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N931 Advanced Principles > Week 2 Obesity and Bariatric Surgery > Flashcards

Week 2 Obesity and Bariatric Surgery Flashcards

1
Q

Define Overweight

A

increased body weight above a standard related to height

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2
Q

Define Obesity

A

excessive body weight for the patient’s age, gender and height
Body weight of 20% more or above ideal body weight

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3
Q

What is obesity a disorder of?

A

energy balance

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4
Q

Define Ideal Body Weight

A

weight associated with maximum life expectancy for a given height and gender

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5
Q

How do you calculate IBW for a man?

A

105lb + 6lb for each inch >5ft

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6
Q

How do you calculate IBW for a woman?

A

100lb + 5 lb for each inch >5ft

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7
Q

What is broca’s index?

A

Height (cm)- x
where x = 100 for males and x= 105 for females
highest allowable weight

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8
Q

What is the equation for adjusted body weight?

A

AdBW= 0.4 (ABW-IBW) + IBW

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9
Q

What is Lean Body Mass?

A

120% of IBW
It considers increased muscle developed to carry extra body weight
Really only used in obese patients

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10
Q

Define BMI

A

accepted measure of body habitus that normalized adiposty for height

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11
Q

What is the equation to calculate BMI?

A

weight in kg/ (height in meters) 2

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12
Q

What is the overweight BMI?

A

25-29.9kg/m2

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13
Q

What is obesity defined as?

A

BMI > 30kg/m2

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14
Q

Class 1 Obesity BMI statisfication

A

30-34.9kg/m2

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15
Q

Class 2 Obesity BMI statisfication

A

BMI 35-39.9kg/m2

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16
Q

Class 3 Obesity BMI statisfication

A

BMI 40-49.9kg/m2

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17
Q

Superobese

A

BMI > 50

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18
Q

What is obese (BMI >30) associated with? (5)

A

increased morbidity related to stroke, ischemic heart disease, HTN and diabetes

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19
Q

Where is android obesity?

A

android fat distribution

abdominal (central) obesity

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20
Q

Calculation of LBW (nagelhout)

A

IBW x 1.3

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21
Q

Android Obesity is more commonly found in

A

men

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22
Q

Android obesity has a higher incidence of

A

metabolic disturbance

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23
Q

Android obesity has an increased risk of (4)

A

ischemic heart disease, stroke, diabetes, and death

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24
Q

Android obesity is metabolically active causing

A

free fatty acid release, and increase in gluconeogenesis and inhibition of insulin uptake

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25
Q

Gynecoid Obesity is

A

fat around the hips and buttocks

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26
Q

Gynecoid obesity is more common in

A

females

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27
Q

Gynecoid obesity is

A

metabolically static

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28
Q

Risk of pathophysiology in obese patients with what waist circumference?

A

> 102cm (40inch) in men

>89cm or 35inches in women

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29
Q

What factors influence obesity?

A

socialization, age, sex, race, genetics and economic status

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30
Q

Associated disturbances with Obesity (12)

A 
OSA/Hypoventilation Syndrome
Restrictive lung disease
HTN
CAD
Hyperlipidemia
Delayed gastric emptying/ GERD
Type 2 DM
Gallbladder disease (cholethiasis)
cirrhosis/fatty liver disease (NALD)
venous statis/thromboembolic disease
degenerative joint/disc disease
increased breast, prostate, cervical, uterine, and colorectal cancer
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31
Q

Respiratory Changes in Obesity (6)

A

chest wall and lung compliance reduced d/t fat accumulation in thorax and abdomen causes breathing at low lung volumes
thoracic kyphosis/ lumbar lordosis
increased pulmonary blood volume
increased oxygen consumption and carbon dioxide production
high minute ventilation
increased WOB

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32
Q

What are the direct lung volume changes in the obese patient?

A

decreased FRC, VC, inspiratory capacity, total lung capacity and expiratory reserve volume

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33
Q

Describe closing capacity in the obese patient

A

close to or with tidal breathing

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34
Q

Smaller lung volumes in the obese patient require

A

increased metabolic demand, increased work of breathing, closure of small airways with V/Q mismatch and resulting hypoxemia

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35
Q

How does progression of respiratory changes in the obese manifest?

