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Anesthesia Physiology II > III. Obesity > Flashcards

III. Obesity Flashcards

1
Q

Excess body fat associated diseases picture

A
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2
Q

BMI equation

A
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3
Q

most commonly used quantifier of obesity

A

BMI

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4
Q

BMI does/does not measure adipose tissue directly.

A

does NOT

Distribution of body fat more important

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5
Q

Overweight BMI

A

25.0-29.9

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6
Q

Obesity (class I) BMI

A

30.0-34.9

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6
Q

Obesity (Class II) BMI

A

35.0-39.9

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7
Q

Morbid Obesity (Class III)

A

> 40

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8
Q

BMI Table Picture

A
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9
Q

Android obesity, characterized by truncal distribution of fat, is more common in what gender?

A

Male

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10
Q

Android vs Gynecoid:
associated with increase in oxygen consumption andn an increased incidence of CVD

A

Android

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11
Q

Gynecoid obesity more common in male/female

A

female

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12
Q

Gynecoid vs android obesity:
adipose distribution in hips, buttocks, thighs

A

gynecoid

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13
Q

intra-abdominal fat is particularly associated with ____ and ____.

A

CV risk, LVD

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14
Q

Obesity has a ____ pattern of ventilation

A

extrinsic restrictive

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15
Q

obesity changes in ventilation:
FRC:
ERV:
TLC:
Chest wall compliance:
Lung Compliance:
Airway resistance:
Closing Capacity:

A

FRC: ↓
ERV:↓
TLC:↓
Chest wall compliance: ↓
Lung Compliance: ↓
Airway resistance: ↑
Closing Capacity: ↑

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16
Q

____ becomes greater than FRC, resulting in atelectasis with normal tidal breathing

A

Closing Capacity

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17
Q

Obesity causes what type of V/Q mismatch?

A

R→L = arterial hypoxemia

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18
Q

Many obese patients have clinically significant ____.

A

OSA

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19
Q

Apnea is defined as ____ of total cessation of airflow despite continuous respiratory effort

A

10 seconds or more

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20
Q

OSA can lead to ____ syndrome.

A

Pickwickian Syndrome (OHS)

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21
Q

Pickwickian Syndrome is characterized by what daytime PaCO2 level?

A

> 45 mmHg

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22
Q

Chronic Pickwickian Syndrome can lead to:

A
  • Pulmonary HTN Cor Pulmonale
  • RV Failure (2/2 Pulmonary HTN)
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23
Q

What disease is a major cause of M&M in obese patients?

A

CVD

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24
Q

Obese patients suffer from systemic HTN 2/2 ____

A

hyperinsulinemia

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25
Q

Obese patients are at risk for CAD, especially those with ____ syndrome.

A

Metabolic

Metabolic syndrome includes high blood pressure, high blood sugar, too much body fat around the waist and irregular cholesterol levels.

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26
Q

Obese patients with CVD may also develop what other heart condition?

A

CHF

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26
Q

____ and ____ increase to perfuse additional fat stores

A

CO
blood volume

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27
Q

Obese patients may undergo LV Remodeling, which is characterized by:

A

Increased SV
Increased Cardiac Workload
Ventricular dilitation

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28
Q

Increased LV Wall stress leads to (5 things):

A
  1. LVH (2/2 systemic HTN)
  2. Reduced compliance
  3. Impaired LV filling
  4. Obesity cardiomyopathy
  5. Biventricular Failure (eventually)
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29
Q

Obesity CV Effects Picture

A
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30
Q

Obesity CV Effect Flowchart Picture

A
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31
Q

Obesity accelerates ____.

A

atherosclerosis

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32
Q

Obese patients that have systemic hypertension usually develop what cardiomyopathy?

A

LVH

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33
Q

Obese patients are at increased risk for hypercoagulability and therefore at risk of ____

A

VTE

obese patients should receive thromboembolism prophylaxis perioperatively (heparin)

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34
Q

____ is a mojor independent risk factor for sudden death from PE postoperatively.

A

MO (morbid obesity)

ABDOMINAL or PELVIC surgery increases risk moreso

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35
Q

Obesity: Aspiration Risk

co-existing issues that increase risk for HH, GERD, & Delayed Gastric Emptying are:

A
  1. Gastroparesis 2/2 DM2 (& weight loss Rx)
  2. non-fasting state
  3. difficult airway (risk of gastric insufflation)
  4. Trauma (non-fasting state)
  5. Pain Meds (osteoarthritis)

opioids will delay gastric emptying

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36
Q

Obesity: Effects on GI System

Gatric volume & acidity are decreased/increased.

