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6901 > Obese Adult and Child Lecture 1 > Flashcards

Obese Adult and Child Lecture 1 Flashcards

1
Q

Formula for BMI

A

weight in kg/ height in meters squared

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2
Q

BMI chart also known as

A

Quetelet’s index

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3
Q

Morbidly obese is BMI>__ or ?

A

40; BMI 35-49.9 with obesity related comorbidity

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4
Q

What is a good predictor of cardio respiratory comorbidity?

A

waist or collar circumference

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5
Q

Another term for IBW is?

A

Broca’s index

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6
Q

lowest morbidity and mortality for a given population

A

IBW

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7
Q

IBW in kg formula for men

A

height (cm)-100

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8
Q

IBW in kg formula for women

A

height (cm)-105

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9
Q

total body weight minus adipose tissue

A

lean body weight

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10
Q

Which weight category of individuals do you use lean body weight for?

A

morbidly obese; not obese

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11
Q

formula for LBW

A

IBW X 1.3

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12
Q

in nonobese and nonmuscular individuals TVW=?

A

IBW

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13
Q

in morbidly obese patients, increase IBW by what percent to equal LBW?

A

20-30%

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14
Q

LBW in morbidly obese is -/- of the difference between IBW and TBW?

A

1/3

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15
Q

apple shape is also called?

A

android

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16
Q

pear shape is also called?

A

gynoid

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17
Q

which body shape has a significant correlation with metabolic syndrome?

A

android/apple

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18
Q

What are 3 side effects of pear/gynoid shape?

A

varicose vein development, joint disease, decrease in type 2 diabetes

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19
Q

This type of fat is metabolically static and functions as energy deposits like when pregnant or lactating?

A

pear/gynoid

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20
Q

man having waist circumference > _ is risk factor?

A

102 cm/ 40 in

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21
Q

woman having waist circumference > _ is risk factor?

A

88 cm/ 35 in

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22
Q

What inflammatory mediators are elevated in obese patients?

A

AGT, transforming growth beta factors, TNF, IL6

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23
Q

most effective tool for long term weight loss?

A

lifestyle counseling

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24
Q

How does weight loss drug Phentermine work?

A

sympathomimetic

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25
Q

How does Orlistat work?

A

blocks the absorption of fat

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26
Q

EBV for obese?

A

45-50 mL/kg

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27
Q

How much does CO increase for every kg of fat gained?

A

0.1 L/min or 100 mL/min

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28
Q

an increasead CO is seen as an increase in __? __ remains the same

A

stroke volume, hr

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29
Q

What are 2 things in obese individual that increase blood volume?

A

hypoxic induced chronic resp insufficiency and increase in Na retention

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30
Q

In what four ways does the increase in circulating blood volume produce a greater demand on the myocardium?

A

by increasing metabolic rate, increasing O2 consumption, increasing CO2 production, and normal or slightly abnormal arteriovenous O2 difference

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31
Q

Most confirmatory test of pulmonary HTN with clinical eval?

A

tricuspid regurg

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32
Q

2 indicators of left ventricular dysfunction?

A

orthopnea or paroxysmal nocturnal dyspnea

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33
Q

Chronically elevated cardiac output leads to?

A

ventricular remodeling

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34
Q

6 step cardiovascular pathway in obese person

A

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

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35
Q

For every 13.5 kg of fat the body regenerates additional __ miles of neovascularization?

A

25

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36
Q

HTN is defined as SBP> ? or DBP > or both?

A

140, 90

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37
Q

BP increases __ mm Hg for every 10% increase in body weight?

A

6.5

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38
Q

What 2 things are released in obese peoples’ blood which increase viscosity?

A

catecholamines, estrogen

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39
Q

hyper__ increases levels of norepinephrine?

A

insulinemia

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40
Q

obese ppl have __ or __ levels of SNS activity?

A

normal or increased

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41
Q

What do increased levels of SNS activity predispose people to (3)?

A

increased insulin resistance, dyslipidemia, and HTN

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42
Q

For every 10 kg of weight gained, the SBP increases by ? and the DBP increases by?

A

3-4 mm Hg, 2 mm Hg

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43
Q

What type of effect does norepinephrine have on Na and Ca?

A

increased renal tubular reabsorption which results in hypervolemia

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44
Q

How does insulin have an effect on Na retention?

A

it stimulates adipocytes to release angiotensinogen then activates the renin angiotensin aldosterone pathway which leads to further Na retention and progression of HTN

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45
Q

Obese nonhypertensive pt: what happens to SVR, blood volume, and how is the heart dilated?

A

decreases SVR, increases blood volume and leads to eccentric dilated heart

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46
Q

Obese and uncontrolled HTN heart: what happens?

