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princip, pharm, phys, regional > principles-obesity > Flashcards

principles-obesity Flashcards

1
Q
  1. a bmi of what is defined as MORBID obesity?
  2. a normal BMI=?
  3. a BMI of what is obese?
A
  1. morbid obesity BMI= 40 kg/m2 or greater
  2. normal BMI= <25kg/m2
  3. obese BMI= 30 kg/m2
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2
Q

2 ways to calculate IBW

A
  1. IBW=height in cm-100 (men)
    & height in cm-105 (women)
  2. IBW=100 lbs +5 for every inch over 5’ tall (women)
    & 105 lbs +5 for every inch over 5’ tall (men)
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3
Q

obesity stats:

  1. what % of americans adults >20 y/o are obese?
  2. what % of adolescents?
A
  1. 33.4% of adults >20 y/o

2. 25% of adolescents

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4
Q
  1. when is fat cell formation most rapid?

2. what diseases is fat gain related to on linear scale?

A
  1. fat cell production most rapid in childhood

2. linear relationship with cv disease, cancer, diabetes & obesity

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5
Q
  1. how is obesity arbitrarily defined?
  2. morbid obesity?
  3. what % of population fits these catergories?
A
  1. 20% over IBW
  2. 2x IBW
  3. 10-15% of population is obese or morbidly obese
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6
Q

define:

  1. grade I obesity:
  2. grade II obesity:
  3. grade III obesity:
A
  1. 25-29 kg/m2 BMI (Men:25% body fat; women 39% body fat)
  2. 30-39.9 kg.m2 BMI; moderate risk of disease
  3. 40 or more: highest risk of mortality
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7
Q
  1. what health issues are common with obese?

2. obesity increases chance of what tumors?

A
  1. obese prone to t2DM, CAD,HTN, IDDM & hypercholesterolemia

2. higher incidence of breast, GI & endometrial tumors in obese

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8
Q

define:

  1. android obesity: what does it cause?

2. gynecoid obesity: why is it better than android?

A
  1. android obesity: fat centrally/ truncal located. fat is more metabolically active and goes to heart (increased CV disease), and higher o2 consumption
  2. gynecoid obesity: more buttocks and thighs, less metabolically active fat, less CV disease risk
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9
Q

respiratory issues with obese:

  1. ___ vO2 (volume of o2)
  2. ___CO2 ________:
  3. ____O2________:
  4. why does this happen?
A
  1. increased VO2
  2. increased CO2 production
  3. increased O2 consumption
  4. fat is metabolically active, so there is increased o2 demand, increased energy expenditure with a decreased O2 reservior so they need to take in more o2
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10
Q

resp effect of obesity:

  1. ____chest wall compliance, lung compliance ____ _____:
  2. in upright position residual volumes ____ _____:
A
  1. DECREASED ;REMAINS UNCHANGED

2. REMAIN NORMAL.

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11
Q
  1. ___ and ___ are reduced so that Vt may fall within range of closing volumes.
  2. this leads to ensuing____ or _________, which ultimately leads to _____.
A
  1. EXPIRATORY RESERVE VOLUME ;FUNCTIONAL RESIDUAL CAPACITY

2. VQ abnormalities ; Left to right shunt; hypoxemia

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12
Q

resp effects of obesity:
1. in supine position ___ falls further within ____ ____
2. this causes ___ _____
3. the normal decrease in FRC in nonobese persons with anesthesia is ____%
in the obese it is a ___% decrease

A
  1. FRC; closing capacity
  2. worsening hypoxemia
  3. 20%; 50%
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13
Q

sleep apnea leads to what conditions?

A
  1. depressed CNS responsiveness to chronic hypoxia leads to
  2. hypercarbia and acidsis and polycythemia
  3. this leads to CAD and stroke
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14
Q
  1. sleep apnea is common in approx___ of obese patients.
  2. females___males
  3. increased icidence of _____, _____,______
A
  1. 1/3
  2. less
  3. HTN, CAD, chronic hypoxia
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15
Q
  1. what % of obese have obese hypoventilation syndrome?
  2. what is it?
  3. s/s:
  4. airway issues:
  5. changes in alveolar ventilation d/t____:
A
  1. 8%
  2. Loss of hyperbaric drive, long term s/e of sleep apnea
  3. hypersomnolence
  4. potential or overt difficult airway
  5. alveolar ventilaton is reduced d/t shallow or inefficient ventilation
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16
Q

pickwickian syndrome

  1. what is it?
  2. how does it develop
  3. what are clinical signs and symptoms?
  4. what physical attributes are indicators?
A
  1. pulmonary hypertension
  2. develops with increased obesity
  3. hypercapnia, cyanosis induced polycythemia, right sided or biventricular heart failure, daytime somnolence, blunted respiratory drive, loud snoring, obstructive sleep apnea (5%) for more than 10 seconds.
  4. large abdomen girth and large kneck circumference are indicators
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17
Q