A

lung disease and pulmonary HTN

PFTs are normal until this occurs

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36
Q

Risk Factors of OSA

A 
middle age
male
obesity (BMI > 30)
ETOH use
drug induced sleep
abdominal fat distribution
neck girth (41cm)
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37
Q

What is the neck circumference for men that would be at an increased risk for OSA?

A

> 17 inches

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38
Q

What is the neck circumference for women that would be at an increased risk for OSA?

A

> 16inches

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39
Q

Define obstructive sleep apnea

A

changes in airway dynamics during sleep

can cause physiologic changes endure beyond sleep

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40
Q

What is OSA caused by

A

mechanical obstruction upper air
loss of respiratory drive
or both

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41
Q

What are the manifestations of OSA

A

repeated episodes of apnea/hypoventilation
oxygen desaturation
sympathetic arousal
awakening, leading to fragmented sleep

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42
Q

Frequent episodes of apnea during sleep in OSA leads to (7)

A

chronic hypoxia, hypercapnia, pulmonary systemic vasoconstriction (HTN)
snoring, sleep fragmentation/daytime somnolence, impaired concentration/memory problems, morning headache

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43
Q

Types of OSA

A

Obstructive Sleep Apnea
Central Sleep Apnea
Obesity Hypoventilation Syndrome/Pickwickian Syndrome

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44
Q

what is obstructive sleep apnea

A

cessation of airflow but maintain respiratory effort

abnormal relaxation of genioglossus & pharyngeal muscles pull tongue forward

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45
Q

What is central sleep apnea

A

cessation of both airflow & respiratory effors

problem with ventilatory center of medulla

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46
Q

What is Obesity Hypoventilation Syndrome/ Pickwickian syndrome

A

most severe chronic OSA leading to cor pulmonale

related to extreme obesity

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47
Q

What is the gold standard for OSA diagnosis

A

polysommography

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48
Q

How is OSA characterized

A

apnea >10seconds total cessation of airflow despite respiratory effort against a closed glottis
Hypopnea is 50% reduction in size or number of breaths that lasts at least 10 seconds compared to normal; or a reduction sufficient enough to cause a 4% or more decrease in arterial SaO2

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49
Q

Apnea- Hypopnea Index Scale

A

> 30 severe
16-30 moderate
15 or less mild

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50
Q

Treatment of OSA

A

CPAP

level of pressure required to sustain airway patency determined in sleep study

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51
Q

What are the benefits of CPAP for OSA

A

attenuates hemodynamic responses induced by apnea including BP surges and increased SNS activity
improved neuropsychiatric functioning
less daytime somnolence

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52
Q

Treatment of OSA in patients with severe arterial oxygen saturation

A

nocturnal oxygen with CPAP

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53
Q

What are the corrective procedures for OSA

A

uvulopalatopharyngoplasty (UPPP) and diathermy palatoplasty

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54
Q

What is an uvulopalatopharyngoplasty

A

enlarges airway through removal

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55
Q

what is diathermy palatoplasty

A

heat tissue producing scar which tightens in 6-8 weeks

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56
Q

Pathophysiology of OSA

A

hypoxemia-> hypercarbia-> pulmonary hypertension-> respiratory acidosis during sleep -> RHF-> pulmonary and systemic vasoconstriction-> polycythemia-> systemic hypertension

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57
Q

Pickwickian Syndrome is

A

a complication of extreme obesity/ long term OSA
extreme obesity with hypercapnia, hypoxia, cyanosis induced polycythemia, somnolence and eventual right sided HF and pHTN

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58
Q

How do you diagnosis Pickwickian syndrome?

A

PCO2>45mmHg in an obese patient without COPD

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59
Q

How is Pickwickian syndrome different then OSA?

A

OSA is a nocturnal sleep distribution while OHS is a nocturnal central apnea events (apnea without respiratory effort)

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60
Q

Characteristics of Pickwickian syndrome (8)

A 
obesity BMI > 30
hypercapnia (PaCO2 >45mmHg in an obese patient without significant COPD)
chronic daytime hypoxemia is better predictor of pHTN and cor pulmonale then presence and severity of OSA
daytime hypersomnolence
pulmonary hypertension
respiratory acidosis
right sided heart failure
airway difficulty
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61
Q

Airway Changes in Obesity (8)

A

TMJ and atlanto-axial joint and cervical spine movement limited by upper thoracic and low cervical fat pads
redundant tissue folds in mouth and pharynx = narrowed airway
Short, thick neck circumferences
fat in suprasternal, presternal, posterior cervical and submental regions
shortened distance between mandible & sternal fat pads
OSA= increase risk of excess pharyngeal tissue on lateral walls

62
Q

What do the airway changes in obese patients create?

