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Mar: Sem 4 - Principles II > Exam 3: Obesity > Flashcards

Exam 3: Obesity Flashcards

1
Q

What is the #1 cause of medically-related preventable deaths?

A

Smoking

Obesity is #2.

S2

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2
Q

Calculation for BMI

A

Kg/m^2

S3

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3
Q

Shortcommings of the BMI calculation

A
  • Doesn’t differentiate between overweight and overfat
  • Doesn’t account for waist circumference, waist-hip ratio or age

S3

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4
Q

What is the android body fat distribution, and what is it associated with?

A
  • “central” or truncal obsity
  • ↑ O₂ consumption
  • CV disease

S4

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5
Q

Gynecoid body fat distributions are described as ____ obstity around the ____. This shape is ____ metabolically active and not as associated with ____ disease.

A

Gynecoid body fat distributions are described as peripheral obestity around the hips, butt and thighs. This shape is less metabolically active and not as associated with CV disease.

S4

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6
Q

Total blood volume is ____ in obesity.

A

increased
because of increased mass

S5

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7
Q

Obesity blood volume to weight ratio is typically lower than ____ mL/kg.

A

50 mL/kg

most volume gets distributed to adipose tissue

S5

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8
Q

What occurs with cardiac output in obese patients?

A

CO will ↑ by 20-30 mL per kg of excess body fat.

CO increases due to LV dilation and ↑ stroke volume.

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9
Q

What causes an increase in cardiac dysrhythmias in the obese patient?

A
  • Fatty infiltrates in the conduction system
  • CAD

S5

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10
Q

What EKG changes are typical of the obese patient?

A
  • ↓ QRS voltage
  • LV hypertrophy
  • Left axis deviation

S5

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11
Q

Increased levels of what coagulative factors are noted in obesity?

A
  • Fibrinogen
  • Factor VII
  • Factor VIII
  • Von Willebrand

Increased levels = hypercoagulability.

S6

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12
Q

Why does endothelial dysfunction occur in the obese patient?

A

Due to ↑ factor VIII and von Willebrand.

S6

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13
Q

Gastric ____ and ____ are increased in the obese patient.

A

Gastric volume and acidity are increased.

S7

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14
Q

What intubation risk factors are present in an Obese patient due to changes in the GI system?

A
  • Delayed gastric emptying
  • ↑ chance of gastric volume > 25mL
  • ↑ chance of pH < 2.5

The low pH and increased gastric volume increase chance for aspiration pneumonitis

S7

Hepatic function is altered = drug metabolism altered

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15
Q

What are the results of increased intragastric pressure secondary to obesity?

A
  • LES relaxation
  • Hiatal hernia formation (often asymptomatic)

S7

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16
Q

Glomerular ____ occurs with obesity due to increased renal blood flow.

A

hyperfiltration

S8

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17
Q

What are the consequences of increased renal tubular reabsorption secondary to obesity?

A
  • Impaired natriuresis
  • RAAS activation = therefore increased systemic BP

S8

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18
Q

What are the endocrine effects of obesity?

A
  • ↑ SNS activity
  • Insulin resistance/impaired glucose metabolism
  • Enhanced NE and Angiotensin II activity
  • Na⁺ retention (coupled with poor diet contributes to HTN)
  • Thyroid hormone resistance = hypothyroidism in 25% of morbidly obese pts

INSET

S9

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19
Q

Common diseases seen in association with obesity

A
  • Type 2 diabetes mellitus
  • Obstructive sleep apnea (side effect of the underlying process)
  • Asthma
  • Chronic obstructive pulmonary disease
  • Hypertension
  • Cardiovascular disease
  • Cancer
  • Osteoarthritis (increased wear/tear on the body bc of increased weight)

D10

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20
Q

Metabolic syndrome diagnosis requires 3 of the following:

A
  • Abdominal obesity
  • ↓ HDL levels
  • ↑ Triglycerides
  • Hyperinsulinemia
  • Glucose intolerance
  • Hypertension
  • Inflammatory state
  • Thrombotic state

S11

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21
Q

Risk factors for metabolic syndrome

A
  • Increased age
  • Men
  • Hispanics and South Asians

HIM

S12

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22
Q

What drugs may cause metabolic syndrome?

A
  • Chronic corticosteroids
  • Antidepressants
  • Antipsychotics
  • Protease inhibitors

S12

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23
Q

With metabolic syndrome, pts have an increased risk of

A
  • CV disease
  • DM2
  • PCOS
  • Non-ETOH fatty liver disease
  • Improper immune responses

98% resolved with bariatric surgery and achieving weight loss goal

S13

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24
Q

Differentiate OSA and hypopnea.

