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Obesity Flashcards

1
Q

what percent of Americans are obese/overweight?

A

75%

over 210 million people

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2
Q

are men or women more obese?

A

women

35% men
40.4% women

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3
Q

__ leading cause of preventable and premature death, behind tobacco

A

second

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4
Q

BMI

A

the measure of body habitus that describes adiposity normalized for height

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5
Q

BMI calculation kg

A

weight (kg) / height (Meters)^2

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6
Q

BMI calculation lb

A

(weight (lbs) / height (inches)^2 x 703)

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7
Q

IBW

A
  • measurement of ht and body mass that exhibits the lowest morbidity and mortality
  • important for calculating infusion doses for the obese population
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8
Q

lean body weight is increased __ d/t increase in muscle mass needed to carry extra weight

A

30%

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9
Q

calculate appropriate dosing for lean body weight

A

men IBW = ht (cm) -100
women IBW = ht (cm) -105

LBW = IBW x 1.3

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10
Q

underweight BMI

A

less than 18.5

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11
Q

normal BMI

A

18.5 - 24.9

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12
Q

overweight BMI

A

25 - 29.9

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13
Q

Obesity I BMI

A

30 - 34.9

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14
Q

Obesity II BMI

A

35 - 39.9

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15
Q

Obesity III BMI

A

greater than 40

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16
Q

greatest risk for comorbities

A

men, higher age, higher BMI

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17
Q

highest comorbidity risk factors

A
  • CV disease
  • cancers
  • diabetes
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18
Q

higher risk for psychological conditions like..

A

depression, anxiety, worthlessness

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19
Q

hormonal & nonhormonal mechanisms

A

breast, GI, endometrial, and renal cell cancers

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20
Q

major integrative physiologic functions of adipose tissue

A
  • protein secreting
  • considered an endocrine organ
  • provides a reservoir of convertible/usable energy
  • insulator
  • liver fat metabolism
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21
Q

liver fat metabolism

A
  • degradation of fatty acid into units of energy
  • synthesis of triglycerides from carbohydrates & proteins
  • synthesis of fatty acids –> cholesterol & phospholipids
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22
Q

each gram of fat provides how many calories?
each gram of carb/protein provides how many calories?

A

9 cal
4 cal

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23
Q

2 types of distribution

A
  • Central/android/abdominal visceral obesity
  • peripheral/gynecoid/gluteal obesity
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24
Q

characteristics of central obesity

A
  • apple: waist/hip ratio > 0.85 in men & 0.92 in women
  • correlated with a higher risk of comorbidities
    -waist circumference is a newly established marker for abdominal obesity
  • waist circumference > 102 cm (40in) in men & 88cm (35 in) in women –> increased risk for ischemic heart disease, dm, HTN, dyslipidemia, death
  • destroys the liver more than pear-shape
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25
Q

central obesity is more common in men or women?

A

men, metabolically active (free fatty acid)

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26
Q

characteristics of peripheral obesity

A
  • pear: waist/hip ratio < 0.76
  • associated with varicose veins, joint disease & reduces the incidence of non-insulin-dependent DM
  • medical risks decreased
  • more common in women, metabolically static, proposed to function as energy deposits for pregnancy and lactation
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27
Q

causes of obesity

A

both genetic and environment

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28
Q

genetic being the primary factor

A
  • prader-willi syndrome
  • bardet-biedl syndrome
  • obesity “hormone” LEPTIN –> not enough, overeating
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29
Q

environmental factors

A

diet, exercise, lifestyle, within family, money

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30
Q

diseases causing obesity

A

PCOS, Cushing’s syndrome, hypothyroidism

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31
Q

early childhood fat cell formation occurs __

A

rapidly

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32
Q

children: overfeeding accelerates __ __ and triggers ___ of fat cells

A

fat storage; hyperproliferation

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33
Q

adolescence: number of fat cells __ and remain __ throughout adult life

A

stabilize; consistent

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34
Q

adolesence become obese through __ in fat cell __

A

increase; numbers

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35
Q

adult: become obese through __ of existing cells

A

hypertrophy

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35
Q

CV disease primary cause of the

A

morbidity & mortality

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36
Q

what kind of CV dx?

