Exam 3 - Obesity (Grayson's) Flashcards
What is the #1 cause of medically-related preventable deaths?
Smoking
Obesity is #2.
what is the BMI equation?
pt weight (kg) / height^2 (m^2)
kg/m2
Android body fat distribution is associated with: select 2.
A. hyperthyroidism
B. DM type 2
C. CV disease
D. increased O2 consumption
C. CV disease
D. increased O2 consumption
Total blood volume is ____ in obesity.
A. decreased
B. increased
C. the same
B. increased
b/c most is distributed to adipose tissue
In obese patients, cardiac output will increase due to: select 2.
A. increased HR
B. increased SV
C. LV dilation
D. RV hypertrophy
B. ↑ stroke volume
C. LV dilation
CO ↑ by 20-30 mL/kg of excess body fat
An obese patient may present with what kind of cardiac rhythm disturbances? select 2.
A. LV hypertrophy and left axis deviation
B. RV hypertrophy and right axis deviation
C. low QRS voltage
D. high QRS voltage
A. LV hypertrophy and left axis deviation
C. low QRS voltage
Increased levels of what hematologic factors cause an obese patient to be hypercoagulable? select 4.
A. Factor I
B. Factor II
C. Factor V
D. Factor VII
E. Factor VIII
F. Factor X
F. von Willebrand
A. Fibrinogen (factor I!)
D. Factor VII
E. Factor VIII
F. Von Willebrand
also causes endothelial dysfunction (factor 8 and vWF)
In obesity, gastric volume and acidity are:
A. increased
B. decreased
C. the same
Gastric volume and acidity are increased. = which places them at higher aspiration risk
Delayed gastric emptying is common in obese patients. What gastric volume and pH place an obese pt at high risk for aspiration pneumonitis?
gastric volume > 25mL
pH < 2.5
What are the results of increased intragastric pressure secondary to obesity? select 2.
A. contraction of LES
B. relaxation of LES
C. formation of hiatal hernia
D. formation of inguinal hernia
B. relaxation of LES
C. Hiatal hernia formation
Increased renal blood flow in obesity results in glomerular ____.
A. hypofiltration
B. hypertension
C. hyperfiltration
D. hypernatremia
C. hyperfiltration
The consequences of increased renal tubular absorption include: select 2.
A. hyperkalemia
B. impaired natriuresis
C. hyperglycemia
D. activation of RAAS
B. Impaired natriuresis
D. RAAS activation
T/F: An increased level of SNS activity is seen in obesity which causes sodium retention and insulin resistance.
True.
Also:
- enhanced activity of NorEpi and Ang-II
- Thyroid hormone resistance - hypothyroidism in 25% of morbidly obese pts
that’s why we commonly associate other diseases with obesity like DM type 2, HTN, OSA, asthma, COPD, CV disease, cancer
Metabolic syndrome diagnosis requires 3 of the following:
- **Abdominal obesity (android)
- **↓ HDLs
- **↑ Triglycerides
- Hyperinsulinemia
- ** Glucose intolerance
- ** HTN
- Proinflammatory state
- Prothrombotic state
Diagnosis of metabolic syndrome uses:
A. BMI
B. waist circumference
C. TBW
D. IBW
B. waist circumference (not BMI)
risk factors for metabolic syndrome include: choose 3.
A. men
B. hispanics
C. younger
D. older
E. chronic NSAID use
F. chronic alcoholism
A. men
B. hispanics and south asians
D. older
rude, we just like tortillas ok..
What drugs may cause metabolic syndrome?
- Chronic corticosteroids
- Antidepressants
- Antipsychotics
- Protease inhibitors (ex: amprenavir, ritonavir…)
Differentiate OSA and hypopnea.
- OSA: Complete cessation of breathing lasting 10 secs or more (5 times or more/hour sleep)
- Hypopnea: Airflow reduction by ≥ 50% lasting 10 secs or more (15 times or more/hour sleep)
both decr sats 4%
mild apnea/hypopnea index (AHI) is:
5 - 15 events/hour
moderate apnea/hypopnea index (AHI) is:
15 - 30 events/hour
severe apnea/hypopnea index (AHI) is:
More than 30 events/hour
What medical mgmt is required for mod/severe OSAHS disease? select 2.
