Test 2 Obesity Flashcards
what is the second leading cause of preventable death in the US?
obesity
__________% of US adults are classified as overweight or obese
75
BMI for “normal weight”
18.5-24.9
BMI for “overweight”
25-29.9
BMI for “obese”
30-34.9
BMI for “severely obese”/”obese 2”
35-39.9
BMI for “extreme obese”/”obese 3”
> /= 40
what is ideal body weight ?
normal/desirable weight
what is the formula for calculating IBW in men?
height (cm) - 100
IBW formula for women
height (cm) - 105
formula for lean body weight (LBW) =
IBW x 1.3
how do you calculate BMI?
weight (kg) / height (m^2)
_________________ is the measurement of height and body mass that exhibits the lowest morbidity and mortality for a given population
ideal body weight
android obesity
central abdominal obesity
waist circumference > _________ cm in men is characteristic for android obesity
102
waist circumfrence > ________ cm in women is characteristic for android obesity
88
35”
which type of obesity has a higher risk of comorbidities, difficult airway, and intubation ?
android
apple shape = ______________ obesity
android
pear shape = _____________________ obesity
gynecoid
which type of obesity will have an increased risk of varicose veins and joint disease
gynecoid
peripheral, gluteal femoral obesity is __________________ obesity
gynecoid
non-surgical management for obesity
- weight loss programs
- lifestyle changes
- behavioral modifications
- pharmacotherapy BMI > 30 kg/m2
- implanted gastric stimulators
in the management of obesity, ______________ options should be individualized to each patient based on the degree of obesity and co-existing dz
non-surgical
which non-surgical management technique is beneficial in the prevention of DM and CV events, and tx’s metabolic syndrome?
weight loss programs
pharmacotherapy options for management of obesity
- orlistat
- phentermine
_______________ is a lipase inhibitor that binds with dietary fats and is useful in the treatment of obesity
orlistat
_______________ is a sympathomimetic / appetite suppressant in the tx of obesity
phentermine
s/e with orlistat
- major GI side effects
- fat soluble vitamin deficiency
- coagulopathies due to vitamin K deficiency
s/e with phentermine
- palpitations
- tachycardia
- uncontrolled HTN
4.tremor - HA
- significant refractor hypotension with anesthesia
which medication for tx of obesity has no published guidelines related to anesthesia and discontinuation ?
phentermine
indication criteria for bariatric surgery?
- BMI > 40 kg/m2
- failed dietary therapy
- psychiatrically stable
- informed consent: procedure and sequelae
- motivated individual
- medical problems not precluding survival from surgery
what are the different types of bariatric surgery
- restrictive
- largely restrictive, mildly malabsorptive
- largely malabsorptive, mildly restrictive
what are the types of restrictive bariatric surgery
- lap adjustable gastric band
- lap sleeve gastrectomy
- vertical banded gastroplasty
lap adjustable gastric band
- reduces and limits food intake
- creates a small pouch from the proximal stomach to the GE jx
- allows for normal stomach emptying of liquids and slowed emptying of solid foods
- avoids permanent alteration of anatomy, has low mortality, and low re-operation rates.
lap sleeve gastrectomy
- permanently removes a portion of the stomach
- overeating can stretch sleeve thus negate the surgery
what are the risks with a lap sleeve gastrectomy
- infection
- staple line
- GERD
- malnutrition
- vomiting
- hypoglycemia
what are your largely restrictive, mildly malabsorptive bariatric surgeries
roux en y
what has become the procedure of choice for clinically severe obesity
Roux-en-Y
roux-en-y
- creation of small gastric pouch connected to the jejunum
- stapling or banding with roux-en-y anastomosis
risks with roux-en- y
- vitamin deficiency
- malnutrition
- ulcers
- perforation
- anemia
- staple line failure
- hernia
- dumping syndrome
what are the types of largely malabsorptive/mildly restrictive bariatric surgery
- biliopancreatic diversion
- duodenal switch
________________ is the gold standard in performing bariatric surgery
laparoscopy
Periop management of OSA and OHS
- positive airway pressure
- regional or local over GA if can
- limited opioids, multimodal analgesia 4. use of short acting drugs
- postoperative monitoring in the PACU
anesthetic implications with OSA
- increased sensitivity to anesthetic agents
- difficult airway
- increased post-op complications
- lg portion of surgical patients are undx
STOP-BANG
- snoring
- tiredness
- observed apnea
- pressure (BP)
- BMI > 35
- Age > 50
- neck circ > 40 cm
- postoperative monitoring in the PACU
obesity hyperventilation syndrome is aka ________________________
pickwickian syndrome
what are the characteristics of obesity hyperventilation syndrome (OHS)
- OSA
- hypercapnia when awake (>45)
- daytime hypersomnolence <
- arterial hypoxia < 70
- polycythemia
- respiratory acidosis
- pulmonary HTN
- R-sided HF
airway management with the obese patient
- ensure optimal pt positioning
- adequate pre-oxygenation (3-5 min 100%)
- careful administration with sedating drugs and of topical anesthesia
- airway plan A/B/C
- consider modified RSI
- have another set of skilled hands with you
why is adequate preoxygenation essential in the obese patient?
rapid desaturation after loss of consciousness, increased O2 consumption, and decreased FRC
respiratory considerations with obesity
- decreased chest wall and pulmonary compliance
- premature airway closing –> increased Vd, CO2 retention, V/Q mismatch, ad hypoxemia
- restrictive breathing pattern
- increased O2 consumption and CO2 production
- respiratory muscle dysfunction
- closely linked with asthma-like sx
T/F: obesity predisposes the patient to respiratory failure
TRUE
extreme obesity is associated with reductions in FRC, ERV, and TLC, what does this mean clinically for anesthesia?
