Obese/GI Flashcards
Overweight v obese
Overweight= inc wt for ht. Obese= inc wt for age, gender, and ht/ 20% or more above ideal weight
Inc cancers in obese pts 5
Breast, prostate, cervical, uterine, and colorectal
Metabolic syndrome: dx when ___ of the following criteria are present 5
- Abdominal obesity, triglycerides, HDL, bp, or fasting bg
Metabolic syndrome criteria for: abd obesity, tg
Waist circumference >102 cm men, >88 cm women. TG >150
Metabolic syndrome criteria: HDL, bp, fasting bg
> 40 men/>50 women. >130/85. >110
How to calc ideal bw using brocas index
IBW (kg) = ht (cm) - x (x= 100 males, 105 females)
How to calculate IBW according to miller for males
50 kg + 2.3 kg each 2.54 cm (or inch) greater than 152 cm (5 ft)
How to calc IBW for women according to miller
45.5 kg + 2.3 kg each 2.54 cm (or inch) greater than 152 cm (5 ft)
How to calculate BMI
Wt in kg / height (meters)
BMI value for: obesity, morbid obesity, super morbid obesity, and super super morbid
O- 30, MO- 40, SMO- 50, SSO- >60.
BMI > ____ assoc w inc morbidity due to 3
- Stroke, ischemic heart disease, and diabetes
____ or central obesity: inc ___ ___ and incidence of __ disease and __ dysfunction
Android. 02 consumption, cv, LV
___ or peripheral obesity. Less ___ disease because the fat is less __ active
Gynecoid, cv, metabolically
Waist circumference and risk of cv patho > ___ cm men, >__ cm women
102 men 88 women
How fat accum on obese pts thorax affects their physio
Inc pulm blood volume bc need to perfuse excess adipose tissue, polycythemia from chronic hypoxemia
Only vent parameter proven to improve resp function in obese pts, range, watch what
Peep, 10-12, bp
4 lung volumes decreased in obesity
ERV, FRC, VC, TLC
Obesity and lung vol: 2 parameters unchanged, 2 WNL
RV, cc. FEV1, FVC
Obesity lung vol: relationship bw __ and __ adversely effected. ___ reduc w anesthesia exaggerated
FRC and cc. FRC
Metabolic changes obese: inc __ consump and __ __ produc. Compensation how (2)
02, c02. Inc CO and inc minute vent
Metabolic obese changes: ___ oxygen tension in morbid obese pts breathing rm air is ___ than predicted
Arterial, lower
Metabolic obese alt: chronic alterations can result in 2
Pulm htn and cor pulm
Apnea: ___ sec or more of total cessation of air desp continuous resp effort against a closed glottis. Dec of sao2 >__%, at least ___x/hr
10 sec. >4%. >5x/hr
Hypopnea: a ___% reduc in airflow that lasts at least ___ seconds OR a reduc big enough to cause a __% dec in sa02
50%, 10 secs. 4%
Apnea-hypopnea index (#per hr): nml, mild, mod, severe
Nml= 5-10. Mild = 15. Mod 16-30. Severe >30
OSA: chronic effects 5
Hypoxia, hypercapnia, pulm/systemic vasoconstriction (htn), secondary polycythemia
OSA: chronic ___ can result in __ __ failure
HPV, right ventricular
Dx of pickwickian syndrome.
PCO2 >45 in an obese pt without COPD
Chronic __ __ is a better predictor of pulm htn and cor pulm than the severity/presence of ___ in pickwickian pt
Daytime hypoxia, OSA
Pickwickian: ____ rm air spo2
Supine. 96%. Hct. PFTs, ABGs, cxr, echo
Blood flow to fat is __-__ ml/100g tissue. ___ ml/kg in obese pt vs __ ml/kg in normal wt pt
2-3. 50 vs 70
Cv alt obesity: inc __ and __ BF, inc ___ bc of ventricular dilation, inc in ___ __.
