Obesity (Cornelius) Exam III Flashcards
Which of the following is the second leading cause of preventable deaths, only behind smoking?
A. Obesity
B. Diabetes
C. Cardiovascular disease
D. Cancer
A. Obesity
Slide 2
What percentage of Americans are considered overweight or obese?
A. 25%
B. 36%
C. 50%
D. 60%
B. 36%
Slide 2
Globally, how many people are classified as obese?
A. 1 billion
B. 100 million
C. 400 million
D. 800 million
C. 400 million
Slide 2
More than __________ people are overweight worldwide, with over __________ million cases and __________ deaths attributed to coronavirus.
A. 2 billion; 53.2; 1.2 million
B. 1.6 billion; 33.2; 999K
C. 1.2 million; 22.3; 500K
D. 1.3 billion; 47.3; 750K
B. 1.6 billion; 33.2; 999K
Slide 2
Obesity ranks as the __________ leading cause of preventable deaths, only behind __________.
A. First; cardiovascular disease
B. Third; alcohol consumption
C. Second; smoking
C. Second; smoking
Slide 2
Which factors influence obesity? (Select 4)
A. Metabolic and behavioral factors
B. Excessive exercise
C. Cultural factors
D. Hormones
E. Socioeconomic factors
F. Exposure to extreme heat/cold
A. Metabolic factors and behavioral factors,
C. Cultural factors,
D. Hormones,
E. Socioeconomic factors
Slide 2
The Body Mass Index (BMI) is calculated by dividing a patient’s __________ (in kg) by their __________ squared (in meters).
A. Weight; height
B. Height; weight
C. Weight; hip ratio
D. Age; waist circumference
A. Weight; height
Patient weight (kg)/ height2 in meters = kg/m2
slide 3
Which of the following is true about the Body Mass Index (BMI)?
A. It is the most widely applied tool for assessing body weight.
B. It differentiates between overweight and overfat.
C. It takes into account waist circumference, waist-hip ratio, and age.
D. It measures body fat directly.
A. It is the most widely applied tool for assessing body weight.
Slide 3
Which factors are not considered in the calculation of Body Mass Index (BMI)? (Select 4)
A. Muscle mass
B. Waist circumference
C. Height and weight
D. Waist-hip ratio
E. Age
A. Muscle mass
B. Waist circumference
D. Waist-hip ratio
E. Age
Slide 3
BMI is the most widely applied tool to assess body weight, but it does not differentiate between __________ and __________.
A. Overweight; overfat
B. Waist circumference; height
C. Muscle mass; fat mass
D. Age; gender
A. Overweight; overfat
Slide 3
Android fat distribution is primarily characterized by which type of obesity?
A. Peripheral obesity
B. Central obesity
C. Lower body obesity
D. Diffuse obesity
B. Central obesity
Slide 4
Which of the following is characteristic of android (central) obesity?
A. Peripheral fat distribution
B. Decreased oxygen consumption
C. Associated with upper body fat
D. Not associated with cardiovascular disease
C. Associated with upper body (truncal) fat
Slide 4
Which of the following factors are associated with android obesity? (Select 2)
A. Increased oxygen consumption
B. Peripheral fat distribution
C. Higher cardiovascular disease risk
D. Less metabolically active
A. Increased oxygen consumption
C. Higher cardiovascular disease risk
Slide 4
Which of the following are characteristics of gynecoid (peripheral) obesity? (Select 3)
A. Upper body fat
B. Found in buttocks
C. Found in hips
D. Found in upper arms
E. Found in thighs
B. Found in buttocks
C. Found in hips
E. Found in thighs
Slide 4
Gynecoid obesity is also referred to as “__________” obesity and is considered _______ metabolically active.
A. central; more
B. peripheral; less
C. visceral; less
D. peripheral; more
B. peripheral; less
Slide 4
True or False
Gynecoid obesity is not associated with CV disease
True
Slide 4
What is a key cardiac change observed in obesity?
A. Decreased total blood volume
B. Increased total blood volume
C. Decreased cardiac output
D. Increased heart rate
B. Increased total blood volume
Slide 5
Total blood volume increases in obesity, but on a volume-to-weight ratio, it is lower at _______ mL/kg.
A. 50
B. 60
C. 40
D. 70
A. 50
Slide 5
What percentage of the total blood volume is distributed to __________ tissue in obesity?
A. Skeletal
B. Connective
C. Nervouse
D. Adipose
D. Adipose
Slide 5
In obesity, cardiac output increases by _______ mL/kg of excess body fat.
A. 5-10
B. 10-15
C. 20-30
D. 30-40
C. 20-30
Slide 5
Cardiac output increases in obesity due to:
A. Increased stroke volume and left ventricular dilation
B. Decreased stroke volume and right ventricular dilation
C. Increased heart rate and decreased oxygen consumption
D. Decreased stroke volume and right ventricular contraction
A. Increased stroke volume and left ventricular dilation
Slide 5
Cardiac dysrhythmias in obesity are commonly caused by fatty infiltrates in the _______ system and _______
A. Conduction; CAD
B. Vascular; PVD
C. Respiratory; ARDS
D. Lymphatic; CAD
A. Conduction; CAD
Slide 5
Which of the following are common cardiac dysrhythmias seen in obesity? (Select 3)
A. Low QRS voltage
B. Right axis deviation
C. Left ventricular hypertrophy
D. Left axis deviation
E. High QRS voltage
A. Low QRS voltage,
C. Left ventricular hypertrophy (LVH), D. Left axis deviation
Cornelius - when you look at their EKG, just because of the distance between the monitoring side and the heart there’s a kind of a decrease in the QRS voltage or amplitude and then you may also notice that left axis deviation and then the LVH
Slide 5
Which factors are increased in the hematologic system of obesity, contributing to hypercoagulability?