A

increased

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37
Q

Obesity: Effects on GI System

Most fasted morbidly obese patients presenting for elective surgery have gastric volumes ____ and gastric fluid pH ____

A

> 25 mL

< 2.5

(generally accepted values that increase risk for pneumonitis 2/2 regurgitation and aspiration)

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38
Q

Obesity: Effects on GI System

no studies have documented increased incidence of aspiration related to ____ (Aspiration risk is multifactorial)

A

BMI

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39
Q

Obesity: Effects on GI System

Obese patients often exhibit delayed gastric emptying, larger ____ & ____.

A
  • larger gastric volumes
  • larger residual volumes
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40
Q

Obesity: Effects on GI System

____ & ____ are often seen in obese patients

A

Hiatal Hernia
GERD

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41
Q

Obesity: Effects on GI System

what organ function is often altered inn obese patients

A

hepatic

Especially if they have CHF = ↓Hepatic Blood Flow

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42
Q

Obesity: Diabetes

High risk for DM 2 = insulin ____

A

resistance

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43
Q

Obesity: Diabetes

Increased adipose tissue = Increased resistance of peripheral tissuses to ____ = ____ intolerance

A
  • insulin
  • glucose
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44
Q

Obesity: Diabetes

Increased stress during surgery will lead to hyperglycemia which may precipitate treatment with ____

A

exogenous insulin

challenging to dose, because we dont always know how patients will respond

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45
Q

Obesity: Diabetes

predisposed to ____

A

wound infection

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46
Q

Obesity: Diabetes

Increased risk ____ during periods of myocardial ischemia

A

acute myocardial infarction (AMI)

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47
Q

Obesity: Diabetes

Increased risk of ____ during periods of hypoxemia (with hyperglycemia)

A

cerebral ischemia

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48
Q

Obesity: Endocrine

Metabolic Syndrome has at least 3 of the following:

A
  1. Excess central obesity
  2. Atherogenic dyslipidemia
  3. HTN
  4. Dysglycemia
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49
Q

Obesity: Endocrine

Metabolic syndrome patients are at increased risk for:

A
  • Increased risk of MI, Stroke and DM 2
  • Higher incidence of adverse periop outcomes
    Infection, atelectasis, postop ventilation
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50
Q

Obesity: Endocrine

Hypothyroid occurs in ____% of MO patients

A

25%

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51
Q

Obesity: Endocrine

Volume of Distribution (VD) in Obese patients is affected by:

A
  • Decreased total body water
  • Increased total body fat
  • Decreased lean body mass
  • Increased blood volume and CO
  • Altered protein binding
  • Altered lipid solubility
52
Q

Obesity: Endocrine

Volume of Distribution is taken into account for ____ dosing

A

loading/induction

53
Q

Obesity: Effects on Drug Elimination

Hepatic clearance is not usually affected, unless:

A
  • significant fatty infiltration
  • CHF (↓HBF = ↓Clearance)
54
Q

Obesity: Effects on Drug Elimination

Renal clearance of drugs is increased in obesity. Why?

A

because of increased renal blood flow and glomerular filtration rate (due to ↑CO and ↑Preload)

55
Q

Obesity: Effects on Drug Elimination

Clearance is considered for ____ dosing.

A

maintenance

56
Q

weight

what weight you get when you weigh yourself

A

total body weight

57
Q

lean body weight

TBW - ____

A

fat weight

generally need % body fat for calculation (sex, weight, height needed)

58
Q

Ideal body weight is based on ____ and ____.

A

sex and height

59
Q

IBW formula

A

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

60
Q

obesity

highly lipophilic drugs (propofol, benzos, opioids) have a/an ____ volume of distribution

A

increased

61
Q

obesity

highly lipophilic drugs are dosed based on ____

A

TBW

for normal patient, not obese?

62
Q

obesity

less lipophilic drugs have what type of change on volume of distribution?

A

little to no change

63
Q

obesity

less lipophilic drugs are dosed based on ____

A

Ideal or Lean body weight

64
Q

Increased blood volumes in obese patients ____ plasma concentrations of rapidly injected IV drugs

A

decreases

65
Q

Fat has poor blood flow and doses calculated on TBW could lead to ____.

A

excessive plasma concentrations

66
Q

Subsequent dosing is based on ____

A

response to first dose

67
Q

What consideration should be made when using succinylcholine with obese patients?

A

obese patients have a higher level of plasma cholinesterase and a greater volume of distribution

68
Q

what method should be used when dosing succinylcholine in obese patients?

A

use TBW

morbidly obese patients will get the whole 200mg stick of succs (must avoid underdosing)

69
Q

What two major systems should be focused on during a preoperative evaluation for an obese patient?

A
  1. cardiopulmonary system
  2. Airway
70
Q

obese pt

What vitals & Labs should be reviewed?

