Obese Adult and Child Lecture 1 Flashcards
1
Q
Formula for BMI
A
weight in kg/ height in meters squared
2
Q
BMI chart also known as
A
Quetelet’s index
3
Q
Morbidly obese is BMI>__ or ?
A
40; BMI 35-49.9 with obesity related comorbidity
4
Q
What is a good predictor of cardio respiratory comorbidity?
A
waist or collar circumference
5
Q
Another term for IBW is?
A
Broca’s index
6
Q
lowest morbidity and mortality for a given population
A
IBW
7
Q
IBW in kg formula for men
A
height (cm)-100
8
Q
IBW in kg formula for women
A
height (cm)-105
9
Q
total body weight minus adipose tissue
A
lean body weight
10
Q
Which weight category of individuals do you use lean body weight for?
A
morbidly obese; not obese
11
Q
formula for LBW
A
IBW X 1.3
12
Q
in nonobese and nonmuscular individuals TVW=?
A
IBW
13
Q
in morbidly obese patients, increase IBW by what percent to equal LBW?
A
20-30%
14
Q
LBW in morbidly obese is -/- of the difference between IBW and TBW?
A
1/3
15
Q
apple shape is also called?
A
android
16
Q
pear shape is also called?
A
gynoid
17
Q
which body shape has a significant correlation with metabolic syndrome?
A
android/apple
18
Q
What are 3 side effects of pear/gynoid shape?
A
varicose vein development, joint disease, decrease in type 2 diabetes
19
Q
This type of fat is metabolically static and functions as energy deposits like when pregnant or lactating?
A
pear/gynoid
20
Q
man having waist circumference > _ is risk factor?
A
102 cm/ 40 in
21
Q
woman having waist circumference > _ is risk factor?
A
88 cm/ 35 in
22
Q
What inflammatory mediators are elevated in obese patients?
A
AGT, transforming growth beta factors, TNF, IL6
23
Q
most effective tool for long term weight loss?
A
lifestyle counseling
24
Q
How does weight loss drug Phentermine work?
A
sympathomimetic
25
How does Orlistat work?
blocks the absorption of fat
26
EBV for obese?
45-50 mL/kg
27
How much does CO increase for every kg of fat gained?
0.1 L/min or 100 mL/min
28
an increasead CO is seen as an increase in __? __ remains the same
stroke volume, hr
29
What are 2 things in obese individual that increase blood volume?
hypoxic induced chronic resp insufficiency and increase in Na retention
30
In what four ways does the increase in circulating blood volume produce a greater demand on the myocardium?
by increasing metabolic rate, increasing O2 consumption, increasing CO2 production, and normal or slightly abnormal arteriovenous O2 difference
31
Most confirmatory test of pulmonary HTN with clinical eval?
tricuspid regurg
32
2 indicators of left ventricular dysfunction?
orthopnea or paroxysmal nocturnal dyspnea
33
Chronically elevated cardiac output leads to?
ventricular remodeling
34
6 step cardiovascular pathway in obese person
1- increased preload and stroke work 2- increased left ventricular heart pressures and wall stress 3- left ventricular hypertrophy 4- cardiomegaly 5- atrial and biventricular dilation 6- biventricular hypertrophy
35
For every 13.5 kg of fat the body regenerates additional __ miles of neovascularization?
25
36
HTN is defined as SBP> ? or DBP > or both?
140, 90
37
BP increases __ mm Hg for every 10% increase in body weight?
6.5
38
What 2 things are released in obese peoples' blood which increase viscosity?
catecholamines, estrogen
39
hyper__ increases levels of norepinephrine?
insulinemia
40
obese ppl have __ or __ levels of SNS activity?
normal or increased
41
What do increased levels of SNS activity predispose people to (3)?
increased insulin resistance, dyslipidemia, and HTN
42
For every 10 kg of weight gained, the SBP increases by ? and the DBP increases by?
3-4 mm Hg, 2 mm Hg
43
What type of effect does norepinephrine have on Na and Ca?
increased renal tubular reabsorption which results in hypervolemia
44
How does insulin have an effect on Na retention?
it stimulates adipocytes to release angiotensinogen then activates the renin angiotensin aldosterone pathway which leads to further Na retention and progression of HTN
45
Obese nonhypertensive pt: what happens to SVR, blood volume, and how is the heart dilated?
decreases SVR, increases blood volume and leads to eccentric dilated heart
46
Obese and uncontrolled HTN heart: what happens?
mixed eccentric/dilated and concentric/ventricular hypertrophy
47
What does obesity and uncontrolled HTN lead to?
heart failure and pulmonary HTN (dilation and hypertrophy)
48
Clotting factors elevated in obese pts?
fibrinogen, factor VII, factor VIII, von willebrand, plasminogen activator inhibitor (inhibits breakdown of clots)
49
how much more of an increase in developing a DVT bc of surgery does an obese pt have versus a nonobese pt?