A

ischemic heart dx, HTN, cardiac failure

increased CO, O2 consumption, & CO2 production

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37
Q

extra fat development …

A

increase need for extra blood vessels and increased circulatory, pulmonary, central, and peripheral blood volume

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38
Q

for every 13.5 kg of gained fat =

A

25 miles of neovascularization

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39
Q

increase CO of 0.1L/ min per

A

kg of fat acquired

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40
Q

chronically elevated CO –>

A

increases left-sided heart pressures and LV hypertrophy

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41
Q

what will lead to HTN and CHHF?

A

cardiomegaly, atrial and biventricular dilation, and biventricular hypertrophy ensue

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42
Q

HNT is

A

SBP > 140 & DBP > 90

2x as high in this population

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43
Q

BP shown to increase __ for every __% increase in body weight

A

6.5; 10

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44
Q

renal mechanisms are associated with

A

the development of obesity-related HTN

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45
Q

hypercholesterolemia (> __ mg/dL) often coexists with __ –> __ & __

A

240; HTN; atherosclerosis; CVA’s

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46
Q

what is frequently associated with obesity but is an independent risk factor appearing with or without HTN, DM, HLD

A

CAD

more common in those with central fat distribution

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47
Q

decrease in respiratory function results from

A
  • compression of fat on abdominal, diaphragmatic, and thoracic structures
  • thoracic kyphosis and lumbar lordosis develop –> impaired rib movement and fixation of thorax in inspiratory position –> chest wall, lung, parenchyma and pulmonary compliance decrease by 35%
  • metabolic needs & increased work of brething –> increased myocardial O2 consumption
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48
Q

increased CO2 porduction & retention & decreased ventilation –>

A

reduced respiratory muscle effort

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49
Q

lung inflation inhibited –>

A

decline in FRC to less than closing capacity

premature airway closure increases dead space causing CO2 retention , V/Q mismatch, shunting & hypoxemia

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50
Q

extreme obesity: __ in FRC, ERV, TLC

A

decrease

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51
Q

FRC __ proportional to BMI

A

inversley

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52
Q

ventilation pattern exhibited those of __ lung disease

A

restrictive

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53
Q

eventual hypoventilation, hpercarbia, and acidosis result from

A

the depression of central nervous responsiveness to chronic hypoxia

polycythemia –> increased risk of CAD and CVA

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54
Q

simply, OSA is __ airway

A

blocked

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55
Q

OSA overview

A

Increasing in direct proportion to the level of obesity
- tend to have BMI > 30
- abdominal fat distribution
- large neck girth: Men > 17 in^2, women > 16 in^2

characterized by excessive episodes of apnea (10 seconds) and hypopnea during sleep caused by complete or partial obstruction
- apnea is the cessation of airflow at nose & mouth for more than 10 seconds
- hypopnea is 50% reduction in airflow for 10 seconds that occurs 15 or more times per hour of sleep

snoring and 4% decrease in O2 saturation

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56
Q

OSA diagnosis

A

diagnosis done via polysomnography (PSG) using apnea-hypopnea index (AHI)

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57
Q

AHI =

A

number of abnormal respiratory events per hour of sleep

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58
Q

american academy defines OSA as:

A

mild: 5 - 15 AHI
moderate: 15 -30 AHI
severe: > 30 AHI

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59
Q

OSA pathogenesis

A

multifactorial dependent on anatomy, muscle, and ventilatory stability
- upper airway obstruction typically in the pharynx
- the pharyngeal luminal area during respiration reflects a balance between collapsing intrapharyngeal negative suction pressure and dilating forces provided by pharyngeal muscles

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60
Q

when awake, patency is maintained by continual mediation of __ of the __ __ in __

A

contraction; tensor muscles; CNS

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61
Q

these dilator muscles __ the negative collapsing force developed during __

A

oppose; inspiration

62
Q

cardivascular possibilites with OSA

A
  • bradycardia during apneic episodes
  • long sinus pause
  • second degree heart block
  • ventricular ectopy
63
Q

muscle tone activation is __ during sleep (also anesthesia)

