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

Test 2: Obesity (pt 3/3) Flashcards

1
Q

What are the S/sx of Cardiac Dz in obese patients?

A

-Dyspnea
-Pedal Edema
-JVD
-Hepatomegaly
-Exercise intolerance
-Body habitus complicates assessment

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2
Q

Why are dysrhythmias common in the obese population?

A

Due to sinoatrial node dysfunction and fatty infiltration of the conduction system.
-ECG changes including Right-Axis deviation & RBB suggest pulmonary HTN and RV Hypertrophy

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3
Q

True/False: A LBBB is common in obesity.

A

False: A LBB Is unusual in obesity and raises suspicion of occult CAD.
-Warrants a Transthoracic Echo (TTE)

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4
Q

Patients with a BMI > ____ need increased doses of anticoagulants for their VTE prophylaxis.

A

> 50 kg/m2

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5
Q

Increased BMI = ______ comorbidities = _______ risk!!

A

Bottom line: increased BMI = increased comorbidities = increased risk!!!

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6
Q

What are some planning considerations to consider for the location and equipment needed in surgery for the obese patient?

A

-Appropriate for outpatient setting?
-Weight limits of OR Table
-BP cuffs may not fit; may require arterial line monitoring for accurate BP
-Difficult IV Access (US)
-Positioning needs
-Airway equipment (video laryngoscope; FOB)
-Additional trained personnel
-Postop monitoring of SPO2 with CPAP, possible ICU admission

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7
Q

What are factors that potentiate injury complications related to positioning in obese patients?

A

-Hypothermia
-Hypotension
-Table positioning
-Pressure from adipose tissue on orthopedic and cardiopulmonary structures

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8
Q

How do you prevent or mitigate risk of positioning injury in obese patients?

A

-Frequent palpation of pulses
-Generous padding
-Correct alignment
-Repeated inspection of extremities for color & temperature
-Treatment of the Panniculus

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9
Q

True/False: You don’t have to worry about weight limits with OR tables.

A

False: Ensure the OR table can support the weight of the patient - high risk for falls and table failure!!!

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10
Q

What are the pharmacokinetic changes associated with obesity?

A

-Increased fat mass
-Increased cardiac output
-Increased blood volume
-Increased lean body weight
-Changes in plasma protein binding
-Reduced total body water
-Increased renal clearance
-Increased volume of distribution of lipid-soluble drugs
-Abnormal liver function
-Decreased pulmonary function

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11
Q

Give water-soluble drugs according to _____.

A

IBW

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12
Q

Give lipid-soluble drugs according to ______.

A

TBW

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13
Q

Can you give inhalational agents to obese patients?

A

Yes; newer inhalational agents (Des/Sevo) have excellent recovery profiles
-Des is less soluble than sevo; clinical differences are minimal

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14
Q

True/False: You can never give Nitrous Oxide to an obese patient.

A

False: Nitrous oxide is being increasingly used in obese patients as a volatile-sparing adjunct.
-Can be used unless a high O2 requirement precludes its administration

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15
Q

What are some benefits to using Nitrous Oxide in obese patients?

A

-Has the potential to reduce chronic postop pain
-The 2nd gas effect of N2O at induction & emergence can accelerate uptake and elimination of the volatile agent.

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16
Q

Appropriate antiemetic prophylaxis should be administered whenever _______, especially _____ are used.

A

Anesthetic gases; Nitrous Oxide

17
Q

What is the induction dose and maintenance dose based on for propofol?

A

Induction: LBW (avoid hypotension)
Maintenance: TBW

Increased fat mass does not affect initial distribution/redistribution during induction; cardiac depression at high doses is a concern

18
Q

What is your intubating dose of succinylcholine based on?

A

TBW

19
Q

Why is succinylcholine dosing based on TBW?

A

Increased fluid compartment and pseudocholinesterase levels require higher doses to ensure adequate paralysis

20
Q

Dosing for Rocuronium/Vecuronium/Cisatracurium is based on:

A

IBW

21
Q

Why are NDMR given based on IBW?

A

Hydrophilic drugs given according to IBW will ensure shorter duration and a more predictable recovery in this respiratory-challenged population

22
Q

What are the Loading Dose and Maintenance Doses based on for Fentanyl/Sufentanil?

A

Loading Dose: TBW
Maintenance Dose: LBW
(remember: can always give more. Need them to be able to breathe)

Increased distribution volume and elimination time correlate with degree of obesity

23
Q

What is the infusion rate of Remifantanil based on?

A

IBW
Distribution volumes and elimination rates are similar to normal-sized individuals; fast offset requires planning for postoperative analgesia

24
Q

What is the infusion rate of dexmedetomidine?

A

Infusion rates of 0.2 mcg/kg per min

Useful as an adjunct; lower than usual infusion rates are recommended to minimize adverse cardiac side effects

25
Q

What is Sugammadex reversal dosing based on?

A

TBW; no change from normal dosing

26
Q

What are the objectives for the maintenance of anesthesia in the obese patient?

A

-strict maintenance of airway
-adequate skeletal muscle relaxation
-optimum oxygenation
-avoidance of the residual effects of muscle relaxants
-provision of appropriate intraoperative and postoperative tidal volume
-effective postoperative analgesia

27
Q

Despite the augmentation of circulatory fluid that accompanies extreme obesity, the estimated blood volume is actually __________.

A

diminished.

28
Q

What should you do differently with volume replacement in obese patients to reduce the risk of cardiopulmonary compromise?

A

Use of reduced parameters for volume replacement and avoidance of rapid dehydration.

29
Q

How do you guide fluid management in the obese patient?

A

BP, HR, and UOP

30
Q

Fluid requirements for bariatric procedures may be ________ than anticipated to maintain renal perfusion.

A

greater

31
Q

True/False: No difference in the criteria between the administration of blood products in normal-weight patients versus severely obese patients has been identified.

A

True

32
Q

What are the things to know regarding mechanical ventilation in the obese population?

A

-Body weight is not the same as lung volume
-Ventilate with 6-8 mL/kg
-No specific ventilator mode is superior (Gegel likes pressure control)
-Alveolar recruitment maneuvers are beneficial

33
Q

What is the only mechanical ventilation parameter shown to improve respiratory function?

A

PEEP

34
Q

What do you need to ensure before considering the use of regional anesthetic techniques?

A

That the patient can tolerate surgical positioning

35
Q

What are some difficulties associated with the use of regional anesthesia in obese patients?

A

Anatomic landmarks are difficult to find or palpate
-Need US guidance

36
Q

What are the positioning recommendations for neuraxial anesthesia in the obese patient?

A

Sit upright:
-Skin folds fall towards OR table
-Improved visualization of landmarks
-Respiratory mechanics enhanced
-Generous use of LA and longer “finder” needles used
-Catheters may migrate due to excess tissue
-Lack of predictability of the LA spread, caution with high regional blockade due to risk of respiratory compromise.

37
Q

In general, patients with a BMI > ____ are not appropriate for Ambulatory Surgery Centers.

A

> /= 50

AP 1 (32 decks)

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