Obesity + DM (Lea) Flashcards

Question

Dose a Propofol bolus based on ___

Answer 1

MAC = 104% Blood-Gas Coefficient = 0.47

Answer 2

MAC = 6% Blood-Gas Coefficient = 0.45

Answer 3

MAC = 2% Blood-Gas Coefficient = 0.65

Answer 4

MAC = 1.7% Blood-Gas Coefficient = 1.8

Answer 5

MAC = 1.4% Blood-Gas Coefficient = 1.4

Answer 6

MAC = 0.75% Blood-Gas Coefficient = 2.3

Answer 7

Volatile agents are lipophilic. Agents with low blood gas solubility coefficients should be used. MAC is unchanged by obesity

Answer 8

Loading dose based on LBW and maintenance based on TBW

Answer 9

Intubating dose based on TBW. This is due to increased blood volume (increased Vd) and increased pseudo cholinesterase activity (increased clearence)

Answer 10

Roc and Vec are dosed on LBW Cisatracurium and atracurium and probably TBW

Answer 11

ALWAYS LBW

Answer 12

Midazolam administered on **TBW** but will cause prolonged elimination and duration

Answer 13

Engorgement of epidural veins and increase in epidural fat content will cause a greater spread of local anesthetics in the epidural space Reduce the dose to 75%

Answer 14

Review: Pharyngeal muscles maintain airway patency Tensor Palatine—opens the nasopharynx Genioglossus---opens the oropharynx Hyoid Muscle---opens the hypopharynx Fat accumulation in the pharynx causes the internal diameter to narrow, decreases airflow and increase airway collapse

Answer 15

Defined as cessation of airflow for at least 10 seconds with five or more unsuccessful efforts to breathe and a greater than 4% reduction in SaO2 Hypoapnea is defined as 50% reduction in airflow for 10 seconds, 15 or more times per hour, and is linked to snoring and decreased SaO2

Answer 16

OSA is directly linked to obesity Increases with BMI > 30 kg/m2, abdominal fat distribution and large neck circumference - men > 17in - women > 16in OSA is an independent risk factor for development of HTN, CV disease, morbidity and death

Answer 17

Polysomnography is the definitive test for OSA, and allows for the calculation of the AHI AHI = # of episodes of apnea/hypoapnea divided by hours of sleep Mild 5-15 Moderate 15-30 Severe > 30

Answer 18

Snoring Tiredness Observed Apnea Pressure (HTN) BMI > 35 kg/m2 Age >50 Neck circumference > 40 cm (15.74in) Gender (male) *High risk > 3 Low risk <3*

Answer 19

- OHS is a long term result of OSA - Medulla fails to respond to hypercarbia - OHS classically includes apnea during sleep without respiratory effort - Pickwickian syndrome is the old term - Signs; obesity, daytime hyper somnolence, hypoxemia, hypercarbia, resp. acidosis, comp metabolic alkalosis, polycythemia and pulmonary HTN

Answer 20

Gastric bypass surgery Roux-en-Y (open or laparoscopic) Biliopancreatic diversion bypass Gastric banding (open or laparoscopic) Gastric sleeve surgery

Answer 21

1. Biliopancreatic diversion bypass 2. Jejuno-ileal bypass 3. Duodenal Switch Gastric reduction and removal of portion of small intestine limits nutrient absorption. Vitamin K, B12, iron and folate depletion

Answer 22

1. Gastric Band 2. Gastric Sleeve Limits the quantity of food that can be consumed. Least invasive. Gastric hormone secretion reduced. Small intestine intact

Answer 23

Roux-en Y gastric bypass Combination of malabsorption and restriction Yields the best weight loss and comorbidity reduction Risk nutrient deficiency

Answer 24

2% incidence Patients should not receive ketorolac Most common signs: - Tachycardia (72%) - Fever (63%) - Abdominal Pain (54%) - Other signs shoulder pain, pelvic pain, substernal pressure, dyspnea, hypotension, oliguria, increased thirst, restlessness, hiccups

Answer 25

- Associated with secretions of vasoactive substances from enterochromaffin cells usually in the GI tract - When liver function is normal carcinoid hormones are cleared, with liver dysfunction sign and symptoms occur - Symptoms can occur if tumors are located in the lungs and bypass the liver and enter the circulation

Answer 26

1. HISTAMINE 2. KININS AND KALLIKRENS 3. SEROTONIN

Answer 27

Bronchoconstriction Vasodilatation Hypotension Flushing of head and neck

Answer 28

Bronchoconstriction Vasodilatation Hypotension Flushing of head and neck Inc. histamine release from mast cells