50%
50
Why do obese patients have an increased risk of stroke?
prothrombotic and chronic inflammatory state seen with excessive adipose tissue accumulation
51
1 unit above BMI, there is a __% risk of ischemic stroke and a __% risk of hemorrhagic stroke?
4;6
52
What happens to elastic resistance and compliance in obese patients?
increased elastic resistance and decreased compliance of chest wall
53
fat accumulation forces the diaphragm where?
cephalad
54
Lung volumes that decrease with obesity?
FRC, ERV, VC, TLC
55
premature airway closure--> _____ --> _______ --> ________
VQ mismatch--> right to left shunting--> arterial hypoxic event
56
Supine positioning in obese pt reduces FRC up to __% as compared to 20% in non obese patient
50%
57
most sensitive indicator of pulmonary fucntion
expiratory reserve volume
58
volume of air present in the lungs at the end of passive expiration; at this the elastic recoil forces of the lungs and chest wall are are equal but opposite and there is no exertion of diaphragm or other muscles
FRC
59
the additonal amt of air that can be expired from the lungs by determined effort after normal expiration
ERV
60
3 lung volumes that remain the same in obese pts
residual volume, closing capacity, FEV1/FVC
61
volume of air still remaining in the lungs after expiratory reserve volume exhaled
residual volume
62
2 factors that contribute to decreased SaO2 during DL in obese pt
decreased FRC and increased O2 consumption
63
apnea is defined as (3):
reduction of airflow > 10 seconds, lasting > 15 episodes per hour of sleep, decrease in O2 saturation >4%
64
gold standard for sleep apnea diagnosis
overnight polysomnography
65
3 types of sleep apnea
central sleep apnea, OSA, mixed sleep apnea
66
type of sleep apnea that is respiratory efforts with no flow, periodic, partial, or complete obstruction, usually produced by excess soft tissue; unable to inhale effectively bc airway collapses
OSA
67
type of sleep apnea that is apnea without respiratory efforts
central sleep apnea
68
what causes pt to wake up with sleep apnea?
decreased O2 levels
69
type of sleep apnea that is delayed effort with varying degrees of obstruction
mixed
70
7 physiologic changes seen from OSA:
hypoxemia, hypercarbia, polycythemia, systemic HTN, pulmonary HTN (mean >25 at rest), right ventricular failure, cor pulmonale (pul HTN and right vent failure)
71
STOP questionnaire stands for?
Snoring, Tiredness, Observed you stop breathing, Pblood Pressure
72
BANG questionnaire stands for?
BMI> 35, Age >50, Neck circumference > 40cm, Gender male
73
High risk of the STOP BANG questionnaire is >__ items?
3
74
Difference in OHS versus OSA is?
nocturnal periods of central sleep apnea
75
Diagnosis of OHS (3)?
BMI> 30, daytime hypoventilation, awake PaCO2> 45
76
Only additional parameter shown to improve ventilation in obese patients?
PEEP
77
3 negatives of PEEP:
decrease CO, decreased venous return, reduced O2 delivery
78
2 GI conditions that are increased with obesity?
gallstones and pancreatitis
79
which sphincter is relaxed in GERD pts
lower esophageal
80
increased intragastric pressure causes 2 things:
lower esophageal sphincter relaxation (GERD) and hiatal hernia
81
what happens to the gastric volume and pH in obese pts?
increased gastric volume and pH more acidic
82
gastric volume > ? and pH
>25 mL, 2.5
83
What causes the delay in gastric emptying in obese patients?
increased abdominal mass, decrease in pH
84
How is gastric emptying affected by obesity?
decreased gastric emptying
85
elective surgery-obese patients should be given what 3 things?
bicitra, reglan, H2 blocker
86
elevated lab with nonalcoholic fatty liver disease?
