Obesity & Drug Abuse Flashcards
What percentage of pregnant women are obese?
20%
What procedure rate is increased with obese pregnancy?
C-section
Morbidity and mortality is increased by what factor with pregnancy?
Obesity
Oxygen consumption and CO2 production in obese pregnancy? Increase or decrease?
Increase due to energy expenditure from increase in body mass
Minute ventilation is obese pregnancy? Increase or decrease?
Increase due to the elevated respiratory demand
What size respirations occur with obese pregnancy?
Frequent shallow breaths
What increases the WOB in obese pregnancy?
Increased weight on the chest wall and the weight gain during pregnancy
What restricts diaphragm movement in the obese pregnancy patient?
Greater abdominal weight
Why do obese pregnancy women deteriorate even quicker with supine or Tburg positioning?
FRC is decreased even further
VQ mismatching
What happens with compliance in obese pregnancy?
Both chest wall and lung compliance decrease
What happens with airway resistance with obese pregnancy?
Increases as a result of reduction in lung volumes
What promotes dependent portion airway closure in obese pregnancy?
Decreased chest wall compliance and greater abdominal weight
What happens to blood volume and cardiac output during obese pregnancy?
Increase
-CO increases due to both SV and HR increases
Both preload and LV afterload are increased in obese pregnancy causing what type of hypertrophy?
Both eccentric and concentric LV hypertrophy
Heart size changes in obese pregnancy
LA size
LV thickness
Interventricular septal thickness
LV mass
What is the consequence of increased HR in the obese pregnant woman?
Limits diastolic fill time
-diastolic relaxation in impaired
What occurs in the pulmonary system as a result of the increased CO and total blood volume in the obese pregnant woman?
Pulmonary HTN
What is 3x higher incidence in pregnancy with a BMI of 30+?
HTN
Supine causes even more what in the obsess pregnant woman?
Aortocaval compression
Fatty infiltration of the heart and conduction system with obese pregnancy causes ~30 fold increase in?
PVCs
Gastric volume and decreased pH in obese pregnancy?
Unclear if affected
What GI conditions are more common in obese that nonobese patients?
GERD
Hiatal hernia
Gallbladder disease
The higher risk for difficult airway management in obese pregnancy increases the risk for what?
Aspiration
Obesity is associated with a higher risk of what coagulation problem?
Thromboembolic complications
What is the leading cause of direct maternal mortality?
Venous thromboembolism
What CV comorbidities risks are increased with obese pregnancy?
HTN
CAD
Cerebrovascular disease
Thromboembolic disease
What endocrine comorbidities risks are increased with obese pregnancy?
DM
Gestational DM
Gall bladder disease
What liver problem is associated with a higher risk with obese pregnancy?
Nonalcoholic fatty liver
What happens with infection risk and obese pregnancy?
Increases
How does BMI affect progress of labor?
Labor progresses more slowly
Uterine contractions are less forceful
Decreased uterine contractility with obese pregnancy is implicated in a higher rate of?
Uterine atony
Postpartum hemorrhage
Medical induction of labor in obese pregnancy has a higher rate of?
Failure
Risk of c-section in obese pregnancy is?
Increased
Fetal macrosomia risk is higher with obese pregnancy and increases the risk for what?
Shoulder dystosia and its associated birth trauma
-forceps delivery
What is the most important risk that is increased with obese pregnancy?
Risk for death
What is the anesthetic of choice for obese pregnancy?
Neuraxial technique
What is increased with neuraxial technique and obese pregnancy?
Higher incidence of failed epidural
Unintentional dural puncture
What BMI and over should be ramped?
30 and over
A BP cuff that exceeds the circumference of the arm by what percentage is needed? If it’s not will it over or under estimate SBP and DBP?
20%
Overestimate
Forearm BP compared to upper arm BP?
Forearm BPs exceed upper arm BPs by 10+/- 10mmHg
Standard operating tables are generally rated for persons weighing?
500 lbs
227 kg
Why is sitting position preferred for epidural placement in obese pregnancy?