A
  • OSA: Complete cessation of breathing lasting 10 seconds or more (5 times or more an hour) decreased sat by 4%
  • Hypopnea: Airflow reduction by ≥ 50% lasting 10 seconds or more (15 times or more an hour) decreased sat by 4%

S14

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25
Q

What is a sleep study called

A

polysomnography

S15

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26
Q

What would a mild apnea/hypopnea index be?

A

5 - 15 events/hour

S15

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27
Q

What would a moderate apnea/hypopnea index be?

A

15 - 30 events/hour

S15

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28
Q

What would a severe apnea/hypopnea index be?

A

More than 30 events/hour

S15

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29
Q

CPAP is necessary for treatment of moderate or severe OSAHS (Obstructive sleep apnea and hypopnea syndrome) due to risk of what complications?

A
  • Systemic/Pulmonary HTN
  • LVH
  • Dysrhythmias
  • Cognitive impairment

Saul Left Dracula Carefully

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30
Q

What’s another name for Obesity Hypoventilation Syndrome?

A

Pickwickian Syndrome

S16

31
Q

What causes Pickwickian syndrome?

A

Long-term OSA
5-10% of mobidly obese

S16

32
Q

What does Pickwickian syndrome cause?

A

Pulm HTN and Cor Pulmonale

S16

33
Q

How is Pickwickian syndrome diagnosed?

A
  • > 30 BMI
  • Awake hypercapnia

S16

34
Q

What drug(s) classes are used to treat obesity?

A
  • Phentermine
  • Orlistat
  • OTC Herbals
  • GLP-1 Agonists

S17

35
Q

How does Phentermine work?
What are it’s side effects?

A
  • Sympathomimetic that decreases appetite
  • ↑HR, palpitations, HTN, dependence, abuse

S17

36
Q

How does Orlistat work?
What are the adverse effects associated with it?

A
  • Orlistat blocks absorption of dietary fat
    • do I remember with Dr. T that orlistat is a 5HT3 inhibitor?
    • Lipase inhibitor, not 5HT3 inhibitor
    • oh sibutramine is the 5HT3/NE inhibitor…
  • Liquid, fatty stools, urgency, flatulence, cramping and malnourishment.
  • Fat soluble vitamin deficiencies

S17

37
Q

How can Orlistat precipitate coagulopathy?

A

Possible Vit K deficiency → prolonged PT

S17

38
Q

Which herbals are pancreatic lipase inhibitors?

A

Caffeine
Green Tea

S17

39
Q

How do ginseng, ephedra, and sunflower oil “treat” obesity?

A

Appetite suppression

S17

40
Q

What berry is an OTC herbal energy stimulant?

A

Acai

S17

41
Q

What OTC Herbals regulate lipid metabolism?

A
  • Soybean Oil
  • Fish Oil
  • Oolong tea

S17

42
Q

For patients taking a GLP-1 Agonist on a weekly basis, it is recommended to hold the dose for ____ prior to surgery.

A

1 week

S18

43
Q

How would a patient be treated if they forgot to hold their GLP-1 Agonist prior to surgery?

A

The patient is to be treated as a full stomach or gastric contents need to be evaluated by US.

S19

44
Q

What to focus on with an obese pt in your preop eval

A
  • HTN
  • DM
  • HF
  • Hypoventilation syndrome or OSA

S24

45
Q

CPAP pressures usage of > ____ cmH₂O are associated with difficult mask ventilation.

A

10 cmH₂O

Corn says to make them very awake for induction and emergence

S24

46
Q

Preop eval surgical history things to focus on

FYI slide

A
  • compare past vs current weight
  • ease vs difficult intubations based on past notes
  • IV access
  • do they need an ICU admission?
  • what were the surgical outcomes?

Even if they have lost weight, they may still have some comorbidities associated with obesity - these pts tend to do poorly with sx (bad wound healing etc)

S25

47
Q

Considerations for obese pts going to the OR

FYI slide

A
  • continue home meds (except antihypertensives, insulin and oral hypoglycemics)
  • ABX
  • DVT prophylaxis
  • Aspiration prophylaxis (pepcid or more)

S26

48
Q

Ventilation abnormalities we should expect in an obese pt

A
  • decreased VC
  • decreased IC
  • decreased ERV
  • decreased FRV
  • low compliance

S27

49
Q

How does closing capacity compare to tidal breathing in the morbidly obese patient?

