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Adv Pr III > Obese/GI > Flashcards

Obese/GI Flashcards

1
Q

Overweight v obese

A

Overweight= inc wt for ht. Obese= inc wt for age, gender, and ht/ 20% or more above ideal weight

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2
Q

Inc cancers in obese pts 5

A

Breast, prostate, cervical, uterine, and colorectal

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3
Q

Metabolic syndrome: dx when ___ of the following criteria are present 5

A
  1. Abdominal obesity, triglycerides, HDL, bp, or fasting bg
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4
Q

Metabolic syndrome criteria for: abd obesity, tg

A

Waist circumference >102 cm men, >88 cm women. TG >150

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5
Q

Metabolic syndrome criteria: HDL, bp, fasting bg

A

> 40 men/>50 women. >130/85. >110

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6
Q

How to calc ideal bw using brocas index

A

IBW (kg) = ht (cm) - x (x= 100 males, 105 females)

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7
Q

How to calculate IBW according to miller for males

A

50 kg + 2.3 kg each 2.54 cm (or inch) greater than 152 cm (5 ft)

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8
Q

How to calc IBW for women according to miller

A

45.5 kg + 2.3 kg each 2.54 cm (or inch) greater than 152 cm (5 ft)

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9
Q

How to calculate BMI

A

Wt in kg / height (meters)

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10
Q

BMI value for: obesity, morbid obesity, super morbid obesity, and super super morbid

A

O- 30, MO- 40, SMO- 50, SSO- >60.

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11
Q

BMI > ____ assoc w inc morbidity due to 3

A
  1. Stroke, ischemic heart disease, and diabetes
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12
Q

____ or central obesity: inc ___ ___ and incidence of __ disease and __ dysfunction

A

Android. 02 consumption, cv, LV

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13
Q

___ or peripheral obesity. Less ___ disease because the fat is less __ active

A

Gynecoid, cv, metabolically

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14
Q

Waist circumference and risk of cv patho > ___ cm men, >__ cm women

A

102 men 88 women

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15
Q

How fat accum on obese pts thorax affects their physio

A

Inc pulm blood volume bc need to perfuse excess adipose tissue, polycythemia from chronic hypoxemia

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16
Q

Only vent parameter proven to improve resp function in obese pts, range, watch what

A

Peep, 10-12, bp

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17
Q

4 lung volumes decreased in obesity

A

ERV, FRC, VC, TLC

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18
Q

Obesity and lung vol: 2 parameters unchanged, 2 WNL

A

RV, cc. FEV1, FVC

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19
Q

Obesity lung vol: relationship bw __ and __ adversely effected. ___ reduc w anesthesia exaggerated

A

FRC and cc. FRC

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20
Q

Metabolic changes obese: inc __ consump and __ __ produc. Compensation how (2)

A

02, c02. Inc CO and inc minute vent

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21
Q

Metabolic obese changes: ___ oxygen tension in morbid obese pts breathing rm air is ___ than predicted

A

Arterial, lower

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22
Q

Metabolic obese alt: chronic alterations can result in 2

A

Pulm htn and cor pulm

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23
Q

Apnea: ___ sec or more of total cessation of air desp continuous resp effort against a closed glottis. Dec of sao2 >__%, at least ___x/hr

A

10 sec. >4%. >5x/hr

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24
Q

Hypopnea: a ___% reduc in airflow that lasts at least ___ seconds OR a reduc big enough to cause a __% dec in sa02

A

50%, 10 secs. 4%

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25
Q

Apnea-hypopnea index (#per hr): nml, mild, mod, severe

A

Nml= 5-10. Mild = 15. Mod 16-30. Severe >30

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26
Q

OSA: chronic effects 5

A

Hypoxia, hypercapnia, pulm/systemic vasoconstriction (htn), secondary polycythemia

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27
Q

OSA: chronic ___ can result in __ __ failure

A

HPV, right ventricular

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28
Q

Dx of pickwickian syndrome.

A

PCO2 >45 in an obese pt without COPD

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29
Q

Chronic __ __ is a better predictor of pulm htn and cor pulm than the severity/presence of ___ in pickwickian pt

A

Daytime hypoxia, OSA

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30
Q

Pickwickian: ____ rm air spo2

A

Supine. 96%. Hct. PFTs, ABGs, cxr, echo

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31
Q

Blood flow to fat is __-__ ml/100g tissue. ___ ml/kg in obese pt vs __ ml/kg in normal wt pt

A

2-3. 50 vs 70

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32
Q

Cv alt obesity: inc __ and __ BF, inc ___ bc of ventricular dilation, inc in ___ __.

