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NA 1 > Obesity - Exam 5 > Flashcards

Obesity - Exam 5 Flashcards

1
Q

Healthy weight is classified as a BMI of:

A

18.5-24.9

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2
Q

BMI formula:

A

BMI = wt in kg / (ht in m)^2
OR
BMI = (wt in lbs/ ht in inches^2) x 703

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3
Q

A person’s degree of obesity is defined using _

A

BMI

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4
Q

Overwt is defined by a BMI of=

A

25-29kg/m^2

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5
Q

Obesity is defined by a BMI of=

A

30kg/m^2

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6
Q

Class I obese BMI:

A

30-34.9kg/m^2

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7
Q

Class II obese BMI:

A

35-39.9kg/m^2

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8
Q

Class III obese BMI:

A

> 40kg/m^2

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9
Q

Lean body mass in obese pts is _ % which accounts for extra muscle needed to carry the weight.

A

30%
-so this means LBW is 30% higher than IBW

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10
Q

Lean body wt (LBW) =

A

IBW x 1.3
male IBW = Ht in cm -100
female IBW = Ht in cm -105

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11
Q

What kind of organ is adipose tissue? What does it secrete?

A

Endocrine; proteins

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12
Q

What are the main functions of adipose tissue?

A
  1. Reservoir of energy
  2. Maintain heat insulatio
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13
Q

What results from liver fat metabolism?

A

Fatty acids –> energy
Triglycerides from carbohydrates and proteins
Phospholipid and cholesterol synthesis

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14
Q

Why is fat a good insulator?

A

Fatty acid chains in fat cells shorten with long-term cold exposure –> becomes more unsatruated –> does not get metabolized because only liquid fat can be metabolized

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15
Q

T/F All cells contain some saturated fats made by the liver

A

False, UNsaturated

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16
Q

Fat cells arise from modified _

A

fibroblasts

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17
Q

Mechanism of obesity (physical change) children vs adults

A

Children become obese due to increased fat cell #

Adults become obese due to enlarged fat cells

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18
Q

Apple body hip/waist ratio associated with comorbidities in men and women?

A

0.85 men < x (nagelhout)
0.92 women < x (nagelhout)

> 1.0 (men/women) bad

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19
Q

Waist circumference associated with increased comorbidities?

A

> 40 in men
35 in women

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20
Q

Waist:Hip ratio is calculated by dividing the _ waist measurement by the _, and is taken while the pt is _

A

narrowest
broadest
standing

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21
Q

pear body hip/waist ratio associated with comorbidities?

A

<0.76

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22
Q

What’s better, pear (gynecoid) or apple (android), why?

A

Pear (gynoid)

Fat stores in gynecoid do not release FFAs (they are metabolically static)
Android fat stores release FFAs –> to liver –> LDL/VDL creation

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23
Q

Which body system is the primary cause of morbidity and mortality associated with obesity?

A

CV
-HTN
-Ischemic heart disease
-CHF

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24
Q

CO goes up by how much per kg of fat?

A

0.1 L/min

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25
Q

How to assess for abdominal obesity?

A

Waist:Hip ratio

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26
Q

Underweight BMI:

A

<18.5

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27
Q

Normal BMI:

A

18.5-24.9

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28
Q

Overweight BMI:

A

25-29.9

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29
Q

Obese (Class I) BMI::

A

30-34.9

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30
Q

Obese (Class II) BMI:

A

35-39.9

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31
Q

Obese (Class III) BMI:

A

> 40

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32
Q

_ fat distribution is metabolically static and proposed to work as energy deposits for pregnancy and lactation

A

gynoid/pear

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33
Q

_ fat distribution is metabolically active regarding free fatty acid release

A

Android/apple

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34
Q

It is possible that hyper_ alone may cause HTN

A

hyperinsulinemia

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35
Q

Adipocytes are known to produce and store several inflammatory mediators such as: (4 items)

A

-leptin
-TNF-alpha
-monocyte chemotactic protein
-IL-6

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36
Q

Number one cause of morbidity and mortality associated with obesity:

A

cardiovascular disease

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37
Q

For every 13.5kg of fat gained, an estimated _ miles of neovascularization is created to provide blood flow rate of - mL/100g of tissue

A

25 miles
2-3mL/100g

increases CO by 0.1L/min per kg of fat gained

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38
Q

Cardiovascular changes with obesity (non-specific pathologies, not physical changes)

A

Increased CO
Increased O2 consumption
Increased CO2 production
Increased blood volume

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39
Q

How much does BP increase per 10% increase in body weight

A

6.5 mmHg per 10% body weight increase

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40
Q

How does obesity activate RAAS?