cardiovascular issues with obesity

  1. changes in c.o., workload, blood volume, vascuature?
  2. reasons?
A
  1. increased cardiac workload, c.o. and blood volume d/t having to perfuse fat (fat needs 2-3ml/100g tissue), also increase in blood vessels to perfuse fat.
  2. increased cardiac output is d/t increased stroke volume (C.O. increases 0.1 l/min) d/t increased o2 demands form girth
  3. blood volume increases (polycythemia) from hypoxia d/t chronic respiratory insuffeciency
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18
Q
  1. what does increase stroke volume lead to?
  2. what does increased pulmonary blood flow lead to?
  3. what does central distribution of fat lead to in heart and in blood?
A
  1. arterial hypertension and left ventricular hypertrophy or cardiomegaly d/t biventricular dilation and hypertrophy
  2. increased pulmonary artery vasoconsriction from persistant hypoxia lead to pulm hypertension and cor pulmonale
  3. CAD from increased circulating fat and increased fat infiltration into heart (cor-adiposum)which interferes with impulse conduction
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19
Q

effects of obesity:

  1. blood pressure-how much of a change /increase in weight, how common is it in obese?
  2. changes in insulin production, this causes what sympathetic response ?
  3. dyslipidemia is a _____ state leading to CAD, HTN, DM
  4. CAD occurs how much sooner in men than women?
A
  1. bp increases 6.5 mmhg per every 10% increase in body weight
    HTN has 50-60% occurence in obese.
  2. increased circulation of cateholamines which leads to increased Na+, Ca++ reabsorption and hypervolemia
  3. chronic inflammatory
    4.10-20 years earlier
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20
Q

endocrine changes with obesity:

  1. Increased abdomen girth leads to what GI issues?
  2. why are obese considered “full stomach” and RSI?
  3. what about chances of cholecystitis?
  4. what about liver issues?
A
  1. increased hiatal hernia, increased intra abdominal pressure, increased reflux and decreased gastric emptying
  2. 90% of obese have >25cc gastric fluid with <2.5 pH
  3. 30% increase in gall stones d/t increased bile salts
  4. increased fatty liver
21
Q

glucose tolerance changes:

  1. what happens?
  2. what resolves it?
  3. what blocks insulin release?
A
  1. increased adipose leads to increased resistance of periphreal tissues to insulin effect causing insulin resistance & DM)
  2. resolved by weight loss in 50% of persons
  3. android fat disposition (metabolically active) releases more faty acids which go to liver which leads to gluconeogenesis (this inhibits insulin release).
22
Q

what is APGAR?

A

acute post gastric reduction surgery neuropathy- causes vomiting, hyporeflexia and muscle weakness

23
Q

how does obesity influence drug pharmokinetics

A

increased blood volume, increased cardiac output, decreased total body water, altered protein binding and lipid solubility of the drug (gets stuck in all that fat) all alter volume of distribution

24
Q

what delays hepatic clearance

A

chf (backs up to liver), and decreased hepatic blood flow

25
Q

renal clearance changes?

A

may increase; GFR may increase (>40%), may cause segmental glumerular sclerosis and proteinuria with decreased renal function

26
Q

dosing medications

A

dose on ideal body weight initially, titrate next doses to response

27
Q

volitile agents and obese

A

obesity has no effect on awakening

28
Q

if your patient is over 100 lbs over IBW, what should you be considering as far as labs and airway?

A
  1. patient may be difficult to mask when sedated, ? awake intubation, RSI or fiberoptic (especially with poor malanpati)
  2. do they need glucose, ekg, labs
29
Q
  1. what pre op actions are more difficult in obese patients
  2. what OTC medications might obese persons be on that you should be aware of
  3. how should the side effect of this be treated?
A
  1. iv access
    regional landmarks
  2. herbs/ diet pills (can lead to catecholamine depletion (hypotension)-should hold 2 weeks prior)
  3. treat hypotension with phenylephrine
30
Q

when assessing an obese patient, what considerations should be taken into account?