A

Renal and sphlanchnic. CO. Stroke volume

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33
Q

Cv alt obesity: inc in __ __ sys and ___. Avg inc ___-__ SBP and ___ DBP per __kg wt Gained

A

RAA and SNS. 3-4, 2. 10 kg

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34
Q

Cv alt obesity: eventually LV wall ___ fails to keep pace with ventricular __ and ___ dysfunction or ___ __ results with eventual biventricular failure

A

Thickening, dilation, systolic. Obesity CM

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35
Q

Obesity pts/cv: exaggerated __ __ with anesthetic agents. Hypoxia and hypercapnia can lead to __ __

A

Negative inotropy. Pulm htn

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36
Q

Why obese pts are at higher risk for arrhythmias intraop 6

A

Hypoxia, hypercapnia, CAD, OSA, inc circ catecholamines, heart structure changes (hypertrophy and fat infiltrates)

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37
Q

Obese heme: hyper coagulation due to inc 5

A

Fibrinogen, factor 7 and 8, VWF, and plasminogen activator inhibitor 1

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38
Q

Morbidly obese fasting volume and ph that puts them at inc risk for pneumonitis should aspiration occur.

A

Vol >25 ml and ph <2.5

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39
Q

Obese GI alt: inc ___ release delays emptying, inc __ __ secretion decreases ph

A

Gastrin. Parietal cell

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40
Q

Renal alt in obese: inc renal __ __ and inc ___.

A

Plasma flow and gfr

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41
Q

Renal alt obese: inc renal __ __ and impaired ___ 2ndry to RAA and SNS activ, and kidney compression

A

Tubular resorption, naturesis

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42
Q

Endocrine changes in obese: abn serum ___ lead to high ___ incidence. ___ common.

A

Lipid, CAD. Hypothyroid

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43
Q

Endo changes obese: fatty tissues are ___ to ___ leading to __ __ and DM 2

A

Resistant, insulin. Glucose intolerance

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44
Q

Neck circumference: __ cm 5% difficult ett, ___ cm 35% difficult ett

A

40, 60

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45
Q

Obese airway mgmt: ramp pt to align what

A

Sternum with ear

46
Q

Obese pharm: VD ___ compartment unchanged. TBW ___. Lipophilic and __ drug vol altered, ex __ and __

A

Central. Decreased. Polar. Benzos and barbs

47
Q

Obese pharm: __ volume increase. Blood conc of ffa/Tgs/cholesterol/a1 glycoprotein lead to ___ free drug concentration

A

Blood vol. decreased

48
Q

Obese pt metab: phase I (__,__,__) ____. Phase II (__,__) _____.

A

Oxid/reduc/hydrolysis unaffected. Glucuronidation, sulfation enhanced.

49
Q

Obese pharm: hepatic clearance ____. Renal clearance ___, why.

A

Hepatic Unchanged. Renal Increased: inc gfr, rbf, and tubular secretion

50
Q

Obese pharm: lipophilic drugs have ___ e 1/2t because of ____ VD but have a ___ clearance

A

Increased, increased. Normal

51
Q

How to adjust dose for obese pt for hydrophilic meds, ex of these meds

A

Add 20% to the IBW. Muscle relaxants

52
Q

How to calculate lean body mass for males, females

A

M: 1.1 x tbw - 128 x(tbw/ht)^2. Females: 1.07 x tbw - 148 (tbw/ht)^2

53
Q

Propofol alt in obese: induc dose based on what/why. Maint dose based on.

A

Induc: LBW, no diff in initial vd b/w obese or nml pts. Maintenance based on TBW

54
Q

Propofol in obese: inc ___ at steady state parallels increased ___. No change in ____

A

VD, clearance. E 1/2 life

55
Q

Benzos in obese: ___ drugs, ___ vd. Intitial dose based on __, titrate to ___. Infusions based on ___.

A

Lipophilic, larger. LBW, TBW. LBW

56
Q

Benzos in obese: ___ DOA secondary to larger ___, need ___ loading doses

A

Prolonged,VD. Higher

57
Q

Obese and NMB: ___ activity increases as weight/ECF inc. = dose sux based on what

A

Pseudocholinesterase, TBW

58
Q

NMB/obese: vec and roc dose based on ___. Atra and cis atra dose based on ___. Overall= ___ DOA

A

LBW. LBW. Prolonged q

59
Q

Suggamadex in obese: dose based on __ according to drug maker’s reccs

A

TBW

60
Q

How to dose fentanyl and sufentanil in obese

A

Both lipid sol= inc Vd and e 1/2 t. Dose fent on LBW. May dose su on TBW, dec maintenance dose to LBM

61
Q

Remi in obese pts: dose based on what, why

A

LBW, pharmacokinetics unchanged in obese pts

62
Q

Precedex in obese: drip dose to reduc narc/anesthetic reqs. Dose based on what

A

0.2-0.7 mcg/kg/hr. TBW

63
Q

IAs in obese: metab greater in obese= inc incidence of __ __. Also inc in __ __. May be best recovery w __. ___ often avoided to maximize __.