A

BP, Glucose, HbA1c, GFR, ECG, ABG, TTE

71
Q

obese

What are signs of cardiac failure that can be observed in preop

A
  1. Elevated jugular venous pressure
  2. Pulmonary Crackles
  3. Peripheral Edema
72
Q

obese pt

Assume ____ HTN

A

pulmonary

73
Q

obese pt

General anesthetic plan considerations

A
  1. Difficult IV
  2. A-Line
  3. Positioning
  4. BP cuff (large arms?/tucking)
  5. Consider regional/local/peripheral nerve blocks
  6. Minimize respiratory depression (post op opioids)
74
Q

Anatomic changes that make difficult airways:

A
  1. Limited joint/cervical mobility (cervical fat pads)
  2. Redundant tissue in mouth, posterior pharynx
  3. Short thick neck
  4. shortened distance between mandible and sternal fat pad, enlarged breasts
  5. very thick submental fat pad

*OSA also predisposes to difficult airway.

75
Q
A
76
Q

single biggest predictor of problematic intubation:

A

neck circumference

77
Q

40 cm neck circumference = ____% probability of problematic intubation

A

5%

78
Q

60 cm neck circumference = ____% problematic intubation

A

35%

79
Q

larger neck circumference is associated with:

A
  1. male sex
  2. higher mallampati
  3. Grade 3 views at laryngoscopy
  4. OSA
80
Q

Obesity: Monitoring

____ should be brought from home (used on the floor, not so much in recovery)

A

CPAP devices

81
Q

Obesity: BP Monitoring

  • falsely ____ if too small
  • forearm measurements will under/over estimate sys/dys BP
A
  • high
  • over
82
Q

obese pt

what BP monitoring devices should be considered?

A

Clear site or Flo Track

83
Q

Obesity: Pre-Op Meds

what type of prophylaxis medication should be considered?

A
  1. DVT Prophylaxis (SCDs, LMW Heparin)
  2. H2 Antagonists
  3. Non-Particulate Antacids
  4. PPIs

sequential compression device (SCD)

84
Q

obesity:

intra-op considerations

A
  • low threshold for intubation (2/2 to increased risk aspiration, hypoventilation, bad A/W)
  • Video DL or FO
  • PPV: may require increased FiO2, especially lithotomy, prone, T-burg
  • Increased minute ventilation to lower EtCO2 prior to insufflation and T-burg
85
Q

What positions may require increased FiO2?

A
  1. Lithotomy
  2. Prone
  3. T-burg
86
Q

What are two instances where we would increase MV ahead of time IOT decreased EtCO2?

A
  1. prior to insufflation
  2. prior to T-burg
87
Q

Hypercarbia will exacerbate pre-existing ____.

A

P. HTN

88
Q

What are two physiologic reasons that obese patients may rapidly desaturate during induction of anesthesia?

A
  1. increased oxygen consumption
  2. Decreased FRC
89
Q

____ during preoxygenation decreases atelectasis formation and improves oxygenation.

A

PPV

90
Q

What position provides the longest safe apnea period during induction of anesthesia?

A

Reverse T-Burg

91
Q

what other adjuncts may be used to optimize patient airway

A

Troop elevation pillow/ stacking pillows/ blankets

92
Q

External auditory meatus should be in line with ____.

A

sternal notch

93
Q

increase the angle between the chin and ____

A

sternum

angle of Dr. Martin

94
Q

complications from supine position:

A
  1. ventilatory impairment
  2. inferior vena cava & aortic compression
95
Q

Trendelenburg further worsens ____ and should be avoided

A

FRC

also decreased chest wall compliance

96
Q

Reverse T-burg increases ____, which results in lower airway pressures (most favorable).

A

compliance

97
Q

Complications with prone position:

A
  1. decrease lung & chest wall compliance, ventilation, & arterial oxygenation
  2. Increased intra-abdominal pressure worsens IVC and Aortic compression, further decreases FRC
98
Q

Factors making controlled ventilation problematic

A
  • Decreased pulmonary O2 reserves = desaturation
    (2/2 Decreased FRC, increased O2 consumption)
  • Trendelenburg or Prone = Decrease chest wall compliance
  • Insufflation = Increased intraabdominal pressure, worsens lung compliance
99
Q

Why do obese patients desaturate quickly?

A
  1. Decrease FRC
  2. Increased oxygen consumption
100
Q

the only ventilatory parameter that has consistently been shown to improve respiratory function in obese patients
Improves

A

PEEP

101
Q

What are the benefits of PEEP?

A
  • Improves FRC,V/Q matching and O2 sat
  • Increases PIP’s, PAWP’s
102
Q

Potential complication of PEEP

A

May reduce venous return and cardiac output

103
Q

What may occur after insufflation with T-burg?