Renal and sphlanchnic. CO. Stroke volume
Cv alt obesity: inc in __ __ sys and ___. Avg inc ___-__ SBP and ___ DBP per __kg wt Gained
RAA and SNS. 3-4, 2. 10 kg
Cv alt obesity: eventually LV wall ___ fails to keep pace with ventricular __ and ___ dysfunction or ___ __ results with eventual biventricular failure
Thickening, dilation, systolic. Obesity CM
Obesity pts/cv: exaggerated __ __ with anesthetic agents. Hypoxia and hypercapnia can lead to __ __
Negative inotropy. Pulm htn
Why obese pts are at higher risk for arrhythmias intraop 6
Hypoxia, hypercapnia, CAD, OSA, inc circ catecholamines, heart structure changes (hypertrophy and fat infiltrates)
Obese heme: hyper coagulation due to inc 5
Fibrinogen, factor 7 and 8, VWF, and plasminogen activator inhibitor 1
Morbidly obese fasting volume and ph that puts them at inc risk for pneumonitis should aspiration occur.
Vol >25 ml and ph <2.5
Obese GI alt: inc ___ release delays emptying, inc __ __ secretion decreases ph
Gastrin. Parietal cell
Renal alt in obese: inc renal __ __ and inc ___.
Plasma flow and gfr
Renal alt obese: inc renal __ __ and impaired ___ 2ndry to RAA and SNS activ, and kidney compression
Tubular resorption, naturesis
Endocrine changes in obese: abn serum ___ lead to high ___ incidence. ___ common.
Lipid, CAD. Hypothyroid
Endo changes obese: fatty tissues are ___ to ___ leading to __ __ and DM 2
Resistant, insulin. Glucose intolerance
Neck circumference: __ cm 5% difficult ett, ___ cm 35% difficult ett
40, 60
Obese airway mgmt: ramp pt to align what
Sternum with ear
Obese pharm: VD ___ compartment unchanged. TBW ___. Lipophilic and __ drug vol altered, ex __ and __
Central. Decreased. Polar. Benzos and barbs
Obese pharm: __ volume increase. Blood conc of ffa/Tgs/cholesterol/a1 glycoprotein lead to ___ free drug concentration
Blood vol. decreased
Obese pt metab: phase I (__,__,__) ____. Phase II (__,__) _____.
Oxid/reduc/hydrolysis unaffected. Glucuronidation, sulfation enhanced.
Obese pharm: hepatic clearance ____. Renal clearance ___, why.
Hepatic Unchanged. Renal Increased: inc gfr, rbf, and tubular secretion
Obese pharm: lipophilic drugs have ___ e 1/2t because of ____ VD but have a ___ clearance
Increased, increased. Normal
How to adjust dose for obese pt for hydrophilic meds, ex of these meds
Add 20% to the IBW. Muscle relaxants
How to calculate lean body mass for males, females
M: 1.1 x tbw - 128 x(tbw/ht)^2. Females: 1.07 x tbw - 148 (tbw/ht)^2
Propofol alt in obese: induc dose based on what/why. Maint dose based on.
Induc: LBW, no diff in initial vd b/w obese or nml pts. Maintenance based on TBW
Propofol in obese: inc ___ at steady state parallels increased ___. No change in ____
VD, clearance. E 1/2 life
Benzos in obese: ___ drugs, ___ vd. Intitial dose based on __, titrate to ___. Infusions based on ___.
Lipophilic, larger. LBW, TBW. LBW
Benzos in obese: ___ DOA secondary to larger ___, need ___ loading doses
Prolonged,VD. Higher
Obese and NMB: ___ activity increases as weight/ECF inc. = dose sux based on what
Pseudocholinesterase, TBW
NMB/obese: vec and roc dose based on ___. Atra and cis atra dose based on ___. Overall= ___ DOA
LBW. LBW. Prolonged q
Suggamadex in obese: dose based on __ according to drug maker’s reccs
TBW
How to dose fentanyl and sufentanil in obese
Both lipid sol= inc Vd and e 1/2 t. Dose fent on LBW. May dose su on TBW, dec maintenance dose to LBM
Remi in obese pts: dose based on what, why
LBW, pharmacokinetics unchanged in obese pts
Precedex in obese: drip dose to reduc narc/anesthetic reqs. Dose based on what
0.2-0.7 mcg/kg/hr. TBW
IAs in obese: metab greater in obese= inc incidence of __ __. Also inc in __ __. May be best recovery w __. ___ often avoided to maximize __.
