caused by increased distance between the heart and leads
  2. Left axis devation - stomach pushes heart up and to the left + LVH secondary to volume overload and HTN
  3. Right axis devation - from RVH due to OSA and volume overload
  4. Ischemia - supply and demand mismatch
  5. Dysrhythmias - fatty infiltration of hte conduction system, myocardial hypertrophy, hypoxemia, hypercarbia, obesity hypoventilation syndrome, and ischemic heart diease
50
Q

The presence of what on TEE may be the most useful confirmation of pulmonary HTN?

A

tricuspid regurgitation

51
Q

In the obese patient, which factors are expected to increase (select 2):

-MAC
-Circulation time
-Volume of distribution of lipohhilic drugs
-Volume of distribution of hydrophilic drugs

A

Volume of distibution of both lipophilic and hydrophilic drugs

  1. the Vd of lipophilic drugs is higher due to a larger fat mass
  2. the Vd of hydrophilic drugs is increased due to a larger muscle mass and blood volume

A high CO hastens (speeds) IV drug delivery to the site of action, shortening circ time (go to sleep quicker with IV induction)

MAC is unchanged

52
Q

How does obesity affect lipophilic vs hydrophilic drugs

A
  1. the Vd of lipophilic drugs is higher due to a larger fat mass
  2. the Vd of hydrophilic drugs is increased due to a larger muscle mass and blood volume
53
Q

As a rule of thumb, what kind of drugs are calculated with what kind of weights?

A

TBW- lipid-soluble drugs
IBW- water-soluble drugs

obesity increases volume of distribution of both water and lipid soluble drugs, so LBW can be used to account for this

54
Q

T/F: a loading dose is primarily depdendent on the volume of distribution, while the maintenance dose is determined by clearance

A

true

55
Q

what happens when you give a lipophilic drug to the obese population?

A

bc the drug will just distribute into the fat compartments, lowering the plasma concentration

56
Q

Using IBW may result in (overdose/underdose) of a drug in the obese population

What about TBW

A

underdose bc the Vd is larger in the obese population (higher blood volume, higher muscle mass)

may overdose bc fat is less fascular than other tissue , so a greate % of the loading dose will go to the vessel-rich group

57
Q

Why don’t you want to dose lipophlic drugs on TBW in the obese population?

A

bc fat receieves a smaller amount of the CO, so a greater % of the loading dose will go to the VRG

58
Q

Calculation for LBW

A

IBW x 1.3

59
Q

How is defluorination affected by obesity and iso/sevo/des

A

iso and des - increased defluorination (but not linked to postop hepatic or renal dysfunction)

-no change in sevo

60
Q

When giving a choice of: sevo, des, iso, and propofol - which 2 agents provide the FASTEST emergergence?

A

sevo and des

61
Q

When giving a choice of: sevo, des, iso, and propofol - which 2 agents provide the FASTEST emergergence?

A

sevo and des

62
Q

Engorgement of hte epidural veins and increased epidural fat will cause a greater spread of local anesthetic in the epidural space. For this reason, the dose should be reduce to what % of the normal dose?

A

75%

63
Q

Which drugs are soley based on TBW vs LBW regardless of induction vs maintenance dose

-PROPOFOL
-MIDAZ
-FENT/SUFENT
-REMI
-ROC/VEC
-CIST/ATRA
-SUX

A

All TBW = MIDAZ - SUX - CIST/ATRA
All LBW = REMI - ROC/VEC

Variable: Propofol & Fent/Sufent
& they are opposite

Prop induction = LBW, mainteneance = TBW
Fentanyl induction = TBW, maintenance = LBW

64
Q

Why do we use TBW to calculate Sux if it’s water soluble

water soluble drugs are typically IBW

A
  1. increased blood volume (increased Vd) and
  2. increased pseudocholinesterase activity (increased clearance)
65
Q

T.F - obesity results in decreased pseudocholinesterase activity

A

False - increased

*increased clearence of sux - larger dose needed

66
Q

What is remi always based on and why?

A

LBW

-it’s rapidly cleared by plasma esterases, so it behaves more like a water-soluble drug

i guess IBW in regular people but shifts to LWB in obese bc LBW helps account for the increased muscle mass…

67
Q

T/F: how is the absorption of orally administered meds affected in the obese population

A

no difference

68
Q

All of the following muscles dilate the upper airway EXCEPT the:

-tensor palantine
-genioglossus
-hyoid muscles
-thyroaretenoid

A

-thyroarytenoid

69
Q

What muscle opens the nasopharynx ?