A

mixed eccentric/dilated and concentric/ventricular hypertrophy

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47
Q

What does obesity and uncontrolled HTN lead to?

A

heart failure and pulmonary HTN (dilation and hypertrophy)

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48
Q

Clotting factors elevated in obese pts?

A

fibrinogen, factor VII, factor VIII, von willebrand, plasminogen activator inhibitor (inhibits breakdown of clots)

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49
Q

how much more of an increase in developing a DVT bc of surgery does an obese pt have versus a nonobese pt?

A

50%

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50
Q

Why do obese patients have an increased risk of stroke?

A

prothrombotic and chronic inflammatory state seen with excessive adipose tissue accumulation

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51
Q

1 unit above BMI, there is a __% risk of ischemic stroke and a __% risk of hemorrhagic stroke?

A

4;6

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52
Q

What happens to elastic resistance and compliance in obese patients?

A

increased elastic resistance and decreased compliance of chest wall

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53
Q

fat accumulation forces the diaphragm where?

A

cephalad

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54
Q

Lung volumes that decrease with obesity?

A

FRC, ERV, VC, TLC

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55
Q

premature airway closure–> _____ –> _______ –> ________

A

VQ mismatch–> right to left shunting–> arterial hypoxic event

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56
Q

Supine positioning in obese pt reduces FRC up to __% as compared to 20% in non obese patient

A

50%

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57
Q

most sensitive indicator of pulmonary fucntion

A

expiratory reserve volume

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58
Q

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

A

FRC

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59
Q

the additonal amt of air that can be expired from the lungs by determined effort after normal expiration

A

ERV

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60
Q

3 lung volumes that remain the same in obese pts

A

residual volume, closing capacity, FEV1/FVC

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61
Q

volume of air still remaining in the lungs after expiratory reserve volume exhaled

A

residual volume

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62
Q

2 factors that contribute to decreased SaO2 during DL in obese pt

A

decreased FRC and increased O2 consumption

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63
Q

apnea is defined as (3):

A

reduction of airflow > 10 seconds, lasting > 15 episodes per hour of sleep, decrease in O2 saturation >4%

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64
Q

gold standard for sleep apnea diagnosis

A

overnight polysomnography

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65
Q

3 types of sleep apnea

A

central sleep apnea, OSA, mixed sleep apnea

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66
Q

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

A

OSA

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67
Q

type of sleep apnea that is apnea without respiratory efforts

A

central sleep apnea

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68
Q

what causes pt to wake up with sleep apnea?

A

decreased O2 levels

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69
Q

type of sleep apnea that is delayed effort with varying degrees of obstruction

A

mixed

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70
Q

7 physiologic changes seen from OSA:

A

hypoxemia, hypercarbia, polycythemia, systemic HTN, pulmonary HTN (mean >25 at rest), right ventricular failure, cor pulmonale (pul HTN and right vent failure)

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71
Q

STOP questionnaire stands for?

A

Snoring, Tiredness, Observed you stop breathing, Pblood Pressure

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72
Q

BANG questionnaire stands for?

A

BMI> 35, Age >50, Neck circumference > 40cm, Gender male

73
Q

High risk of the STOP BANG questionnaire is >__ items?

A

3

74
Q

Difference in OHS versus OSA is?

A

nocturnal periods of central sleep apnea

75
Q

Diagnosis of OHS (3)?

A

BMI> 30, daytime hypoventilation, awake PaCO2> 45

76
Q

Only additional parameter shown to improve ventilation in obese patients?

A

PEEP

77
Q

3 negatives of PEEP:

A

decrease CO, decreased venous return, reduced O2 delivery

78
Q

2 GI conditions that are increased with obesity?

A

gallstones and pancreatitis

79
Q

which sphincter is relaxed in GERD pts

A

lower esophageal

80
Q

increased intragastric pressure causes 2 things:

A

lower esophageal sphincter relaxation (GERD) and hiatal hernia

81
Q

what happens to the gastric volume and pH in obese pts?

A

increased gastric volume and pH more acidic

82
Q

gastric volume > ? and pH

A

> 25 mL, 2.5

83
Q

What causes the delay in gastric emptying in obese patients?

A

increased abdominal mass, decrease in pH

84
Q

How is gastric emptying affected by obesity?

A

decreased gastric emptying

85
Q

elective surgery-obese patients should be given what 3 things?

A

bicitra, reglan, H2 blocker

86
Q

elevated lab with nonalcoholic fatty liver disease?

A

ALT

87
Q

Pathophysiology behind nonalcoholic fatty liver disease?

A

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
Q

Severe cases of NAFLD can lead to (3)?

A

portal HTN, cirrhosis, hepatocellular carcinoma

89
Q

What happens to thryoid stimulation hormone in obese?