A. gastric sleeve procedure
B. liposuction
C. CPAP
D. wt loss
E. ECMO
C. CPAP
D. weight loss
What causes Pickwickian syndrome (OHS)?
A. renal disease
B. long term OSA
C. HTN
D. a fib/a flutter
B. Long-term OSA
5-10% of morbidly obese
Pickwickian syndrome (OHS) can eventually cause:
A. left axis deviations
B. left BBB
C. cor pulmonale
D. congestive heart failure
C. cor pulmonale - usually caused by pulmonary HTN!
The diagnosis of Pickwickian syndrome requires: select 2.
A. BMI > 30
B. BMI > 40
C. mod-severe AHI
D. awake hypercapnia
A. BMI > 30 kg/m2
D. Awake hypercapnia
Used for medical mgmt of obesity, which drug is a sympathomimetic that decreased appetite, but also caused tachycardia and palpitations?
A. orlistat
B. ozempic
C. ginseng
D. phentermine
D. phentermine
(fda approved for only 3 mos)
Orlistat blocks absorption of dietary fat. What are the side effects associated with this medication?
A. constipation
B. increased pulse rate
C. liquid stools and fecal urgency
D. hypoglycemia
C. Liquid stools and fecal urgency, as well as flatulence and abd cramping.
Chronic use of Orlistat led to possible deficiencies in what:
A. vWF
B. vit A, D, E, and K
C. factor VII
D. vitamin B12
B. vitamin A, D, E, and K (fat soluble vitamins!)
note: vit K deficiency = prolonged PT!
Which OTC herbals are pancreatic lipase inhibitors? select 2.
A. acai berry
B. caffeine
C. green tea
D. sunflower oil
B. Caffeine
C. Green Tea
Ginseng, ephedra, and sunflower oil are OTC herbals that are:
A. energy stimulants
B. pancreatic lipase inhibitors
C. appetite suppressants
D. lipid metabolism regulators
C. Appetite suppressants
This OTC herbal is an energy stimulant used for weight loss.
A. caffeine
B. acai berry
C. soybean
D. ephedra
B. acai berry
What OTC Herbals regulate lipid metabolism? select 3.
A. acai berry
B. ginseng
C. soybean
D. fish oil
E. oolong tea
F. sunflower oil
C. soybean
D. fish oil
E. oolong tea
For patients taking a GLP-1 Agonist on a weekly basis, it is recommended to hold the dose for ____ prior to surgery.
A. 3 days
B. 24 hrs
C. 1 week
D. 2 weeks
C. 1 week
cornelius said sometimes 2 weeks but the ppt says 1 week…also make sure to manage their sugars tho if they’re taking this for diabetes
How would a patient be treated if they forgot to hold their GLP-1 Agonist prior to surgery?
The patient is to be treated as a full stomach or gastric contents need to be evaluated by US.
so RSI them
CPAP pressures of > ____ cmH₂O are associated with difficult mask ventilation.
10 cmH₂O
Based on this ppt, which home meds do you want to discontinue preoperatively? Select 3.
A. antihypertensives
B. multivitamins
C. antipsychotics
D. antidepressants
E. insulin
F. oral hypoglycemics
A. antihypertensives (esp ACE-I)
E. insulin
F. oral hypoglycemics (metformin, glipizide, etc)
How does closing capacity compare to tidal breathing in the morbidly obese patient?
Closing capacity ≈ Tidal breathing
Especially when recumbent/supine.
What is the most important respiratory/ventilatory intervention that can be done for the obese patient prior to intubation?
Preoxygenate. Desaturation occurs rapidly!
What can possibly lead to renal failure when a morbidly obese patient is placed in the supine position?
Rhabdomyolysis on gluteal muscles
What kind of shape does the oropharynx change into because of the extra adipose tissue?
ellipse - short transverse/long AP axis
Is prone or lateral decubitus positioning preferred in the obese patient?
Lateral decubitus - b/c prone causes too much pressure and skin breakfdown
What is the relationship between degree of obesity and pharyngeal area?
Inverse relationship
More obese = Less pharyngeal area.
may be hard to get tube in there
What are some predictors of difficult intubation to watch out for? select 3.