Inorganic fluride. Halothane hepatitis. Des. N20, pa02
When rx recommended after life style changes fair: 2 situations
BMI >30 or BMI 27-29.9 + obesity related medical issue
SE of SSRI fenfluramine and phentermine
Pulm htn, valvular heart disease, htn, tachycardia, abuse, withdrawal
Greatest cause of 30 day mortality after bariatric surgery
PE
Lap bariatric sx: need complete __ __. Positioning reqs put pt at high risk for what. Also risk of what w a/w
Muscle relaxation. Fall from OR table. Right mainstem ett.
Lap bariatric sx: prior to gastric diversion ensure what removed. After gastric __ in place avoid what. Incidence of ___ more common than w open sx.
Endogastric devices. Pouch, blind NG placement. Rhabdomyolysis.
2 anesthesia consid for implantable gastric stim placement
Avoid NV (valsalva can dislodge electrodes), may have ecg interference
Preop obese pts: signs of what may be hidden by fat. Signs of pulm htn
Cardiac failure. Dyspnea, fatigue, syncope, tric regurg on echo, ecg (rah, tall r waves, r axis dev), prominent PA on cxray
Preop consid obese: repeat bariatric sx pts can suffer from what, severe ones can lead to what
Vit b12/iron/ca/folate deficiencies. Severe can lead to acute postgastric reduc sx neuropathy (APGARS)
APGARS: s/s. Careful dosing of what if symptomatic
NV, hyperreflexia, muscle weakness. NMB
Obese preop: may have chronic vit __ deficiency. Need to get __ studies
K. Coag
Preop obese: premeds for 2. What kind of med route unreliable. OSA- get preop __. Most imp factor on a/w assessment
Anxiolysis and asp pneumonitis. IM injections. ABG. Neck circumference
Max weight reg OR table
200 kg
Indications for CVP or PA cath 2
Severe cv or pulm disease. When large fluid shifts expected
VTE prophylaxis: LMWH limits what. preop __ and warfarin to INR __.
Postop pain tx options. Aspirin, 2.3
Induction: ___ most important step. ___ degrees of what. Decreased ___. Peep ___ helpful if bp tolerates it.
Pre oxygenation. 30 degrees reverse trend. 10
Intraop fluid balance: greater ___ ___ compared w nonobese with less ability to ___. Leads to early threshold for what.
Blood loss, compensate. Replacement w colloids or blood products
In bariatric sx risk of __ __ __ w inadequate fluid replacement
Acute tubular necrosis
Regional: how to adjust local doses. Changes in epidural space. Inc risk of what w spinals/why
Reduce 20-25%. Epidural vasc engorgement and dec vol of epidural space. High spinal. Subararach space unpredictable. Hypotension common due to IVC comp
Acls: use ___ joules on defibrillator. ___ and lma useful airway emergency devices
- Combitude
GI dis preop: clotting abn may need to be corrected bc fat sol vit k needed for what.
