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AP 1 > Test 2: Obesity (pt 2/3) > Flashcards

Test 2: Obesity (pt 2/3) Flashcards

1
Q

Why do CV changes occur in obesity?

A

Due to the progressive compensatory processes that evolve to meet the increased metabolic demands of the fat organ.

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2
Q

What is the primary cause of Morbidity & mortality in obese patients?

A

CV Dz:
-Ischemic Heart Dz
-HTN
-Cardiac Failure

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3
Q

There is an increased CO of _____ for each Kg of fat acquired.

A

0.1 L/min

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4
Q

Chronically elevated CO leads to what side effects?

A

Cardiac workload is augmented by the increased stroke volume (CO increases but HR stays the same)
-LVH
-Cardiomegaly
-HTN
-Eventual CHF

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5
Q

What is the definition of HTN for this test?

A

> 140 / >90

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6
Q

What is the pathophysiology behind why patients with obesity have HTN?

A

-Increased blood viscosity
-Altered catecholamine kinetics
-Increased estrogen concentrations

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7
Q

What are the renal factors that predispose obese patients to HTN?

A

-Visceral compression of the kidneys from fat deposits in/around the kidney
-Impaired Na excretion
-Activation of the RAAS
-Increased SNS activity

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8
Q

Obesity co-occurring with CAD results in what symptoms/comorbidities?

A

-Angina
-CHF
-MI
-Death
-Ischemic Heart Dz is more common in obese individuals with a central Android fat distribution

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9
Q

Why are obese patients predisposed to atherosclerosis and CVA?

A

Hypercholesterolemia (Cholesterol >240 mg/dL) often coexists with HTN, predisposing obese patients to atherosclerosis and CVA.

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10
Q

True/False: CAD is an independent risk factor of obesity.

A

True

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11
Q

The presence of OSA/OHS, as well as the increased total blood volume that is associated with obesity, leads to increased workload on the heart and ultimately, the common pathway leads to ______.

A

Biventricular Failure (see slide 21 obesity ppt)

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12
Q

Why are obese patients predisposed to Aspiration?

A

-Increased gastric residual volume & acidity
-Increased incidence of GERD & Hiatal Hernia
-Increased abdominal pressure

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13
Q

Nonalcoholic Steatohepatitis (NASH) or Fatty Liver Dz is present in up to ____% of obese patients, and can progress to _______ and _______.

A

90%; can progress to hepatitis and hepatocellular carcinoma.

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14
Q

What defines metabolic syndrome?

A

-Abdominal/Truncal obesity
-HTN
-Insulin Resistance
-Hyperlipidemia

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15
Q

Patients with HgbA1c levels > ___% have increased postoperative complications, specifically _______.

A

8%; surgical wound infections

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16
Q

Subclinical hypothyroidism occurs in ___% of the obese population, and may be due to TH resistance in the periphery

A

25%

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17
Q

True/False: Altered Liver Function adversely affects drug metabolism

A

True

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18
Q

Laparoscopic and open cholecystectomies are commonly performed in obese patients because?

A

-High cholesterol in bile → gallstones
-Increased incidence of gallbladder dz in obese patients

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19
Q

What are risk factors associated with the development of Metabolic Syndrome?

A

-Men > women
-Inc risk CV disease and DM
-Polycystic ovarian syndrome
-Fatty Liver Dz
-Malignancy/CA
-Sexual Dysfunction
-Pro-inflammatory
-Sleep Disturbances

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20
Q

Why do obese patients develop osteoarthritis?

A

From mechanical stress on weight-bearing joints.
-There is a linear relationship between weight and the degree of arthritis.

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21
Q

Which joints are frequently burdened with osteoarthritis?

A

Ankles, hips, knees, and the lumbar spine

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22
Q

Why are obese patients at risk for stress fractures?

A

Bone resorption occurs secondary to limited physical activity and reduces bone density.

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23
Q

What percentage of young people aged 2-19 years old are considered overweight or obese?

A

31.8% (or approx 1/3)

24
Q

What is the diagnosis for obesity in pediatrics based off of?

A

Weight-for-height > 90th percentile or a BMI >/= the 95th percentile (Age and sex speific)

25
Q

What are the links between early childhood/adolescent obesity and adulthood obesity?

