Principles Ii, Exam 1

Front 1

What does obese mean?

Back 1

the amount of fat tissue is increased to such an extent that physical and mental health are affected and life expectancy is reduced

Front 2

Why do we care about obesity?

Back 2

-technical difficulties
-physiologic changes
-co-morbidities (increase M&M)
-40% of US population

Front 3

What is the formula for BMI?

Back 3

kg/m2

(lbs/ in x in )x703

*cm= in x 2.54 m= in x 0.0254

Front 4

What is the formula for IBW

Back 4

Height (cm) - X
x= 100 for adult males
x=105 for adult females

Front 5

At what BMI has morbidity and mortality been noted to increase?

Back 5

30

Front 6

if the actual body weight is greater than 30% of the calculated IBW you should calculate the ____?

Back 6

Adjusted body weight (ABW)

Front 7

What is the formula for ABW?

Back 7

IBW + 0.4(actual weight-IBW)

Front 8

BMI less than 20 is classified as?

Back 8

underweight

Front 9

BMI 20-25 is classified as?

Back 9

normal

Front 10

BMI 26-29 is classified as?

Back 10

Overweight

Front 11

A BMI of 30-39 is classified as?

Back 11

Obese

Front 12

A BMI of greater than 40 is classified as?

Back 12

Extreme obese

Front 13

A BMI greater than 50 is classified as?

Back 13

Super obese

Front 14

A BMI greater than 60 is classified as?

Back 14

Super-super obese

Front 15

Total blood volume is (increased/decreased) in the obese?

Back 15

increased
*but on a volume to weight basis, they have less blood volume...only 50ml/kg (non obese= 70ml/kg)

Front 16

most of the blood flow is disributed to the ____.

Back 16

fat
blood flow to fat = 2-3ml/100g of tissue

Front 17

What are some increases related to the cardio system and obesity?

Back 17

-Increased CO (0.1L/min to perfuse 1 kg of fat)
-increased Stroke volume
-Increased blood volume
-increased dysrhythmias

Front 18

Obese patients have ____ to ___ HR

Back 18

normal to increased

Front 19

Obese pts suffer from left ventricle _____ and cardiac _____.

Back 19

dilation, hypertrophy

Front 20

What are some cardio complications from obesity? (8)

Back 20

-HTN
_cardiomegaly
-CHF (10% of pts)
-CAD/Ischemic heart disease
-PVD
-Pulm HTN
-Thromboembolism
-Sudden death

Front 21

An obese person with HTN leads to an increase in preload and afterload which leads to _____ and _____.

Back 21

Dilation and hypertrophy

Front 22

Obese pts have poor tolerance to hypotension, hypertension, tachycardia and fluid overload secondary to ____ ___ ___.

Back 22

Limited cardiac reserve
(try to keep their BP and HR where they normally live)

Front 23

Increased CO comes from and increase in ____ secondary to LVH which is secondary to _____.

Back 23

workload, volume
*all increases metabolic demand which increases CO

Front 24

Becuase of increase pulm blood flow and HPV and obese pt can suffer from _____ ____ which leads to cor pulmonale and right sided heart failure.

Back 24

pulmonary HTN

Front 25

What are some reasons for increased rish of arrhythmias? (6)

Back 25

-hypertrophy
-hypoxemia/hypercapnia
-fatty infiltration in cardiac conduction
-diuretic (hypotension with induction)
-increased catecholamines
-sleep apnea

Front 26

Excess metabolically active adipose + increases workload on supportive muscle leads to?

Back 26

increased CO2 production (hypercarbia) and increased O2 consumption (hypoxia)

Front 27

because of increased tissue, obese patients suffer from _____ lung disease.

Back 27

restrictive

Front 28

Restrictive lung disease leads to...
____ chest wall compliance
diaphragm forced ____
____ lung volumes

Back 28

decreased
up
decreased

Front 29

The effects of restrictive lung disease are worsened by ___ and ____ positions

Back 29

supine and trandelenburg

Front 30

If FRC falls below closing capacity the _____ collapse and that leads to _____ ________.

Back 30

alveoli, V/Q MISMATCH!
*prone to atelectasis

Front 31

In PFTs, all of the following things are moderately decreased (4)

Back 31

-TV
-inspiratory reserve volume
-total lung capacity
-vital capacity

Front 32

in PFTs, all of the following things are significantly decreased (2)

Back 32

-expiratory reserve volume
-functional residual capacity

Front 33

There is an (increase/decrease) in metabolism but the ___ ____ ___ is WNL.

