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Obesity Anesthesia Exam 3 Flashcards

1
Q

What is obesity?

A
  • A complex, chronic disease
  • Characterized by an excessive amount of body fat.
  • It develops from an interplay between genetic factors and environmental influences.
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2
Q

Why is obesity significant in public health?

A
  • It is the second leading cause of preventable death in the United States
  • Associated with medical and surgical conditions and morbidity.
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3
Q

What pathophysiological changes are associated with obesity that affect anesthesia?

A
  • Altered body composition
  • Increased adipose tissue
  • Physiological alterations that impact pharmacokinetics and pharmacodynamics
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4
Q

What are the pharmacological considerations for obese patients under anesthesia?

A
  • Alterations in drug distribution
  • Metabolism, and excretion
  • Necessitating adjustments in dosing and careful monitoring
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5
Q

What specific anesthetic considerations are necessary for obese patients?

A
  • Adjusting dosages for weight
  • Monitoring respiratory function
  • Managing potential cardiovascular issues
  • Preparing for difficult airway management
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6
Q

How can anesthesia care be optimized for obese patients?

A
  • Comprehensive preoperative assessment
  • Customizing anesthetic techniques and drug selections
  • Preparing for complications associated with obesity
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7
Q

Where does obesity rank among causes of preventable deaths in the US?

A
  • Is the second leading cause of preventable deaths in the US
  • Following smoking.
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8
Q

How prevalent is childhood obesity compared to other major diseases?

A

Is more common than:

  • Diabetes
  • Cystic fibrosis
  • All cancers combined
  • Making it a critical public health concern
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9
Q

How many calories do fats, carbohydrates, and proteins provide per gram?

A
  • Fats provide 9 calories per gram
  • Carbohydrates 4 calories per gram
  • Proteins 4 calories per gram
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10
Q

What are the main factors contributing to obesity?

A
  • Genetic factors
  • Pathophysiological factors
  • Pharmacological factors
  • social factors
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11
Q

Which Cardiovascular conditions are associated with Obesity?

A
  • CAD
  • HTN
  • Dyslipidemia
  • CVA
  • Thromboembolic disease
  • Cardiomegaly
  • CHF
  • Pulmonary Hypertension
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12
Q

Which Endocrine conditions are associated with Obesity?

A
  • Type 2 Diabetes
  • Thyroid disorders
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13
Q

Which Respiratory conditions are associated with Obesity?

A
  • Restrictive lung disease
  • Obese hypoventilation syndrome (OHS)
  • Obstructive sleep apnea (OSA)
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14
Q

Which Gastrointestinal conditions are associated with Obesity?

A
  • Hiatal or Inguinal Hernia
  • Gallbladder disease
  • Non-ETOH fatty liver disease
  • GERD

NON-ETOH: Steatosis, Cirrhosis, Hepatomegaly

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15
Q

Which other conditions are associated with Obesity?

A
  • Gout
  • Infertility
  • Impaired immune response
  • Wound infections
  • Osteoarthritis
  • Malignancy
  • Urinary incontinence
  • Pancreatitis
  • Low back pain
  • Obstetric complications

Malignancy: Esophageal, Gallbladder, Colon, Breast, Uterine, Cervical, Prostate, Renal.

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16
Q

What is BMI?

A
  • Most used clinical tool that relates a person’s weight to their height
  • Does not take fat distribution (android, gynecoid)
  • Can be skewed with large % of muscle mass (body builders, athletes)
  • Morbidity increases in direct proportion to BMI
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17
Q

Classification of Overweight and Obesity by BMI table

Memorize it

A
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18
Q

Android obesity is more common in:

A
  • Men
  • Known as Apple-shaped fat patterning
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19
Q

Android obeisty is charactherized by:

A
  • Central or abdominal fat accumulation
  • Waist size > 40 in Men
  • Waist size > 35 in Women
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20
Q

What is the risk associated with waist size > 40 inches men and > 35 inches women ?

A
  • Ischemic heart disese
  • Hypertension
  • Dyslipidemia
  • Insulin resistance
  • Death
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21
Q

Gynecoid obesity is more common in:

A
  • Women
  • Known as Pear-shaped fat patterning
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22
Q

Gyenocoid obesity is charactherized by:

A
  • Gluteal fat accumulation
  • Femoral fat accumulation
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23
Q

How is Gynecoid fat in relation to metabolic?

A
  • Metabolically inactive
  • Used for energy storage (primarily)
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24
Q

Patients with Gynecoid fat are more likely to develop:

A
  • Joint disease
  • Varicose veins
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25
Q

Gynecoid fat is associated with:

A
  • Reduced incidence of non-insulin dependent diabetes
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26
Q

What is metabolic syndrome?

A
  • Known as syndrome X
  • Incorporates with several disease states
  • Concides with obesity
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27
Q

What is the cardiovascular risk associated with metabolic syndrome?