ALT
87
Pathophysiology behind nonalcoholic fatty liver disease?
increased adipose tissue leads to intrahepatic triglycerides, impaired insulin activity, and release of inflammatory cytokines which leads to destruction of hepatocytes and disarray of hepatic physiology
88
Severe cases of NAFLD can lead to (3)?
portal HTN, cirrhosis, hepatocellular carcinoma
89
What happens to thryoid stimulation hormone in obese?
increases and have subclincal hypothyroidism
90
Why does obesity cause decreased insulin secretion?
pancrease becomes infiltrated with fat
91
What promotes insulin resistance in obese patients?
enlargement of adipocytes
92
3 factors that increase wound infection and silent MI?
insulin resistance, hyperglycemia, abnormal glucose tolerance test
93
One reason surgery increases need for exogenous insulin?
adrenal glands release cortisol in response to surgical stress
94
3/5 of these is metabolic syndrome
central obesity, HTN, high triglycerides, low HDL, insulin resistance
95
high triglyceride value?
>150
96
low HDL value?
men
97
insulin resistance is glucose >?
100 or 110
98
HTN in metabolic syndrome is BP>?
130/85
99
Metabolic syndrome is associated with what 2 conditions?
diabetes and cardiovascular events
100
AHA recommended what for metabolic syndrome patients as prophylaxis against events?
low dose ASA
101
Cancers associated with obesity?
breast, endometrial, colon, kidney, gallbladder, prostate
102
Most common symptom of pulmonary HTN?
SOB, tired, syncope
103
Vd of lipid soluble drugs decreases or increases in obese?
increases
104
is preop assessment of liver function in obese pts recommended?
yes
105
What happens to weight limitation in reverse positioning?
it is much less
106
Nerves at increased risk of damage in obese patients?
ulna, brachial plexus, radial, peroneal, and sphenoid
107
sniffing position-chin higher than?
chest
108
pharmacology in obese patients-give H2O meds according to what weight and lipid soluble meds for what weight?
H2O LBW and lipid total body weight
109
lipophilic drugs in obese pt have decreased or increased Vd?
increased, which means that the elimination 1/2 is prolonged d/t large vol of distribution
110
2 examples of commonly given lipophillic meds in anesthesia?
benzos and barbs
111
What do you have to be careful about as far as lipophilic meds go in the obese patient?
do not give multiple doses because they will accumulate in adipose tissue and you will see a prolonged effect
112
What happens to the Vd of hydrophilic drugs in obese pt?
it is unchanged
113
Nondepolarizing MR are calculated based off of what body weight?
IBW
114
Suxx is calculated based off of what body weight? Why?
TBW; pseudocholinesterase activity increases in obesity
115
Why does remifentanyl have limited potential to accumulate in fat tissue even thought it is highly lipophilic?
it is metabolized readily and rapidly by plasma esterase
116
the newer volatile anesthetics such as sevo and des are more water or lipid soluble?
water
117
What would a lipid soluble gas mean for emergence?
it would be more likely to accumulate in obese pts and delay emergence
118
Drugs with extensive extra hepatic metabolism have what kind of pharmacokinetics in obese and lean?
similar-remifent is an example
119
What kind of body weight do you base propofol induction dose on?
LBW
120
What kind of body weight do you base propofol maintenance dose on?
TBW
121
Because obese patients are vulnerable to side effects, how should you figure out the correct medication dose?
typically increase the dose by 20-40% over IBW so that it is based on lean body weight
122
Loading dose of Fent based on what?
TBW
123
Recommended rate of Dexmedetomidine in obese pts?
0.2mcg/kg/min
124
Remifent infusion rates are based on what body weight?
IBW
125
How many mL of clear fluids is okay 2 hours before surgery?
300 mL
126
How long should preoxygenation be in obese patient?
5 min
127
Emergency intubation in obese patient preox should be?
4 VC breaths on 100% FiO2 within 30 seconds of induction
128
Suxxs dose for RSI in obese?
1mg/kg of TBW
129
Neck circumference >? is risk factor for intubation?
60
130
Thyromental distance of what is risk factor for difficult intubation?
131
EBV in obese patient?
45-55 mL/kg
132
Restrict use of FiO2 to ? in obese pts during maintenance to prevent ateletctasis?
133
6 things to improve mechanical ventilation issues in obese pt?
FiO2
134
Signs/symptoms of anastomotic leak?
tachycardia >120, fever, abdominal pain, shoulder pain (left), SOB, hypotension, hiccups, restlessness
135
Why are NSAIDs not recommended for post op bariatric pts?
high risk of developing GI bleed
136
Major post op complication in obese pts?
respiratory failure
137
Why is there an increased incidence of AFIB in obese pts?
left atrial dilation, increased circulating volume, or left ventricular remodeling d/t ventricular diastolic dysfunction
138
leading cause of mortality post op in the obese?