A

Inorganic fluride. Halothane hepatitis. Des. N20, pa02

64
Q

When rx recommended after life style changes fair: 2 situations

A

BMI >30 or BMI 27-29.9 + obesity related medical issue

65
Q

SE of SSRI fenfluramine and phentermine

A

Pulm htn, valvular heart disease, htn, tachycardia, abuse, withdrawal

66
Q

Greatest cause of 30 day mortality after bariatric surgery

A

PE

67
Q

Lap bariatric sx: need complete __ __. Positioning reqs put pt at high risk for what. Also risk of what w a/w

A

Muscle relaxation. Fall from OR table. Right mainstem ett.

68
Q

Lap bariatric sx: prior to gastric diversion ensure what removed. After gastric __ in place avoid what. Incidence of ___ more common than w open sx.

A

Endogastric devices. Pouch, blind NG placement. Rhabdomyolysis.

69
Q

2 anesthesia consid for implantable gastric stim placement

A

Avoid NV (valsalva can dislodge electrodes), may have ecg interference

70
Q

Preop obese pts: signs of what may be hidden by fat. Signs of pulm htn

A

Cardiac failure. Dyspnea, fatigue, syncope, tric regurg on echo, ecg (rah, tall r waves, r axis dev), prominent PA on cxray

71
Q

Preop consid obese: repeat bariatric sx pts can suffer from what, severe ones can lead to what

A

Vit b12/iron/ca/folate deficiencies. Severe can lead to acute postgastric reduc sx neuropathy (APGARS)

72
Q

APGARS: s/s. Careful dosing of what if symptomatic

A

NV, hyperreflexia, muscle weakness. NMB

73
Q

Obese preop: may have chronic vit __ deficiency. Need to get __ studies

A

K. Coag

74
Q

Preop obese: premeds for 2. What kind of med route unreliable. OSA- get preop __. Most imp factor on a/w assessment

A

Anxiolysis and asp pneumonitis. IM injections. ABG. Neck circumference

75
Q

Max weight reg OR table

A

200 kg

76
Q

Indications for CVP or PA cath 2

A

Severe cv or pulm disease. When large fluid shifts expected

77
Q

VTE prophylaxis: LMWH limits what. preop __ and warfarin to INR __.

A

Postop pain tx options. Aspirin, 2.3

78
Q

Induction: ___ most important step. ___ degrees of what. Decreased ___. Peep ___ helpful if bp tolerates it.

A

Pre oxygenation. 30 degrees reverse trend. 10

79
Q

Intraop fluid balance: greater ___ ___ compared w nonobese with less ability to ___. Leads to early threshold for what.

A

Blood loss, compensate. Replacement w colloids or blood products

80
Q

In bariatric sx risk of __ __ __ w inadequate fluid replacement

A

Acute tubular necrosis

81
Q

Regional: how to adjust local doses. Changes in epidural space. Inc risk of what w spinals/why

A

Reduce 20-25%. Epidural vasc engorgement and dec vol of epidural space. High spinal. Subararach space unpredictable. Hypotension common due to IVC comp

82
Q

Acls: use ___ joules on defibrillator. ___ and lma useful airway emergency devices

A
  1. Combitude
83
Q

GI dis preop: clotting abn may need to be corrected bc fat sol vit k needed for what.

A

Synthesis of factor 2. 7. 9. 10 in the liver

84
Q

Gastric lesions/resection often have what 2 issues

A

Iron deficiency anemia and megaloblastic vit b12 anemia

85
Q

Fasting guidelines

A

4 hrs breast milk. 6 hrs formula or non human milk. 6 hrs light meal

86
Q

Factors that reduce LES tone 12

A

Inhaled agents, TPL, prop, opioids, anticholinergics, b agonists, TCAs, glucagon, cricoid pressure, obesity, hiatal hernia, pregnancy

87
Q

Factors that increase LES tone 9

A

Anticholinesterases, acetylcholine, sux, alpha adrenergic agonists, antacids, reglan, serotonin, histamine, BB