A

tensor palantine

70
Q

What muscle opens the oropharynx?

A

Genioglossus (tongue)

71
Q

What muscles open the hypopharynx?

A

The hyoid muscles

72
Q

T/F: the incidence of OSA is directly proportional to BMI

A

True

73
Q

T/F: OSA is an indepdent risk factor for the development of HTN, CV morbidity, and death

A

True

74
Q

OSA is definted as cessatation in airflow for at least how long (apnea)….with how many unsuccessful efforts to breathe (obstruction) and a greater than what % reduction in SaO2

A

10 second apneic period
5 or more unsuccessful efforts to breathe
> 4 % reduction in SpO2

75
Q

What is definited as a 50% reduction in airflow for 10 seconds, 15 or more times per hour and is linked to snoring and decreased o2 sats

A

hypopnea

76
Q

Neck girth risk in men vs women for OSA

A

men- neck > 17inches
women- neck >16

77
Q

Describe the pathophysiologic cycle of apnea:

A

sleep → decreased upper airway tone → increased upper airway resistance → obstruction (snoring) → hypoemia/hypercarbia (SNS stimulation) → arousal (daytime sleepiness) → increased upper airway tone → pt breathes

78
Q

Which apnea/hypopnea index score is consistent with mild OSA?

-3
-12
-25
-40

A

12

The value is derived by the number of apnea episodees and hypopnea divided by the total hours of sleep

Mild = 5-15 epidodes/hr
moderate = 15-30 episodes/hr
severe > 30 episodes per hour

79
Q

Why is it important to screen all patients for OSA?

A

bc most patients are underdiagnosied and it’s a major contributer to periop M&M

80
Q

What is the definitive test for OSA?

A

Polysomnography

81
Q

How many episodes per hour determines miild, moderate, vs severe sleep apnea

what is the rating system called?

A

5-15 = mild
15-30 = moderate
>30 = severe

Apnea-hypopnea index (AHI)

82
Q

Bedside assessment tool for OSA

how many = high risk vs low risk

A

STOPBANG

Snoring
Tirdness
Observed apnea
Pressure*
BMI >35 (obese class 2) *
Age > 50 *
Neck circumfrence > 40cm
Gender - male *

* = things you can get from chart

=/> 3 yeses = high risk
<3 = low risk

so a male over 50 with HTN = high risk just with those 3 yeses alone

83
Q

How many patients with sleep apnea are undiagnosed?

A

60-70%

84
Q

T/F: Obesity hypoventilation syndrome is a long-term consequence of untreated OSA

A

True

overtime, the respiratory center in the medulla fails to respond to hypercarbia appropriately

85
Q

3 diagnositic critera for obesity hypoventilation syndrome

A
  1. BMI > 30 (obesity class 1 compared to class 2 [>35] for OSA)
  2. Awake PaCO2 > 45
  3. Dysfunctional breathing during sleep
86
Q

Risk of anesthesia and Pickwickian syndrome

A

administation of any respiratory depressant drugs puts these patients at high risk of airway obstruction nad resp arrest

*when planning your management, try to think of multi-modal approaches to pain that do not impact resp drive: regional, nsaids, tylenol, ketamine, dex

87
Q

What is the MOST sensitive sign of an anastomotic leak following gastric bypass?

A. shoulder pain
B. unexplained tachycardia
C. abdominal pain
D. fever

A

B. unexplained tachycardia

88
Q

T/F- bariatric surgery is the most effective treatment f or reversing obesity

A

True

89
Q

T/F: bariatric surgery usually leads to resolution of comorbidities such as HTN and type 2 diabetes

A

True

90
Q

What are the 3 approaches to surgical weight loss

which yeilds the best weight loss and improvement of comorbidities?

