Obese Patients Flashcards
BMI
Formula?
Doesn’t differentiate between: (2)
weight (kg)/ height2 in meters = kg/m2
Doesn’t differentiate between
1. Overweight and overfat
2. Waist circumference, waist-hip ration, age
Distribution of Fat:
-Which one has CV disease?
-Which one has ^ O2 consumption?
-Metabolic?
Android? ____ Obesity
Gynecoid? ____ Obesity
Android
* “central” obesity
* Upper body (truncal)
* Associated with ↑ oxygen consumption/cardiovascular dz
Gynecoid
* “peripheral” obesity
* Hips, buttocks, thighs
* Less metabolically active
* Not really associated with CV disease
Common associated diseases
(8)
Lungs (2)
<3: (2)
Endocrine: (2)
Muscular skeletal (1)
Common associated diseases
1. Type 2 diabetes mellitus
2. Obstructive sleep apnea
3. Asthma
4. Chronic obstructive pulmonary disease
5. Hypertension
6. Cardiovascular disease
7. Cancer
8. Osteoarthritis
Cardiac
Volume to weight ratio: _____ ml/kg
^CO due to:
1.) Excess fat: ____ ml/kg excess body fat
2.)
3.)
Cardiac Dysrhythmias
What kind (2):
Cause: (2):
Total blood volume increased
* On a volume-to-weight ratio is lower 50ml/kg
* Most distributed to adipose tissue
↑ Cardiac output
1.) 20-30ml/kg of excess body fat
2.) d/t LV dilation
3.)↑ stroke volume
Cardiac dysrhythmias
* d/t fatty infiltrates of conduction system, and CAD
* Low QRS voltage, LVH, left axis
Hematologic system
Hypercoagulability: Increase in:
1.)
2.)
3.)
4.)
- Endothelial dysfunction bc increase:
1.)
2.)
- Hypercoagulability
- ↑er levels of: …… 7,8,v,f
1.) fibrinogen
2.) Factor VII,
3.) Factor VIII
4.) von Willebrand
–> Endothelial dysfunction 8v
* d/t levels of factor VIII (8) and von Willebrand
GI system
___: Gastric volume
___: Gastric acidity
___: Gastric emptying
___: Intra-gastric pressure
____: LES and hiatal hernia formation
Aspiration risk for asp. pneumonitis:
Volume >___ mL
pH <____
^: Gastric volume
^: Gastric acidity
Delayed: gastric emptying
^ : Intra-gastric pressure
Relax: LES and hiatal hernia formation
Aspiration risk for asp. pneumonitis:
Volume >___ mL
pH <____
Renal system
Glomerular ___filtration
___: RBF
___: Renal Tubular reabsorption
_____: Renin-angiotensin system
_____:Natriuresis (excretion of Na)
Glomerular HYPER-filtration
↑ RBF
^: Renal tubular reabsorption
Activates: renin-angiotensin sys
Impairs: Natriuresis
Endocrine system
___: SNS activity
___: Insulin resistance
_______: glucose metabolism
_____: pressor activity of norepi and angiotensin II
_____:Sodium retention
____:Thyroid hormone resistance
_____thyroidism in 25% of morbidly obese patients
^: SNS
^: Insulin resistence
Impaired glucose metabolism
^ enhanced: pressor activity of NE/ATII
Sodium retention
Thyroid hormone resistence
hypothyroidism in 25% of morbidly obese patients
Metabolic Syndrome
3 of these for diagnosis
- Abdominal obesity
- Decreases levels of HDL
- Hypertriglyceridemia
- Hyperinsulinemia
- Glucose intolerance
- Hypertension
- Proinflammatory state
- Prothrombotic state
Risk Factors for Metabolic Syndrome:
___ age
Men or women
___race
What meds??
(4)
Risk factors
* Increased age
* Men > women
* Hispanics and South Asians
- Chronic corticosteroids
- Antidepressants
- Antipsychotics
- Protease inhibitors: viral meds
Metabolic Syndrome = increased risk of:
(5)
<3, endo, repro, liver
____% resolved with weight loss surgery
- Cardiovascular disease
- Type 2 diabetes mellitus
- Polycystic ovary syndrome
- Nonalcoholic fatty liver disease
- Improper immune responses
- 98% resolved with bariatric surgery/weight loss goal
Obstructive sleep apnea and
hypopnea syndrome (OSAHS)
- OSA
- Hypopnea
both last how long??
how much x per hr?
decrease sat by__%?