A. Fibrinogen, Factor VII, Factor VIII, von Willebrand
B. Platelets, Hemoglobin, Hematocrit, von Willebrand
C. Fibrinogen, Factor V, Platelets, Factor IX
D. Platelets, Factor II, von Willebrand, Factor IX
A. Fibrinogen, Factor VII, Factor VIII, von Willebrand
C - They tend to have an increased incidence of clotting disorders. So things like DVTs, PEs are a little bit more predominant and then you couple that with their decreased activity level.
Slide 6
True or False
When a obese person gets microclots they tend to have less symptoms due to accessory pathways created over time.
True
Corndog - …because of their decreased activity level, they tend to be less symptomatic than patients that are more active and have a large P/E.
They tend to have like a serial of events, not just like a one time.
A lot of times you’ll see that if they mobilize or experience some sort of life change that they’ll start showering little micro clots. As a result of that, they kind of build up a accessory pathway that lets them get through the event a little bit easier..
slide 6
What is one of the main consequences of increased levels of **von Willebrand factor and factor VIII **in obesity?
A. Thrombocytopenia
B. Endothelial dysfunction
C. Increased oxygen carrying capacity
D. Anemia
B. Endothelial dysfunction
Slide 6
In obesity, gastric volume and acidity are increased, leading to delayed ________ and increased risk of aspiration pneumonitis.
A. Peristalsis
B. Gastric emptying
C. Intestinal absorption
D. Metabolism
B. Gastric emptying
slide 7
What gastric volume and pH levels are risk factors for aspiration pneumonitis in obese patients?
A. Volume > 25 mL and pH > 2.5
B. Volume < 25 mL and pH > 2.5
C. Volume > 25 mL and pH < 2.5
D. Volume < 25 mL and pH < 2.5
C. Volume > 25 mL and pH < 2.5
Slide 7
Hepatic function and ________ are often altered in patients with obesity, affecting drug metabolism.
A. Renal function
B. Cardiac function
C. Endocrine function
D. Intragastric pressure
D. Intragastric pressure
Slide 7
Relaxation of the _______ and formation of a hiatal hernia are common complications in the GI system of obese patients.
A. Lower esophageal sphincter (LES)
B. Upper esophageal sphincter (UES)
C. Pyloric valve
D. Duodenal sphincter
A. Lower esophageal sphincter (LES)
C - ..because of the body habitus, you also tend to see that there’s an increase in the intragastric pressure, and as a result of that, that lower esophageal sphincter will relax a little bit and they tend to form a hiatal hernius.
You will also see that when patients go in for like sleeve gastrectomies or lap bands, that commonly they will have a hiatal hernia repair as well.
Slide 7
What is one of the renal effects of obesity that increases renal blood flow?
A. Glomerular hyperfiltration
B. Decreased renal blood flow
C. Increased natriuresis
D. Glomerular hypofiltration
A. Glomerular hyperfiltration
Slide 8
Which renal system mechanisms are typically impaired in obesity? (Select 2)
A. Glomerular filtration
B. Natriuresis
C. Renal tubular reabsorption
D. Renin-angiotensin activation
B. Natriuresis,
D. Renin-angiotensin activation
Brian G. Cornelius - they’ll have a little bit more increase in blood pressure.
So it’s kind of a constant battle for these folks regulating the miles of vasculature. Regulating their fluid status and the kind of pairing that with the decrease in activity.
Slide 8
Which of the following are consequences of increased SNS activity in obesity? (Select 3)
A. Insulin resistance
B. Enhanced pressor activity of norepinephrine
C. Sodium retention
D. Decreased angiotensin II activity
E. Sodium excretion
A. Insulin resistance
B. Enhanced pressor activity of norepinephrine and angiotensin II
C. Sodium retention
Slide 9
Which of the following are effects of thyroid hormone resistance in morbidly obese patients? (Select all that apply)
A. Increased metabolic rate
B. Hypothyroidism
C. Decreased sodium retention
D. Impaired glucose metabolism
B. Hypothyroidism,
D. Impaired glucose metabolism
C - Diabetes, POTs, chronic pain syndromes, those sorts of things tend to go hand in hand with a lot of these same patients.
Slide 9
What percentage of morbidly obese patients suffer from hypothyroidism due to thyroid hormone resistance?
A. 10%
B. 25%
C. 50%
D. 75%
B. 25%
Slide 9
Which of the following diseases are commonly associated with obesity? (Select 4)
A. Type 2 diabetes mellitus
B. Osteoarthritis
C. Hypertension
D. COPD
E. Alzheimer’s disease
F. Rheumatoid Arthritis
A. Type 2 diabetes mellitus - “side effect”
B. Osteoarthritis - increased wear and tear on their joints as a result of the high body habitus.
C. Hypertension,
D. Chronic obstructive pulmonary disease (COPD)
Slide 10
Which of the following diseases are commonly associated with obesity? (Select 4)
A. Obstructive sleep apnea
B. Asthma
C. Cardiovascular disease
D. Cancer
E. Renal failure
F. Hyperthyroidism
A. Obstructive sleep apnea - “side effect of obesity”
B. Asthma
C. Cardiovascular disease
D. Cancer
Slide 10
A diagnosis of metabolic syndrome requires at least ___ of the defining criteria to be present.
A) 2
B) 3
C) 4
D) 5
B) 3
Slide 11
Which of the following are the most *common causes of metabolic syndrome as stated by Dr. Cornelius and starred * in the lecture slide? (Select 5)
A) Abdominal obesity
B) Decreased levels of HDL
C) Hypertriglyceridemia
D) Glucose intolerance
E) Hypertension
F) Prothrombotic state
G) Proinflammatory state
A) *Abdominal obesity
B) *Decreased levels of HDL
C) *Hypertriglyceridemia
D) *Glucose intolerance
E) *Hypertension
Slide 11
Which of the following are metabolic abnormalities associated with metabolic syndrome? (Select 3)
A) Abdominal Obesity
B) Increased HDL
C) Proinflammatory state
D) Hyportriglyceridemia
E) Prothrombotic state
A) Abdominal obesity
C) Proinflammatory state
E) Prothrombotic state
Slide 11
Which of the following is used to assess metabolic syndrome instead of BMI?
