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Flashcards in Obesity II Deck (19)
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What are some weight loss medications?

  • Meds that suppress hypothalamic appetite regulatory center:
    • Phentermine
    • Benzphetamine
    • Diethylproprion
    • Phentermine w/topiramate
    • Phendimetrazine
  • Drug that blocks fat absorption
    • Orlistat
  • Inhibits NE and serotonin reuptake
    • Sibutramine
  • Ephedra


What are the three categories of bariatric surgeries?

  • Gastric restriction- goal to restrict food intake
    • gastric binding (adjustable)
    • gastric sleeve
  • Intestinal malabsorption- bypasses part of small intestine
    • jejunoileal bypass
    • Biliopancreatic diversion
    • duodenal switch
  • combined restrictive/malabsorbtive
    • Roux-en-Y


What are some surgical complications for bariatric surgeries?

  • Anastomotic leaks
  • stricture formation
  • PE
  • sepsis
  • gastric prolapse
  • nutritional complications
  • dumping syndrome


________ are the greatest cause of perioperative 30-day mortality of bariatric surgeries.

  • Pulmonary emboli


What do you need to assess in your pre-op evaluation of an obese patient?

  • Assess patient in a non-judgemental fashion
  • emphasis should beon the difficulties obesity presents to the anesthesia provider
  • discuss the likely post-op course
  • Assess all the systems


What is the one extra thing you would do in the airway assessment of an obese pt?

  • Measure the neck circumference
    • single best predictor of difficult intubation
  • 40 cm = 5% 
  • 60 mc = 35%


What is the screening tool for OSA?

  • STOP-BANG questionnaire
    • snoring?
    • tired?
    • observed?
    • High blood pressure?
    • BMI?
    • Age?
    • neck size?
    • gender?


What kind or pre-op studies would you want to do to assess the pulmonary situation of an obese patient?

  • CXR
  • Room aire SaO2
  • ABGs
  • PFTs
  • Optimize pulmonary status preop


How should you assess an obese pts cardiovascular system pre-op?

  • Signs of HTN, RV/LV hypertrophy and PHTN should be assessed
  • assess venous access
  • EKG
  • CXR
  • ECHO
  • LV ejection fraction
  • cardiac clearance if needed
  • previous diet aids


How should you assess the endocrine/metabolic system of an obese pt pre-op?

  • fasting blood sugar
  • diabetes non-insulin or insulin dependent
  • does the pt have a hx of reflux?


What pre-op labs do you want for an obese pt?

  • liver function tests
  • albumin level
  • glucose
  • consider clotting studies if they have risk factors


What should you consider in positioning of obese patient?

  • Might need special designed table or 2 together
    • careful when strapping pt
  • Ramp up for intubation
  • Protect pressure points- high incidence of pressure sores and nerve injuries
  • consider using two armboards
  • compression of vena cava when supine
  • FRC and oxygenation is reduced when supine


How do you want the pt positioned when ramping?

Ear even with sternal notch


Can you use regional for an obese patient?

  • Yes, use regional whenever possible
    • best for pain control and decreases the incidence of post-op resp depression
    • may be technically difficult- use longer needles and US
  • requires 20% less LA
    • epidural vascular engorgement and fatty infiltrates decrease volume in epidural space


Considerations for the GA of an obese patient regarding meds.

  • Higher doses of Succ
  • Des, sevo, and iso useful
  • avoid nitrous d/t oxygen demands
  • short acting opioids to minimize respiratory depression
  • dexmedetomidine good
  • profound muscle relaxation needed for laparoscopy
    • vec, roc, cisatracurium


How should you mechanically ventilate an obese patient?

  • Peep of 10 cm H2O can improve FRC and arterial oxygenation--watch BP d/t decreased preload
  • recruitment maneuvers to improve oxygenation
  • pressure-controlled ventilation may help
  • changing I:E ratio


How do you calculate fluid requirement in an obese patient?

  • Based on LBW or IBW
  • Expect greater blood loss compared to non-obese r/t technical difficulties/extensive surgical dissection


What is the biggest problem in emergence of an obese patient?

How can it be avoided?

  • Respiratory failure #1 problem
    • extubate after fully awake, reversed, and adequate MV confirmed
    • semi-upright position (>30 degreed head up)
    • wean on pressure support ventilation w/PEEP
    • O2 100%
    • place nasal airway
  • Ventilatory support post-op
    • CPAP, BiPAP
    • mechanical
    • monitor closely


What is the best way to provide post-op analgesia to an obese patient?

How are opioids dosed?

  • B/c opioid induced ventilatory depression is a concern, a multimodal approach is used
  • peripheral nerve blocks with continuous infusion of LA with or without small doses of opioids
  • Local infiltration of wound
  • Opioids dosed based on IBW