Obesity SG 10-18 Flashcards
To master the care and anesthesia for the the hot and fluffy hippo hopper population
When should an obese pt be extubated (what are you going to assess for)
- Hemodynamically stable
- Able to be placed in a heads up or sitting position
- Muscle relaxant adequatly reversed (and verifed with twitch monitor
- Awake and alert
- Sustain head lift x 5 seconds
- Effective cough
What are the following respiratory values for extubation of the obese pt Respiratory Rate- Neg inspiratory Force- Vital Capacity- Tidal Volume-
Respiratory Rate- < 30 bpm
Neg inspiratory Force- -25 to -30 cmH2O
Vital Capacity- 10-15 ml/kg
Tidal Volume- 5ml/kg (of IBW)
What is included in the post-operative management of the obese pt? ( Basically what are you going to do to the pt when you drop them off in PACU)
- Semi upright position (45 degree if poss)
- Nasal Airway
- O2 sat monitoring
- O2 if needed
- CPAP if OSA hx
- Carefull admin of pain meds
- Lung recrutment tech (IS)
What may be a complication in obese pt’s especially with bariatric pt’s with BMI > 40, from laying in one position too long?
Rhabdomyolysis (and renal failure)
How is the CV system impacted by obesity?
- Systemic HTN
- CAD
- Left and/or Right sided HF
- Increased metabolic demend
- Increased CO
- Increased SV
- Increased circulating blood volume
Just to tie it all together**all this leads to LVH and pump failure due to the chronically high SVR with decreased coronary artery perfusion, and when demand is not met our friend MI makes a little visit*
How is the respiratory system impacted by obesity?
- frequently (do not think always or automatic) difficult airway dur to excessive pharyngeal tissue (AKA redundant tissue)
- OSA
- OHS
- Orthopnea
- Decreased FRC
- Increasd O2 comsumption
- Increased CO2 production
B/c the obese pt has a decreased FRC what may often occur upon induction? and extubation?
Induction: rapid decline of SPO2
extubation: increased anxiety (if waking supine)
How is the GI system impacted by obesity?
- Increased gastric emptying
- Increased IAP
- Increased risk of GERD
- Increased risk of pulmonary aspiration
How is the Liver impacted by obesity?
- Abnorma LFTs
- Fatty liver disease (hepatitis)
- Increased fat stores for VAA
Alterations in volume of distribution are r/t what in the obesity pt?
- Size of fat organ
- Increased blood volume
- Increased CO
- Decreased body water
- Alterations in protein binding
- alterations in lipophilicity of the drug
Highly lipophillic (hydrophobic) drugs have a _______ volume of distribution in obese pt’s leading to a need for ____________ drug doses.
-high
- Increased
a litle example.
That being said.. larger fat stores provide and increased VD for lipid soluable drugs such as narcotics and Benzos
Water soluble drugs have a _________ volume of distribution, leading to a need for __________ drug doses
- Smaller
- decreased
a little example
NMB , water soluable, have a smaller VD in obese pt’s and dose should be based on IBW
Sevo causes increased levels of serum inorganic fluorides to be metabolizes at a rate a ______% ________ in obese pt’s than in non-obese pts
- 100%
- faster
Obese pt’s frequently have liver impairment due to infiltration of ________ by _________? therfore drugs with hepatic metabolism should be given ______
- hepatocytes
- triglycerides
- cautiously
What is the down and dirty relationship b/t obesity and DM??
- 80% of NIDDM (type II) patiens are obese
- The risk of typeII DM increases linearly with BMI
How is OSA defines (or diagnoses)
airflow cessation of more than 10 sec and characterized by frequent episodes of apnea or hypopnea (yes thats a word) during sleep.
What kitchen utensil would you be?
A spork b/c it’s the most helpful but most underappretiated
- It makes eating icecream and cake more effective
- It allows one to eat salad and soup with one utensil
- it dominate mashed potatoes with gravy
- awesome choice for chilli
- and most importantly it looks fucking awesome.
What is hypopnea?
airflow decreased below a given % of the surrounding baseline and may require the presence of a degree of oxyhemoglobin desturation
how is the severity of OSA determined? and what is the classification for sleep apnea syndrome
- measured by the average number of incidents per hour
- > 5 per/hr is considered sleep apnea syndrome
OSA is oftern characterized by what s/s?
- Snoring
- daytime somnolence
- fragmented sleep
- physiologic changes
- arterial hypoxemia
- arterial hypercarbia
- polycythemia
- systemic HTN
- Pulm HTN
- Right ventricular failure
Estimate how many windows are in New York
I would say 42 million!!!
Current strategies for sugically induced weigth loss fall into 2 categories. What are they?
gastric restriction
intestinal malabsorption
Name 4 of the different types of Bariatric surgeries
Laparoscopic adjustable gastric banding
Biliopancreatic diversion (BPD) procedure
Roux-en-Y gastric bypass (RYGB)
Gastric sleeve
What is Laparoscopic adjustable gastric banding. which category does it fall into?
a small gastric pouch 10-12 mm in disance is created via sugically placing an adjustable band around the abdomen, with a port in the SQ tissue of the abd. The band is then adjusted via adding solution to the port thus tightening the band around the stomach
-restrictive
what is an example of a malabsorptive bariatric procedure
Biliopancreatic diversion (BPD) procedure with or without duodenal switch and the distal gastric bypass
what category of bariatric sx does the Roux-en-Y gastric bypass (RYGB) fall under
both restrictive and malabsorptive
How many quarters would you need to reach the height of the Empire State building
the Empire State Building is about 448 metres (448,000mm) high. A quarter is 1.75mm thick, so 448,000 divided by 1.75 equals approx. 256,000
since you learned all about the problems associated with being “pleasently plump” what special considerations should be made foe these pt’s inrelation to anesthesia considerations (broad answers)
- good pulm and CV workup
- Possiable difficult IV access poss need for CVP
- NIBP may be difficult, may need A-line
- Difficult ventilation
Post bariatric sugical pt’s that require surgery after a signficant weight loss should be evaluated for what prior to sx?
- anemia
- electrolytes
- protein loss
- osteoporosis
- B-12 deficiency