A) Waist circumference
B) Body fat percentage
C) BMI
D) Body water content
A) Waist circumference
Slide 12
Which gender is more likely to be affected by metabolic syndrome?
A) Women
B) Men
C) Both are equally likely
D) Gender is not a factor
B) Men
Slide 12
Metabolic syndrome is more prevalent in ________ compared to other groups.
A) African Americans and Pacific Islanders
B) Hispanics and South Asians
C) Caucasians and Non-Hispanic
D) Hispanics and African Americans
B) Hispanics and South Asians
Slide 12
Metabolic syndrome may result from the chronic use of which of the following medications? (Select 4)
A) Corticosteroids
B) Antidepressants
C) Antipsychotics
D) Antibiotics
E) Protease inhibitors
F) Antifungals
A) Corticosteroids,
B) Antidepressants,
C) Antipsychotics,
E) Protease inhibitors
Slide 12
Metabolic syndrome increases the risk of which of the following conditions?
A) Cardiovascular disease
B) Alzheimer’s disease
C) Psoriasis
D) Autism
A) Cardiovascular disease.
C - He keeps mentioning POTS - so here is a definition from the Google -
POTS: Signs and Symptoms
Postural orthostatic tachycardia syndrome (POTS) is a chronic condition that causes an abnormally rapid heart rate when standing up or sitting up.
Slide 13
Metabolic syndrome increases the risk of which of the following diseases? (Select 3)
A) Gastrointesinal disease
B) Type 2 diabetes mellitus
C) Nonalcoholic fatty liver disease
D) Multiple sclerosis
E) Polycystic ovary syndrome
B) Type 2 diabetes mellitus,
C) Nonalcoholic fatty liver disease,
E) Polycystic ovary syndrome
Slide 13
______% of metabolic syndrome cases are resolved with bariatric surgery or weight loss goals.
A) 60%
B) 75%
C) 98%
D) 50%
C) 98%
Slide 13
Obstructive Sleep Apnea (OSA) is characterized by which of the following?
A) Complete cessation of breathing lasting less than 5 seconds
B) Complete cessation of breathing
C) Reduction in airflow by 50%
D) Cessation of breathing only during exercise
B) Complete cessation of breathing
Slide 14
Which of the following are characteristics of Obstructive Sleep Apnea (OSA)? (Select 3)
A) Complete cessation of snoring
B) Lasting 10 seconds or more
C) Occurs more than 5 times per hour of sleep
D) Decreases oxygen saturation by 10%
E) Decreases oxygen saturation by 4%
B) Lasting 10 seconds or more,
C) Occurs more than 5 times per hour of sleep, E) Decreases oxygen saturation by 4%
Slide 14
Which of the following criteria is associated with hypopnea?
A) Reduction in airflow by 50% or more lasting 15 seconds
B) Reduction in airflow by 30% or more lasting 20 seconds
C) Reduction in airflow by 50% or more lasting 10 seconds or more
D) Reduction in airflow by 10% or more lasting 10 seconds or less
C) Reduction in airflow by 50% or more lasting 10 seconds or more
Slide 14
Which of the following are characteristics of hypopnea? (Select 2)
A) Reduction in airflow by 50% or less
B) Lasting less than 5 seconds
C) Occurs more than 15 times per hour of sleep
D) Decreases oxygen saturation by 4%
E) Reduction in oxygen levels by 20%
C) Occurs more than 15 times per hour of sleep,
D) Decreases oxygen saturation by 4%
C - Same kind of duration, same decrease in SPO2, but they’re having an actual airflow reduction.
So as far as like testing a lot of times, these patients will not only have monitoring for oxygen saturation, but they’ll also do spirometry while they’re testing them.
Slide 14
What is another term for the sleep study used to diagnose OSAHS?
A) Echocardiogram
B) Polysomnography
C) Electroencephalogram
D) Spirometry
B) Polysomnography
Slide 15
The apnea/hypopnea index (AHI) classifies severe OSAHS as how many events per hour?
A) 5-15 events per hour
B) 15-30 events per hour
C) >30 events per hour
D) 20-25 events per hour
C) >30 events per hour
Slide 15
The apnea/hypopnea index (AHI) classifies moderate OSAHS as having ______ events per hour.
A) 5-10
B) 15-30
C) 25-40
D) 10-20
B) 15-30
Slide 15
The apnea/hypopnea index (AHI) classifies mild OSAHS as how many events per hour?
A) 5-15 events per hour
B) 15-30 events per hour
C) >30 events per hour
D) 20-25 events per hour
A) 5-15 events per hour
Slide 15
Which of the following are included in the treatment strategies for moderate/severe OSAHS? (Select 2)
A) CPAP
B) Cognitive therapy
C) Use of diuretics
D) Weight loss
E) Sleep medication
B) CPAP,
D) Weight loss
Slide 15
Which of the following conditions are NOT at increased risk for moderate/severe OSAHS?
A) Systemic hypertension
B) Cognitive impairment
C) Renal failure
D) LVH (Left ventricular hypertrophy)
E) Cardiac dysrhythmias
C) Renal failure
Slide 15
Obesity hypoventilation syndrome is also known as:
A) Pickwickian syndrome
B) Sleep apnea syndrome
C) Cor pulmonale syndrome
D) Metabolic syndrome
A) Pickwickian syndrome
C - used to be known as Pickwick syndrome, and I guess that wasn’t nice and people didn’t like having a term. So we started calling it OHS instead.