A
  1. malabsorption (jejuno-ileal bypass)
  2. restriction (gastric band and sleeve gastrectomy)
  3. combination (roux-en-y- gastric bypass)

roux-en-y

91
Q

T/F- duodenal switch is the least invasive bariatric procedure

A

False- gastric bands/sleeves are least invasive (restrictive surgeries)

duodenal switch is a malabsorptive

92
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

Jejunoileal bypass

A

Malabsorption

-gastric reduction and removal of part of the small intestines, limitng nutrient absorption

93
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

gastric band

A

restrictive

-limits quantitiy of food that can be consumed
*restrictive procedures are least invasive

94
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

Bilopancreatic diversion

A

Malabsorption

gastric reduction and removal of portion of hte small intestine
-limits nutrient absorption

95
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

Roux-en-Y gastric bypass

A

combination

bands/sleeves

yields best weight loss and improvement
*risk of nutritional deficiency

96
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

does NOT lead to nutrient deficiency

A

Restrictive

small intestine is left intact!

97
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

Sleeve gastrectomy

A

Restrictive

-least invasive, no nutrient issues
-limits amount of food that can be consumed

98
Q

What type of bariatric procedure: malabsoprtive, restrictive, combination:

duodenal switch

A

malabsorption

gastric reduction and removal of part of the small intestine

99
Q

if someone has a gastric band or sleeve- are you consered about nutrient deficiencies?

A

no- small intestine is left intact

this is the least invasive type of procedure
small intestine is left intact

100
Q

If someone has a history of a duodenal switch, jejunoileal bypass, or bilopancreatic diversion, or roux-en-y gastric bypass- what do you want to look at ?

why might you want to avoid nitrous

A

Coags - poss increased INR due to vitamin K deficiency

risk of having vit b12 deficinecy and folate depletion

101
Q

Gastric bypass is associated with what % of an anastomotic leak:

0.02%
0.2%
2%
12%

A

2%

102
Q

What do you know about toradol and gastric bypass surgery

A

old evidence says its contraindicated due to risk of bleeding and ulcers but the latest evidence suports it as a means to reduce opioid consumption

103
Q

3 most common s/s anastomatic leak

A
  1. tachycardia (72%)
  2. fever (63%)
  3. abdominal pain (54%_

unexplained tachycardia is most sensitive sign.
unexplained HR of > 120bmp is concerning even if no other s/s present

104
Q

Match each appetite suppressant with it’s drug class:

-Phentermine
-Ma Huang
-Sibutramine
-Orlistat

  • Ephedra alkaloid, NE reuptake inhibitor, NE and serotonin reuptake inhibitor, lipase inhibitor
A

-Phentermine: NE reuptake inhibitor
-Ma Huang + Ephedra lkaloid
-Sibutramine + NE and SSRI
-Orlistat + Lipase inhibitor

105
Q

T/F: Obesity is the most significant risk factor for hte development of nonalcoholic fatty liver disease (NAFLD) and nonalcholic steatohepatitis (NASH)

A

True

106
Q

How should you calculate fluids for obese ppls

A

LBW

many obese pts have diastolic dysrunction which means they are less tolerant of excessive fluid administration, placing them at risk for fluid overload

107
Q

OSA is associated with cessitation of airflow for more than:

A. 10 seconds
B. 15 seconds
C. 20 seconds
D. 25 seconds

A

A. 10 seconds

108
Q

Which of the following are associated with obesity? (select 3)

-increased total body water
-decreased lean body weight
-decreased Vd of lipid soluble drugs
-increased blood volume
-increased CO
-increased renal clearance

A

increased blood volume
-increased CO
-increased renal clearance

109
Q

All of the following contribute to HTN in the obese ptatient EXCEPT:
A. Cytokines
B. Hyperinsulinemia
C. angiotensinogen
D. decreased blood viscosity

A

D. decreased blood viscosity

*they have increased blood viscostiy

110
Q

Blood pressure can increase how much for every 10% increase of body weight?

A

6.5mmHg

seems like a random triva question

111
Q

Which of the following complications are associated with maternal obesity (select 2):

-decreasedd duration of 1st stage labor
-increased risk of preterm labor
-excessive blood loss during c-section
-increased risk of type 1 diabetes

A

-increased risk of preterm labor
-excessive blood loss during c-section

  • increased duration of first and second stages of labor
  • increased risk of needing a c-s
  • increased risk of surgical complications
  • increased incidence of macrosomnia (large for gestational age)
112
Q

T/F- maternal obesity increases the risk of needing a C/S

A

True

113
Q

What is the estimated blood volume of the patient with class III obesity?

A. 40ml/kg
B. 50ml/kg
C. 60ml/kg
D. 70ml/kg

A

B. 50ml/kg

Obesity (2 decks)

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