Answer 29

Bronchoconstriction Vasodilatation Hypotension Supra ventricular tachydysrhythmias Inc. GI motility, diarrhea, abdominal pain

Answer 30

- Histamine releasing drugs: MS meperidine, atracurium, thiopental, and succinylcholine - Succinylcholine induced fasciculation causes hormone release from tumor cells - Exogenous catecholamines can precipitate hormone release - Sympathomimetic agents ephedrine and ketamine

Answer 31

- Somatostatin (octreotide or lanreotide) inhibit release of vasoactive substances from carcinoid tumors - Antihistamines (H1 and H2) diphenhydramine and ranitidine or cimetidine - 5HT3 antagonist (ondansentron) - Steroids - Phenylephrine or vasopressin for hypotension

Answer 32

Life threatening response in patients with carcinoid syndrome S/S include: - Inc. HR - hypertension or hypotension - intense flushing (#1) - abdominal pain - diarrhea (#2)

Answer 33

Endocrine & Exocrine Organ Anatomy 15 cm in length Weighs 60-140 grams Anatomic relationship Duodenum Ampulla of Vater Common bile duct Superior mesenteric artery Portal vein Spleen Transverse colon Left lobe of the liver

Answer 34

Composed of two tissue types: 1st. Acinar Cells - Make up 98% of the glands weight and secrete digestive fluids into duodenum (exocrine function) 2nd. Islets of Langerhans - Make up 2% of glands weight and compose of alpha, beta, delta, and pancreatic peptide (PP) cells (endocrine function)

Answer 35

1. PP cells secrete pancreatic polypeptide which inhibits exocrine secretions 2. Delta cells secrete somatostatin which restrains the rate in which nutrients are absorbed (10%) 3. Alpha cells secrete glucagon which raises blood sugar (25%) 4. Beta cells secrete insulin and amylin. Insulin regulates fat and carbohydrate metabolism and causes the cell to take up glucose (70%)

Answer 36

Inhibits pancreatic exocrine secretion, gallbladder contraction, gastric acid secretion, and gastric motility

Answer 37

- Growth-hormone-inhibiting-hormone - Released by the delta cells - Inhibits insulin and glucagon - Inhibits splenic blood flow, gastric motility and gallbladder contraction

Answer 38

- A catabolic hormone that promotes energy release from adipose and the liver - A physiologic antagonist to insulin - Released between meals (BG < 90 mg/dL), glucagon concentration increases to maintain fuel production - Exogenous glucagon administration - Increases myocardial contraction, HR, and AV conduction - Useful in BB overdose, CHF, Low CO after MI, relaxing sphincter during ERCP, and hypoglcemia - Side effect N/V

Answer 39

- An anabolic hormone that promotes energy storage - Elimination ½ life of 7 minutes - Increases glucose permeability in skeletal muscle, liver, and fat - Converts carbohydrates to glycogen in the liver and skeletal muscle - Converts excess carbohydrates to fat - Promote cellular uptake of amino acids, potassium, magnesium and phosphate

Answer 40

1 unit per hour into portal circulation After a meal insulin increases 5-10 fold Total is 40u per day

Answer 41

5 – 10% of people with diabetes have Type 1 And absolute deficiency in insulin Entirely dependent on exogenous insulin Insulin dependent diabetics Autoimmune destruction of the beta cells of the pancreatic islets

Answer 42

90% of people with diabetes have Type 2 Impaired insulin secretion peripheral insulin resistance and excess hepatic glucose production Relative to BG, an insulin deficiency exists May be complicated by nonketotic hyperosmolar, hyperglycemic state Treatment includes hypoglycemic agent, exercise and diet therapy Insulin-treated diabetics

Answer 43

Microvascular: - Retinopathy - Neuropathy - Nephropathy Macrovascular: - Coronary artery disease - Peripheral vascular disease - Cerebrovascular disease Other: - Infections - Cataracts - Stiff Joint Syndrome - Glaucoma - Poor wound healing

Answer 44

Onset: 5 to 15 minutes Peak: 45-75 minutes Duration: 2 to 4 hours Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

Answer 45

Onset: 30 min Peak: 2 - 4 hours DOA: 6 - 8 hours Regular (Human Regular) (Novulin Regular)

Answer 46

Onset: 2 hours Peak: 4-12 hours DOA: 18-28 hours NPH (Humulin NPH) (Novolin NPH)