A. small mouth opening
B. missing teeth
C. inablitiy to stick tongue out
D. limited neck mobility
E. retrognathia
F. neck circumference
A. small mouth opening
D. limited neck mobility
E. retrognathia
also:
- large/protuberant teeth
- BMI (but not necessarily an independent predictor)
What 3 axes need to aligned for intubation?
Laryngeal, Pharyngeal, and oropharyngeal (C in pic)
may need to ramp pt for this to occur or roll blankets under their shoulders
How quickly will a patient with a normal BMI desaturate from 100% to 90% SpO₂?
what about morbidly obese BMI?
normal BMI (18.5-25) : 6 minutes
morbidly obese BMI (>40) : less than 3 mins
What is the best positioning on an OR table for recruitment in an obese patient?
-
30° Reverse Trendelenburg
or 2. head elevated 25-30°
What measures should be taken for alveolar recruitment to prevent atelectasis and desaturation in the obese patient?
- CPAP 10 cmH₂O during preoxygenation
- Positioning (30deg reverse T)
- Recruiting maneuvers then PEEP 10cm H2O
- Mechnical ventilation quickly after induction
also consider waking them up on CPAP to keep this recruitment!
If an obese has identifiable aspiration risk factors, what prophylaxis measures should you take? select 2.
A. PPIs and/or H2-R antagonists
B. RSI
C. OGT
D. nasal intubation
A. PPIs and/or H2-R antagonists
B. RSI
Regional anesthesia may be a great alternative for obese patients but what are some considerations to be mindful of? select 2.
A. might need more airway manipulation
B. less postop pain control
C. epidurals will require smaller doses
D. more risk of PONV
E. hypotension after block d/t IVC compression
C. epidurals will require smaller doses d/t smaller space so worry about cephalad spread
E. hypotension after block d/t IVC compression - consider co-loading them to avoid the HoTn!
BP cuff bladders should circle at least ____% of circumference.
75%
Which medications are preferred in obese/OSA patients? select 3.
A. remifentanil
B. sufentanil
C. dexmedetomidine
D. ketamine
E. midazolam
A. Remifentanil or Fentanyl = short acting!
C. dexmedetomidine
D. ketamine - cornelius mentioned it again
What volatile is NOT favored in obese patients due to their greater O₂ demand?
A. sevoflurane
B. desflurane
C. nitrous
D. isoflurane
C. nitrous
What anesthetic will diminish ventilatory response to CO₂?
A. TIVA with propofol
B. volatiles
C. midazolam
D. dexmedetomidine
B. volatiles
Initial dosing of drugs in obese patients should be based on:
A. lipid solubility
B. protein/albumin levels
C. tissue solubility
D. pKa
A. Lipid solubility
- if based on tissue solubility then desflurane probably favored
Which 4 common anesthetic drugs are dosed based on Ideal Body Weight (IBW)?
- Propofol
- Vecuronium
- Rocuronium
- Remifentanil
Which common anesthetic drugs are dosed based on Total Body Weight (TBW)?
- Midazolam
- Succinylcholine
- Cisatracurium
- Fentanyl
- Sufentanil
IV fluids requirements are ____ (less or greater) than what’s predicted in order to prevent acute tubular necrosis in the obese patient.
IV fluids requirements are greater than what’s predicted in order to prevent acute tubular necrosis in the obese patient.
If pt has difficult IV access, what should be placed?
central line
If BP cuff doesn’t fit or having a diffcult time getting accurate measurements, what should you do?
Arterial line
also consider this if you need to monitor ABGs!!!
What should be given to FULLY reverse neuromuscular blockade?
sugammadex!
During emergence, what should you do to keep some level of recruitment?
A. give neostigmine and atropine
B. suction oropharynx
C. keep pressure support
D. place LMA
C. keep pressure support!
and AVOID LMAs since they won’t really seat well and end up stimulating pt way more = NPA is way better!
Which drugs/classes have exaggerated responses in obese patients (particularly those with OSA)? select 3.
A. ketamine
B. opioids
C. propofol
D. dexamedatomidine
E. benzodiazepines
B. opioids
C. propofol
E. benzodiazepines
consider doing short acting like remifentanil