A

increases and have subclincal hypothyroidism

90
Q

Why does obesity cause decreased insulin secretion?

A

pancrease becomes infiltrated with fat

91
Q

What promotes insulin resistance in obese patients?

A

enlargement of adipocytes

92
Q

3 factors that increase wound infection and silent MI?

A

insulin resistance, hyperglycemia, abnormal glucose tolerance test

93
Q

One reason surgery increases need for exogenous insulin?

A

adrenal glands release cortisol in response to surgical stress

94
Q

3/5 of these is metabolic syndrome

A

central obesity, HTN, high triglycerides, low HDL, insulin resistance

95
Q

high triglyceride value?

A

> 150

96
Q

low HDL value?

A

men

97
Q

insulin resistance is glucose >?

A

100 or 110

98
Q

HTN in metabolic syndrome is BP>?

A

130/85

99
Q

Metabolic syndrome is associated with what 2 conditions?

A

diabetes and cardiovascular events

100
Q

AHA recommended what for metabolic syndrome patients as prophylaxis against events?

A

low dose ASA

101
Q

Cancers associated with obesity?

A

breast, endometrial, colon, kidney, gallbladder, prostate

102
Q

Most common symptom of pulmonary HTN?

A

SOB, tired, syncope

103
Q

Vd of lipid soluble drugs decreases or increases in obese?

A

increases

104
Q

is preop assessment of liver function in obese pts recommended?

A

yes

105
Q

What happens to weight limitation in reverse positioning?

A

it is much less

106
Q

Nerves at increased risk of damage in obese patients?

A

ulna, brachial plexus, radial, peroneal, and sphenoid

107
Q

sniffing position-chin higher than?

A

chest

108
Q

pharmacology in obese patients-give H2O meds according to what weight and lipid soluble meds for what weight?

A

H2O LBW and lipid total body weight

109
Q

lipophilic drugs in obese pt have decreased or increased Vd?

A

increased, which means that the elimination 1/2 is prolonged d/t large vol of distribution

110
Q

2 examples of commonly given lipophillic meds in anesthesia?

A

benzos and barbs

111
Q

What do you have to be careful about as far as lipophilic meds go in the obese patient?

A

do not give multiple doses because they will accumulate in adipose tissue and you will see a prolonged effect

112
Q

What happens to the Vd of hydrophilic drugs in obese pt?

A

it is unchanged

113
Q

Nondepolarizing MR are calculated based off of what body weight?

A

IBW

114
Q

Suxx is calculated based off of what body weight? Why?

A

TBW; pseudocholinesterase activity increases in obesity

115
Q

Why does remifentanyl have limited potential to accumulate in fat tissue even thought it is highly lipophilic?

A

it is metabolized readily and rapidly by plasma esterase

116
Q

the newer volatile anesthetics such as sevo and des are more water or lipid soluble?

A

water

117
Q

What would a lipid soluble gas mean for emergence?

A

it would be more likely to accumulate in obese pts and delay emergence

118
Q

Drugs with extensive extra hepatic metabolism have what kind of pharmacokinetics in obese and lean?

A

similar-remifent is an example

119
Q

What kind of body weight do you base propofol induction dose on?

A

LBW

120
Q

What kind of body weight do you base propofol maintenance dose on?

A

TBW

121
Q

Because obese patients are vulnerable to side effects, how should you figure out the correct medication dose?

A

typically increase the dose by 20-40% over IBW so that it is based on lean body weight

122
Q

Loading dose of Fent based on what?

A

TBW

123
Q

Recommended rate of Dexmedetomidine in obese pts?

A

0.2mcg/kg/min

124
Q

Remifent infusion rates are based on what body weight?

A

IBW

125
Q

How many mL of clear fluids is okay 2 hours before surgery?

A

300 mL

126
Q

How long should preoxygenation be in obese patient?

A

5 min

127
Q

Emergency intubation in obese patient preox should be?

A

4 VC breaths on 100% FiO2 within 30 seconds of induction

128
Q

Suxxs dose for RSI in obese?

A

1mg/kg of TBW

129
Q

Neck circumference >? is risk factor for intubation?

A

60

130
Q

Thyromental distance of what is risk factor for difficult intubation?

A
131
Q

EBV in obese patient?

A

45-55 mL/kg

132
Q

Restrict use of FiO2 to ? in obese pts during maintenance to prevent ateletctasis?

A
133
Q

6 things to improve mechanical ventilation issues in obese pt?

A

FiO2

134
Q

Signs/symptoms of anastomotic leak?

A

tachycardia >120, fever, abdominal pain, shoulder pain (left), SOB, hypotension, hiccups, restlessness

135
Q

Why are NSAIDs not recommended for post op bariatric pts?