A

Difficult mask

difficult intubation and direct laryngoscopy

63
Q

Cardiovascular changes in obesity (6)

A 
increased total blood volume
increased CO
increased RAAS and SNS
HTN
increased risk of CAD
increased Left sided heart pressures and left ventricular hypertrophy
64
Q

EKG changes in Obese

A

left or right ventricular hypertrophy, ischemia and conduction events

65
Q

Increased Left ventricular wall stress causes

A

hypertrophy, reduced compliance, impaired left ventricular filing (diastolic dysfunction) elevated left ventricular and diastolic pressure progresses to pulmonary edema

66
Q

Obesity Cardiomyopathy

A

eventual left wall thickening and fails to keep pace with ventricular dilation and systolic dysfunction

67
Q

Hematologic Alternation in Obesity (4)

A

polycythemia & Hyper-coagulation
Thromboembolic risk
increased intra-abdominal pressure
immobility leads to venostasis

68
Q

Explain how obese patients have an increase risk for DVT

A

polycythemia leads to increased blood viscosity

increased fibrinogen factor VII, Factor VIII Von Willebrand factor plasminogen activator inhibitor-1

69
Q

Obese patients have an increased incidence for

A

hiatal hernias

gerd and gallbladder disease

70
Q

Risk of aspiration pneumonitis in obese patients are

A

the same as non-obese individual when following NPO guidelines

71
Q

Hepatic Alternations in Obesity include

A

fatty infiltration of liver and abnormal LFTs

72
Q

What defines fatty infiltration of the liver in obesity (3)

A

prevalence of nonalcoholic fatty liver disease
inflammation
cirrhosis and focal necrosis

73
Q

Renal Alternations in Obesity

A

increased renal plasma flow and increased GFR
Increase renal tubular reabsorption and impaired naturesis secondary to SNS and renin-angiotensin system activation
eventually nephron function can be lost

74
Q

Endocrine Alternations in Obesity

A

obese patients secrete more insulin, but resistance to the effects of insulin
Metabolic syndrome

75
Q

Name the possible signs of metabolic syndrome?

A

large waist circumference, high triglyceride levels, low levels of high density lipoproteins (HDL) cholesterol, glucose intolerance and hypertension

76
Q

Musculoskeletal changes in Obesity

A

osteoarthritis and degenerative joint disease

77
Q

CNS in Obesity

A

ANS dysfunction
peripherial neuropathies
stroke
idopathetic intracranial hypertension

78
Q

Hyperlipidemia is

A

increased LDL and decreased HDL cholesterol linked to atherosclerosis
premature coronary artery disease
premature vascular disease
pancreatitis

79
Q

Pharmacokinetics of Obesity

A 
increase blood volume and CO
decreased total body water
adipose and lean tissue increaes
varaible alternation in protein binding
organomegaly
80
Q

Clearance in Obesity

A

hepatic clearance unchanged despite histological and LFT alternations
renal clearance of drugs increased (increased GFR, RBF and tubular secretion)

81
Q

Liphophilic drugs have an

A

increased elimination half-life because of increased Vd, but normal clearance

82
Q

Dosing in Obesity

A

weak or moderate liphophilicity dose on IBW or LBM

83
Q

Propofol dose and obesity

A

induction dose should be based on LBW

84
Q

Maintenance dose of propofol

A

TBW

85
Q

Benzodiazepine Dose in Obesity

A

highly lipophilic drugs with larger Vd

86
Q

Initial Benzodiazepine Dose

A

LBW can titrate to TBW

87
Q

Benzodiazepine infusions Dose

A

LBW

88
Q

Pseudocholinesterase activity increases

A

as weight increases and ECF increases

linear relationship

89
Q

Succ Dose in obesity based on

A

TBW

90
Q

Vec and Roc dose

A

IBW

91
Q

Cis Dose

A

TBW

92
Q

General trend of NMB

A

exhibit prolonged DOA and recovery

93
Q

Fentanyl and Sufentanil

A

are highly lipophilic
increased Vd and elimination 1/2 life
dose on TBW but then decrease to IBW and response