A

mask ventilation/ intubation difficulties
gerd prophylaxis
bed size (can it hold the patient)
and positioning (will you need more ramps)
bp cuff size and placement

31
Q

assessment of obese person:

cardiac

A 
assess for:
LVH or RVH on ekg, 
prolonged QT, 
ischemic heart disease, 
consult cardiology if need be
32
Q

obese person:

respiratory assessment

A 
look for orthopnea, 
tripod position,
 hypoventilation syndrome (with questionaire),
 sleep apnea
may need :
cxr, 
pulmonary consult, 
ABGs
33
Q

obese person assessment:

GI:

A 
risk of regurg d/t increased gastric volume from slower motility and increased gastric pressure, also increased ph
give 
reglan 10 mg
pepcid 20mg or zantac 50 mg
bicitra 30 cc (all 1 hour prior to surgery)
possible glucose check
hgb A1c <7% increases surgical risk
cbc, lipids, LFTs, coags, lytes
34
Q

airway assessment in obese

A 
airway assessment -"any difficulties" with past intubations, 
neck girth, 
malmampati score, 
limited mouth opening,
 fat pad on back of neck limits neck extension, 
redundant tissue in mouth, 
short mandible distance, 
limited TMJ and allanto-occipital joint
35
Q

surgical treatment of obesity:

A

gastric banding
gastroplasty with roux-en-Y gastroenterostomy
gastric sleeve

36
Q
  1. what is a gastroplasty with roux-en-y?

2. what are side effects? how much weight can be lost?

A
  1. gastric antrum (distal stomach)and proximal small intestine are almost completely bypassed, the proximal jejunum is connected to a small part of gastric fundus (proximal stomach)
    • decreased digestive time leads to dumping syndrome
      - decreased intake leads to nutrient malnutrition
      - 55-65% weight loss
37
Q

criteria for gastric bypass et:

A
  • less than 65 y/o
  • 100 lbs over IBW
  • previous attempt
  • r/o psych issues
  • physiological eval
  • agree to long term follow up

morbidity rte 10-15%

38
Q

anesthetic management:

A
  • GETA (especially if really obese) if short GYN case and patient is “chubby, LMA is ok).
  • regional may be difficult
  • ramp the bed
  • large BP cuff
  • large body surface cools quick (bair hugger)
  • OR table extenders
  • ramping with blankets
39
Q

how to dose medications:

  1. fat slouble drugs based on what body weight? why?
  2. what fat soluble drug should you base on lean body weight intitially, then bolus by total body weight?
A
  1. fat soluble=total body weight (TBW) due to increased volume of distribution into fat cells
  2. propofol =LBW initially, then TBW for maintainance
40
Q

water soluble drugs:

  1. what body weight to base dose on?
  2. why?
  3. what water soluble drug goes against the rule of thumb?
A
  1. water soluble=IBW (ideal body weight) since they have a small volume of distribution (cannot pass thru lipid membranes).
  2. succinylcholine is highly water soluble but must be dosed on TBW for intubation
41
Q

spinal anesthesia in the obese:

  1. how to dose :
  2. why?
A
  1. reduce spinal and epidural amount by 20-25%
  2. due to epidural fat, abdominal pressure and distended epidural veins, there will be a higher spinal if the amount is not adjusted.
42
Q

best 2 choices for intubation of obese:

A
  1. awake with fiberoptic (best option)

2. RSI (only after careful consideration)

43
Q
  1. best VA for obese?

2. why?

A
  1. desflurane is best metabolized (,.02% is excreted in kidneys); sevo has fluoride compound metabolites-bad for kidneys (no delay in emergence in obese though)
44
Q

narcotic management of obese:

what are 3 best approaches to pain control

A
  1. front load narcotics to decrease post op pain without side effects (no narcs at the end of the case)
  2. epidural for inpatient with anticipated pain issues
  3. encourage surgeon to give local
    keep to minimum to delay post op narcotization
45
Q

muscle relaxats in the obese:

keys to use

A

fully reverse, avoid if necessary- remember airway issues from re-curization (especially negative pressure pulmonary edema)

46
Q

what is good to prevent atalectasis in obese patiets

A
  1. recruitment manuvers
  2. “sigh” program in vent
  3. peep on vent
  4. pre-oxigenate with peep
  5. ventilate with large Vt (15 ml/kg)at rate of 8-10
  6. PC vent with 1:1 ratio (longer I time)
  7. keep O2 at less than 80% to decrease atalectasis
47
Q

positioning in obese:

  • pressure points (which are most affected),
  • for oxigenation and intubation
  • OR table weight (what is standard limit)?
A
  • pad bony prominences (risk for sciatic and ulnar nerve palsies
  • ramp patient into sniffing position, sometimes can leave that way throughout case
  • standard OR bed limit is 300 lbs.
48
Q
  1. best emergence for obese?

2. what can be used in pacu for obese

A
  1. awake (especially if RSI)
  2. head up 45 degree to decrease diaphragm pressure, cpap/ bipap (home or hospital) in pacu
  3. supplemental O2 (even if sat ok)
49
Q
  1. obese have high incidence of respiratory issues with what surgeries (keeping in mind they may already have pickwickian or obesity hypovenilation syndrome)
  2. name two DONT’S to obese/obstetrics post op/ respiratory care
A
  1. abdominal and thoracic surgery (including obstetrics)
  2. …
    - do NOT extubate early
    - do NOT give late narcotics

princip, pharm, phys, regional (18 decks)

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