they do not tolerate periods of apnea/hypoventilation; will desaturate quickly especially during induction
OSA is associated with other co-morbiditeis
CAD
HTN
Ht. failure
CVA
what is the definition of OSA
repetitive upper airway collapse leading to cessation of breathing during sleep lasting 10+ seconds
what is the dx test for OSA
polysomnography
the polysomnography for the dx of OSA determines the ______________, which is the?
apnea-hypopnea index; # of abnormal respiratory events/hr of sleep
mild OSA = AHI of ___________
15-May
moderate OSA = AHI of ______________
15-30
severe OSA = AHI > ___________
30
CV concerns with obesity
- increase CO and blood volume –> increased cardiac work load
- HTN
- hypercholesterolemia
- CAD <
- renal impairment
what is an independent risk factor for obesity
CAD
what is the primary cause of morbidity and mortality in obese pts
CV disease: IHD, HTN, cardiac failure
CO increases by ___________ for each kg of fat acquired
0.1 L/min
the increased cardiac workload from increased CO d/t obesity can lead to what?
- LVH
- cardiomegaly
- HTN
- eventual biventricular failure
CAD is more common with what type of fat distrubtion
android (central)
the cardiopulmonary sequelae ultimately results in _____________
biventricular failure
blood pressure ahs been shown to increase __________ mmHg for every 10% increase in body weigh
6.5
GI effects of obesity
- increased gastric residual volume/acidity
- GERD
- increased abdominal pressure
- hiatal hernia
- NASH - fatty liver dz
- cholelithiasis
- metabolic syndrome
T/F: obesity is correlated with the incidence of subclinical hyperthyroidism in 25% of cases
false; hypothyroidism
what is one of the most common surgeries performed in the obese patient?
laproscopic cholecysectomy
if someone has metabolic syndrome (d/t obesity), this increases their risk for what?
- CV dz
- DM
- postoperative complications
characteristics of metabolic syndrome
- abdominal/truncal obesity
- HTN
- insulin resistance
- dyslipidemia
pts with _______________ type obesity are more correlated with the development of metabolic syndrome
android
metabolic syndrome is more common in ______________ with obesity
men
metabolic syndrome d/t obesity is correlated with other diseases/conditions?
- CV dz
- Polycystic ovarian syndrome
- fatty liver dz
- malignancy/cancer
- sexual dysfunction
- inflammation
- sleep disturbances
what are the orthopedic implications of obesity
- OA d/t stress on weight bearing joints
- bone resorption and reduced bone density –> stress fracture risk
which joints are commonly injured due to obesity
ankles, hips, knees, Lumbar spine
during your preoperative evaluation of the obese pt, what drugs should you ask them if they are taking?
- wt loss drugs
- herbal supplements
- their daily meds
- Abx
- VTE prophylaxis
what preoperative testing may be required for the obese patient?
those related to Cardiopulmonary, endocrine, GI/hepatic, and renal labs based on H&P and planned surgery
due to the risk of CV dz and DM in the obese patient, what preoperative testing should be considered routine?
ECG
the risk of _______________ after extubation is increased in obese patients
airway obstruction
what position do CRNAs typically place an obese patient into prior to extubating
sitting / head up
if there is doubt in the ability of an obese pt to maintain their airway if extubated, what can the CRNA do to evaluate?
extubate over an airway exchange catheter or via fiberoptic bronchoscope
obese pt with R axis deviation/RBBB on ECG is suggestive of?
pulmonary htn and RVH
obese pt with L BBB raises the concern of ________________
occult CAD
why are dysrhythmias common in the obese pt?
fatty infiltration of the conduction system (SA/AV nodes)
pts with a BMI > ______ will need increased dose of anticoagulants
50
perianesthesia management of the obese pt
- planning is vital: suitable location, equipment, personnel
- IV access difficulty
- potential for difficult airway
- potential for GI aspiration: GI prophylaxis
- postoperative monitoring: SpO2, CPAP, ICU
surgical position of the obese patient
- extra caution to prevent complications to prevent injury
- frequent assessment of pulses
- generous padding
- correct alignment + repeated inspection
- careful tx of the panniculus
there is a high risk for _____________ and ____________ with obese patients in the OR, thus ensure the table can support the weight of the pt prior to surgery
falls; table failure
what are the pharmacokinetic changes with obesity
- increased fat mass
- increased CO
- increased blood volume
- increased lean body weight
- changes in plasma protein binding
- reduced total body water
- increased renal clearance
- increased volume of lipid soluble drugs
- abnormal liver fx
- decreased pulmonary fx
how do you give/dose water soluble drugs to the obese pt
according to IBW
how do you give/dose lipid soluble drugs to the obese pt?
total body weight
which inhalation agents have excellent recovery profiles in the obese pt?
des and sevo
propofol administration implications for the obese pt
- induction dose on LBW
- maintenance dose on TBW
- cardiac depression at high doses in a concern
T/F: fat mass does not affect the initial dose/redistribution of fat during induction
TRUE
administration implications of succinycholine in the obese patient
- intubating dose based on TBW
- increased fluid compartment and pseudocholinesterase levels require higher doses to assure adequate paralysis
administration implications of roc in the obese pt
all doses based on IBW
administration implications of cisatracurium in the obese pt
all doses based on IBW
administration implications of fentanyl/sufentanil in the obese pt
- loading dose based on TBW
- maintenance dose based on LBW & response
- increased distribution volume and elimination time correlate with the degree of obesity
T/F: higher than usual infusion rates of precedex are recommended in the obese pt
false; lower than usual to minimize cardiac side effects
rate of precedex in the obese pt
0.2 mcg/kg/min
dosing of neostigmine in the obese pt is based on
TBW
suggamadex in the obese pt is dosed based on ______________
TBW