A
  • 50%
  • Greater than general population
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28
Q

Diagnosis of Metabolic syndromes requires 3 of these signs:

A
  1. Fasting BG 100-110 mg/dL
  2. Abdominal obesity ( men >40; women > 35)
  3. Serum Tryglyceride > 150 mg/dL
  4. Serum HDL < 40 mg/dL men; < 50 mg/dL Women
  5. BP > 130/85
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29
Q

Metabolic syndrome table criteria!

A
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30
Q

What is Ideal Body Weight (IBW)?

A
  • Describes the BMI associated with the lowest risk of body weight-related comorbidities
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31
Q

Ideal Body Weight Formula (IBW)

A
  • Men (kg) = Height (cm) - 100
  • Women (kg) = Height (cm) - 105
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32
Q

BMI Formula

A

Convert:

  1. Lbs to Kg
  2. Inches to Cm ( 1in = 2.54 cm)
  3. Cm to Mts^2 ( cm/100)
  4. Total/ 100
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33
Q

How much does Cardiac Output increases with Obesity?

A
  • Increases 100 mL/min
  • For every extra kg of fat
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34
Q

What are the factors that account the majority of CO increase?

A
  • Increased Preoload
  • Incrased Stroke volume
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35
Q

What is the CV impact due to Obesity?

A
  • Incrased Intravascular volume
  • High CO
  • Higher workload on the Myocardium
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36
Q

What cardiac dysfunctions are prompted by obesity?

A
  1. Diastolic dysfunction (initially)
  2. Systolic dysfunction
  3. Biventricular HF
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37
Q

What are the factors that cause Hypertension in Obesity?

A
  • Hyperinsulinemia
  • SNS + RAAS activation
  • Increase Cytokine plasma concentration
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38
Q

What are the EKG changes in Obesity?

A
  • Axis deviation (L or R)
  • Low voltage
  • Dysrhythmias
  • Ischemia
39
Q

What respiratory defect is produced by Obesity?

A

Restrictive ventilatory defect

40
Q

How is the FRC related to BMI?

A

FRC is inversely proportional to BMI

41
Q

The reduction in FRC below closing capacities causes:

A

Distal airway collapse during tidal breathing

42
Q

Premature airway closure also increases?

A

Dead space

43
Q

What is the effect of General anesthesia in FRC?

A

FRC falls by 50%

44
Q

A higher O2 consumption with small FRC predisposes obese patients to:

A
  • Rapid desaturation during apnea
45
Q

How does the metabolic activity of fat influence respiratory demands in obese patients?

A
  • Increase Oxygen consumption
  • Increase CO2 production
  • Mintue ventilation must be increase to keep normal ABGs tension
46
Q

Ventilator management in Obesity?

A
  • Preoxygenate with 100% FiO2
  • CPAP 10 cm H2O
  • Until ETO2 > 90%
  • Tidal volume 6-8 mL of IBW
47
Q

How is PaCo2 better manage in obese patients?

A
  • Increasing Respiratory rate

Not increasing tidal volume

48
Q

What pulmonary post-induction condition are obese patient at risk for?

A

Atelectasis

49
Q

What are the strategies to prevent Atelectasis?

A
  • FiO2 < 80%
  • Alveolar recruitment maneuvers
  • PEEP
50
Q

What are the intubation consideration for Obesity alone without risk factors?

A

Does not mandate RSI

Risk Factors: GERD or Diabetes

51
Q

What may occur to Obese patient after extubation?

A
  • PostOP Hypoxemia
  • Right after extubation
  • Up to 2-5 days post Sx
  • OSA patients at higher risk
52
Q

Obstructive Sleep Apnea (OSA) Definition:

A
  • Cessation of airflow at least 10 sec (apnea)
  • Obstruction with 5 or more unsuccessful efforts to breath
  • > than 4% reduction of SaO2
53
Q

What is a common phenomenon is OSA?

54
Q

How is Hypopnea defined?

A
  • 50% reduction of airflow for > 10 secs
  • 15 or more episodes per hour
  • Linked to snoring
  • Decreased SpO2
55
Q

The incidence of OSA is directly proportional to:

56
Q

What factors increse the risk of OSA?

A
  1. BMI > 30 kg/m2
  2. Abdominal fat distribution
  3. Large neck girth > 17 in men; > 16 in women
57
Q

OSA is an independent risk factor for the development of these conditions:

A
  • Hypertension
  • Cardiovascular morbidity
  • Death
58
Q

What is the definitive diagnostic test for OSA?

A

Polysomnography

  • Calculates apnea-hypopnea index (AHI)
  • Used to quantify OSA severity
59
Q

What are the Apnea-Hypopnea Index classifications for OSA?

A
  • Mild = 5-15 episode/Hr
  • Moderate = 15-30 episodes/Hr
  • Severe = > 30 episodes/Hr
60
Q

Patients with severe OSA are at higher risk for:

A
  • Difficult mask ventilation
  • Difficult intubation
61
Q

STOP-Bang Screening Tool

62
Q

PeriOP Anesthsia management of OSA table

63
Q

Obese Hypoventilation syndrome (OHS)

A
  • Pickwickian syndrome (AKA)
  • Long-term untreated OSA
64
Q

What is the classic presentation of OHS?