A

Fat compresses the kidney, stimulating the sympathetic nervous system , also impairs sodium excretion

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41
Q

What is hypercholesterolemia?

A

> 240 mg/dL

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42
Q

How do respiratory parameters change with obesity?

A

Decreased:
FRC
ERV
TLC

Increased:
Dead space
CO2 retention
(Restrictive lung disease)

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43
Q

What is the relationship between BMI and FRC?

A

FRC exponentially decreases

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44
Q

Respiratory changes in obesity lead to what risk factors cardiovascularly?

A

Chronic hypoxia –> polycythemia –> CAD/Stroke

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45
Q

Definition of OSA?

A

apnea during sleep longer than 10 seconds despite ventilatory efforts, 5+ more times/hr of sleep, decrease in SpO2 > 4%

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46
Q

What is hypoapnea?

A

50% reduction in airflow for 10 seconds, 15 + times during an hour of sleep

5-15 mild
15-30 moderate

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47
Q

Which muscles dilate/contract the pharyngeal airway?

A

Intrapharyngeal –> contract/collapse
Pharyngeal –> dilate

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48
Q

What keeps your airway open as you sleep?

A

Tensor muscles via CNS

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49
Q

Pathophysiology of sleep apnea?

A

Multifactorial causes (neural, physical obstruction, mechanical issues) –> Upper airway collapse –> pharyngeal dilator muscle activity surge –> hyperventilation –> decreased CO2 –> decreased respiratory drive –> repeat

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50
Q

Increased vagal tone is associated with…(increased/decreased OSA?)

A

increased OSA

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51
Q

Gold standard OSA diagnosis

A

Overnight PSG

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52
Q

What is Pickwickian syndrome?

A

AKA Obesity hypoventilation syndrome (OHS)

-Most severe form of OSA
-Hypercapnia (sleep-disordered breathing not due to other syndromes)
-NO respiratory effort
-Hypersomnolence during the day
-Cyanosis-induced polycythemia
-Respiratory acidosis (Pa CO2 > 45)
-Pulmonary HTN
-R sd HF
-Dependent edema
-Obesity (BMI > 30)

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53
Q

Which component of CO causes its increase in obese individuals: HR, SV, or both?

A

SV
-this causes cardiomegaly, bivent hypertrophy, and atrial and biventricular dilation -> HTN -> CHF

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54
Q

Factors influencing increase in HTN with obesity:

A

-increased blood viscosity
-altered catecholamine kinetics
-increased estrogen concentration
-hyperinsulinemia
-elevated mineralcorticoids
-abnormal sodium reabsorption
-RAAS activation
-increased SNS activity

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55
Q

Thoracic _ (kyphosis/lordosis) and lumbar _ (kyphosis/lordosis) result in impaired _ movement and fixation of the thorax in an _ (inspiratory/expiratory) position

A

Thoracic KYPHOSIS
Lumbar LORDOSIS
rib
inspiratory

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56
Q

Chronically elevated CO precedes increased _ (right/left) sd heart pressures and _ (right/left) vent hypertrophy

A

left
left

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57
Q

Skeletal changes from obesity such as kyphosis and lordosis cause a _ (increase/decrease) in chest wall, lung, parenchyma, and pulmonary compliance of about 35%

A

decrease

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58
Q

Which 2 factors regarding obesity cause an increase in myocardial O2 consumption?

A

-metabolic needs of fat tissue
-greater mechanical WOB

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59
Q

Which factors cause increases CO2 production and retention in obese pts?

A

-reduced respiratory muscle efficiency
-decreased ventilation

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60
Q

Reductions in chest wall and lung compliance in obese pts cause a _ pattern of breathing

A

restrictive

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61
Q

In obese pts, lung inflation is _ causing a decrease in FRC to _ than closing capacity.

A

inhibited
less

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62
Q

Premature airway closure in obese pts causes: (5 items)

A

-increased CO2 retention
-increased dead space
-VQ mismatch
-shunting
-hypoxemia

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63
Q

EXTREME obesity is associated with reductions in which 3 respiratory parameters?

