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Surgical Indications for the Obese Flashcards

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1
Q

What percentage of adults in the US are considered obese?

A

65%

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2
Q

What percentage of adolescents and children are obese in the US?

A

15%

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3
Q

What is a determining factor in development of co-morbidities related to weight?

A

BMI

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4
Q

At what BMI is a patient considered low risk for developing co-morbidities?

A

BMI of 25-30

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5
Q

At what BMI is a patient considered high risk for developing co-morbidities?

A

BMI greater than 40

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6
Q

What percentage of anesthetic incidents involve obesity as a contributing factor?

A

50%

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7
Q

What were majority of the closed claims extubation or recovery claims related to?

A

Difficult intubation on induction, obesity or OSA

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8
Q

What is the most practical way to figure out IBW?

A

Broca’s index:
Male: IBW = ht (cm) - 100
Female IBW = ht (cm) -105

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9
Q

What is the formula to calculate a patient’s BMI?

A

Quetelet’s Index

weight in kg) / (height in meters squared

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10
Q

What does ideal body weight tell us?

A

Measurement of height compared to body mass

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11
Q

What does the NIH consider as a Grade I obese patient?

A

BMI 26-29.9

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12
Q

What does the NIH consider as a Grade II obese patient?

A

BMI 30-39.9

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13
Q

What does the NIH consider as a Grade III obese patient?

A

BMI greater than 40

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14
Q

What is considered a normal BMI?

A

BMI 24-26

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15
Q

What is considered mild obesity?

A

BMI 27-30

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16
Q

What is considered moderate obesity?

A

BMI 31-35

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17
Q

What is considered severe/morbid obesity?

A

BMI greater than 35

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18
Q

What is considered super morbid obesity?

A

BMI greater than 55

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19
Q

What are the two type of obesity?

A

Android “Apple”

Gynecoid “Pear”

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20
Q

How does a patient with android obesity present?

A

Significant weight above the waist, especially in the face and neck
The adipose is centrally deposited

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21
Q

How does a patient with gynecoid obesity present?

A

Weight is carried below the waist

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22
Q

What is a more efficient predictor of mortality than BMI or waist circumference alone?

A

Fat distribution

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23
Q

What is considered low, moderate and high risk in females based on their waist to hip ratios?

A

Low: 0.8
Moderate: 0.81-0.85
High: 0.85 and up

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24
Q

What is considered low, moderate and high risk in males based on their waist to hip ratios?

