Bariatics And Robotics Flashcards by Jackson Jones

At what point does BMI become a problem?

Morbid obesity

> 40 is automatically ASA III

How well did you know this?

Not at all

Perfectly

Endocrine function of adipose tissue

• A reserve energy source & insulates vital organs
• Produces cytokines, chemokines and steroids

-result is chronic inflammation

How well did you know this?

Not at all

Perfectly

Two types of adipose distribution

Android- central/trunkal-associated with cardiovascular risk

Gynecoid- all in the legs
NO increased CV risk

How well did you know this?

Not at all

Perfectly

Leptin

Hormone signaling to CNS/hypothalamus

Produced in adipose cells

-signals fullness-but you can become resistant with the high circulating levels found in obesity

How well did you know this?

Not at all

Perfectly

Adiponectin

Hormone produced in adipose

Signals CNS

Modulates insulin sensitivity- levels are low in obesity

How well did you know this?

Not at all

Perfectly

Ghrelin

Hunger hormone of the stomach

How well did you know this?

Not at all

Perfectly

Arcuate nucleus

In the hypothalamus

Receives and transmits signals based on information received from adipocytes

How well did you know this?

Not at all

Perfectly

3 components of the pathophysiology of obesity

-leptin/adiponectin/ghrelin

-arcuate nucleus

-efferent system

How well did you know this?

Not at all

Perfectly

What do we do with extra calories?

Converted to triglycerides and stored in adiopocytes

How well did you know this?

Not at all

Perfectly

Explain adipocytes accommodation of extra triglycerides in obesity

They EXPAND until a BMI of 40

Then the PROLIFERATE to accept more energy

How well did you know this?

Not at all

Perfectly

Percentage of energy needed for resting metabolic rate

60%

How well did you know this?

Not at all

Perfectly

Define hypopnea

50% reduction in airflow for >10 seconds

How well did you know this?

Not at all

Perfectly

Differentiate central sleep apnea and obstructive sleep apnea

-lack of brain signaling to respiratory muscles-usually in presence of severe systemic illness

-partial or complete periodic obstruction of the upper airway

How well did you know this?

Not at all

Perfectly

3 criteria in obesity hypoventilation syndrome

BMI >30

PaCO2 over 45 mmhg

No alternative explanation

How well did you know this?

Not at all

Perfectly

How is OSA classified?

Number of hypopneic events in an hour

Mild- 5-14

Moderate- 15-29

Severe > 30

How well did you know this?

Not at all

Perfectly

How common is OHS in the morbidly obese?

Only 5-10%

How well did you know this?

Not at all

Perfectly

Main difference between OHS and OSA

OSA is transient at night and OHS results in chronic changes in PaCO2 and PAO2

How well did you know this?

Not at all

Perfectly

Obesity airway concerns

DECREASED pharyngeal area

Excess hypopharyngeal tissue

Posteriorly displaced hyoid bone

Difficulty laying flat

High incidence of GERD/OSA

How well did you know this?

Not at all

Perfectly

Pulmonary compliance in obesity

Decreases exponentially with increasing BMI

chest wall lung compliance DECREASES to 35% of predicted values

How well did you know this?

Not at all

Perfectly

Most commonly reported respiratory issues in obese patients

Decreased FRC and ERV

How well did you know this?

Not at all

Perfectly

Most sensitive indicator of obesity affects on pulmonary function

ERV

Change in cardiac output with obesity

Increases buy 20-30ml/kg of excess fat

Ex. 1kg of fat increases CO by 100ml/min

SO-increased blood volume and increased LV workload

Impact of obesity on cardiovascular plumbing

Accelerated atherosclerosis
-fat can infiltrate cardiac tissue and the conduction system

Fluid administration in obesity

Easy to overload with rapid administration
-can cause intraop ventricular failure

DVT risk in obesity

2 fold greater risk -immobility and inflammation

If someone is chair bound what are we worried about?

Unidentified cardiac disease -if they don’t exert themselves how do we know they don’t have exertional Dyspnea?

Hypertension in obesity

Renin-angiotensin system • ↑ levels of angiotensin, aldosterone, angiotensin converting enzyme: Hypertension • 5% reduction in body weight leads to significant reduction in levels

GI highlights in obesity

Give bicitra! -delayed gastric emptying, increased gastric volume and more acidic Drug metabolism can be adversely affected

Liver in obesity

Elevated LFTs Fatty infiltration (NAFLD) Inflammation Focal necrosis Cirrhosis

Metabolic syndrome

Cluster of metabolic abnormalities- Diagnosis-central obesity + four factors • Glucose intolerance • HTN • Dyslipidemia (raised triglycerides, HDL) • Associated with increased risk of CV disease

Renal and obesity

Increased Renal blood flow and GFR

Pharmacology of obesity

Increased Vd- consider with loading dose -don’t overload but be prepared with more

Good indicator of systemic changes with obesity

Do they have systemic HTN?

OSA implications

May require inpatient management for a “day surgery” Neck circumference > 40cm is strong predictor of OSA RAPID desaturation

Best predictor of difficult DL in obese patients

Neck > 40cm

Impact of BMI on DL view

Minimal, where is the fat?

Most common neuropathy after bariatric surgery

Carpal tunnel Watch positioning!!

Positioning in obesity

Rhabdo! Check weight guideline on table Careful in supine positioning

Stats on preoxygenation in obese patient

GA in an obese patient reduces FRC by 50% (compared to 20% in non-obese) Decreased FRC and increased oxygen need**

Only proven vent change to help with hypoventilation in obesity

Peep

Postop care of the obese patient

Ensure reversal Extubate upright CPAP NO intrathecal narcotics

Extubation criteria obesity

• 5-second head lift: following commands • Hemodynamically stable • Normothermic • TOF >0.9 • 10>RR>30 • SpO2 >95% • Tidal volume >5mL/kg (IBW) • Acceptable pain control

Consideration in sleeve gastrectomy

Make sure anything in the esophagus is not stapled… dilators/bougies/ogts

Two types of bariatric surgery

Restrictive vs malabsorptive

Roux-en-y

Restrictive and malabsorptive Most effective Worst complications- low rate

Most common cause of mortality in bariatric surgery

Anastomosis leak

Bariatric surgery complications

venous thromboembolism: PE Bowel obstruction Vitamin deficiency Intestinal stenosis Anastomosis leak* most common

What to never fucking do during robotic surgery

Move the patient with the robot is in the patient -always communicate with the surgeon

Robotic surgery and patient safety

Place a table over the patients face! Robots don’t feel pressure