A

-FRC
-expiratory reserve volume (ERV)
-total lung capacity
(also decreasing vital capacity)

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64
Q

Rapid, shallow breathing seen with obese pts is characteristic of _ lung disease. These patterns will eventually burn out, causing a _ in CNS responsiveness to chronic hypoxia. This leads to _ventilation and respiratory _ (alkalosis/acidosis)

A

restrictive
decrease
hypoventilation
acidosis

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65
Q

Recurrent hypoxemia leads to secondary _

A

polycythemia
-increases risk for CAD and CVA

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66
Q

Apnea is the cessation of airflow at the nose/mouth for > _ sec

A

10 sec

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67
Q

Hypoponea characteristics:

A

-50% drop in airflow for 10 sec
-happens 15+ times / hr of sleep
-assoc with snoring and 4% decrease in O2

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68
Q

OSA is diagnosed by _ using an apnea-hypopnea index (AHI)

A

polysomnography (PSG)

-AHI is # of abnormal respiratory events during sleep

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69
Q

Minimum DIAGNOSTIC criteria for OSA:

A

AHI of 10
WITH
symptoms of excessive daytime sleepiness

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70
Q

Diagnostic criteria for OSA per the American Academy of Sleep Medicine

Mild OSA:
Moderate OSA:
Severe OSA:

A

Mild: 5-15 AHI

Mod: 15-30 AHI

Severe: >30 AHI

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71
Q

Minimum MEDICARE criteria for OSA:

A

-AHI of 15
OR
-AHI of 5 WITH 2 comorbidities

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72
Q

T/F CAD is a risk factor for obesity

A

false, it is independent

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73
Q

Genetic factors involved with obesity:

A

-Prader Willi Syndrome
-Baret Biedl Syndrome
-Obesity “hormone” LEPTIN (not enough -> overeating)

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74
Q

Diseases that can CAUSE obesity:

A

cushings, PCOS, hypothyroidism

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75
Q

T/F FRC is directly proportional to BMI

A

false
INVERSELY (increased obesity = decreased FRC)

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76
Q

Physical factors related to OSA that increase as obesity increases:

A

-BMI > 30
-abdominal fat distribution
-neck girth (men >17inches ^2, women >16inches^2)

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77
Q

The site of upper airway obstruction is usually the _

A

pharynx

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78
Q

Patho of OSA:
1.While awake, patency is maintained by mediation of contraction of the _ muscles in the CNS
2. Then, _ muscles oppose the neg inspiratory forces that collapse them
3. While asleep, these muscles relax and cause the soft-walled _ to collapse between the _ and _
4. The resulting hypoventilation triggers a surge of _ dilator muscle activity, which opens the airway then causing _.
5. _ reverses the hypercarbia, which reduces the _ drive to breathe again. This is a vicious cycle.

A
  1. tensor
  2. dilator
  3. oropharynx, uvula, epiglottis
  4. pharyngeal, hyperventilation
    5.Hyperventilation, CNS

this causes fluctuating hypercarbia and hypoxia, poor sleep, and triggers adrenergic output with each cycle

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79
Q

HR abnormalities associated with OSA:

A

-bradycardia
-sinus node dysfunction
-asystole

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80
Q

_ or more clinically significant apneic episodes per hr or > _ episodes per night cause hypoxia, hypercapnia, systemic and pulmonary _, and cardiac _

A

5 times/hr or 30 times /night
systemic and pulm HTN
cardiac arrhythmias

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81
Q

STOP BANG =

A

Snoring = do you or others think you snore
Tired = daytime tiredness/fatigue
Observed = anyone witnessed apnea
blood Pressure = treatments for HTN

BMI >35
Age >50yo
Neck circumference >40cm
Gender = male

-high risk OSA = yes to 3+ items
-low risk OSA = yes to <3 items

82
Q

Things to ask obese pts regarding OSA even without a diagnosis:

A

-sleeping patterns
-snoring
-apnea
-arousals thru night
-daytime sleepiness

-OSA is significantly UNDERdiagnosed

83
Q

Preop methods to reduce OSA concerns

A

-individualized anesthetic planning tailored to comorbidities
-preop consults for other coexisiting conditions with obesity (PSG, endocrine, etc)
-minimal or no sedation if possible, premedication with precedex to minimize opioid needs