Back 33

increase, basal metablic rate

Front 34

the most common cause of hypoxemia in obese is from ____ ____.

Back 34

V/Q mismatch

Front 35

Pulmonary perfusion is increased secondary to increased ____ and increase ___ ___.

Back 35

CO and blood volume

Front 36

Airway closure due to decreased ____ (which is lower than closing capacity) leads to decreased _____ ventilation.

Back 36

FRC, alveolar

Front 37

Pulmonary HTN is developed secondary to ___ ___ ___

Back 37

hypoxic pulmonary vasoconstriction (HPV)

Front 38

All of the respiratory problems leading to hypoxemia are overall related to ___ ____ ____.

Back 38

Increased pulmonary shunt

Front 39

On the hemoglobin destaturation curve, obese people ____ much quicker

Back 39

desat
*the more preoxy the better!

Front 40

Obese people are at risk for spinal deformities such as?

Back 40

kyphosis and lordosis

Front 41

Obese people are at risk for an upper airway obstruction while sleeping known as?

Back 41

obstructive sleep apnea (OSA)

Front 42

OSA is dx by a period of apnea grater than ____ seconds and a desat to at least ____%

Back 42

10 seconds, 85%

Front 43

People with OSA exhibit, ____ ____, _____, _____ and _____.

Back 43

loud snoring, hypercarbia, hypoxia and somnia

Front 44

Risk factors for OSA include (7)

Back 44

-age over 65
-men
-african americans
-craniofacial anatomy
-obesity
-smoking and ETOH
-diabetics

Front 45

WIth a neck size of ____ inches for men and ___ inches for women, they are at an increased risk of OSA because of smaller upper airway and increase collapsibility of pharyngeal airway related to large neck mass.

Back 45

17, 16

Front 46

OSA can be caused by changes in neural compensatory mechanisms such as _____________.

Back 46

diminished protective reflexes
(normally maintain airway patency)

Front 47

increase waist circ contributes to OSA because of reduced ____ ____

Back 47

lung volumes which leads to caudal traction of airway

Front 48

low lung volumes are also associated with diminished ____ ____.

Back 48

oxygen stores

Front 49

There are two types of sleep apnea. In obstructive sleep apnea you have respiratory ____ but in central sleep apnea you do not.

Back 49

effort

Front 50

The apnea hypoxia index (AHI) is what is used to rate the severity of OSA. WHat is the scale?

Back 50

mild: 5-15 events/hr of sleep
moderate: 15-30 events/hr of sleep
severe: >30 events/hr of sleep

Front 51

What is the acronym for the predisposition towards OSA?

Back 51

Stop-Bang
S-Snoring
T- tired
O-Observed (apnea)
P- Pressure =treated for HTN
B- BMI>35
A- Age> 50
N- Neck circ> 17 males, 16 females
G- Gender, male
High risk = 3 or more yes
Low risk = less than 3 yes

Front 52

What are the 6 things to do to treat OSA?

Back 52

-weight loss
-avoidance of ETOH and sedatives
-CPAP
-UPPP (take out uvula)
-Trach (extreme cases)
-genioglassal advancement (jaw forward)

Front 53

Obesity hypoventilation syndrome is known as?

Back 53

Pickwickian Syndrome

Front 54

Besides hypercapnia and hypoxemia what are some other more serious effects of Pickwickian syndrome?

Back 54

-respiratory acidosis
-secondary polycythemia
-pulm htn
-right vent hypertrophy
-right heart failure
-biventricular failure if not treted
*like OSA with more heart problems!*

Front 55

Obese pts have decreased neck ____ and _____ because of numerous chins and fat pads

Back 55

flexion and extension

Front 56

Obese pts have ___ mouth opening

Back 56

decreased

Front 57

Obese pts have a shortened distance between ____ and sternal fat pads

Back 57

mandible

Front 58

The laryngeal position in obese pts is?

Back 58

high/anterior

Front 59

the obese pts airway is narrowed due to large _____, fleshy ____ and copious flaps of palatal, pharyngeal, supra-laryngeal tissue.