OSA
* Complete cessation of breathing
* Lasting 10 seconds or >
* 5x or > each hour of sleep
* Decreased sat 4%
Hypopnea
* Reduction in airflow 50% or >
* Lasting 10 seconds or >
* 15 x or more/hour of sleep
* Decreased sat 4%
Sleep study for OSAHS
Polysomnography:
Mild=
Moderate=
Severe=
Treatment =CPAP. bc risk of:
(4)
Reported as: apnea/hypopnea index (AHI)= total # of events/total sleep time
- Mild: 5-15/hr
- Moderate: 15-30/hr
- Severe: > 30/hr
Risk of:
* Systemic/Pulmonary HTN
* LVH
* Cardiac dysrhythmias
* Cognitive impairment
Obesity hypoventilation syndrome
* Aka: Pickwickian syndrome
-Results from: _______
-___% of morbid obesity
Results in:
Resp =
Diagnosis??
(2)
- Results from long-term OSA…5-10% of morbidly obese
Results in:
* Pulmonary hypertension
* Cor pulmonale
- Diagnosis
- BMI > 30 kg/m2
- Awake hypercapnia
Drug Dosing Guidelines:
Based on IBW: (4)
Based on TBW: (5) —- pain?
Based on tissue solubility;
Based on IBW
* Propofol
* Vecuronium
* Rocuronium
* Remifentanil
Based on TBW
* Midazolam
* Succinylcholine
* Cisatracurium
* Fentanyl
* Sufentail
Based on tissue solubility
* Desflurane probably favored…
Phentermine
Function?
FDA for ___ months
Symptoms:
- Sympathomimetic which ↓ appetite
- FDA approved for only 3 months
Tachycardia, palpitations, hypertension
dependence, abuse
- No longer in combo with Fenfluramine
Orlistat
Function?
S/E:
Chronic use –> _____ (3)
- Blocks absorption of dietary fat
Side Effects
Liquid stool, oily spotting, fecal urgency, flatulence, abdominal cramps
Chronic Use:
1.) Fat soluble vitamin deficiencies
2.) Possible Vit K deficiency… = ^BLEEDING
3.) prolonged PT
OTC Herbals
Pancreatic lipase inhibitors… (2)
Appetite suppressors… (3)
Energy stimulants…(1)
Regulate lipid metabolism… (3)
OTC Herbals
Pancreatic lipase inhibitors…
* caffeine, green tea
Appetite suppressors…
* ginseng, ephedra, sunflower oil
Energy stimulants…
* acai berry
Regulate lipid metabolism…
* soybean, fish oil, oolong tea
___ response with opioids/prop/benzos
What short acting pain drugs are favored?
What alpha 2 agonist favored?
VA: effect on breathing??
What gas is NOT favored?
Exaggerated responses (especially in pts with OSA)
remi/fentanyl most favored
α2 agonists…dexmedetomidine
- Decrease pharyngeal musculature
- Decreased airway patency
-Diminish ventilatory response to CO2
-Nitrous not favored d/t high oxygen demand in pts
- ___ vital capacity
- ___ inspiratory capacity
- ___ expiratory reserve volume
- ___ functional residual capacity
- ____compliance
- Closing capacity is close to or within tidal breathing
- Especially when supine/recumbent
- Rapid desaturation
- ⬇️ vital capacity
- ⬇️ inspiratory capacity
- ⬇️ expiratory reserve volume
- ⬇️ functional residual capacity
- Low compliance
- Closing capacity is close to or within tidal breathing
- Especially when supine/recumbent
- Rapid desaturation
- Increased adipose deposited:
1.
2.
3.
4.
5.
6.
- Increased adipose deposited into
1. Uvula
2. Tonsils
3. Tonsillar pillars
4. Tongue
5. Aryepiglottic folds
6. Lateral pharyngeal walls
- Changes oropharynx into an ellipse Short transverse/long AP axis
- Inverse relationship between degree of obesity and pharyngeal area
Predictors of difficult intubation:
- BMI?
- Mouth?
- Teeth?
- Neck
- Mandible?
Predictors of difficult intubation:
- BMI not necessarily an independent predictor
- Small mouth opening
- Large/protuberant teeth
- Limited neck mobility
- Retrognathia (unusual mandible position)
- In an effort to prevent atelectasis and desaturation:
- Preoxygenation with:
- Positioning head: _____ degrees
- 30 degrees reverse Trendelenburg even better
- Recruitment maneuvers then PEEP ____.
CPAP during preoxygenation… 10cm H20
25-30 degrees head up for obese patients
- 30 degrees reverse Trendelenburg even better
PEEP 10 cm and vent after ventilation