88
Q

Hiatal hernia and GERD/asp prec guidelines

A

GERD not due to hernia, more due to LES integrity. Asp prec only indicated if pt symptomatic

89
Q

Small bowel obstruc: pt at risk for what 4

A

Bacterial toxemia/septicemia, hemoconcentration, hypovolemia, hypokalemia

90
Q

Large bowel obstruc: competent v incompetent ileocecal valve. After perforation occurs leads to what. 3 overall SE

A

Competent- bowel dilation, necrosis, perf. Incompetent- backed to small bowel, Feculent vomiting. After perf Bac tox/septic. Hemoconcentration, hypovolemia, hypokalemia

91
Q

SE of therapies in bowel obstruc: ___ from TPN, __ or __ from aggressive tx hypokalemia, ___ from too rapid tx of hypovolemia

A

Hypophosphatemia. Hyperkalemia/arrhythmias. CHF

92
Q

Goals in bowel obstruc overall: restore __, correct __ and __. Normalize ___: correction of deficits, maintenance, and what during correction

A

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.

93
Q

PNS activity leads to inc bowel peristalsis. __ __ inc freq of waves in colon, esp if diseased. __ and __ help reduce this effect

A

Cholinesterase inhibitors. Atropine and glyco

94
Q

Acute pancreatitis: hallmark inc serum ___. ___ deficit. Hypo___ and hyper___. Pleural ___ and ___ lead to dyspnea. ___ and __ failure

A

Amylase. Fluid. Calcemia/glycemia. Effusions, ascites. Ards, renal

95
Q

Acute pancreatitis: ___ fluid admin, up to how much. ___ for pain, ___ within first 24-72 hrs to remove stones

A

Aggressive, 10L. Opioids, ercp

96
Q

Crohn’s disease: bowel ___, often ___. Often on ___ and ___ drugs

A

Obstruction, dehydrated. Steroids and immunosuppressives

97
Q

Ulc colitis: __ and __ imbalances. Assess for __ and __. Often on __ and __

A

Lyte and fluid. Arthritis and hepatitis. Steroids and immunosuppressives

98
Q

Carcinoid tumors: usually ___ but if not may have symp of 4

A

Asymptomatic. Abd pain, diarrhea, obstruc, gi bleed

99
Q

Carcinoid tumors: __ __ secrete hormones that are transported to ___ where they are __

A

Non metastatic, liver, inactivated

100
Q

Substances secreted by carcinoid tumors

A

Serotonin, histamine, sub p, catecholamines (dopamine), bradykinin, tachykinin, motilin, corticotropin, prostaglabdins, Kallikrein

101
Q

Carcinoid syndrome: symp/hormone mediated by: skin, lungs

A

Cutaneous flushing of neck/upper body (kinins, histamine). Bronchoconstriction (serotonin, bradykinin, sub p)

102
Q

Carcinoid syndrome: symp/hormone med by: ___glycemia, bp

A

Hyperglycemia (serotonin), hypotension (kinins, histamine) or htn (serotonin)

103
Q

Carcinoid syndrome symp/hormone med by: GI, heart

A

Diarrhea (serotonin, prostaglandins), heart disease (serotonin)

104
Q

Carcinoid triad

A

Flushing, diarrhea, cardiac dysfunction

105
Q

Carcinoid heart disease: usually ___ sided with ___ __.

A

Right, tricuspid regurg

106
Q

Preop mgmt carcinoid: __ __ monitoring. __ __ monitoring needed. Cvp/pa/tee if what

A

Blood glucose. Arterial bp. Carcinoid heart disease

107
Q

Anes mgmt carcinoid syndrome: ___ for dvl/ett placement. Avoid __ __ drugs and ex 5

A

Deep. Histamine releasing: sux, NMB that rel histamine, tpl, morphine, demerol

108
Q

Carcinoid syndrome anesthesia: regional ___ better than ___, avoid ___. Treat with __ and ___.

A

Epidural > spinal. Hypotension. Fluid and octreotide

109
Q

Preventative octreotide infusion dose. Intraop carcinoid crisis octreotide dose/how you may know its happening

A

50-100 mcg/hr. 25-100 mcg IVP (hypotension, bronchospasm)

110
Q

Carcinoid syndrome anesthesia: ___ for refractory hypotension. ___ 2nd line. For hypertension ___ or what

A

Vaso, aprotinin. Labetolol or inc dose volatiles

111
Q

Drugs that can precipitate a carcinoid crisis 5

A

Histamine, norepi, epi, dopamine, ephedrine

Adv Pr III (4 decks)

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