PE
139
interval between surgery and PE is how many days?
13
140
Most frequent peripheral nerve injuries in obese patients?
ulnar, peroneal, femoral cutaneous
141
4 risk factors for rhabdomyolysis?
position, duration of surgery, diabetes, BMI> 55
142
What is one association that is negative between childhood obesity and adverse respiratory events during anesthesia?
bronchospasm
143
How does maternal obesity affect labor?
first and second stages of labor are longer
144
2 ways in which a bariatric surgery works?
reduces nutrient intake or reduces absorption
145
when is bariatric surgery indicated?
if BMI> 40 or >35 with significant comorbidity or severe DM; all non surgical measures tried, psychiatrically stable w/out alcohol or drug dep; committed to long term follow up; BMI>50
146
2 types of bariatric corrective surgery:
gastric restrictive procedures; restrictive and nutrient malabsorptive procedures
147
3 types of restrictive procedures?
vertical banded gastroplasty; laparoscopic adjustable gastric banding; lap sleeve gastrectomy
148
which restrictive bariatric procedure is historic?
vertical banded gastroplasty
149
which restrictive bariatric surgery is removable and results in shorter hospital stay and fewer complications?
lap adjustable gastric banding
150
which restrictive bariatric surgery resects the stomach to 20% of its original size?
lap sleeve gastrectomy
151
type of largely restrictive, mildly malabsorptive surgery?
roux en y
152
most effective bariatric procedure?
roux en y gastric bypass
153
this bariatric surgery is when a small gastric pouch is created, which restricts the amount of food eaten and then the distal end is resected and anastomosed to ilium to form common small intestinal limb
roux en y gastric bypass
154
type of largely malabsorptive, mildly restrictive surgery?
biliopancreatic diversion with duodenal switch
155
this bariatric surgery is usually done for the super obese
biliopancreatic diversion with duodenal switch
156
Some problems with the biliopancreatic diversion with duodenal switch surgery?
severe malabsorption, dumping, liver failure, cardiac failure, renal stones
157
Advantage of biliopancreatic diversion with duodenal switch surgery?
less intestinal SA for absorption to occur
158
What 2 things do you have to worry about with bariatric surgery in the head up position?
decreased venous return and decreased CO d/t venous pooling in lower limbs
159
pneumoperitoneum does what to venous return and CO, intra abdominal pressure, and possibly ETT?
decreases venous return and CO; increases intra abdominal pressure and may cause ETT migration
160
Signs of pneumoperitoneum??
high inspiratory pressures and PEEP
161
the 5 components of the risk factors scale for obesity surgery?
BMI>50, male, HTN, high risk DVT, age >45
162
Obese patients may be sensitive to what type of drugs?
lipid soluble
163
3 affects of hyperinsulinemia?
Na retention, increased blood volume, increased catecholamines
164
this type of ventricular hypertrophy develops from increased SVR?
concentric
165
most effective surgical treatment of obesity is?
roux en y gastric bypass
166
reversal of comorbidities is greatest after which weight loss surgery?
LAGB
167
this bariatric surgery is mostly formed on the super obese (BMI> 55)
biliopancreatic diversion with duodenal switch
168
mechanical ventilation using what kind of support (volume or pressure) improves oxygenation in MO pts?
pressure
169
most common cause of surgically related mortality in bariatric pt surgery?
anastomosis leak
170
in obese pts undergoing surgery there is some evidence that alveolar recruitment maneuvers in presence of PEEP may improve what 2 things w out adverse HD changes?
oxygenation and respiratory system compliance
171
pounds and inches BMI formula?
(weight in pounds/height in inches) x 73
172
how to convert inches to cm
inches x 2.54
173
hyperinsulinemia is bad for what 2 reasons?
1-increases amts of norepi which cause Na and Ca retention and hypervolemia; 2- adipocytes release angiotensinogen, which activates RAAS and contributes to Na retention and HTN
174
influencing factors leading to venostasis and DVT?
increased fibrinogen levels, chronic inflammatory state, increased abdominal pressure, immobility, polycythemia
175
increased adipose tissue causes what 3 things to happen to liver which cause destruction?
intrahepatic triglycerides, impaired insulin activity, and release of inflammatory cytokines
176
what happens to the Vd of hydrophillic agents in obese pts?
remains unchanged
177
are muscle relaxants fat or water soluble?
water
178
Does diabetes increase the risk of rhabdo?
yes
179
What lab value helps detect rhabdo?
serum CPK