Back 59

tongue
cheeks

Front 60

Obese pts are at a severe risk of _____ due to: GERD, gallstones, hiatal hernia and increased abd pressure.

Back 60

aspiration

Front 61

after an 8hr fast 85-90% of obese pts have gastric volumes of greater than ___ mls and pH less than ___.

Back 61

25mls
2.5
*give 25ml Bicitra before if concern for GERD

Front 62

glucose tolerance is frequently impaired because pancreatic islet cells ______, hyperinsulineamia exists, high prevalence of ____ in obese.

Back 62

hypertrophy
DM

Front 63

Abnormal lipid profiles are associated with increased prevalence of ____ ____ ___.

Back 63

ischemic heart disease

Front 64

Metabolic Syndrome is defined as: (5)

Back 64

-decreased HDL (by >40 women, >50 men)
-HTN
-Increased fasting glucose >100
-Triglycerides > 150
-Waist circ greater than 35 in women, >40 in men

Front 65

Pharmacological considerations for the obese patient are increased...

Back 65

-adipose tissue
-lean body mass
-blood volume
-alpha 1 acid glycoprotein
-CO
-proteins and free fatty acids
-GFR

Front 66

Pharmacological considerations for the obese patient are decreased/abnormal....

Back 66

-decreased PFT
-abnormal liver fxn

Front 67

Pharmacological considerations for the obese patient that is unchanged is....

Back 67

albumin

Front 68

Obesity effects the _____, _____ and _____ of drugs.

Back 68

distribution, binding and elimination

Front 69

body composition, regional blood flow, affinity for plasma proteins and or tissue components are the main factors affecting ___ ____.

Back 69

tissue distribution

Front 70

Obese pts have a high volume of distribution (Vd) meaning that the drug goes to the tissues and is not in the _____ for it to be distributed to vital organ like the brain heart etc.

Back 70

plasma

Front 71

Increased lipid tissue, increased lean body mass, increased blood volume and CO, reduced body water, alterations in protein binding and lipophilicity of a drug all affect ___ in the obese.

Back 71

Vd

Front 72

lipophilic drugs have a ____ Vd

Back 72

increased

Front 73

For lipophilic drugs you need and ___ initial dose, there is a _____ elimination half life and maintenance dosing is _____.

Back 73

larger
longer
decreased

Front 74

Hydrophilic drugs have a ____ Vd.

Back 74

normal

Front 75

hyprophilic durgs have a ____ half life.

Back 75

normal

Front 76

Water soluble drugs are doses on ____ and lipid soluble drugs are dosed on _____.

Back 76

-IBW
-TBW

Front 77

What are some examples of lipophilc drugs?

Back 77

-propofol
-ketamine
-benzos
-fentanyl
-sufentanil
-IAs
*dose on TBW

Front 78

Towards the end of the case, you should consider giving ___ or ___ for pain control because fentanyl/sufenta will last longer in the obese pt.

Back 78

tylenol or toradol

Front 79

What is an example of a hyprdophlic drug?

Back 79

non depolarizing muscle relaxants
*dose on IBW

Front 80

There is (increased/decreased) pseudocholinesterase activity?

Back 80

increased

Front 81

Obese patients are prone to decrased liver fxn (failure) because of (increased/decreased) liver blood flow?

Back 81

increased

Front 82

Metabolism and GFR are (increased/decreased)

Back 82

increased

Front 83

Don't overdose your obese pt...

Back 83

you can always give more!

Front 84

increase cardiac output ____ induction

Back 84

slows

Front 85

increased alveolar ventilation _____ induction

Back 85

speeds

Front 86

Preop Airway Eval Includes

Back 86

-hx of prior anesthetics
-range of motion (TMJ)
-Thyromental Distance
-Mask vent issues (claustrophobic)
-Awake Intubation?

Front 87

Preop Pulm eval includes?

Back 87

-smoking hx
-OSA/OHS
-CPAP
-PFT
-Room air sats
-Baseline ABG/CXR
-Orthopnea-sit up at night?

Front 88

Preop Circ Eval includes?

Back 88

-S&S of CHF
-HTN; angina, PVD, Prior MI
-EKG
-CXR
-Exercise tolerance/chest pain
-ECHO required?
-IV access

Front 89

vascular access is challenging because fat obscures ____ _____.