84
Q

Intraop methods to reduce OSA concerns

A

-regional blocks if appropriate
-ramping to enhance preoxygenation, airway visibility, and pt comfort
-CPAP in preoxygenation phase
-ASA difficult airway algorithm
-minimize/ avoid opioids
-short acting agents if possible
-regional/ multimodal analgesia (NSAIDs, tylenol, tramadol, ketamine, gabapentin, pregabalin, dexamethasone)
-propofol for maintenance
-sevo or desflurane (quick on/off - less soluble)
-CAPNOGRAPHY

85
Q

Reversal of anesthesia methods to reduce OSA concerns:

A

-verify full reversal of NMB
-fully awake/cooperative before extubation
-semi-upright angle for extubation/recovery

86
Q

Postop methods to reduce OSA concerns:

A

-CPAP and supp O2
-avoid opioids
-intense respiratory monitoring
-VTE proph
-local/regional techniques for outpt surgeries
-transfer arrangements available for inpatient admission if needed
-longer monitoring period in PACU

87
Q

T/F Pickwickian/ OHS is associated with elevated bicarb levels.

A

TRUE-in early stages!!
normocapnia, base excess and high bicarb while awake due to chronic hypercapnia during sleep

88
Q

OHS/Pickwickian is diagnosed when:

A

PCO2 is >45mmHg during wakefulness with compensatory hypoxemia (PO2 <70mmHg)
-symptomatic obese pts are screened for diagnosis

asymptomatic obese pts with only hypoxia but all other parameters WNL are not screened

89
Q

Which respiratory condition is associated with cardiac enlargement, cyanosis, polycythemia, and twitching in obese pts?

A

Pickwickian/ OHS

90
Q

Early diagnosis of OHS/Pickwickian is achieved by review which 2 labs while the pt is asleep?

A

-ABG
-base excess (elevated bicarb)

91
Q

4 GI conditions associated with obesity

A

-GERD
-gallstones
-pancreatitis
-NAFLD (steatosis, steatohepatitis, fibrosis, cirrhosis, hepatomegaly, abnormal liver biochemistry)

92
Q

What causes alveolar ventilation to reduce in obese pts?

A

-shallow and inefficient ventilation
-decreased Vt
-poor respiratory strength
-poor elevation of diaphragm

93
Q

Most common liver condition worldwide?

A

NAFLD
-confirmed with liver biopsy

94
Q

NAFLD increases the risk for:

A

-cirrhosis
-hepatic decompensation
-hepatocellular carcinoma

95
Q

Gallstone formation in obese individuals occurs due to high concentrations of _ in the bile and high ratios of bile salts to _

A

cholesterol
lecithin

96
Q

Weight gain with _ obesity is a major predictor of metabolic syndrome

A

visceral

97
Q

Metabolic syndrome consists of an array of disorders :

A

-glucose intolerance
-T2DM
-HTN
-dyslipidemia
-CV disease

98
Q

Patients with metabolic syndrome exist in a pro- _ and pro- _ state.

A

pro-inflammatory
pro-thrombotic

99
Q

AHA Metabolic Syndrome Diagnostic criteria:

A

3 or more of following:

-elevated waist circumference (men 40inches+, women 35 inches+)

-elevated triglycerides (150mg/dL +)

-reduced HDL (men <40mg/dL, women<50mg/dL)

-high BP (130/85+)

-high fasting BG (100mg/dL +)

100
Q

Joints commonly affected by OA from obesity:

A

-ankles
-hips
-knees
-L spine

101
Q

How can limited activity lead to the development of fractures?

A

bone resorption from immobility causing loss of bone density and contributing to stress fractures

102
Q

Pediatric obesity is recognized as a BMI > the _ percentile on the CDC growth chart.

A

95th

103
Q

T/F Obesity can slow gastric emptying and cause a reduction in gastric pH

A

true

104
Q

T/F Obese kids have a higher risk of being obese as an adult and have higher risks of developing comorbidities throughout their lives.

A

true

105
Q

Most significant link to increases in birth weight:

A

maternal obesity

NOT diabetes

106
Q

Obesity causes which stages of labor to last longer?

A

1st and 2nd

107
Q

Americans of which descent are at higher risk of developing T2DM as children?