64
Q

whats the percentage of OSA undiagnosed & untreated

65
Q

OSA patients have a higher incidence of

A

comorbidities

66
Q

with OSA consider:

A
  1. sleep apnea status
  2. anatomical & physiological abnormalities
  3. status of coexisting dx
  4. nature of surgery
  5. type of anesthesia
  6. need for postoperative opioids
  7. age
  8. adequacy of postoperative observation
  9. capabilities of OP facility (emergency airway equipment)
67
Q

STOP-BANG

A
  1. Snoring: snore loudly?
  2. Tired: often fatigued?
  3. Observed: Did you stop breathing during sleep?
  4. blood Pressure: high BP

BMI higher than > 35
Age: more than 50 years old?
Neck circumference: greater than 40cm
Gender: male?

high risk of OSA: answering yes to 3 or more items
low risk: answering yes to fewer than 3 items

68
Q

anesthetic concern with patients with OSA:
preoperative concern

A
  • cardiac arrhythmias and unstable hemodynamic profile
  • multisystem comorbidites
  • sedative premedication
  • OSA risk stratification, evaluation, and optimization
69
Q

anesthetic concern with patients with OSA:
intraoperative concern

A
  • regional anesthesia
  • difficult intubation
  • opioid-related respiratory depression
  • carry-over sedation effects from longer-acting intravenous sedatives and inhaled anesthetic agents
  • excessive sedation in monitored anesthetic care
70
Q

anesthetic concern with patients with OSA:
reversal of anesthesia

A

post-extubation airway obstruction and desaturations

71
Q

anesthetic concern with patients with OSA:
immediate postoperative period

A
  • respiratory
  • suitability for outpatient surgery
  • postoperative respiratory event in known and suspected high-risk patients with OSA
72
Q

Pickwickian syndrome

A
  • AKA obesity hypoventilation syndrome (OHS)
  • characterized by OSA, hypercapnia, daytime hypersomnolence, arterial hypoxemia, cyanosis-induced polycythemia, respiratory acidosis, pulmonary HTN, and right-sided HF
  • OHS = obesity (BMI > 30), daytime hypoventilation with awake PCO2 > 45 and sleep disordered breathing
  • 8% of obese population
  • cardiac enlargement, cyanosis, polycythemia, twitching
73
Q

what gastrointestinal disease’s increase with obesity?

A

increased incidence of GERD, gallstones, pancreatitis, nonalcoholic fatty liver dx (NAFLD)

74
Q

NAFLD =

A

steatosis, steatohepatitis, fibrosis, cirrhosis, hepatomegaly, abnormal liver chemistry. confirmed with liver biopsy

  • most common liver condition worldwide
  • related to insulin resistance with higher incidence in those with central obesity or diabetes
  • clinically asymptomatic
  • higher mortality rate, higher incidence of CV disease and diabetes

steatosis = fat build up in an organ
steatohepatitis = fatty liver

75
Q

what endocrine/metabolic disorders should be monitored for?

A

thyroid, adrenocortcoid, & pituitary functions

76
Q

gallstone increase __ %

A

30%

higher concentration of cholesterol in bile, laparoscopic approach

77
Q

menstrual functions may signify the presence of __-__ abnormalities

A

hypothalamic-pituitary

77
Q

what percent of people who are obese have diabetes type II?

78
Q

ankles, hips, knees, and lumbar spine often develop..

A

OA from increased mechanical stress

78
Q

metabolic syndrome

A

consists of glucose intolerance +/- DM II, HTN, dyslipidemia, and CV dx

  • create a proinflammatory and prothrombotic state
  • increases the risk of CAD, stroke, PVD, and DM II,
  • CV risk increase alone is 50-60% higher than healthy population
79
Q

decreased bone resorption from __ physical activity can lead to __ bone density and lead to __ fractures

A

decreased; decreased; stress

79
Q

what is the percentage of the obese pediatric population? 2-19 yrs of age

80
Q

whats the percentage of obese children that have a chance of being obese as an adult?