94
Q

Remifentanil

A

dosing on IBW

similar pharmacokinetics with non-obese

95
Q

Precedex

A

0.2-0.5mcg/kg/min to reduce analgesic and anesthetic requirements
based on TBW

96
Q

Sugammedex in Miller

A

IBW

97
Q

Sugammadex in Nagelhout

A

TBW

98
Q

Volatile Anesthetics

A

avoid N20

desflurane

99
Q

Appetite Suppressants

adrenergic reuptake inhibitors- phentermine

A

decreases appetite and increases metabolic rate

100
Q

S/E of Appetite suppressants

A

hypertension

tachycardia

101
Q

Lorcaserin

A

appetite suppressant
5-HT2C receptor agonist
selective serotonin agonist
reduces food intake through the activation of pro-opiomelanocortin

102
Q

Lipase inhibitors- Orlistat

A

acts by blocking absorption and digestion of dietary fat and binding lipases in GI tract

103
Q

Pre-Op Evaluation in Obesity

A

assess patient in non-judgemental way
emphasis should be on difficulties obesity presents to anesthesia provider
discuss the likely post-operative course
airway/respiratory system/cardiovascular/ endo/gi/metabolic/ musculoskeletal

104
Q

Morbid obesity is an independent risk factor for

A

sudden death from acute PE

105
Q

Thromboprophylaxis includes

A

heparin
pneumatic compression stockings
LMWH

106
Q

Pulmonary HTN signs

A

dyspnea, fatigue, syncope, tricuspid reg on echo, ECG (RVH, tall precordial R waves, right axis deviation) prominent pulmonary artery on CXR

107
Q

Obesity have a high incidence of (4)

A

HTN pulmonary HTN R/L ventricular failure CAD

108
Q

Airway Pre-Op

A 
does patient have a history of previous difficult airway
OSA
mouth opening
thyromental distance
interior of the mouth
mallampati classification
neck size
109
Q

WHat is the best predictor of problematic intubation?

A

neck size

110
Q

identifiy signs of severe respiratory disease

A

orthopnea
sleep apnea
obesity hypoventilation syndrome
previous history of upper airway obstruction especially regarding a past anesthetic

111
Q

STOP BANG

A 
snoring
tired
observed
high blood pressure
BMI
age neck size
gender
112
Q

Respiratory Pre-Op

A 
chest xray
room air on Sao2
ABGs
optimize pulmonary status pre-op
PFTs
--stop smoking
113
Q

Cardiovascular Pre-OP

A 
signs of HTN, RV and/or LV hypertrophy and pHTN should be assessed
EKG
Chest xray
ECHO
LV ejection fraction
cardiac clearance if needed
previous diet aids
114
Q

Endocrine/Metabolic/GI Pre-op

A

glucose
diabetes non or insulin dependent
reflux history

115
Q

Pre-Op Labs may include

A

liver function tests
albumin level
glucose
consider clotting studies

116
Q

Aspiration Prophylaxis

A

H2 receptor antagonist
bicitra
metoclopramide
omeprazole

117
Q

Mechanical Ventilation

A

PEEP can improve FRC and arterial oxygenation
watch BP
reciruitment manuevers to improve oxygenation
pressure-controlled ventilators help
changing I:E ratio

118
Q

Fluid management

A

calculation of fluid requirement in obese patient based on lean body weight or IBW
greater blood loss compared to non-obese r/t technical difficulties/extensive surgical dissection

119
Q

What is the #1 problem of emergence in obesity?