Lateral can obscure midline
Distance from skin to epidural space is minimized in sitting-flexed position
What factors increase the likelihood of difficult laryngoscopy on obese pregnancy?
large breasts
Greater AP chest diameter
Airway edema
Reduced chin-to-chest distance
How quickly can sodium citrate effectively increase gastric pH?
5 minutes
Cephalad retraction of panus has what affect?
Difficulty with ventilation
Hypotension
How long should preoxygenation occur?
3 minutes
- or 8 deep tidal breaths
Succs dosing for obese pregnancy?
1-1.5mg/kg of IBW
Vt for obese pregnancy?
6-8ml/kg IBW
What can be done during periods of apnea and tracheal intubation to help increase the time to desaturation?
N/C insufflating oxygen at 5L/min
Is MAC altered in the obese pregnant patient?
No more than what it normally is with pregnancy
How should obese preg be extubated?
Awake
Semi-upright
2 choices for neuraxial anesthesia in pregnant obese c-section?
Spinal
CSE
Epidural okay if already in place and functional
Typically a GA will be preformed due to what? But can be considered for what else?
Emergent section
Active vomiting, extreme reflux
Most of the anesthesia related deaths occur from?
Airway issues
There is no contraindication to which heparin prophylaxis treatment?
SQ standard unfractionated heparin
LMWH:
Needle placement
10-12 hours after last dose
1st post op dose of LMWH
6-8 hours post op
Remove epidural catheter after LWMH?
At least 10-12 hours after last dose
No LMWH till how long after epidural catheter removal?
At least 2 hours
High doses of LMWH:
Needle placement
Not till 24 hours after last dose
1st post op dose of high dose LMWH?
Not till 24 hours after surgery
When can high dose LMWH be restarted after indwelling catheter removal?
At least 2 hours before initiation of therapy
Is it okay to do an epidural with ASA use?
No significant risk
What percentage of pregnant women abuse drugs?
5%
What is the highest leading cause of preventable birth defects?
Alcohol
Awareness can occur with alcohol use because?
Of high requirements
What is the most common substance abused?
Smoking
What problems can smoking cause (with pregnancy)?
Bronchospasm (marijuana too)
Low birth weight
Alcohol use during pregnancy can lead to what life long defects?
Heart
Behavioral
Physical
Intellectual
Caffeine use during pregnancy can cause what complications?
Withdrawal can be mistaken for PDPH
Increased anxiety
Restlessness
Decreases fertility
Quitting smoking when has the greatest benefit for mom and baby?
Before 15 weeks gestation
What is one of the most important modifiable causes of poor pregnancy outcomes?
Smoking
What risk is increased with a smoker and GA? (Besides bronchospasm)
Pneumonia
Smoking causes what respiratory changes?
Volume and composition of mucus thicker
Impaired mucociliary clearance
More bronchitis and COPD
Fetal mortality is what percentage higher in smokers?
40%
Compared to non smokers, smokers are:
More likely to die (17%)
Have serious heart and lung problems (53%)
Greater risk of heart attack after sx, delayed healing (77%)
Marijuana elimination?
25-30 days
Is marijuana associated with congenital abnormalities?
No
-some show association with increased risk of still-birth, preterm birth and neurobehavioral abnormalities
Long-term associated effects of marijuana in children?
Inattention and impulsivity
Deficits in problem solving
Academic underachievement
Predisposition to smoking MJ and tobacco
Affect of MJ on NMB?
Potentials NMB
How does chronic use of MJ affect induction?
Requires higher doses of anesthetics
Peak introp HR can increase by how much with MJ use?
24%
Acute use of MJ can cause what with he heart?
Tachycardia and arrhythmias
Chronic use of MJ can cause what with the heart?
Bradycardia and hypotension
What part of MJ has an anti-hemostasis effect? How?
Cannaboid
Diminished ability for platelet aggregation
What part of MJ may be prothrombic and favor CV events and stroke?
THC
What is the most important thing for anesthesia to remember with cocaine abuse?