81
Q

pediatric obesity is associated with higher chance of

A

premature death in adulthood

82
Q

pediatric obesity

A
  • linked to cardiac and endocrine problems
  • 3x more likely to suffer stroke or heart attack by 65
  • joint replacement is more likely
  • pediatric obesity is more common than diabetes, HIV, cystic fibrosis and all childhood cancers combined
  • HTN, OSA, those with type 2 diabetes are usually obese, psychosocial
83
Q

maternal obesity

A
  • pregravid obesity –> complications
  • maternal obesity seems to be the most significant link to the increase in birth weight
  • longer 1st & 2nd stages
  • GHTN, GDM, hydraminos
  • metabolic syndrome during pregnancy will show as preeclampsia, preterm labor, C/S, PP hemorrhage, infection, PIH and macrosomic infants
84
Q

fetal macrosomia =

A

wt > 4000g

increased risk of adolescent metabolic syndrome and DMII

macrosomia = growth beyond a specific threshold, regardless of gest age

85
Q

peripartum risks

A
  • C/S, difficult epidural/spinal placement, difficult intubation, decreased ability of US to detect craniospinal or cardiac defects, increased postop complications (longer surgery, wound infections, endometriosis, VTE, excessive blood loss)
  • C/S rates increased in those with a hx of bariatric surgery
86
Q

maternal obesity –>

A

significant risk factor in adverse outcomes in pregnancy

87
Q

higher birth weights have a definite connection in

A

children and obesity as adults

88
Q

some FDA approved drugs for the long-term treatment of obesity

A
  • sympathomimetic amine/antiepileptic combination: phentermine/topiramate ER (qsymia)
  • lipase inhibitor: orlistat (Xenical) (Alli)
  • serotonin receptor agonist: lorcaserin (Belviq)
  • opioid antagonist/antidepressant combination: naltrexone/bupropion (contrave)
  • GLP 1- receptor agonist: liraglutide (saxenda)
88
Q

mechanism of action of select bariatric operations: restrictive

A
  • vertical banded gastroplasty (VBG; historic purposes only)
  • laparoscopic adjustable gastric banding (LAGB)
  • laparoscopic sleeve gastrectomy (LSG)
89
Q

mechanism of action of select bariatric operations: largely restrictive, mildly malabsorptive

A

roux-en-Y gastric bypass (RYGB)

90
Q

mechanism of action of select bariatric operations: largely malabsorptive, mildly restrictive

A
  • biliopancreatic diversion (BPD)
  • duodenal switch (DS)
91
Q

indications for bariatric surgery

A
  • BMI greater than 40 or BMI less than 35 with an associated medical comorbidity worsened by obesity
  • failed dietary therapy
  • psychiatrically stable without alcohol dependence or illegal drug use
  • knowledgeable about the operation and its sequelae
    motivated individual
  • medical problems not precluding probable survival from surgery
92
Q

postoperative complications

93
Q

most common S/S of leak

A
  • tachycardia, fever, abdominal pain
  • tachycardia most sensitive sign. BPM > 120 should be investigated
  • tachypnea or desaturating can also be an early sign of sepsis from a leak
94
Q

BOX 48.8 S/S anastomotic leak

A
  • unexplained tachycardia (> 120bpm)
  • shoulder pain (usually left)
  • abd pain
  • pelvic pain
  • substernal pressure
  • shortness of breath
  • fever
  • increased thirst
  • hypotension
  • unexplained oliguria
  • hiccups
  • restlessness
95
Q

obesity causes physiological changes tht can affect __ & __ of anesthetic agents

A

pharmacokinetics; pharmacodynamics

96
Q

give water-soluble drugs according to

97
Q

give lipid-soluble drugs according to

98
Q

lean body mass increases 〜20-40% in obesity, so adding __% to the IBW is a convenint dose adjustment

99
Q

postoperative respiraotry __ is problematic, consider __ acting opioids

A

depression; short

100
Q

consider what IVA becasue they have a faster off?