Slide 16
Obesity hypoventilation syndrome is characterized by which of the following? (Select 2)
A) Pica disorder
B) Results from untreated long-term OSA
C) Results in hyperventilation
D) 5-10% of morbidly obese
E) Diagnosed with BMI < 30 kg/m²
F) 3-8% of morbidly obese
B) Results from untreated long-term OSA
D) 5-10% of morbidly obese
Slide 16
Which of the following are conditions that obesity hypoventilation syndrome can result in? (Select 2)
A) Cor pulmonale
B) Pulmonary hypertension
C) Systemic hypotension
D) Cardiac arrhythmias
E) Congestive heart failure
A) Cor pulmonale - Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs
B) Pulmonary hypertension
Slide 16
The diagnosis of obesity hypoventilation syndrome includes which of the following characteristics? (Select 2)
A) BMI > 30 kg/m²
B) Chronic cough
C) Awake hypercapnia
D) Dyspnea on exertion
E) BMI < 35 kg/m²
F) Pulmonary edema
A) BMI > 30 kg/m²,
C) Awake hypercapnia
Slide 16
Which of the following are known effects of Phentermine? (Select 4)
A) Decreased appetite
B) Hypertension
C) Palpitations
D) Fecal incontinence
E) Dependence and abuse
F) Regulate lipid metabolism
A) Decreased appetite
B) Hypertension
C) Palpitations, and Tachycardia
E) Dependence and abuse potential
Slide 17
Phentermine, a sympathomimetic drug, is FDA approved for ______.
A) Indefinite use
B) Only 3 months
C) Use with Fenfluramine
D) 1-year use
B) Only 3 months
Slide 17
Phentermine is no longer combined with Fenfluramine (commonly known as “Fen Fen”) due to which of the following reasons? (Select 2)
A) Increased risk of liver failure
B) Higher incidence of gastrointestinal discomfort
C) Valvular symptoms
D) Severe allergic reactions
E) Risk of sudden death
C) Valvular symptoms
E) Risk of sudden death
Slide 17
Orlistat works by:
A) Suppressing appetite
B) Reducing cravings for sugar
C) Stimulating the pancreas
D) Blocking absorption of dietary fat
D) Blocking absorption of dietary fat
Slide 17
Which of the following are side effects of Orlistat? (Select 3)
A) Liquid stool
B) Constipation
C) Fecal urgency
D) Flatulence
E) Nausea
A) Liquid stool,
C) Fecal urgency,
D) Flatulence
Orlistat can lead to fat-soluble vitamin deficiencies with chronic use, including possible ______ deficiency.
A) Vitamin A
B) Vitamin D
C) Vitamin K
D) Vitamin C
C) Vitamin K
Prolonged PT and clotting disorders
Slide 17
Matching
Match the OTC herbal with the bodily effects
Pancreatic lipase inhibitors → C. caffeine, green tea
Appetite suppressors → D. ginseng, ephedra, sunflower oil
Energy stimulants → A. acai berry
Regulate lipid metabolism → B. soybean, fish oil, oolong tea
Slide 17
GLP-1 receptor agonists are primarily approved by the FDA for which of the following conditions? Select 2
A) Hypertension
B) Type 2 diabetes mellitus
C) Cardiovascular risk reduction
D) Chronic obstructive pulmonary disease
D) Osteoarthritis
B) Type 2 diabetes mellitus and cardiovascular risk reduction
Slide 18
Which of the following are true regarding the use of GLP-1 receptor agonists?
(Select 3)
A) They are also used for weight loss
B) They should be taken on the day of a surgical procedure
C) Recommended to hold these either the day before or day of the procedure
D) For weekly dosing, the dose should be held for a week before a procedure
E) Recommended to hold these either three days before or day of the procedure
A) They are also used for weight loss
C) For daily dosing, recommended to hold these drugs either the day before or day of the procedure
D) For weekly dosing, the dose should be held for a week before a procedure
Slide 18
Matching
Match the Generic Drug with the Trade name for Glucagon-like Peptide-1 Receptor Agonists (GLP-1)
Dulaglutide → D. Trulicity
Exenatide (IR) → A. Byetta
Liraglutide → B. Victoza
Semaglutide → E. Ozempic, Wegovy
Semaglutide (Oral) → C. Rybelsus
Slide 19
Matching
Match the GLP-1 with the Gastric Emptying/Half-life
Dulaglutide (Trulicity) → B
Exenatide (IR) (Byetta) → C
Liraglutide (Victoza) → A
Semaglutide (Ozempic, Wegovy) → D
Semaglutide (Oral) (Rybelsus) → E
Slide 19
What should be considered if GLP-1 agonists prescribed for diabetes management are held for longer than the dosing schedule? A. No additional actions are necessary
B. Increase the dosage of GLP-1 agonists after the procedure
C. Consult an endocrinologist for bridging antidiabetic therapy
D. Switch to an alternative medication
C. Consult an endocrinologist for bridging antidiabetic therapy
Slide 20
What should be considered if a patient on GLP-1 agonists presents with gastrointestinal symptoms such as severe nausea, vomiting, or abdominal bloating on the day of the procedure? (Select 2)
A. Proceed with the procedure
B. Delay the elective procedure
C. Increase the dosage of GLP-1 agonist
D. Assess the risk of regurgitation
E. Follow standard fasting guidelines
B. Delay the elective procedure
D. Assess the risk of regurgitation and *pulmonary aspiration of gastric contents *
Slide 21
What precautions should be considered if a patient did not hold GLP-1 agonists as advised? (Select 3)
A. Evaluate gastric volume by ultrasound
B. Treat the patient as having a ‘full stomach’
C. Proceed with the procedure without any precautions
D. Delay the procedure if the stomach is full
E. Delay procedure for 8 hours to allow for digestion
A. Evaluate gastric volume by ultrasound,
B. Treat the patient as having a ‘full stomach’ - pepcid, bicitra
D. Delay the procedure if the stomach is full
Slide 21
If no evidence suggests an optimal duration of fasting for patients on GLP-1 agonists, what guideline should be followed?
A. Standard GLP-1 fasting guidelines
B. Current ASA fasting guidelines
C. No fasting is required
D. Current AANA fasting guidelines
B. Current ASA fasting guidelines
Slide 21
True or False
After doing a gastric ultrasounds on patients that are high risk for aspiration, whether it’s because they’re taking GLP ones or something else is going on, you should put in a NG tube to help decompress the stomach and continue with surgery.
FALSE
C - …some places that they recommend putting in a gastric tube beforehand. The problem?