A
  • Ventilation may be impeded
  • PAWP, EtCO2 increasing,
  • TV decreasing
  • EtCO2: hypercarbia, respiratory acidosis, worsen pulmonary HTN
104
Q

What to do IOT manage obese patients undergoing insufflation in T-burg?

A
  • 7.5-8.0 ETT, cuff up (larger tube better)
  • Hyperventilate after intubation - VERY IMPORTANT
  • Increase I/E: if not a risk for auto PEEP, can limit increased PAWP (1:2 to 1:1)
  • Recruitment maneuvers to prevent atelectasis
  • Using pressure-controlled ventilation
  • increase FiO2 (100%)
  • Monitor the bellows (should be very smooth up/down)
105
Q

Increasing the I:E ratio should be used with caution if patient has:

A

COPD (Emphysema, Chronic Bronchitis)

High-risk for Auto PEEP

These patients benefit from increasing EXPIRATORY phase, so they do not air trap (Auto PEEP can cause decreased venous return, extreme HoTN)

106
Q

obesity: insufflation & T-burg

biphasic cardiovascular response

A

as intraabdominal pressure increases:
-10mmHg: ↑ venous return, CO, BP
-20mmHg:
↓venous return (LE), ↑renal vascular resistance (2/2
backup), ↓RBF, ↓GFR
**Aortic Compression: ↑SVR, LV wall stress, ↑myocardial O2
demand (therefore consider decreasing afterload)
**IVC compression* and see decreased preload & HoTN (Tx:
Milrinone?)

107
Q

How to treat HTN 2/2 to T-burg and insufflation:

A
  • start with increasing VA
  • Systemic VD (Hydralazine, SNP, CCB)
108
Q

In T-burg there is decreased femoral blood flow which puts patients at increased risk of ____.

A

DVT

109
Q

P

Major post-operative concern:

A

Respiratory Failure

110
Q

Postoperatively, obese patients are at increased risk of ____.

A

hypoxia

especially when hypoxia present preop

111
Q

Safest way to extubate obese patients:

A
  • Sitting upright
  • awake
  • Full NMB reversal
  • Supplemental O2
  • CPAP or BiPAP
112
Q

Best method of analgesia:

A

multimodal (avoid opioids)

113
Q

reason patients come in with low sats (92%)

A

baseline atelectasis
(will likely worsen perioperatively)

114
Q

only way to treat low baseline sats?

A

incentive spirometer to try and re-expand airways

115
Q

OSA picture

A
116
Q

OSA is an independent risk factor for:

A

HTN
Cardiovascular morbidity and mortality
Sudden death

117
Q

OSA: Greater risk for both ____ and postoperative airway ____ & ____.

A
  • difficult mask ventilation/intubation
  • obstruction
  • hypoventilation
118
Q

OSA patients may exhibt the following chronic complications:

A

o1. hypercapnia
2. cyanosis-induced polycythemia
3. Right HF
4. Somnolence
5. Blunted Respiratory Drive
6. A/W obstruction
7. Apnea

119
Q

OSA causes what perioperative complications:

A
  1. HTN
  2. Hypoxia
  3. Arrythmias
  4. MI
  5. Pulm Edema
  6. Stroke
  7. Death
120
Q

During Postop period, OSA patients are vulnerable, especially with ____

A

sedation

(supine patients may obstruct)

121
Q

STOP BANG

A
  • snore loudly
  • Tired
  • Observed stop breathing during sleep
  • Pressure (high blood pressure)
  • BMI > 35
  • Age >50
  • Neck >40 cm (15.7”)
  • Gender (male)

0-2 = low risk
3-4 = intermediate risk
≥5 = high risk

3+ = Positive

122
Q

AHI (Apnea-Hypopnea Index) scoring:

Combined average number apnea, hypopnea episodes occurring per hour of sleep

A

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

123
Q

What secondary variable does AHI look at to evaluate OSA severity?

A

O2 Saturation (“nadir”)

<90% = moderate
>80% = severe

124
Q

Severe OSA, BMI’s > 45-50 = No/Yes to ASC

A

NO

125
Q

patient with OSA unable to stay awake on PACU, RN must place O/A and jaw thrust to keep O2 Sats>90%. What is occuring physiologically?

A
  • severe respiratory acidosis
  • CO2 narcosis
  • potential electrolyte imbalance (Potassium?)
  • needs to be reintubated
126
Q

STOP BANG questionnaire sensitivity increases with ____

A

increasing AHI Severity

5-15 = 83%
15-30 = 93%
>30 = 100%

127
Q

Obese Patient Ramping Picture

A
128
Q

Recommended Weights for Dosing of Common Anesthetic Drugs in Obese Picture

A

Anesthesia Physiology II (3 decks)

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