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Principles 2 Test 2

Anesthesia for the Obese Patient / Bariatric Surgery

What is obesity and what is the most common way to measure it? abnormally high percentage of body fat, usually measured with BMI
What percentage of Americans are overweight or obese? 65%
What percentage of adults are obese? 30%
Other than BMI, what are some indicators for obesity? waist circumference (WC), waist height ratio (WHR), waist stature ratio (WSR)
Obese patients have increased incidence of which health issues? depression, OSA, gall bladder disease, reflux, cancer
Obesity is an independent risk factor for which 2 heart related health issues? ischemic heart disease and heart failure
What are 5 obesity related diseases? HTN, DM type 2, CAD, stroke, malignant tumors
1 kg per year weight gain over 10 years..... is an increased risk to health
Central android fat distribution (apple shape) is associated with what? increased O2 consumption, CV disease, ventricular disfunction, increased ETOH consumption, increased free fatty acids, increased LDL, increased insulin resistance
Why is peripheral gynecoid/gluteal (pear shape) fat distribution associated with less health risks? because fat distribution in the lower half of the body, not around the abdomen means the fat is metabolically static
Which measure of obesity is the new standard for determining abdominal obesity? Why? waist circumference (WC); it correlates better with mortality and obesity-related diseases
WHR > ___ in women and > ____ in men is associated with increased morbidity and mortality. 0.9 (women); 1.0 (men)
It is recommended that WC not exceed 1/2 the ______. This is a measure of ______. stature; WSR (waist stature ratio)
In obese patients FRC, ERV, VC, TLC are all ____________ (decreased or increased). decreased
The decrease in FRC is primarily due to a marked reduction in _____ ERV
What lung function measure remains normal in the obese patient? RV (residual volume)
What is the most sensitive indicator of effects of obesity on pulmonary function testing? decreased ERV
Obesity causes an increase in the _________ of oxygen and a decrease in the _________ of oxygen demand; supply
Why is an obese patient's FRC reduced even more so when they are supine? Because the extra abdominal weight pushes the diaphragm cephalad
Restrictive airway disease is defined as a FEV1/FVC ratio of what? 0.9 with reduced volumes
Decreased functional residual capacity in the obese patient population causes ________________ to exceed normal tidal volume. closing capacity
What is closing capacity? the volume in the lungs at which the smallest airways (respiratory bronchioles) collapse
Increased closing capacity in the obese leads to what? airway closure, atelectasis, VQ mismatch, IP shunt
True or False: Regardless of pre oxygenation, obese patients experience rapid desaturation during apnea time on induction. True
Increased metabolic activity of excess fat and stress on supporting respiratory muscles in the obese leads to an increase in what 2 things? CO2 production and VO2
How do obese patient's bodies try to cope with the increased demand for O2 and increased production of CO2? by increasing minute ventilation and cardiac output
Increased pulmonary blood volume in the obese leads to what? decreased pulmonary compliance, pulmonary HTN, cor pulmonale
Chronic hypoxia in the obsess leads to what? polycythemia
True or False: since obese patients are larger, their airways are also larger in diameter. False!
What is another name for Obesity Hypoventilation Syndrome? Pickwickian Syndrome
What is Pickwickian Syndrome? Desensitization of the respiratory center in obesity leads to inefficient ventilation, hypercapnia, hypoxia, polycythemia, cyanosis and eventually right sided CHF and for pulmonale
Obese patients are more or less sensitive to the respiratory depressant effects of general anesthesia? more sensitive!