A

African, Hispanic, Asian, and Native American

108
Q

T/F Prepregnant obesity greatly increases the risk of needing a CS

A

true

109
Q

Pregnancy outcomes that are complicated by obesity:

A

Preeclampsia (heightened risk with metabolic syndrome)
gestational diabetes (GDM)
CS and instrumented deliveries
preterm labor
postpartum hemorrhage (PPH)
infection
pregnancy-induced hypertension(PIH)
macrosomic infants (weight >4kg)
difficult neuraxial placement
difficult intubation

110
Q

The first _ wks of pregnancy have increased risk of spontaneous abortion and miscarriage in obese women.

A

6wks

111
Q

Drug classes for long-term obesity treatment:

A

Sympathomimetic Amines
-Benzphetamine, Phentermine

Sympathomimetic Amines/AntiEpileptic combo
-Phentermine/Topiramate ER

Lipase Inhibitors
-Orlistat

Serotonin Receptor Agonist
-Lorcaserin

Opioid Antagonist/Antidepressant combo
-Naltrexone/Bupropion

GLP-1 Receptor Agonists
-Liraglutide, Semaglutide (Ozempic, Wegovy), Terzepetide (Mounjaro)

112
Q

Indications for bariatric surgery:

A

Must meet all the following:
-BMI >40 or <35 with accompanying comorbidities
-Failed dietary therapy
-Psychiatrically stable with no alcohol dependence or illegal drug use
-Understand the operation and its sequelae
-Motivated patient
-Other medical issues do not significantly add to surgical risk

113
Q

MOA of Bariatric Surgeries

A

RESTRICTIVE
-Vertical banded gastroplasty (VBG-older)
-Lap adjustable gastric banding (LAGB)
-Lap sleeve gastrectomy (LSG)

MOSTLY RESTRICTIVE, MILDLY MALABSOPTIVE
-Roux-En-Y gastric bypass (RYGB)

MOSTLY MALABSORPTIVE, MILDY RESTRICTIVE
-Biliopancreatic Diversion (BPD)
-Duodenal Switch (DS)

bold = most common

114
Q

Procedure of choice for clinically severe obesity:

A

Roux-en-Y gastric bypass

115
Q

Drug therapy for obesity can begin once BMI > _ or if it is _ - _ with comorbidities

A

> 30 or 27-29.9

116
Q

Common approach for dosing medications and obesity is to give water-soluble drugs based on _ and lipid-soluble drugs based on _

A

Water-soluble: ideal body weight IBW (adding 30% to this accounts for the increases in lean body mass)

Lipid-soluble: total body weight TBW

117
Q

Best volatile anesthetics for obese pts:

A

Sevo + Des

-adding N2O helps reduce these doses too while reducing postop pain - just give antiemetics with it

118
Q

Dosing changes of IV agents in Obese Pts:

A

Propofol = induce with LBW , maintain with normal wt

Sux= intubate with normal dose

NDMR(Roc, Vec, Cisatracurium)= All doses via IBW

Fentanyl + Sufentanil = normal loading dose, maintenance via LBW and response

Remifentanil= infusion via IBW

Precedex= infusion rates of 0.2mcg/kg/min

Sugammadex=normal wt doses

119
Q

Medications that are dosed via TBW (normal wt)=

A

Prop (maintenance)
Sux
Fentanyl + Sufentail (LOADING dose)
Sugammadex

120
Q

Medications dosed using alternative wts=

A

LBW:
-Prop(induction)
-fentanyl+sufentanil (maintenance)

IBW:
NDMR (roc, vec, cisatracurium) (all doses)
Remifentanil (infusions)

Lower rate altogether:
-Precedex (adjunct infusion 0.2mcg/kg/min -minimize cardiac effects)

121
Q

Preop lab tests considered routine for obese pts:

A

EKG + glucose check

122
Q

Preop considerations for obese pts:

A

-herbal, weight reducing, or anorexiant drugs
-abx + VTE proph
-OSA symptoms, sputum, smoking, URI
-eval for masking or airway difficulty

123
Q

Outside of clinical exam, which test is the most confirmatory for pulmonary hyptertension?