…you’re kind of creating a portal for things to come out through the lower esophageal sphincter. So there at increased risk of aspiration and you may have been the one that just created the conduit for that to happen
Slide 22
Preoperative evaluation focuses on evidence of which of the following conditions? (Select 3)
A. Hypertension
B. Diabetes
C. Heart failure
D. Hyperventilation syndrome
E. Renal insufficiency
A. Hypertension, - Baseline BP?
B. Diabetes, - Diabetes controlled?
C. Heart failure - Insidious! Echo or functional limitations?
Slide 23
Preoperative evaluation for patient that are obese should include which of the following?
A. Hyperventilation syndrome
B. Hypoventilation syndrome
C. Respiratory alkalosis
D. Pneumonia
B. Hypoventilation syndrome
C - if you’re not sure how well they’re breathing, they look like they’re little suspect.
I would certainly consider getting bedside spirometry.
Probably not to the point of getting like FEV or anything a detailed pulmonary function test, but just see what sort of volumes they can get and a lot of time.
Slide 24
CPAP usage of more than _______ cm H₂O suggests difficult mask ventilation during anesthesia.
A. 5
B. 8
C. 10
D. 12
C. 10
Slide 24
Which of the following is an important factor to consider during preoperative evaluation regarding surgical history?
a) Food allergies
b) Past and current weight comparison
c) Family medical history
d) Immunization record
b) Past and current weight comparison
Corn: They may not be in kind of the same body habitus that they used to be.You’ll see that this is somebody that used to have weighed several 100 lbs.
And now they’re a lot smaller than that, but they may still have some of the ill effects they did before. So just be cautious
Slide 25
PreOp Eval
Evaluating previous ________ can help anticipate challenges in managing the airway during surgery.
a) Surgical sites
b) Blood transfusions
c) Intubations
d) Medication doses
c) Intubations
Other things to think about if you’re able to pull previously anesthesia records, how difficult were they to intubate in the past? You may see that even though they were really large or are really large, that they’re not necessarily difficult intubation
Slide 25
PreOp Eval
True or False:
The need for ICU admission is a factor that should be explored during the preoperative evaluation of surgical history
True
Cornelius: Other things that come into play is this somebody that’s going to need to go to the Critical Care unit afterwards because of these underlying complications is a result of that. You may consider pushing them either to a hospital or to more of a tertiary care center. So probably not somebody you want to do in a surgery center.
Slide 25
PreOp Eval
Which of the following is a common difficulty faced in patients with overlying tissue or poor vein visibility?
a) Airway management
b) Vascular access
c) Pain management
d) Postoperative monitoring
b) Vascular access
Cornelius: Access can be a struggle in these patients. Fortunately, you know, now we can use the ultrasound for vascular access because it’s not so much that they have bad vent.
Slide 25
PreOp Eval
Evaluating past ________ can provide insights into potential risks and complications for the upcoming surgery.
a) Laboratory results
b) Surgical outcomes
c) Family history
d) Insurance policies
b) Surgical outcomes
Cornelius: So just think about things like that from a surgery standpoint.
They may be OK, but sometimes the surgeons don’t think about the anesthesia side of things. They have poor wound healing. They tend to get infected. They get PEs. They’re not out of bed very quickly. So you need to kind of evaluate. Is this really what should be done for this patient
Slide 25
Which of the following preoperative medications are typically considered for obese patients? (Select 4 that apply)
a) Continuation of antihypertensives
b) Continuation of insulin
c) Continuation of oral hypoglycemics
d) Administration of antibiotics
e) Discontinuation of all home medications
continue home meds
a) Continuation of antihypertensives
b) Continuation of insulin
c) Continuation of oral hypoglycemics
d) Administration of antibiotics usually indicated
Slide 26
Which of the following types of prophylaxis are typically indicated preoperatively? (Select 2 that apply)
a) DVT prophylaxis
b) Pain prophylaxis
c) Aspiration prophylaxis
d) Fluid prophylaxis
e) Infection prophylaxis
a) DVT prophylaxis
c) Aspiration prophylaxis
Slide 26
Intraoperative care
Which of the following are airway abnormalities commonly associated with impaired physiology? (Select 4 that apply)
a) Decreased vital capacity
b) Increased inspiratory capacity
c) Decreased expiratory reserve volume
d) Increased functional residual capacity
e) Low lung compliance
f) Rapid desaturation
a) Decreased vital capacity
↓ Inspiratory capacity
c) Decreased expiratory reserve volume
↓ Functional residual capacity
e) Low lung compliance
f) Rapid desaturation
Slide 27
Intraoperative care
______ is close to or within tidal breathing, especially when the patient is supine or recumbent.
a) Vital capacity
b) Functional residual capacity
c) Closing capacity
d) Expiratory reserve volume
c) Closing capacity
Slide 27
What can possibly lead to renal failure when a morbidly obese patient is placed in the supine position?
a) Compression of the lungs
b) Decreased venous return
c) Rhabdomyolysis of the gluteal muscles
d) Dehydration
c) Rhabdomyolysis of the gluteal muscles
Slide 30
Intraoperative care
True or False:
During intraoperative care, the choice of anesthetic technique should be planned.
True
Cornelius: but just be very cautious with these patients. They tend to wake up very slowly. No matter what your anesthetic technique is.So if you’re able to do this under regional order axial, that may be a better option for you. Other things to think about as far as like agent selection, something that doesn’t stick around quite as long.
Slide 29
Which of the following are potential complications associated with the supine position during surgery? (Select all that apply)
a) Ventilatory impairment
b) Compression of the inferior vena cava (IVC) and Aorta (Ao)
c) Rhabdomyolysis on gluteal muscles
d) Increased risk of axillary nerve compression
a) Ventilatory impairment
b) Compression of the inferior vena cava (IVC) and Aorta (Ao)
c) Rhabdomyolysis on gluteal muscles
Slide 30
Which of the following are potential complications associated with the prone position during surgery? (Select all that apply)
a) Excessive pressure from cushioning pads
b) Skin breakdown
c) Tissue necrosis
d) Increased risk of infections
a) Excessive pressure from cushioning pads
b) Skin breakdown
c) Tissue necrosis
d) Increased risk of infections
Slide 30
Which of the following are potential complications associated with the lateral decubitus position during surgery? (Select 2 that apply)
a) Dependent hip pressure ulcers
b) Difficulty placing axillary rolls
c) Compression of the aorta and inferior vena cava
d) Respiratory compromise due to lung compression
e) Venous pooling in the lower extremities
a) Dependent hip pressure ulcers
b) Difficulty placing axillary rolls
Slide 30
True or False
Lateral Decubitus positioning is favored over prone.