Obese Hypoventilation Syndrome

A
  • Episodes of apnea during sleep
  • Without any respiratory efforts
65
Q

What is the diagnosis criteria for OHS?

Obese Hypoventilation Syndrome

A
  • BMI > 30 kg/m2
  • Awake PaCO2 > 45 mmHg
  • Dysfunctional breathing during sleep
66
Q

What are the signs of OHS?

Obese Hypoventilation Syndrome

A
  • Obesity
  • Hypersomnolence day time
  • Hypoxemia
  • Hypercarbia
67
Q

What are the effects of respiratory depresant drugs to patients with OHS?

A
  • Airway obstruction
  • Respiratory arrest
68
Q

Bariatric Surgery Approaches Table

A

Know how to identify each one

69
Q

MOA Bariatric Surgery Table
Bariatric Surgery Indications table

70
Q

Procedures (APEX table):

Malabsorption
Restriction
Combination

A

Know the key points!

71
Q

What procedure is associated with Anastomotic Leak?

A

Gastric bypass 2%

72
Q

Is ketoralac given IntraOp?

A
  • Some say no for bleeding and ulcers risk
  • Newer evidance supports it as it reduces Opioid intake
73
Q

What are the MOST common sings and symptoms of Anastomotic Leak ?

A
  • Tachycardia 72%
  • Fever 63%
  • Abdominal pain 54%
74
Q

What is the MOST sensitive sign of Anastomotic Leak?

A
  • Unexplained Tachycardia
  • Sustained HR > 120 bpm

Is alarming even in patients with no other symptoms.

75
Q

Signs and Symptoms associated with Anastomotic Leak:

76
Q

What is the formula to calculate Lean Body Weight (LBW) ?

A

LBW = IBW x 1.3

77
Q

What weight is used to calculate Water-soluble drug doses?

A

Ideal Body Weight (IBW)

  • Men (kg) = Height (cm) - 100
  • Women (kg) = Height (cm) - 105
78
Q

What weight is used to calculate Lipid-soluble drug doses?

A

Total Body Weight

The patient’s actual weight

79
Q

The volume of distribution (Vd) of a drug in Obese Patients is altered by:

A
  • Increased blood volume
  • Increased Cardiac output
  • Altered Plasma Protein Binding
  • Lipid solubility of the drug

See more details of image

80
Q

Pharmacologic changes associated with Obesity Table

81
Q

APEX: Pharmacological consideration Table

A

Focus on the Recomendations

82
Q

What volatile agents should be use with Obese patients?

A
  • Agents with lowest blood:gas coefficients
  • Volatile agents are lipophilics
  • Sevo or Des faster emergence than Iso or Propofol

Preffer: Des > Sevo

83
Q

What is the effect of Obesity on MAC?

A

Is unchanged by Obesity

84
Q

Which anesthetic gases increase defluorination?

A
  • Isoflurane
  • Desflurane

However; is not linked to PostOp hepatic or renal dysfunction

85
Q

Which anesthetic gas is avoided with Obese patients?

A

Nitrous Oxide

  • Restricts the max FiO2 to be deliver
86
Q

What risk is increased post Extubation with Obese patients?

A

Airway obstruction

87
Q

The decission to extubate an obese patient depends on:

A
  1. Ease of mask ventilation
  2. Tracheal intubation
  3. Lenght of surgery
  4. Type of surgery
  5. Preexisting medical conditions

Extubation must include all standard objective and subjective criteria

Including OSA

88
Q

How is an obese patient position prior to extubation?

A

Sitting position

89
Q

What may be considered for obese patients if there is doubt about their ability to breathe adequately post-surgery?

A
  • Leave ETT in placed
  • Extubation over an airway exchange catheter
  • Via a fiberoptic bronchoscope
90
Q

What are some Appetite Suppresants?

A
  1. Ma Huang
  2. Phentermine
  3. Sibutramine
  4. Orlistat
91
Q

Ma Huang?

A
  • Natural source of Ephedrine
  • Indirect-acting adrenergic agonist
  • Thermogenic agent
92
Q

Phentermine and Sibutramine?

A
  • NorEpi and Serotonin reuptake inhibitor
  • Increases BMR
  • Risk: adrenergic overstimulation
  • Serotonin Syndrome

Acts as an appetite suppresant

93
Q

Orlistat?

A
  • Lipase inhibitor
  • Reversibly binds to Lipase
  • Hinders absorption and digestion of fats
  • Contains Vit D, A, K, E not absorbed by the gut
  • Must be supplemented orally
  • Low vit K+ intake impairs factors 2, 7, 9, 10
  • May cause coagulopathy
94
Q

On the cardiovascular changes that occur in the elderly, everything decreases, except:

A
  • Myocardial Hypertrophy
  • Blood Pressure
  • Pulse Pressure
  • Systolic Function (No Change)

Special Population-RCM (8 decks)

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