A

Tricuspid regurg results on a 2DE

124
Q

3 strongest predictors of difficult intubation in obese pts:

A

-MP >3
-increased neck circumference
-hx OSA

125
Q

Neck circumference measurements:
normal
high risk difficult intubation
higher risk difficult intubation

A

normal: 35cm
high risk: 40cm
higher risk: 60cm

126
Q

Factors indicating need for fiberoptic intubation:

A

-poor mouth opening
-presence of neck or arm pain
-inability to place head in sniff position

127
Q

GLP-1 agonist considerations:

A

pts usually need to stop medication for at least 1 wk, and still may require RSI

-US is the only way to confirm gastric content

128
Q

Pharmacokinetic changes with obesity:

A

Increased:
-fat mass
-CO
-blood volume
-LBW
-renal clearance
-volume of distribution for lipid-soluble drugs

Reduced:
-total body water
-pulmonary function

Altered:
-plasma protein binding
-liver function

129
Q

Postop complications of bariatric surgery(Anastomotic Leak)
-s/s

A

-unexplained, possibly asymptomatic tachycardia (>120) #1
-fever
-abd/pelvic pain
-tachypnea (w/ desat = sepsis?)
-L shoulder pain
-substernal pressure
-HoTN
-SOB
-thirst
-restlessness
-hiccups
-oliguria

Toradol increases the incidence of this

130
Q

OR prep for obese pt:

A

-ensure bed is compatible with pt wt
-larger straps, stirrups, arm boards, Bairhugger sheets, etc
-BP cuff on forearm ~ok, but will OVERestimate bp; switch to A-line if dicey
-diff airway cart nearby multiple sizes of equipment (LMAs too)
-5 lead EKG if cardiac hx
-blankets/foam/pillows for ramping

131
Q

BP cuff must encircle a minimum of _ % of upper arm circumference

A

75%
-FA cuff pressures will be HIGHER than actual, ok unless unreliable readings - > A line

132
Q

GERD considerations in obese pts:

A

-recent gastric banding = increased asp risk
-check gastric US, if < 1.5mL/kg = low risk asp
-RSI ready
- aspiration proph measures (H2 blockers, PPI, cric pressure-maybe)
-opioid sparing if poss

133
Q

Positioning for intubation in obese pts:

A

-sniffing or ramped
“HELP” head-up-laryngoscopy position reminds us of positioning importance
-reverse trend a bit (better FRC, better view)
-want head, neck, and shoulders greatly elevated above chest imaginary horizontal line connecting sternal notch and external auditory meatus

134
Q

T/F Obese pts need to fast longer than nonobese pts

A

false
same fasting time, can have up to 300ml of clear liq up to 2hr preop

135
Q

When to do awake or propofol only intubations in obese pts:

A

-if BMI > 50 or lower with high risk factors of OSA or large neck circumference

136
Q

Which has a higher incidence of postop nausea, gastric sleeve or gastric banding?

A

sleeve > banding

137
Q

T/F If DL doesn’t work, LMA certainly won’t work for obese pts

A

false, may help establish airway immediately

138
Q

Goal of cricoid pressure:

A

occlude esophagus between cricoid cartilage and vertebral body, reduce risk asp(debatable), better view of cords

139
Q

Preoxygenation of obese pts:

A

100% mask O2 for 3-5 min with CPAP as tolerated
-v important bc of reduced FRC and increased O2 consumption, reduces atelectasis while laying flat and increasing PaO2

-alternatively HFNC O2 can help prevent desat pre intubation

140
Q

Modified RSI:

A

-preoxygenate with cricoid pressure

141
Q

T/F The surgeon or another skilled anesthesia provider MUST be in attendance during intubation

A

true

142
Q

How to manage muscle hypotonus in lower mouth, and soft tissue obstruction with hypoxia in obese pt during induction:

A

2 person mask/vent technique

143
Q

How to improve FRC and arterial O2 tension in an anesthetized obese pt:

A

PEEP!

