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Flashcards in Obesity II Deck (19)
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1

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

2

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

3

What are some surgical complications for bariatric surgeries?

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

4

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

  • Pulmonary emboli

5

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

6

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%

7

What is the screening tool for OSA?

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

8

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

9

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

10

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?

11

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

12

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

13

How do you want the pt positioned when ramping?

Ear even with sternal notch

15

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

16

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

17

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

18

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

19

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

20

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