A

-Obese adolescents have a 70% to 80% chance of being obese adults.
-Childhood obesity is associated with a higher chance of premature death and disability in adulthood, particularly in urban areas.
-Childhood and adolescent overweight and obesity are linked with adult cardiovascular and endocrine problems. (CVA, HTN, DM 2, OSA, psychosocial disorders)
-Obese children are three to five times more likely to suffer a heart attack or stroke before they reach the age of 65.

26
Q

When is bariatric surgery used in children?

A

In carefully selected obese children with serious comorbidities and unresponsiveness to interventions.

27
Q

Prepregnancy obesity increases risk for what?

A

-Cesarean delivery
-Prolonged 1st & 2nd stages of labor
-Gestational HTN & DM, pre-eclampsia, preterm labor, infection, macrosomic infants
-Difficult placement of spinals & epidurals
-Difficult intubation risk
-Inc postop complications (wound infections, VTE, blood loss)
-Increased rate of miscarriage in first 6 weeks

28
Q

Maternal Obesity does NOT increase risk for what?

A

-No changes seen in neonatal outcomes
-No increased risk of postpartum hemorrhage

29
Q

A multimodal approach in the treatment of obesity includes what?

A

-Dietary intervention
-Increased exercise
-Behavior modification
-Drug therapy
-Surgery

30
Q

What are the non-surgical treatment options for obesity?

A

1) Weight loss programs - prevention of DM & CV events; tx of metabolic syndrome
2) Lifestyle changes - diet & exercise
3) Behavioral Modifications - self-monitoring, goal setting, & education
4) Pharmacotherapy (for BMI > 30 kg/m2 or lower BMI with coexisting dz)

31
Q

Pharmacotherapy is initiated for BMI > _____, or a BMI between ____ and ____ with a coexisting medical condition.

A

> 30 kg/m2; or between 27-29.9 kg/m2 with a coexisting condition.

32
Q

A Lipase inhibitor that binds with dietary fats.
-Major GI side effects
-Fat soluble vitamin deficiency
-Coagulopathies due to vitamin K deficiency

A

Orlistat

33
Q

A sympathomimetic / appetite suppressant.
-Adverse reactions: palpitations, tachycardia, uncontrolled HTN, tremor, headache
-Significant refractory hypotension with anesthesia!!!
-No official published guidelines related to anesthesia and discontinuation – Hold 7 days prior to elective surgery

A

Phentermine

34
Q

What are the 4 most common bariatric procedures?

A

1) Roux-en-Y Gastric Bypass
2) Laparoscopic adjustable gastric bypass (LAGB)
3) Laparoscopice sleeve gastrectomy (LSG)
4) Biliopancreatic Diversion with duodenal switch (BPD with DS)

All are safe, effective, minimally invasive, and relatively cost-effective.

35
Q

Surgical approaches designed to treat obesity can be classified as _______ or __________.

A

Malabsorptive or restrictive.
-Malabsorptive: not commonly used

36
Q

What is the gold standard approach for treatment of morbid obesity due to improved surgical times and improved morbidity and mortality r/t bariatric surgery?

A

Laparoscopic surgery

37
Q

Bariatric surgeries should be followed by what?

A

Rehabilitation of previous lifestyle patterns by counseling and support from psychologists, dietitians, physical therapists, and internists.

38
Q

What are the indications for bariatric surgery?

A

-BMI > 40 kg/m2 (or BMI of 35 w/ associated comorbidity worsened by obesity)
-Failed dietary therapy
-Psychiatrically stable without alcohol dependence or drug use
-Informed consent of procedure & sequelae
-Motivated individual
-Medical problems not precluding survival from surgery

39
Q

Which bariatric surgeries are Restrictive?

A

-Lap Adjustable Gastric Band
-Lap Sleeve Gastrectomy

40
Q

Which bariatric surgeries are Restrictive/Mild Malabsorptive?

A

Roux-en-Y Gastric Bypass

41
Q

Which bariatric surgeries are Malabsorptive/Mild Restrictive?