-costs CO and O2 delivery tho
-GA reduces FRC 50% in obese pts

144
Q

Optimized vent settings for obese pt:

A

-Vt= 6-10mL/kg of IBW avoids barotrauma
-pressure or volume control ventilation
-get ABG if SpO2 <95% during induction to assess for OHS/Pickwickian
-RR 12-14 for lap cases
-PEEP 10-12cmH2O -prevent/reverse atelectasis
-keep end-inspiratory pressure<30cmH2O
-mild permissive hypercap
-use at least 50% FiO2 but aim for less than 80%
-use recruitment breaths/intermittent sighs

145
Q

Potential problems with longer cases and cases involving the abdomen,spine,thorax:

A

-recumbent position decrease FRC and increase filling pressures of heart on R sd, increases CVP
-higher myocardial O2 consumption, CO, PAOP, PIP, increased venous admixtures above sitting value (give PEEP to fix this)

146
Q

Methods to maintain postop lung expansion:

A

-CPAP/BiPAP immediately after
-Supp O2 PRN
-Upper body elevated is poss
-pain control
-incentive spirometry
-early ambulation
-monitor pt for 24 hr postop if appropriate

147
Q

FRC can briefly be improved with large Vt - mL/kg but only minimally improves arterial O2 tension

A

15-20mL/kg

148
Q

Intraop factors that can decrease alveolar ventilation, cause atelectasis, and pulm congestion:

A

-subdiaphragmatic packing
-cephalad displacement of organs
-surgical retraction

149
Q

What can cause cardiopulmonary decompensation intraoperatively in severely obese pts?

A

-PEEP (decreases venous return)
-inability to raise CO

-this causes vent ectopy, HoTN, hypoxia, rales, and CHF symptoms = try to bag the pt by hand to reduce PEEP and fix HoTN

150
Q

PEEP of > _ cmH2O should be avoided.

A

15

-can actually impair oxygenation when given with large Vts

151
Q

Risks leading to postop respiratory compromise:

A

-hemorrhage intraop
-hypotension intraop
-vertical abdominal incision
-poor pain mgmt (reduces diaphragmatic excursion, vital capacity, potential atelectasis and VQ mismatch)

152
Q

What is a recruitment/vital capacity breath?

A

sustained pressure of 35-40cmH2O for 8-10 sec

helps improve FRC and prevent atelectasis
monitor for bradycardia or HoTN when doing this

153
Q

Anesthetic choice considerations in obese pts:

A

-shorter acting meds if poss
-avoid residual NMBD, use sugammadex and TOF
-multimodal approaches (pain, anesthesia, PONV) - lidocaine, ketamine, precedex
-epidurals for postop pain?
-optimize O2

154
Q

T/F Estimated blood volume is increased in obese pts

A

false
decreased!

155
Q

What changes should be made when calculating EBV in obese pts?

A

Use 45-55mL/kg !!!! not 70mL/kg

156
Q

Fat is _ - _ % water so it contributes _ fluid to total body water compared to equal amounts of muscle

A

8-10%
less

157
Q

Normal adult total body water =
Obese pts total body water =

A

60-65%
40%

158
Q

T/F Fluid management and blood replacement strategies are different in obese pts

A

false
-go by BP, HR, UO as usual
-replace blood as usual

159
Q

Renal failure risks for bariatric patients:

A

-hypovolemia
-BMI>50
-prolonged case
-intraop HoTN
-preexisiting disease

160
Q

Hetastarch must not be given more than _ mL/kg of IBW

A

20mL/kg IBW

-dilution coags, factor VIII inhibition and platelet aggregation reduction from excess admin
-use albumin as indicated

161
Q

T/F We want to enhance lordosis when obese pt is on OR table

A

true!
-use towel/blanket to support lower back lordosis so they don’t have to lay completely flat

162
Q

Extubation consideration for obese pt

A

-be ready to reintubate asap if needed (positioning and equipment ready)
-have OPA, exchange cath, pt sitting up if poss
-safest method = AWAKE emergence!

163
Q

Regional considerations for obese pts:

A

-may need longer Touhy needle (>7in)
-generous lidocaine (may need multiple attempts, numb well!)
-kinda unpredictable to determine spread (higher rate of epidural failure and resp complication from high regional blk)

164
Q

How to prevent cephalad/rostral spread in obese pts receiving regional:

A

-less LA
-more time sitting upright

165
Q

Max decrease in PaO2 in obese individuals occurs _ - _ days postop

A

2-3

166
Q

Most common cause of postop mortality after bariatric surgery in obese individuals

A

Thromboembolism

167
Q

Rhabdo risks for obese pts following bariatric surgery:

A

-male
-old
-elevated BMI
-prolonged operation

diagnostic: CPK levels

168
Q

Rhabdo treatment:

A

hydration with goals to avoid:
-hypovolemia
-aciduria
-tubular obstruction
-free radical release

bicarb admin

mannitol

169
Q

VTE risk factors in obese pts:

A

-BMI >60
-venous stasis disease process
-OHS
-OSA
-previous PE

170
Q

VTE risk prevention in obese pts:

A

-heparin 5000 units subcut twice daily
-antiembolic stockings
-SCD
-early ambulation
-IVC placement preop

171
Q

Pulmonary compliance decreases by _% in obese individuals

A

35%

172
Q

What is the relationship between BMI and FRC?