It depletes catecholamines
-decreased response to stress
Cocaine use increases risk of:
Increased risk of: STDs Preterm labor No prenatal care Abruption
Chronic use of cocaine leads to _________ of receptors
Upregulation
-requires higher dose
Cocaines effect on the peripheral nervous system
HTN and/or lability BP
Tachycardia
Widespread vessel occlusion through vasospasm, thrombosis and endothelial injury
Cocaine’s effect on CV
Increases peripheral vascular resistance
Increases contractility
Increases myocardial oxygen demand
Coronary vasoconstriction
What is a common complaint among cocaine users who present to the ED?
Chest pain (cocaine induced)
Why is labetalol preferred when cocaine induced hypertension requires treatment?
Beta blockade may result in unopposed alpha mediated vasoconstriction, labetalol is an alpha and beta antagonist
What other class of medications can be given to help relieve some of the CV effects of cocaine use?
Benzodiazepines
Magnesium
What vassopressor may cocaine users not respond to? So which should you use?
May not respond to ephedrine
Use phenylephrine
GI effects of cocaine
Ischemia
Ulceration
Perforation
Why does cocaine cause delayed gastric emptying?
Cocaine’s anticholinergic effect
Neurologic effects of cocaine
Cocaine induced seizures
Respiratory effects from smoking cocaine
Bronchospasm
Chronic cough
Diffusion capacity abnormalites
Hematologic effect of cocaine? Tx?
Cocaine induced thrombocytopenia
-responds to corticosteroids
How does cocaine cause hyperthermia?
Impairs cutaneous vasodilation and sweating
Does cocaine cross the placenta?
Readily
OB complications associated with maternal cocaine use?
Higher incidence of placental abruption and preterm labor
What condition can cocaine toxicity mimic?
Preeclampsia or eclampsia
-HTN, HA, blurred vision, sz
What anesthetic technique can reduce circulating levels of catecholamines in cocaine patients?
Neuraxial anesthesia
How is hypotension in cocaine patients treated?
Volume
Direct acting vasopressor: phenylephrine
Changes in mu and kappa receptors and altered baseline endorphin levels may result in what in cocaine patients?
Increased perception of pain
What anesthetic may potential the vasoconstrictive effects of cocaine?
Ketamine
What anesthetic can result in disinhibition of CNS control of extrapyramidal activity, just like cocaine?
Etomidate
What drug may delay the onset of seizures in cocaine patients?
Dexmedetomidine
What medication may impair metabolism of cocaine?
succinylcholine (she says, but cocaine is metabolized by the liver???)
-may compete for plasma cholinesterase
What is the half-life of cocaine?
30-90 minutes, up to 6 hours
Drinking alcohol with cocaine use has what affect?
Synergistic
- greater physiologic effect
- prolongs half life
- increases risk of sudden death by 25%
Most common illicit substance that requires medical treatment in pregnancy?
Meth
Meth use may result in what affect on labor?
Preterm labor
Small for gestational age
Low birth weight
Long term affects on fetus of meth
Fall behind in school and sports
Increased risk of retinal defects, cleft palate and rib malformations
Decreased overall rate of growth and motor development
CV effects of meth
Vasoconstriction
Tachycardia
Labile BP
(Similar to cocaine)
Sensory hallucinations with meth use are due to what?
Dehydration
How is heroin metabolized and what drugs can inhibit clearance?
cytochrome P450
-omeprazole, amitriptyline
What class of drugs may increase heroin clearance?
Anticonvulsants
What type of activity do opioids have on the CNS?
Reduce SNS
Increase PNS
What do opioids promote the release of?
Histamine from mast cells
How does opioid induced respiratory depression occur?
Through direct effect on the brainstem that reduces ventilators response to hypercapnia
Abuse of IV opioids or others are at increased risk for:
Infective endocarditis (tricuspid most commonly affected) HIV Viral hepatitis Septic emboli Pulmonary abscess formation
What is considered the first-line medication for pregnant opioid-dependent women new to treatment?
buprenorphine
Why is buprenorphine considered first line treatment?
Hospitalizations and complications less frequent
Amount of morphine needed to tx infant is less
Signs of neonatal opioid withdrawal syndrome (NOWS)
Irritability Poor feeding Abnormal sleep patterns Diarrhea Fever Seizures
Heroin use during pregnancy is associated with first trimester:
spontaneous abortion
Preterm delivery
Fetal growth restriction