Synthesis of factor 2. 7. 9. 10 in the liver
Gastric lesions/resection often have what 2 issues
Iron deficiency anemia and megaloblastic vit b12 anemia
Fasting guidelines
4 hrs breast milk. 6 hrs formula or non human milk. 6 hrs light meal
Factors that reduce LES tone 12
Inhaled agents, TPL, prop, opioids, anticholinergics, b agonists, TCAs, glucagon, cricoid pressure, obesity, hiatal hernia, pregnancy
Factors that increase LES tone 9
Anticholinesterases, acetylcholine, sux, alpha adrenergic agonists, antacids, reglan, serotonin, histamine, BB
Hiatal hernia and GERD/asp prec guidelines
GERD not due to hernia, more due to LES integrity. Asp prec only indicated if pt symptomatic
Small bowel obstruc: pt at risk for what 4
Bacterial toxemia/septicemia, hemoconcentration, hypovolemia, hypokalemia
Large bowel obstruc: competent v incompetent ileocecal valve. After perforation occurs leads to what. 3 overall SE
Competent- bowel dilation, necrosis, perf. Incompetent- backed to small bowel, Feculent vomiting. After perf Bac tox/septic. Hemoconcentration, hypovolemia, hypokalemia
SE of therapies in bowel obstruc: ___ from TPN, __ or __ from aggressive tx hypokalemia, ___ from too rapid tx of hypovolemia
Hypophosphatemia. Hyperkalemia/arrhythmias. CHF
Goals in bowel obstruc overall: restore __, correct __ and __. Normalize ___: correction of deficits, maintenance, and what during correction
Volume, ph, electrolytes. SVR: correct deficits w salt sol and colloid. Maint D5 1/2 NS w 20-40 of K. May need vasodilators during correction.
PNS activity leads to inc bowel peristalsis. __ __ inc freq of waves in colon, esp if diseased. __ and __ help reduce this effect
Cholinesterase inhibitors. Atropine and glyco
Acute pancreatitis: hallmark inc serum ___. ___ deficit. Hypo___ and hyper___. Pleural ___ and ___ lead to dyspnea. ___ and __ failure
Amylase. Fluid. Calcemia/glycemia. Effusions, ascites. Ards, renal
Acute pancreatitis: ___ fluid admin, up to how much. ___ for pain, ___ within first 24-72 hrs to remove stones
Aggressive, 10L. Opioids, ercp
Crohn’s disease: bowel ___, often ___. Often on ___ and ___ drugs
Obstruction, dehydrated. Steroids and immunosuppressives
Ulc colitis: __ and __ imbalances. Assess for __ and __. Often on __ and __
Lyte and fluid. Arthritis and hepatitis. Steroids and immunosuppressives
Carcinoid tumors: usually ___ but if not may have symp of 4
Asymptomatic. Abd pain, diarrhea, obstruc, gi bleed
Carcinoid tumors: __ __ secrete hormones that are transported to ___ where they are __
Non metastatic, liver, inactivated
Substances secreted by carcinoid tumors
Serotonin, histamine, sub p, catecholamines (dopamine), bradykinin, tachykinin, motilin, corticotropin, prostaglabdins, Kallikrein
Carcinoid syndrome: symp/hormone mediated by: skin, lungs
Cutaneous flushing of neck/upper body (kinins, histamine). Bronchoconstriction (serotonin, bradykinin, sub p)
Carcinoid syndrome: symp/hormone med by: ___glycemia, bp
Hyperglycemia (serotonin), hypotension (kinins, histamine) or htn (serotonin)
Carcinoid syndrome symp/hormone med by: GI, heart
Diarrhea (serotonin, prostaglandins), heart disease (serotonin)
Carcinoid triad
Flushing, diarrhea, cardiac dysfunction
Carcinoid heart disease: usually ___ sided with ___ __.
Right, tricuspid regurg
Preop mgmt carcinoid: __ __ monitoring. __ __ monitoring needed. Cvp/pa/tee if what
Blood glucose. Arterial bp. Carcinoid heart disease
Anes mgmt carcinoid syndrome: ___ for dvl/ett placement. Avoid __ __ drugs and ex 5
Deep. Histamine releasing: sux, NMB that rel histamine, tpl, morphine, demerol
Carcinoid syndrome anesthesia: regional ___ better than ___, avoid ___. Treat with __ and ___.
Epidural > spinal. Hypotension. Fluid and octreotide
Preventative octreotide infusion dose. Intraop carcinoid crisis octreotide dose/how you may know its happening
50-100 mcg/hr. 25-100 mcg IVP (hypotension, bronchospasm)
Carcinoid syndrome anesthesia: ___ for refractory hypotension. ___ 2nd line. For hypertension ___ or what
Vaso, aprotinin. Labetolol or inc dose volatiles
Drugs that can precipitate a carcinoid crisis 5
Histamine, norepi, epi, dopamine, ephedrine