A

FRC exponentially decreases

173
Q

Which muscles dilate and contract the pharyngeal airway?

A

Intrapharyngeal: contract / collapse
Pharyngeal: dilate

174
Q

What keeps your airway open when you’re asleep?

A

tensor muscles via CNS

175
Q

OSA is associated with _ (increased/decreased) vagal tone

A

increased

176
Q

Calories in fat (1g)
Calories in protein (1g)
Calories in carbs (1g)

A

fat= 9 cal
protein = 4 cal
carbs = 4 cal

177
Q

What is leptin?

A

a hormone made by adipose cells that act as satiety factor in regulating appetite

178
Q

Is insulin pro or anti inflammatory?

A

Anti-inflammatory

179
Q

What is NASH?

A

Non-alcoholic steatohepatitis

-involves lobular inflammation and fibrosis and is the inflammatory version of NAFLD

180
Q

Postop lung problems with obese pts

A

-atelectasis
-hypoxemia
-increased pulm workload
-vital capacity decreases

181
Q

Worst position for obese pts :

A

supine

182
Q

PACU monitoring for obese pts:

A

-3hr longer before DC home
-7 hr longer if there is a room air apneic episode

183
Q

Why does CO increase with fat?

A

fat requires vasculature

184
Q

How does obesity cause HF?

A

Diastolic dysfunction
Increased CO -> dilates heart -> walls thicken to push back on pressure -> reduces compliance -> dilates beyond the ability to increase wall thickness -> systolic dysfunction -> biventricular heart failure

185
Q

Mendelson’s Criteria:

A

gastric volume > 0.35mL/kg TBW

186
Q

Which drugs are highly lipid soluble?

A

Barbiturates, benzos

-remifentanil has no change in distribution

187
Q

Which drugs are weakly lipid soluble?

A

propofol, roc/vec, sugammadex

188
Q

Single biggest predictor of diff intubation in extremely obese pt:

A

neck circumference
5% = 40cm neck
35% = 60cm neck

normal neck = 35cm

189
Q

Should you RSI obese pts (if no other risk factors)?

A

no
only if other risk factors present like GERD

190
Q

Should RR be set higher or lower for obese pts?

A

higher

191
Q

What happens with inspiratory pressure for obesity?

A

increases
-decreased pulmonary compliance

192
Q

When to paralyze pt for awake intubation?

A

after tube placement is confirmed

193
Q

Criteria for extubation in obese pt:

A

-Vt/RR at preop level
-VS at preop level
-VC more than 2x Vt
-head lift 5 sec
-NIP 25-30cm
-SpO2 at preop level
-normocapnia

194
Q

Qualification for bariatric surgery:

A

-under 65
-100lb over IBW
-other methods failed
-psychologically stable
-loss of 40-60% of wt
-monitored for 5 yrs

195
Q

What is the Roux-en-Y bypass?

A

takes part of jejunum and attaches it further up in stomach (bypasses rest of stomach)

196
Q

Pathogenesis of NAFLD is associated with:

A

insulin resistance

197
Q

What symptoms do you expect to see in men and women with endocrine mediated obesity?

A

-menstrual issues
-decreased libido/impotence
-low serum follicle stimulating hormone and testosterone levels

198
Q

Gynecoid fat distribution is associated with which obesity related disorder?

A

Metabolic syndrome

199
Q

Metabolic syndrome and pregnancy increases risk of which 2 peripartum disease

A

preeclampsia
diabetes

200
Q

Which EKG changes are seen in obese pts?

A

Low voltage
-axis deviation and atrial tachyarrhythmias are common
-QT prolongation could be a sign of LVH -> get 2DE asap, this is a red flag for potential arrest!

NA 1 (31 decks)

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