TRUE
Cornelius: If we have a choice, there’s lots of times we can do cases in multiple different positions. So as opposed to turning somebody prone, we may put them in like a lateral decubitis or even like a sloppy lateral position, and then to help us out a little bit with the pulmonary issues.
Slide 30
Which of the following are potential complications associated with the lithotomy position during surgery? (Select 3 that apply)
a) Regular stirrups may not support the patient’s weight
b) Increased risk of nerve injury
c) Tissue compression
d) Compartment syndrome
e) Airway compromise
a) Regular stirrups may not support the patient’s weight
c) Tissue compression
d) Compartment syndrome
Slide 30
What is a potential issue that can occur when the bed used during surgery is too large?
a) The patient may be uncomfortable during the procedure
b) It becomes almost impossible for the surgeon to access the patient
c) The anesthetic gases may not circulate properly
d) The surgical instruments may be out of reach
b) It becomes almost impossible for the surgeon to access the patient
Slide 31
What are the potential positioning problems in this scenario? (Select 4 that apply)
a) Inadequate padding over the hips
b) Poorly secured Velcro strap
c) Arm potentially sinking into the bed, risking nerve injury
d) Overuse of pink foam on the upper arm
e) Inadequate support for the body, leading to sliding
f) Perfect positioning without any issues
a) Inadequate padding over the hips
b) Poorly secured Velcro strap
c) Arm potentially sinking into the bed, risking nerve injury
e) Inadequate support for the body, leading to sliding
Slide 31
What are the potential positioning problems and issues in this scenario? (Select 4 that apply)
a) Securing the patient with Koban rather than solid straps
b) Poor leg positioning leading to imbalance on the table
c) Risk of pressure injuries under the breasts
d) Use of friction locks and buckles
e) Concern for calf pressure during the surgery
f) Perfect positioning with no issues present
a) Securing the patient with Koban rather than solid straps
b) Poor leg positioning leading to imbalance on the table
c) Risk of pressure injuries under the breasts
e) Concern for calf pressure during the surgery
Slide 32
What are the potential positioning problems and risks associated with the patient prone on the Jackson frame in this scenario? (Select 3 that apply)
a) Pads are not properly positioned under the patient
b) The patient is at risk of sliding through the table
c) Risk of pressure ulcers due to poor distribution of body weight on the pads
d) The pads provide perfect support for the patient’s body habitus
e) The Jackson frame is always safe for patients without any modifications
a) Pads are not properly positioned under the patient
b) The patient is at risk of sliding through the table
c) Risk of pressure ulcers due to poor distribution of body weight on the pads
Slide 33
What are the potential positioning problems and risks in this scenario involving a large patient on a fracture table? (Select 3 that apply)
a) Knees are poorly supported
b) Inappropriate use of equipment to hold the feet
c) Risk of pressure injuries due to wrinkles in draw sheets
d) Proper positioning with no concerns
e) Patient’s head is not adequately supported
a) Knees are poorly supported
b) Inappropriate use of equipment to hold the feet
c) Risk of pressure injuries due to wrinkles in draw sheets
It could also be as simple as something like your EKG leads
Slide 34
What should you do if you observe awkward or uncomfortable positioning that seems unusual or potentially harmful to the patient?
a) Ignore the situation as it is likely normal and accepted
b) Express your concerns to the CRNA or another experienced team member
c) Immediately remove the patient from the positioning device
d) Wait for the attending physician to notice the problem
b) Express your concerns to the CRNA or another experienced team member
Cornelius: So it may be normal.
It may also be that everybody else in the room is thinking the same thing you are. They’ve just kind of gotten away with it and made it OK for so long. Try and figure out what you can
Slide 34
Airway:Assessment and intubation
In which of the following areas is increased adipose tissue NOT typically deposited in obese patients, contributing to airway obstruction?
a) Uvula
b) Tonsils
c) Tongue
d) Soft palate
e) Aryepiglottic folds
f) Lateral pharyngeal walls
d) Soft palate
Slide 35
In morbidly obese patients, what change occurs in the oropharynx that can affect airway management?
a) The oropharynx changes into a circular shape
b) The oropharynx changes into an ellipse
c) The oropharynx becomes smaller and more triangular
d) The oropharynx remains unchanged
b) The oropharynx changes into an ellipse
Short transverse/long AP axis
Slide 35
There is an inverse relationship between the degree of __ and the __.
a) Obesity; pharyngeal area
b) Exercise; lung capacity
c) Obesity; cardiac output
d) Age; blood pressure
a) Obesity; pharyngeal area
Inverse relationship between degree of obesity and pharyngeal area.
Slide 35
Which of the following is NOT necessarily an independent predictor of difficult intubation?
a) Large teeth
b) Limited neck mobility
c) Small mouth opening
d) BMI
d) BMI
Cornelius: BMI in itself may not be the only predictor, but it’s definitely something to consider.But look at your physical assessment of these patients.