A

respiratory failure

120
Q

Emergence

A 
extubation after fully awake and NMB fully reversed, adequate MV confirmed
semi-upright position
wean pressure support w/ peep
oxygenation 100%
placement of nasopharygneal airway
121
Q

Ventilatory support post op

A

CPAP BiPAP
mechanical ventilation
respiratory monitoring

122
Q

Postoperative Anesthesia Pain Management

A

peripheral nerve blocks with continuous infusions of LA with or without small doses of opioids
local infiltration of wound
judicious use of opioid

123
Q

Bariatric Surgery is reserved for patients

A

with BMI >40

or BMI > 35 with related comorbidities not controlled by medical therapy

124
Q

Bariatric surgery is

A

surgical alteration of small intestine or stomach to promote weight loss

125
Q

Malabsorptive procedures

A

jejuno-ileal bypass and biliopancreatic diversion

126
Q

Restrictive procedures

A

vertical banded gatroplasty (VGB) and the adjustable gastric banding (AGB)

127
Q

combined restrictive and minimal malabsorptive is

A

roux en Y gastric bypass

128
Q

What is the greatest cause of bariatric perioperative 30 day mortality

A

Pulmonary emboli

129
Q

Laparoscopic Bariatric Surgery

A

less post-op pain, lower morbidity, faster recovery, less third spacing of fluid, decreased wound infection, smaller incisions
complete NMB important
high risk for mainstem intubation
incidence of rhabdo higher compared with open procedure

130
Q

Prior to gastric diversion need to ensure

A

all endogastric devices are removed (avoid stapling in place or transection)

131
Q

Avoid in bariatric surgery

A

blind NG insertion

132
Q

How is the implantable gastric stimulatior implanted via laparoscopy?

A

2 lead EKG placement on greater curvature of stomach

SQ electric pulse generator implanted on abdominal wall

133
Q

How does the implantable gastric stimulator work?

A

simulates gastric smooth muscle, decreases peristalsis

in theory patients feels less hungry

134
Q

Anesthetic Considerations for the implantable gastric stimulator

A

avoid N &V
valsalva may dislodge electrodes
EKG interference

135
Q

Pre-medication Pre-Operative Considerations of the Obese Patient

A

anixolysis and aspiration pneumonitis precautions

136
Q

What is the most important airway assessment pre-operatively?

A

neck circumference

137
Q

Other Pre-operative considerations for Obese patient

A

IM injections unreliable
DVT prophylaxis
OSA/OHA increased risk difficulty- pre-op ABG

138
Q

What can hide signs of cardiac failure in Obese?

A

excess adipose tissue

139
Q

What are pulmonary HTN signs?

A

dyspnea, fatigue, syncope, tricuspid reg, EKG (RVH, tall precordial R waves, R axis deviation)
prominent pulmonary artery on CXR

140
Q

Positioning Considerations of the Obese Patient

A

watch OR table weight

high incidence of pressure sores and nerve injuries

141
Q

What is stacking?

A

ramped position for intubation to align ear with sternum

142
Q

Monitoring considerations of Obese patient

A 
monitors 
appropriate sized BP cuff
IV/arterial line access
Consider CCVP or PAP catheter
significant CV or pulmonary disease or when large fluid shifts expected
143
Q

Prevention of Thromboembolism

A

LMW heparin

pre-op aspirin adn warfin to INR 2.3

144
Q

How to decrease risk of thromboembolism

A

pre-operative excerise, anti-thrombic drugs, stock prophylaxis, nonpolycycthemic HCT, increased CO an early ambulation

145
Q

What causes the most mortality in the 30 day perioperative period after bariatric surgery?

A

PE

x3 more frequent than anastomotic leak with subsequent sepsis

146
Q

What is the most important step of induction for Obese patients?

A

pre-oxygenation

147
Q

What does pre-oxygenation help with?

A

decreased FRC, increased O2 consumption, higher incidence of difficult airway

148
Q

Considerations of induction in Obese

A 
induction doses altered
consider awake intubation with minimal sedative
RSI- aspiration concerns
May need 2 handed mask
breath sounds difficult to ausculate
PEEP 10cm H2O can be helpful
Routine use of reverse trendelenburg
149
Q

Fluid Balance in Obese patient

A

greater blood loss
less able to compensate for blood loss (low threshold for replacement)
risk of acute tubular necrosis with inadequate fluid replacement

150
Q

Regional Anesthesia in Obese

A

avoidance of intubation challenges VS technically challenging landmark identification
central neuraxial blockade easier in the lumbar region
Longer needle may be required
US and fluoroscopy have been used to place catheter in epidural space

151
Q

What changes in the LA dose for obese patients?

A

20-25% reduction

epidural vascular engorgement and decreased epidural space

N931 Advanced Principles (14 decks)

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