A

Low: 0.95
Moderate: 0.96-1
High: 1 and up

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25
What medical risks are associated with android fat distribution?
Increased myocardial fat content Ischemic hear disease NIDDM Stroke
26
What medical risks are associated with gynecoid fat distribution?
Varicose veins Degenerative joint disease Fat metabolically static
27
What gender is android fat distribution typically seen in?
Males
28
What can occur when free fatty acids are delivered to the liver?
Stimulation of hepatic synthesis of VLDL and increased circulation of LDL Glyconeogenesis and inhibition of insulin uptake --> NIDDM
29
Define concentric hypertrophy.
Increased wall thickness and diminished volume
30
Define eccentric hypertrophy.
Myocardial volume increases more than wall thickness
31
How does concentric hypertrophy form?
Increased demand causes remodeling of the heart, cardiac fibroblasts produce interstitial collagen
32
How does the heart function in a lean, normotensive patient?
Preload and after load are balanced
33
How does the heart change in a lean but hypertensive patient?
Increased after load = increased wall thickness and diminished volume which leads to concentric hypertrophy
34
How does the heart change in an obese but normotensive patient?
Increased preload = myocardial volume increases more than wall thickness
35
How does the heart change in an obese hypertensive patient?
Increased preload and after load with periods of hypoxemia = LV dilation and wall stress leading to eccentric and concentric changes
36
Which cardiac changes are seen more clearly in an obese hypertensive patient?
Concentric more than eccentric
37
How much does CO increase with body fat?
0.1L/kg of fat to deliver blood at a rate of 2-3mL/100g tissue
38
What co-morbidities are associates with a obese, hypoxic individual?
Obesity + hypoxia leads to heart disease and increased risk of sudden death
39
Where is blood redirected when a patient's BMI is greater than 40?
20% greater to splenic blood flow to feed intestines
40
What type of lung disease is often seen in obese patients?
Restrictive lung disease thoracic kyphosis lumbar lordosis
41
What syndrome can occur with worsening obesity and OSA?
Pickwickian Syndrome
42
What are the signs of Pickwickian syndrome?
``` Hypercarbia Hypoxemis Polycythemia Pulmonary HTN Biventricular failure ```
43
What can result from worsening obesity-hypoventilation syndrome?
Loss of hypercarbic drive Hypersomnolence Increased DAW
44
How does obesity affect the GI system?
High gastric volumes, acidity and decreased GI motility
45
What are the characteristics of metabolic syndrome?
Obesity HTN (high cholesterol and lipids) DM II Insulin resistance
46
How does obesity affect the kidneys?
Increases renal clearance of drugs due to increased renal blood flow and increased GFR
47
What type of malignancies are associated with obesity?
``` Breast Prostate Colorectal Cervical/Endometrial Ovarian ```
48
What is a skin condition that is highly associated with insulin resistance?
Acanthosis Nigricans (skin folds and creases)
49
What tow skin conditions frequently occur in an obese patient?
Intertrigo-reddened rash | Carbuncles-clusters of boils
50
What condition can occur in the obese patient that has signs and symptoms associated with a brain tumor but no tumor is present?
Idiopathic Intracranial HTN (pseudotumor cerebri)
51
What is meralgia paeasthetica?
Entrapment of femoral cutaneous nerve at inguinal ligament, get numbness and tingling
52
Is morbid obesity considered an independent risk factor for sudden death from acute postoperative PE?
Yes
53
How much heparin should be administered to an obese patient after surgery based on ASBS guidelines?
5000u SQ for 12h
54
When should a patient stop smoking prior to surgery?
At least 6 weeks
55
What degree of reverse T-berg is useful during induction of an obese patient?
Greater than 30 degrees
56
What are common nerve injuries in an obese patient?
Brachial plexus stretch Sciatic nerve palsy Ulnar neuropathy
57
Why are the obese more prone to nerve injuries?
Poor perfusion
58
How should propofol be dose in an obese patient?
Induction: IBW Maintenance: TBW
59
How should Fentanyl be dose in an obese patient?
TBW
60
How should remifentanil be dose in an obese patient?
IBW
61
How should succinylcholine be dose in an obese patient?
TBW
62
How should vet, roc and atra be dose in an obese patient?
IBW
63
Why is nitrous oxide useful in the obese population?
Fat insoluble Rapid onset Minimal metabolism
64
Why isn't nitrous used at much in the obese population?
Limites due to higher FiO2 needed to maintain PaO2
65
What is the oil gas partition coefficient for Sevoflurane?
47
66
What is the oil gas partition coefficient for Desflurane?
19
67
How should the estimated blood volume be calculated in an obese patient?
45-55ml/kg actual body weight
68
What is the goal in volume replacement of an obese patient?
Euvolemia
69
What is the percentage of total body in an average adult compared to an obese adult?
Normal: 60-65% Obese: 40%
70
How does the EBV differ in an obese patient compared to an averaged sized adult?
EBV is actually decreased despite increased circulatory fluid volume
71
What is an appropriate tidal volume for an obese patient?
10-15mL/kg based on IBW
72
What is an appropriate FiO2 to use on an obese patient?
No less than 0.5 FiO2
73
How should the provider treat intraoperative hypoxemia in an obese patient?
Recruitment maneuvers with PEEP (15cmH2O)
74
If placing an epidural for an obese patient why is it that the provider must dose down?
Reduction in dose due to epidural fat and distended veins in space

Advanced Principles (16 decks)

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