Slide 36
Which of the following are predictors of difficult intubation? (Select 4 that apply)
a) Small mouth opening
b) Large/protuberant teeth
c) Limited neck mobility
d) Retrognathia
e) Low BMI
a) Small mouth opening
b) Large/protuberant teeth
c) Limited neck mobility
d) Retrognathia
Slide 36
What is a common issue encountered when positioning obese patients for intubation in the supine position?
a) They are usually comfortable without additional support
b) They may have difficulty breathing, requiring additional positioning support under the head
c) They breathe better in the supine position compared to the seated position
d) The Troop pillow is always sufficient for all patients
b) They may have difficulty breathing, requiring additional positioning support under the head
Slide 37
Which of the following positions is commonly used to optimize intubation, particularly in obese patients?
a) Trendelenburg position
b) Ramped position
c) Supine position
d) Lithotomy position
b) Ramped position
Slide 37
What axes should be aligned to optimize visualization during intubation?
a) Oral axis, tracheal axis, and esophageal axis
b) Oral axis, pharyngeal axis, and laryngeal axis
c) Pharyngeal axis, spinal axis, and abdominal axis
d) Laryngeal axis, nasal axis, and tracheal axis
b) Oral axis, pharyngeal axis, and laryngeal axis
Cornelius: the big thing to take away from this is you don’t need to just lift up their head. But in these patients, a lot of times because of that extra body habitus, you’re also going to have to sit up their shoulders and then their head, and it may be a multi step process.
Slide 38
What factors were studied in relation to intubation success during simulated endotracheal intubation in the ramped position?
a) Patient weight and age
b) Bed angle and height
c) Airway pressure and oxygen saturation
d) Anesthesia depth and medication dosage
b) Bed angle and height
Cornelius: if you set up the head of the bed, you can improve your intubation success pretty drastically
Slide 39
What is the most important respiratory intervention that can be done for the obese patient prior to intubation?
a) Increase tidal volume
b) Preoxygenate
c) Perform a chest X-ray
d) Administer sedatives
b) Preoxygenate
Slide 40
Match the following patient types with the time it takes to desaturate to 90% during intubation:
Normal BMI
Morbidly obese BMI
a) Less than 3 minutes
b) 6 minutes
Normal BMI - (b) 6 minutes
Morbidly obese BMI - (a) Less than 3 minutes
Slide 40
Which of the following are effective positions for lung recruitment in an obese patient during surgery? (Select 2 that apply)
a) 30° Reverse Trendelenburg
b) 25-30° head up
c) Supine position
d) Prone position
e) 10° head down Trendelenburg
a) 30° Reverse Trendelenburg
b) 25-30° head up
Slide 41
What measures should be take for alveolar What measures should be taken for alveolar recruitment to prevent atelectasis and desaturation in the obese patient? (Select 4 that apply)
a) CPAP 10 cmH₂O during preoxygenation
b) Positioning
c) Recruiting maneuvers followed by PEEP 10 cmH₂O
d) Mechanical ventilation after induction
e) Supine positioning without further adjustments
to prevent atelectasis and desaturation in the obese patient?
a) CPAP 10 cmH₂O during preoxygenation
b) Positioning
c) Recruiting maneuvers followed by PEEP 10 cmH₂O
d) Mechanical ventilation after induction
Slide 41
What is an important initial step when managing obese patients prior to intubation?
a) Administer sedatives
b) Perform a bronchoscopy
c) Place a pulse oximeter to obtain a baseline oxygen saturation
d) Begin mechanical ventilation immediately
c) Place a pulse oximeter to obtain a baseline oxygen saturation
Cornelius: What I’ll do with these patients is as soon as I roll into the room, I put a pulse ox on him. If I didn’t have one in preOp so I can get a baseline set because lots of times they’re preOp saturation is not going to be normal… It’s going to be low, so that way you kind of know what you’re working with to start off with
Slide 40
Is obesity alone a predictor of aspiration in fasting, non-diabetic patients?
a) Yes, obesity alone is a strong predictor of aspiration risk
b) No, gastric volume and pH are the same
c) Only in patients with a BMI over 50
d) Obesity alone always increases gastric acidity
b) No, gastric volume and pH are the same
Slide 42
Which of the following are used as prophylaxis in patients with identifiable risk factors for aspiration? (Select 4 that apply)
a) Histamine receptor agonists
b) Proton pump inhibitors
c) Rapid sequence intubation (RSI)
d) Awake fiberoptic intubation
e) Supraglottic airway devices
a) Histamine receptor agonists
b) Proton pump inhibitors
c) Rapid sequence intubation (RSI)
d) Awake fiberoptic intubation
Slide 42
True or False
Rapid sequence intubation (RSI) is used only for aspiration concerns, not ventilation concerns.
FALSE
RSI for aspiration concerns or ventilation concerns
Cornelius: if you’re ever in doubt, go ahead and secure that airway quickly. Whether it’s because you don’t think you’ll be able to ventilate them or you don’t think that you’ll be able to intubate them very easily.
Slide 42
Regional anesthesia is especially effective in obese patients, particularly for __ and __ anesthesia, based on obstetrical experience.
a) General; local
b) Spinal; epidural
c) Peripheral nerve; local
d) Conscious sedation; epidural
b) Spinal; epidural
Slide 43
Which of the following are advantages of regional anesthesia in obese patients? (Select 4 that apply)
a) Less airway manipulation
b) Decreased chance of postoperative nausea and vomiting (PONV)
d) Larger doses needed for spinal anesthesia
e) Fewer cardiopulmonary depressants
f) Better postoperative pain control (at least initially)
a) Less airway manipulation
b) Decreased chance of postoperative nausea and vomiting (PONV)
e) Fewer cardiopulmonary depressants
f) Better postoperative pain control (at least initially)
Slide 43
Which of the following is NOT a reason why regional anesthesia is technically difficult in obese patients?
a) Longer needles are needed
b) Different ultrasound probes are required
c) Smaller doses are used for epidurals due to cephalad spread
d) Higher rates of block success are common
e) Higher rates of hypotension occur after blocks due to IVC/Ao compression
d) Higher rates of block success are common
Higher rates of block failure
Slide 43
Proper size cuff is important. The blood pressure will be falsely elevated if the cuff is too ______, and the bladder should circle at least ______ of the arm’s circumference.
a) small; 50%
b) large; 80%
c) small; 75%
d) large; 60%
c) small; 75%
- Falsely elevated if the cuff is too small
- Bladders should circle at least 75% of the circumference
Slide 44
matching
Needs stem from comorbidities (often occurring with obesity)
- Pulmonary HTN - d) Pulmonary artery catheter or TEE
- Difficult IV access - ma) Central line placement
- High risk of DVT and PE - b) IVC filter
- Difficult non-invasive BP - c) Arterial line
- Need to monitor ventilation/ABGs - e) Arterial line
Slide 44
True or False
No particular anesthetic plan is favored for obese patients undergoing surgery.