Answer 47

Glargine (Lantus) Onset: 1.5 hour Peak: NONE DOA: 20-24 hours Detemir: Onset: 2 hours Peak: 5-9 hr DOA: 6 - 24 hours

Answer 48

Glargine (Lantus) Onset: 1.5 hour Peak: NONE DOA: 20-24 hours Detemir: Onset: 2 hours Peak: 5-9 hr DOA: 6 - 24 hours

Answer 49

Degludec Onset: 2 hours Peak: none DOA: 40+ hours

Answer 50

Hypoglycemia Allergic Reaction Lipodystrophy Insulin Resistance Drug Interactions

Answer 51

High risk if exogenous insulin given during fasting Under GA sign and symptoms are masked SNS stimulation increases HR, BP and the presence of diaphoresis Possible cause of delayed emergence Brain requires glucose: confusion, seizures coma, brain damage and death Treat with D50 50-100ml or glucagon

Answer 52

More common when animal derived products were used Chronic NPH use (or fish allergy) may sensitize to protamine Use caution with large doses

Answer 53

- Lipodystrophy: Fat accumulation at injection site - Resistance: When dose exceeds 100u/day antibodies develop to the cell receptor - Drug Interactions: Drugs that counter the hypoglycemic effects of insulin: Epinephrine, glucagon, estrogen, and adrenocorticotropic hormone or enhance the hypoglycemic effect Drug Interactions: - Drugs that counter the hypoglycemic effects of insulin: Epinephrine, glucagon, estrogen, and adrenocorticotropic hormone - Drugs that enhance the hypoglycemic effect: MAO inhibitors, salicylates, and tetracycline

Answer 54

Biguanides Sulfonyureas Meglitinides Thiazolidinediones Alpha-Glucosidase Inhibitors Glucagon-like Peptide-1 receptor Agonist Dipeptidyl-Peptidase-4 Inhibitors Amylin Agonist

Answer 55

Metformin Inhibits gluconeogenesis and glycogenolysis in the liver and decreases peripheral insulin resistance. Does not cause hypoglycemia Risk of lactic acidosis, increases with renal and liver disease Discontinue 48 hrs. before surgery

Answer 56

Metformin Inhibits gluconeogenesis and glycogenolysis in the liver and decreases peripheral insulin resistance. Does not cause hypoglycemia Risk of lactic acidosis, increases with renal and liver disease Discontinue 48 hrs. before surgery

Answer 57

Glyburide, Glipizide, Glimepride Stimulate insulin secretion from pancreatic beta cells Avoid if sulfa allergy Sulfonylureas usually the initial choice for treatment of type II diabetes Hypoglycemia most common side effect Closes K (ATP) channels, inhibits myocardial preconditioning, increases morbidity in high risk patients

Answer 58

Repaglinide, Nateglinide Stimulate insulin secretion from pancreatic beta cells Risk of hypoglycemia

Answer 59

Rosiglitazone and Pioglitazone Decrease peripheral insulin resistance and increase hepatic glucose utilization Does not cause hypoglycemia Contraindicated in liver failure, expand ECF causes edema and increase risk of CHF

Answer 60

Rosiglitazone and Pioglitazone Decrease peripheral insulin resistance and increase hepatic glucose utilization Does not cause hypoglycemia Contraindicated in liver failure, expand ECF causes edema and increase risk of CHF

Answer 61

Acarbose and Migitol Active in the small intestine and result in a delay in glucose absorption. Should be given before a meal. Does not cause hypoglycemia

Answer 62

Acarbose and Migitol Active in the small intestine and result in a delay in glucose absorption. Should be given before a meal. Does not cause hypoglycemia

Answer 63

Exenatide, Liraglutide Increases insulin release from beta cells decreases glucagon release from alpha cells and prolongs gastric emptying Risk of hypoglycemia

Answer 64

Meds end in suffix -liptin Increases insulin release Decreases glucagon release Risk of hypoglycemia

Answer 65

Pramlintide Inhibits glucagon release from alpha cells and reduces gastric emptying Risk of hypoglycemia when used with insulin, may cause nausea and vomiting

Answer 66

Fasting and pre-prandial plasma glucose 70-130 mg/dl Peak post prandial <180 mg/dl Glycosylated Hemoglobin (HbA1c) < 7%

Answer 67

Decreased insulin secretion Decreased response to insulin by target tissue Increase in the counterregulatory hormones that oppose the effects of insulin - Resistin - Adiponectin Primary cause of Type 1 DM - T lymphocytic mediated destruction of beta cells of pancreatic islet