A

sevoflurane & desflurane

101
Q

what inhaled anesthetic is safer for those who do not require high O2

A

Nitrous oxide

  • can be used as volatile-sparring adjunct
  • second gas effect
  • can reduce chronic postoeprtive pain
102
Q

succ should be given according too

103
Q

remifentanil should be given according to

A

IBW

popular d/t rapid offset

104
Q

what is a good adjunct to opioid/sedation/amnesia/analgesia

A

dexmedetomidine

105
Q

sugammadex is given in the usual doses

A

check twitches & don’t be afraid to give more

106
Q

pharmacokinetic changes associated with obesity

A
  • increased fat mass
  • increased cardiac output
  • increased blood volume
  • increased lean body weight
  • changes in plasma protein binding
  • reduced TBW
  • increased renal clearance
  • increased volume of distribution of lipid-soluble drugs
  • abnormal liver function
  • decreased pulmonary function
107
Q

preanestetic evaluation: medication

A
  • take note of weight-reducing substances, herbal supplements, anorexiant drugs, ozempic
  • most meds can be taken up until surgery except insulin and oral hypoglycemics
  • VTE prophylaxis d/t increase incidence
  • abx administration important d/t increase in would infections in this population
108
Q

pre anesthetic evaluation: lab testing

A
  • d/t high risk of CV dx, consider ECHO, ECG
  • d/t high risk of DM, consider glucose and A1C testing
  • BUN creatinine levels may be higher d/t dehydration or renal dysfunction
  • LFTs typically elevated in obese patients d/t infiltration of the hepatocytes and triglycerides –> may require a lesser dose of anesthetic if severe fatty liver
  • patients on anticoagulants for DVT or Affib treatment may show elevated PT/PTT times
109
Q

pre anesthetic evaluation: cardiac

A
  • investigate for prior MI, HTN, angina, PVD
  • LV dysfunction comes from exercise intolerance, hx of orthopnea, & paroxysmal nocturnal dyspnea
  • cardiac meds
  • exercise testing is typically helpful, but patients typically can’t complete
  • CXR
110
Q

ECG is essential d/t increased incidences of

A

CAD & MI

  • cardiac clearance or office visit to compare to the day of surgery
  • ECG may show low voltage based on excess overlying tissue and therefore might result in underestimating of severity of ventricular hypertrophy

axis deviation & tachyarrhythmias are common

111
Q

QT prolongation is a marker for sudden

A

cardiac arrest

  • more common in the obese population with LVH
  • if this is suspected, obtain ECHO
  • tricuspid regurg on ECHO is most confirmatory test of PHTN
111
Q

pre anesthetic evaluation: respiratory

A
  • a pt who becomes dyspneic & desaturates when recumbent will experience the same during induction in the supine position
  • evaluate for OSA/OHS/orthopnea, wheezing, sputum production, smoking hx
  • recent URI, snoring, sleep disturbances may signal obstructive processes
  • difficult mask ventilation
112
Q

airway evaluation

A
  • refer to your airway evaluation
  • high mallampati + large neck circumference and hx of sleep apnea is a good predictor of difficult intubation
113
Q

“big boy” hydraulic beds should be used

A
  • heavy-duty stirrups
  • extra-large retractors
  • elongated instruments
  • arm sleds, double arm boards, gel pads
113
Q

OR table –>

A

weight restriction

verify with OR staff on equipment needed for table

114
Q

T/F BP can not be used on forearms

115
Q

T/F more hypothermic d/t large body surface area exposed

116
Q

consider difficult __ cart and assorted intubation equipment & __

A

airway; sizes

117
Q

T/F not the same NPO guidelines as non-obese people

118
Q

what ECG leads should be monitored for myocardial ischemia detection?

119
Q

patients with hx of recent gastric banding are at increased risk of

A

pulmonary aspiration of esophageal contents

119
Q

forearm measurments with standard cuffs overestimate __ & __ in obese patients

120
Q

nausea following bariatric surgery is very

A

common

  • highest after gastric sleeve, lowest with gastric band
  • standard antiemetic therapy & consider opioid-free anesthetic
121
Q

sniffing or ramping

A
  • placement of towels/blankets under shoulders & head
  • easier view with a little reverse Trendelenburg: better for pt FRC, greatly improves view, helps with recue ventilation if needed
  • want pt positioned with head neck and shoulders significantly elevated above chest, imaginary line to connect sternal notch with the external auditory meatus
122
Q

intubation considerations

A
  • reverse trendlenburg
  • on OR table if able
  • preoxygenation 3 to 5 mins
  • careful with sedatives
  • “awake” look
  • modified RSI
123
Q