True
Slide 45
What problems can arise in obese OSA patients as a result of sedative use? (Select 2 that apply)
a) Decreased pharyngeal musculature
b) Increased airway patency
c) Decreased airway patency
d) Improved lung function
a) Decreased pharyngeal musculature
c) Decreased airway patency
Slide 45
Which drug classes have exaggerated responses in obese patients, particularly those with obstructive sleep apnea (OSA)? (Select 3 that apply)
a) Opioids
b) Benzodiazepines
c) Propofol
d) Nonsteroidal anti-inflammatory drugs (NSAIDs)
e) Antihistamines
a) Opioids
b) Benzodiazepines
c) Propofol
Slide 45
Which opioids are preferred in obese patients with obstructive sleep apnea (OSA)?
a) Morphine and Hydromorphone
b) Remifentanil and Fentanyl
c) Meperidine and Codeine
d) Methadone and Oxycodone
b) Remifentanil and Fentanyl
Short-acting Opioids
Slide 45
___ is not a favored volatile in obese patients due to their greater O₂ demand.
a) Desflurane
b) Sevoflurane
c) Nitrous
d) Isoflurane
c) Nitrous
(N₂O)
Cornelius: I would just continue with just 100% oxygen and give them a little bit longer to wake up
Slide 45
What drug class, in general, will diminish the ventilatory response to CO₂?
a) Opioids
b) Volatile anesthetic agents (VAAs)
c) Benzodiazepines
d) Nonsteroidal anti-inflammatory drugs (NSAIDs)
b) Volatile anesthetic agents (VAAs)
Cornelius: As far as our volatile agents go, a lot of times it’s preferred over something like propofol just because you have control over the situation….They will hold on to the volatile agents longer than a normal patient would but you can get rid of them faster. There are also agents out there like Desflurane that are kind of targeted for these patients.
Slide 45
The initial dosing of drugs in obese patients should be based on which factor?
a) Cardiac output
b) Lipid solubility
c) Blood pressure
d) Muscle mass
b) Lipid solubility of the drug
Slide 46
Which common anesthetic drugs are dosed based on Ideal Body Weight (IBW)? (Select all that apply)
a) Vecuronium
b) Propofol
c) Remifentanil
d) Rocuronium
e) Midazolam
a) Vecuronium
b) Propofol
c) Remifentanil
d) Rocuronium
Memory Trick: ” Very Proportioned Remaining Rock is Ideal”
Slide 46
Which common anesthetic drugs are dosed based on Total Body Weight (TBW)? (Select all that apply)
a) Midazolam
b) Succinylcholine
c) Fentanyl
d) Cisatracurium
e) Sufentanil
f) Rocuronium
a) Midazolam
b) Succinylcholine
c) Fentanyl
d) Cisatracurium
e) Sufentanil
Memory Trick: “Total Body Weight Might Sux For Cis Sufferers”
Slide 46
Which volatile anesthetic is likely favored in obese patients due to its lower tissue solubility?
a) Isoflurane
b) Sevoflurane
c) Desflurane
d) Halothane
c) Desflurane
Slide 46
Which of the following are considerations for proper use of an OR table when managing an obese patient? (Select 3 that apply)
a) Ensure the OR table is weight appropriate
b) Utilize safety straps
c) Use a bean bag with a sheet
d) Use doubled arm boards or mayo stands
e) Consider not using sleds
a) Ensure the OR table is weight appropriate
b) Utilize safety straps
Use a bean bag with NO sheet
Use doubled arm boards NOT mayo stands
e) Consider not using sleds
Corn: They tend to not fit, so they’re putting pressure on their body tissueThe other thing is they’re not gonna keep that patient’s arm from falling off.
Slide 47-48
IV fluid requirements are ___ than what’s predicted in order to prevent acute tubular necrosis (ATN) in the obese patient.
a) Lower
b) Greater
c) The same
d) Slightly lower
b) Greater
Slide 48
When managing obese patients in the OR, __ is critical to prevent hypothermia due to their increased body surface area.
a) Thermal management
b) Blood pressure monitoring
c) IV access
d) Airway management
a) Thermal management
Slide 47
A lot of times these patients are a good choice for ______.
a) invasive pulmonary monitoring
b) non-invasive cardiac monitoring
c) MRI-based monitoring
d) manual blood pressure monitoring
b) non-invasive cardiac monitoring
Slide 48
Which of the following are recommended postoperative management strategies in obese patients? (Select 4 that apply)
a) Sit up postoperatively
b) Fully reverse neuromuscular blockade
c) Use only opioid-based pain management
d) Use pressure support mode during emergence
e) Continue home levels of CPAP
f) Avoid non-opioid sparing options
a) Sit up postoperatively
b) Fully reverse neuromuscular blockade
* Sugammadex
* Dosed on IBW or TBW
d) Use pressure support mode during emergence
* Once spontaneously breathing
e) Continue home levels of CPAP
use non-opioid sparing options
Slide 49
Which of the following are examples of non-opioid or opioid-sparing medications recommended for postoperative management in obese patients? (Select 4 that apply)
a) Tramadol
b) Fentanyl
c) Dexmedetomidine
d) Ketamine
e) Clonidine
f) Morphine
a) Tramadol
Corn:try and avoid things that won’t cause excessive sedation, and certainly things that won’t affect my pulmonary status.So consider giving them a long acting agent up front.
Corn: As far as the OR, give these patients…
c) Dexmedetomidine
d) Ketamine
e) Clonidine
Slide 49
True or False
In postoperative management, it is important to consider when and where cases are done to ensure appropriate care for obese patients.
True
Cornelius: you’ll see that a lot of off locations can be problematic for these types of cases, so you may want to bring them to kind of your anesthesia happy place and do it in the OR.
Slide 49