Answer 68

Lack of effective insulin - Initial manifestation of DM - Treatment errors - Critical illnesses (MI, trauma, burns….) - Infections Increased serum glucose - Increased hepatic glucose output & Decreased glucose uptake Clinical hallmarks - Metabolic acidosis - Dehydration - Electrolyte abnormalities

Answer 69

Pathophysiology Osmotic diuresis and a hyperosmolar state Ketosis and acidosis Low insulin levels = markedly increased glucagon levels - unchecked lipolysis = fatty acids are converted to ketone bodies Acetoacetate and beta hydroxybutyrate cause metabolic acidosis

Answer 70

Polyuria Polydipsia Anorexia/Nausea/vomiting Abdominal pain Weakness & myalgias Headache Hypothermia Kussmaul’s respirations - Metabolic acidosis - pH < 7.0 and/or [HCO3-] < 12 mEq/L Acetone breath Intravascular volume depletion Hypo-reflexia Altered mental status

Answer 71

**Glucose (300-800 mg/dl)** **Ketones** HCO3- (0-15 mEq/L) pH (6.80-7.30) Na+ (total body depletion) K+ (total body depletion) Creatinine/BUN (slightly elevated BUN, Cr false increase) Hemoconcentration Leukocytosis Hyperuricemia Elevated lactate

Answer 72

Diagnosis of DKA cannot be made without the presence of ketones Glucose concentration is not a good index of the severity of metabolic derangement Initially give NS to restore intravascular volume regardless of Na+ or K+ values Phosphaturia accompanies all forms of metabolic acidosis

Answer 73

Replete volume Treat hyperglycemia Correct hyperosmolality Reverse ketonemia Reverse acidemia Correct K+ depletion

Answer 74

Fluid resuscitation NS 2-3 liters over first 2 hours Thereafter - 1/2NS at high flow rates Avoid LR When BS approaches 250 mg/dl add D5W Discontinue IV fluids when diet is tolerated and anion gap acidosis resolved

Answer 75

Profoundly depleted regardless of initial K+ Serum K+  by 0.6 mEq/L for ea 0.1  in pH below 7.40 20-30 mEq/hr is initiated Observe for adequate UOP Hypokalemia - Rehydration - Insulin therapy - Correction of acidosis

Answer 76

IV bolus of regular insulin at 0.1u/kg Regular insulin IV infusion at 0.1u/kg/hour SC regular insulin 2 hours prior to discontinuation of insulin infusion NaHCO3 - cardiovascular instability or altered mental status with pH < 7.0

Answer 77

IV bolus of regular insulin at 0.1u/kg Regular insulin IV infusion at 0.1u/kg/hour SC regular insulin 2 hours prior to discontinuation of insulin infusion NaHCO3 - cardiovascular instability or altered mental status with pH < 7.0

Answer 78

5% mortality Infection Arterial thrombosis Shock Lactic acidosis Hyperchloremic acidosis Cerebral edema - H/A, papilledema & altered mental status Hypokalemia Hypophosphatemia (potassium phosphate)

Answer 79

Severe hyperglycemia > 800 mg/dl Severe hyperosmolality > 350 mOsm/L Profound intravascular volume depletion - More severe than DKA - 10-20% of total body wt. Absence of ketoacidosis Impaired renal function Mental status changes Patient profile: - Elderly - Mild, type II diabetes - Symptomatic polyuria - Loss of ability to ingest or retain fluids as a result of illness, drugs or injury

Answer 80

Metabolic Aberrations End – Organ complications Peripheral neuropathies & Stiff joints Renal disease ANS dysfunction – delayed gastric emptying BG – ketones – electrolytes – BUN – creatinine – UA - ECG

Answer 81

Painless myocardial ischemia Orthostatic hypotension Lack of heart rate variability (fixed tachycardia) Reduced HR response to atropine and beta blockers Neurogenic bladder Lack of sweating Impotence Gastroparesis

Answer 82

Glycosylation of joints– stiff joint syndrome with reduced ROM of AO joints The prayer sigh suggests joint glycosylation and increases the risk of difficult intubation

Answer 83

A + prayer sign can be elicited on exam w/ the patient unable to approximate the palmar surfaces of the phalangeal joints while pressing their hands together. demonstrates a cervical spine immobility and the potential for difficult intubation

Answer 84

Depends. If you do IBW, you'll get adequate intubating conditions and faster recovery but shorter duration. If you use TBW, you'll get faster onset but longer duration. (well fucking DUH is this answer for real)

Obesity + DM (Lea) Flashcards

(132 cards)