What percentage of morbidly obese patients have Pickwickian Syndrome? 10%
What is considered a cardinal sign of Pickwickian Syndrome? hypercapnia while awake
Cardiac output is ______(increased or decreased?)____ in obesity. Increased
Renin-angiotensin is __(increased or decreased?)__ in obesity. Increased --> more fluid retention
Myocardial workload, VO2, CO2 are all ___(increased or decreased?)___ in obesity. increased
Is SVR increased or decreased in obesity? increased
Increased in cardiac output in obese patients is due primarily to an increase in heart rate or an increase in stroke volume? stroke volume
Increased preload in obesity leads to what cardiac abnormality? cardiomegaly and atrial and biventricular dilation
Are an obese person's ventricles more or less compliant than a healthy and normal weight person's? Less
What do obese patients have increased blood viscosity when compared with a normal weight patient? polycythemia
Does an obese patient have more or less circulating catecholamines? more
Explain how an obese patient could have undetected CAD. decreased activity means less stress on the heart; symptoms typically appear when heart is stressed
Without looking at a weight or BMI on a patient's chart, what could you look at that would lead you to suspect the patient may be obese? EKG -- obesity typically causes left axis deviation meaning LVH which is associated with obesity
In a preanesthetic assessment of an obese patient, why would you ask them if they can walk up 2 flights up stairs without stopping? Because the stress on the body from walking up 2 flights of stairs is the same stress that is put on the body during laryngoscopy and induction and emergence of anesthesia
Orthopnea can be an indication of what? left ventricular dysfunction
After an 8 hour fast, what percentage of morbidly obese patients have > 25 mls of gastric volume? 80 - 90%
Are obese patients more likely to have a more acidic or basic stomach compared to patients of normal weight? acidic
Are obese patients always treated as full stomachs? No...there is much controversy over this issue
What are some medications to consider in obese patients in terms of GI function? any aspiration prevention measures possible.....gastrokinetics (reglan), pre-op PPI (protonix, nexium, omeprazole), H2 antagonists (zantac, pepcid)
What 4 things constitute metabolic insulin resistance syndrome, which is associated with obesity? insulin resistance, impaired glucose tolerance, HTN, dyslipidemia
Risk for type 2 DM increases __________ with BMI increase. linearly
Lipophilic drugs have a(n) ___________ volume of distribution in obese patients. increased
Water soluble drugs have a(n) __________ volume of distribution in obese patients. limited
Explain how an obese patient reacts differently to Succinylcholine than a lean patient. obese patients have increased plasma pseudocholinesterase activity, so they metabolize it faster; also they experience less gross fasiculations and myalgia due to proportionately lower muscle mass
Obese patients have _______ albumin levels but ________ alpha 1 acid glycoprotein levels. decreased; increased
A prudent CRNA knows that in terms of drug dosing for obese patients, dosing of lipid soluble drugs should be based on ______ and maintenance doses should be given ______ frequently. Why? TBW; less; slower clearance of lipid soluble drugs
A prudent CRNA knows that in terms of drug dosing for obese patients, dosing of water soluble drugs should be based on ______. IBW - dosing based on TBW could lead to overdose since volume of distribution of these drugs does NOT increase with body weight
Inhalation agents take _________ to reach equilibrium in obese patients and __________ is delayed. longer; emergence
In terms of selecting inhalation agent for an obese patient, a prudent CRNA knows which agent is faster on and off than the other two? desflurane
Why is there a reduction of free drug concentrations in obese patients? because they have increased alpha 1 acid glycoprotein levels
Why do drugs depending on renal clearance have higher elimination in obese patients? higher cardiac output
In terms of NMBs, which are the only 2 that should be dosed on IBW in obese patients? vecuronium and rocuronium
Which is the only opioid that should be dosed on IBW in obese patients? remifentanil
How should you position an obese patient for intubation? raise head of bed or put patient in reverse trendelenburg if possible
Why is PEEP beneficial in obese patients? reduces venous return thereby decreasing CO and VO2
What is the single best predictor of problematic intubation in an obese patient? neck circumference
True or False: regarding BP measurement, forearm is as reliable as the upper arm true
Is regional anesthesia easier or more difficult in an obese patient? more difficult
What percentage of patients who present for bariatric surgery have OSA? > 70%
What is the best treatment for OSA? bi-pap/cpap; preferably, the patient's own from home
True or False: some evidence suggests that patients who are treated for OSA pre-op have fewer peri-op complications than those who are untreated True
Which position is better for laryngoscopic view in obese patients: ramped or sniffing? ramped
Is RSI indicated for every bariatric surgery patient? No; it needs to be considered on an individual basis
True or false: the larger percentage of airway difficulties in bariatric surgery patients occur during induction and intubation rather than extubation and in the PACU during recovery. False! more issues occur during extubation and in recovery period in PACU
Studies have shown that in bariatric surgery expertise or drug selection/techinue is more important in promoting early return of the patient's airway reflexes? expertise
For medications with unknown pharmacodynamics and pharmacokinetics in morbidly obese individuals, dosing should be based on _____ LBM (IBW)
Created by: Mary Beth