A

high risk of developing GI bleed

136
Q

Major post op complication in obese pts?

A

respiratory failure

137
Q

Why is there an increased incidence of AFIB in obese pts?

A

left atrial dilation, increased circulating volume, or left ventricular remodeling d/t ventricular diastolic dysfunction

138
Q

leading cause of mortality post op in the obese?

A

PE

139
Q

interval between surgery and PE is how many days?

A

13

140
Q

Most frequent peripheral nerve injuries in obese patients?

A

ulnar, peroneal, femoral cutaneous

141
Q

4 risk factors for rhabdomyolysis?

A

position, duration of surgery, diabetes, BMI> 55

142
Q

What is one association that is negative between childhood obesity and adverse respiratory events during anesthesia?

A

bronchospasm

143
Q

How does maternal obesity affect labor?

A

first and second stages of labor are longer

144
Q

2 ways in which a bariatric surgery works?

A

reduces nutrient intake or reduces absorption

145
Q

when is bariatric surgery indicated?

A

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
Q

2 types of bariatric corrective surgery:

A

gastric restrictive procedures; restrictive and nutrient malabsorptive procedures

147
Q

3 types of restrictive procedures?

A

vertical banded gastroplasty; laparoscopic adjustable gastric banding; lap sleeve gastrectomy

148
Q

which restrictive bariatric procedure is historic?

A

vertical banded gastroplasty

149
Q

which restrictive bariatric surgery is removable and results in shorter hospital stay and fewer complications?

A

lap adjustable gastric banding

150
Q

which restrictive bariatric surgery resects the stomach to 20% of its original size?

A

lap sleeve gastrectomy

151
Q

type of largely restrictive, mildly malabsorptive surgery?

A

roux en y

152
Q

most effective bariatric procedure?

A

roux en y gastric bypass

153
Q

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

A

roux en y gastric bypass

154
Q

type of largely malabsorptive, mildly restrictive surgery?

A

biliopancreatic diversion with duodenal switch

155
Q

this bariatric surgery is usually done for the super obese

A

biliopancreatic diversion with duodenal switch

156
Q

Some problems with the biliopancreatic diversion with duodenal switch surgery?

A

severe malabsorption, dumping, liver failure, cardiac failure, renal stones

157
Q

Advantage of biliopancreatic diversion with duodenal switch surgery?

A

less intestinal SA for absorption to occur

158
Q

What 2 things do you have to worry about with bariatric surgery in the head up position?

A

decreased venous return and decreased CO d/t venous pooling in lower limbs

159
Q

pneumoperitoneum does what to venous return and CO, intra abdominal pressure, and possibly ETT?

A

decreases venous return and CO; increases intra abdominal pressure and may cause ETT migration

160
Q

Signs of pneumoperitoneum??

A

high inspiratory pressures and PEEP

161
Q

the 5 components of the risk factors scale for obesity surgery?

A

BMI>50, male, HTN, high risk DVT, age >45

162
Q

Obese patients may be sensitive to what type of drugs?

A

lipid soluble

163
Q

3 affects of hyperinsulinemia?

A

Na retention, increased blood volume, increased catecholamines

164
Q

this type of ventricular hypertrophy develops from increased SVR?

A

concentric

165
Q

most effective surgical treatment of obesity is?

A

roux en y gastric bypass

166
Q

reversal of comorbidities is greatest after which weight loss surgery?

A

LAGB

167
Q

this bariatric surgery is mostly formed on the super obese (BMI> 55)

A

biliopancreatic diversion with duodenal switch

168
Q

mechanical ventilation using what kind of support (volume or pressure) improves oxygenation in MO pts?

A

pressure

169
Q

most common cause of surgically related mortality in bariatric pt surgery?

A

anastomosis leak

170
Q

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?

A

oxygenation and respiratory system compliance

171
Q

pounds and inches BMI formula?

A

(weight in pounds/height in inches) x 73

172
Q

how to convert inches to cm

A

inches x 2.54

173
Q

hyperinsulinemia is bad for what 2 reasons?

A

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
Q

influencing factors leading to venostasis and DVT?

A

increased fibrinogen levels, chronic inflammatory state, increased abdominal pressure, immobility, polycythemia

175
Q

increased adipose tissue causes what 3 things to happen to liver which cause destruction?

A

intrahepatic triglycerides, impaired insulin activity, and release of inflammatory cytokines

176
Q

what happens to the Vd of hydrophillic agents in obese pts?

A

remains unchanged

177
Q

are muscle relaxants fat or water soluble?

A

water

178
Q

Does diabetes increase the risk of rhabdo?

A

yes

179
Q

What lab value helps detect rhabdo?

A

serum CPK

6901 (18 decks)

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