RSI

A

To use cricoid pressure or to not
- when pressure is applied to the cricoid cartilage, causes occlusion to the esophagus between cricoid cartilage & vertebral body
- cricoid pressure –> reduction of LES pressure in anesthetized patients: gastric pressure < esophageal pressure & barrier remains intact
- may cause lateral displacement of the esophagus
- conflicting studies

124
Q

GA causes __% decrease in FRC in obese population, __% in nonobese population

125
Q

adding PEEP improves

A

FRC & arterial O2 tension, only at the expense of CO and O2 delivery

126
Q

TV __ to __ mL/kg of IBW (avoid barotrauma)

127
Q

RR __ - __ for laparscopic procedures

128
Q

prolonged procedures (2-3 hrs) and hose involving abd/spine/thorax –> negative influence on respiratory function

A
  • Trendelenburg/recumbent positioning decreases FRC, and causes elevated filling pressures –> increase in RV preload
  • myocardial O2 consumption, CO, pulmonary arterial occluding pressures, PIP, and venous admixtures are increased above sitting values
129
Q

optimizing oxygenation by using at least __% O2

A

50

use recruitment breaths

130
Q

anesthetic choice

A
  • patient dependent
  • short-acting anesthetics recommended
  • avoid residual muscle relaxants
  • consider multimodal (regional for less narcotics)
  • epidurals are great for postoperative pain
131
Q

estimated blood volume is __ in obese population

A

diminished

132
Q

fat contains __ - __% water, contributes less fluid to TBW than equivalent amounts of muscle

A

8-10%

normal adult TBW to 60-65%
severely obese patients 40%

133
Q

calculated EBV for obese ppl is what instead of 70mL

A

45-55 mL/kg

134
Q

renal failure in __% of bariatric surgery

A

2%

predisposing factors: hypovolemia, BMI > 50, prolonged surgery time, intraop hypotension, preexisting dx

135
Q

adequate intraop fluid replacement helps

136
Q

Regional anesthesia

A
  • may be used as primary anesthetic, for post-op pain & mobility management
  • more difficult to obtain d/t body habitus & inability to view landmarks
  • subarachnoid/epidural anesthesia: consider longer tuohy or spinal needle, generous lidocaine for reinsertion, lack of predictability of spread
137
Q

Hetastarch volume expander should NOT be administered more than

A

20 mL/kg of IBW

dilution coagulopathy, factor VIII inhibition & decreased platelet aggregation results from excessive administration

138
Q

extubation

A
  • increased risk of airway obstrtuction
  • emergence based on mask ventilation, intubation, preexisting medical conditions..
  • have patient sitting up, OPA, exchange catheter
139
Q

postoperative managment

A

obese patients are more sensitive to the respiratory depressant effects of opioids
- supplemental O2 & pulse ox
- if patient on CPAP prior to anesthesia, should be on in PACU

140
Q

postoperative complications: rhabdomyolysis

A
  • CPK pre and postoperatively to aid in early diagnosis & treatment: cpk is the most sensitive diagnostic
141
Q

risk factors for rhabdo

A

male, elevated BMI & prolonged procedure time

142
Q

treatment rhabdo:

A
  • preserve renal function
  • avoid dehydration, hypovolemia, tubular obstruction, aciduria, & free radical release: administer fluids, bicarb & mannitol
142
Q

postoperative complications: thromboembolism

A
  • amplified with higher BMI
  • facilitated by immobility, increased blood viscosity, increased abdominal pressure & abnormalities in serum procoagulant & anticoagulants
  • 50% of deaths
143
Q

VTE risk factors:

A
  • venous stasis
  • BMI > 60
  • truncal obesity
  • OHS/OSA
144
Q

treatment of VTE:

A
  • heparin 5000 u SQ BID
  • anti embolic stockings
  • compression booties lessen the occurrence
  • early ambulation

NA 1 (15 decks)

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