A

Closing capacity ≈ Tidal breathing

Especially when recumbent/supine - we will see rapid desatting.

S27

50
Q

Plan for these things with your intraoperative care of an obese pt

(FYI and duh)

A
  • Positioning (can be difficult)
  • Airway management (plan for the worst - glidescope)
  • Monitoring
  • Choice of anesthetic technique
  • Pain control
  • Fluid management

S29

51
Q

What is the most important respiratory/ventilatory intervention that can be done for the obese patient prior to intubation?

A

Preoxygenate.

Corn

52
Q

Complications of the supine position with an obese pt

A
  • Ventilatory impairment
  • Compression of IVC and Aorta
  • Rhabdomyolysis of the gluteal muscles - leads to renal failure and death

S30

53
Q

Is prone or lateral decubitus positioning preferred in the obese patient?

A

Lateral decubitus

S30

54
Q

What oropharynx change occurs with obesity?

A

Oropharynx shape becomes elliptical w/ a short transverse and long AP axis.

S35

55
Q

Increased ____ ____ deposited into the airways can complicate airway management.

A

Adipose tissue

S35

56
Q

What is the relationship between degree of obesity and pharyngeal area?

A

Inverse relationship

More obese = Less pharyngeal area.

S35

57
Q

What predictors of difficult intubation are of particular importance in the obese patient?

A
  • BMI (though not all the time)
  • Small mouth opening
  • Large Teeth
  • Limited neck mobility
  • Retrognathia or micrognathia

S36

58
Q

What axes need to line up for intubation?

A

Laryngeal, Pharyngeal, and oropharyngeal

with obese pts, don’t just lift up the head, their shoulders need lifting up too and neck extension

S37

59
Q

How quickly will a patient with a normal BMI desaturate from 100% to 90% SpO₂?

A

6 minutes

Andy

60
Q

How quickly will a patient with a morbidly obese BMI desaturate from 100% to 90% SpO₂?

A

3 minutes or less

Andy

61
Q

What is the best positioning on an OR table for recruitment in an obese patient?

A
  1. 30° Reverse Trendelenburg
  2. 25-30° with the head up

S41

62
Q

What measures should be taken for alveolar recruitment to prevent atelectasis and desaturation in the obese patient?

A
  1. CPAP 10 cmH₂O during preoxygenation
  2. Positioning
  3. Recruiting maneuvers then PEEP 10cm
  4. Mechnical ventilation after induction

S41

63
Q

Which drug classes have exaggerated responses in obese patients (particularly those with OSA) ?

A
  • Opioids
  • Benzo’s
  • Propofol

S45

64
Q

Which agents are preferred in obese OSA patients?

A

Short-acting Opioids

  • Remifentanil
  • Fentanyl
  • and α2 agonists…dexmedetomidine

S45

65
Q

What dose of propofol would you use for induction in an obese pt?

A

Trick Question: Volatiles are preferred over prop because you have more control - but these pts do hang onto volatiles longer desflurane is targeted for these pts

S45

66
Q

____ is not a favored volatile in obese patients due to their greater O₂ demand.

A

N₂O

but Corn likes it because it’s off faster

S45

67
Q

What drug class (in general) will diminish ventilatory response to CO₂?

A

Volatile anesthetics

S45

68
Q

Initial dosing of drugs in obese patients should be based on ____

A

Lipid solubility of the drug

S46

69
Q

Which common anesthetic drugs are dosed based on Ideal Body Weight (IBW)?

A
  • Propofol
  • Vecuronium
  • Rocuronium
  • Remifentanil

I PRRV (this is slide 69…Perv)

S46

70
Q

Ideal Body weight Calculation

I have a feeling they may be tricky and ask this….

A

Men IBW = 50kg + 2.3 kg for each inch over 5 feet
Women IBW = 45.5 + 2.3 kg for each inch over 5 feet

Dr. T

71
Q

Which common anesthetic drugs are dosed based on Total Body Weight (IBW)?

A
  • Midazolam
  • Succinylcholine
  • Cisatracurium
  • Fentanyl
  • Sufentanil

MS Combs Found Sue

S46

72
Q

Why do obese pts get cold quicker?

A

Larger surface area

be aware of your thermal management

S47

73
Q

IV fluids requirements are ____ than what’s predicted in order to prevent acute tubular necrosis in the obese patient.

A

greater

S48

Mar: Sem 4 - Principles II (27 decks)

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