A

-Biliopancreatic Diversion
-Duodenal Switch

42
Q

The creation of a small pouch from the proximal stomach to the GE junction.
-Allows for normal stomach emptying of liquids and slowed emptying of solid foods
-Reduces and limits food intake
-Avoids permanent alteration of anatomy, has low morbidity & mortality, shorter LOS, lower hospital costs, and low re-operation rates

A

Adjustable Gastric Band

43
Q

The permanent removal of a portion of the stomach.
-Risks: infection, staple line leakage, GI stricture, hernia, GERD, and malnutrition
-Overeating can stretch and negate surgery.
-Need for psychological counseling

A

Sleeve Gastrectomy

44
Q

A saline filled balloon is placed via EGD in the stomach to limit food intake.
-FDA approval in place for 6 months in order to “retrain” the stomach, then it is removed.
-Risks: balloon deflation, GI obstruction, stomach ulcers, perforation

A

Intragastric Balloon

45
Q

The creation of a small gastric pouch connected to the jejunum.
-Changes GI hormones: risk for vitamin deficiency, malnutrition, ulcers, perforation, anemia, staple line failure, hernia, and dumping syndrome

A

Roux-en-Y Gastric Bypass

46
Q

A sleeve gastrectomy that keeps the pyloric valve, and connects the distal small bowel to the stomach pouch.
-Bypasses a majority of the small bowel
-Risk of malnutrition due to loss of pancreatic enzymes & bile

A

Biliopancreatic Diversion/Duodenal Switch

47
Q

What are some goals of the preoperative evaluation with an obese patient?

A

-Establish rapport and explain anticipated events
-Weight loss drugs (!!), herbal supplements
-Antibiotic prophylaxis: inc risk of wound infections
-VTE prophylaxis
-Lab tests: renal, hepatic, CV, and endocrine (only if indicated in hx, physical, or for surgery)
-ECG & Glucose due to high risk of CVD and DM
-Thorough airway evaluation!!!

48
Q

Why are obese patients at high risk for difficult airway/Difficult mask ventilation?

A

-OSA, large tongue
-Neck circumference (best predictor for difficult intubation)

49
Q

Having what risk factors prompts a discussion with the patient about the potential for an awake intubation?

A

-Large neck circumference
-Male gender
-High Mallampati
-Prior Hx of difficult intubation

50
Q

How should the obese patient be positioned for airway management?

A

Head elevated in Reverse Trendelenburg position to promote patient comfort, reduce gastric reflux, provide easier mask ventilation, improve respiratory mechanics, and maintain FRC.

51
Q

Obese patients need adequate preoxygenation of ____ at ____% O2?

A

3-5 min at 100% O2 (with CPAP as tolerated)
-done to attenuate desaturation and maximize O2 content in the lungs.

52
Q

What should be your cautious airway plan in an obese patient?

A

1) Careful administration of sedative drugs and application of topical anesthesia to the oropharyngeal structures
2) Nasal O2 during awake laryngoscopy
3) If the epiglottic and laryngeal structures are visualized, attempt asleep intubation
4) If structures cannot be visualized, LMA intubation, awake fiberoptic intubation, or another method should be used.
5) Have another set of skilled hands present.

Consider modified RSI if aspiration is a concern.

53
Q

Explain the Modified RSI technique.

A

1) Preoxygenation & Cricoid Pressure
2) Lungs are lightly ventilated prior to securing the airway

Approach avoids rapid desaturation in obese patients, and reduces risk of aspiration.

54
Q

True/False: Obese patients should be intubated in Sniffing Position.

A

False, it is more difficult. Obese patients should be placed in the “Ramped” Position with towels under shoulder/head, and placed in the reverse trendelenburg position.

55
Q

What are concerns with extubating an obese patient?

A

1) Ensure full reversal of NMB first!!!!!
2) Risk of airway obstruction after extubation is increased.
3) Must meet all criteria for extubation
4) Be placed in head up or sitting position
5) In doubt of ability to breathe adequately, leave it in place!!!

56
Q

The decision to extubate an obese patient is based on:

A

-Evaluation of the ease of mask ventilation & tracheal intubation
-The length and type of surgery
-The presence of preexisting medical conditions, such as OSA

AP 1 (32 decks)

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