Back 89

blood vessels

Front 90

Central line placement is difficult because vessels are distorted by _____.

Back 90

anatomy/adipose tissue

Front 91

Obese pts have a total body water of ____% whereas non obese have 60-65%

Back 91

40%

Front 92

EBV in obese pts is

Back 92

50ml/kg

Front 93

avoid rapid rehydration to avoid?

Back 93

cardiopulm compromise

Front 94

Replace blood loss with crystalloids at the ratio of?

Back 94

3:1

Front 95

Volume replacement should be figured out on ____ but also have adjusted body weight calculated too.

Back 95

IBW

Front 96

Obese patients have the appearance of ______.

Back 96

hypovolemia

Front 97

before inducing consider an H2 antagonist (Zantac), Reglan and Bicitra for increased risk of

Back 97

aspiration pneumonitis

Front 98

before induction avoid unnecessary respiratory ____.

Back 98

depressants

Front 99

Semi sitting or reverse trandelenberg may be the best position for ____?

Back 99

induction

Front 100

Obese pts should be treated like ____ _____ which means ____ is indicated.

Back 100

full stomachs
RSI

Front 101

Paralytic doses are based on ____?

Back 101

IBW

Front 102

It is important to align the __, ___ and ___ in obese pts, this will require significant _______ and position changes.

Back 102

OA, LA and PA
ramping

Front 103

Make slow position changes because ____ status can change precipitously.

Back 103

volume

Front 104

all agents should be ___ at the end to minimize sedation at extubation and long acting agents should be _____.

Back 104

tapered
avoided

Front 105

To ventilate the obese patient, the following things should be done (6)

Back 105

-cuffed ETT
-min 50% FIO2
-PPV
-PEEP
-minimize peak airway pressures
-prone/trandelenberg can worsen oxygenation

Front 106

Reverse trandelenburg is the best position for obese pts because it _____ pulmonary compliance and FRC and returns ____ to baseline. It is a better solution than large TV and PEEP

Back 106

increases
PaO2

Front 107

the bladder of the BP cuff should be greater than or equal to ___% of circ

Back 107

75%

Front 108

Goals for maintenance of anesthesia

Back 108

1. strict maintenance of airway
2. adequate skeletal muscle relaxation
3. optimum oxygenation
4. avoid residual effects of NDMR
5. appropriate TV
6. effective post op analgesia
7. effective volume replacement

Front 109

When extubating an obese patient, you should always reverse _____, make sure they are completely ____ and always be ready to ______.

Back 109

NDMR
awake
reintubate

Front 110

Early ___ is important for post op pain relief

Back 110

ambulation

Front 111

_____ anesthesia is sometimes best for post op pain.

Back 111

epidural

Front 112

PCAs are dosed on ____.

Back 112

IBW

Front 113

IM narcs are _____.

Back 113

unpredictable

Front 114

Things to consider in the post op period...

Back 114

1. increased M&M
2. Post-op ventilation
3. ICU for pickwickian pts
4. transport to PACU with O2
5. O2 and pulse ox monitoring (continue CPAP if app.)
6. fowlers position, avoid supine
7. increased risk for DVT, PE and infection

Front 115

For spinal anesthesia, a longer ____ may be required and the procedure can be technically difficult.

Back 115

longer

Front 116

Dose requirements may decrease by ___% for spinal anesthesia

Back 116

20

Front 117

spinal anesthesia in the obese pt makes it difficult to predict level which can _____ onset and lead to a high spinal which causes _____ ____.

Back 117

slow
respiratory compromise

Front 118

_____ spinal anesthesia may be a better option because you can give small incremental doses and assess as you dose.

Back 118

continuous

Front 119

Epidural anesthesia dose is also decreased by 20% because there is a ____ ____.

Back 119

smaller space

Front 120

The Roux-En Y procedure is the _____ _____.

Back 120

gold standard
(pouch from the upper part of the stomach, leads to protein and vitamin deficiencies)

Front 121

Complications after gastric surgery are?

Back 121

-decreased O2 up to 2 days post op
-anastomotic leaks (fever)
-risk of rhabdomylosis
-risk of thromboembolism, infection and atelectasis

Front 122

Clinical Pearls with obese patients:

Back 122

1. Induce with Des, comes off quicker
2. Use precedex for pain control
3. use pressure control vent instead of a volume control mode.