The mortality from liver cirrhosis is for obese people is.....

1.5 to 2.5 times that of non-obese

Name three types of "non alcoholic fatty liver disease" assoicated w/ obesity

Steatosis

Steatohepatitis

Fibrosis

Cirrhosis

Hepatomegaly

Abnormal liver biochemistry

This is caused by mechanical stress on weight bearing joints.

Osteoarthritis

Our lack of physical activity, similar to that of obese people, can contribute to stress fractures. Tell me why and what areas are typically affected.

-Physical activity can lead to bone reabsorption and reduce bone density causing stress fractures

-Areas involved include: ankles, hips, knees, lumbar spine

If I give a highly lipophilic drug such as an opioid or benzo, what happens to my distribution, elimination half life and clearance rates?

-the patient will have INCREASED volume of distribution

-LONGER elimination half-life

-SIMILAR clearance rates

How should you administer maintenance doses in obese pts & why?

-Maintenance doses should be administered LESS FREQUENTLY because of slower clearance with a larger volume of distribution

Your going to give Digoxin, Remifentanyl, or procainamide-(which are high lipophilic doses) how should you dose?

According to IBW

Water soluble drugs such as (NMBAs) have a more _________ volume of distribution, which should/or should not be influenced by fat stores.

water soluble drugs have a more LIMITED volume of distribution, which SHOULD NOT be influenced by fat stores

How should I dose water soluble drugs such as NMBAs?

Dose should be based on ideal body weight to avoid overdose

What is the most likely cause of slow awakening in obese patients from volatile agents?

A increased central sensitivity, not storage in adipose tissue

According to the slide-Volatile agents are distributed so______ to lipid stores that increased fat reservoir has _______ clinical effect on wake up time even during long surgical procedures.

volatiles are distributed so SLOWLY to lipid stores that increased fat reservoir has LITTLE clinical effect on wake up time.

What is probably the best volatile to use in mobidly obese pts?

DESFLURANE!

-because of its low solubility profile, rapid washout, absence of hepatic and renal toxicity, and support of blood pressure

Whats the dealio w/ using Sevoflurane in obese pts?

Sevo causes increased levels of serum inorganic fluorides (that we all know!) but do you remember that these can be metabolized at a rate 100% faster in obese pts. (so put down the whopper!)

You've decided your brave enough to give this obese pt a regional-how will you dose your local?

20-25% LESS local related to epidural fat and distended epidural veins

What is the advantage of a PCEA?

It provides pain relief with decreased respiratory complications.

How can you obviate the undesirable cephalad spread of local anesthetics?

Reduce the volume and increase the patients upright sitting time

Assessment is a key issue: you've discovered that your patient uses noradrenergic and serotonergic therapy. What are you concerned about?

Your pt was on chronic noradrenergic therapy, you induce her and have a profound hypotension. How will you treat it?

The hypotension is refractory to indirect acting vasopressors, however PHENYLEPHRINE is usually effective.

How long should a patient be abstinent from noradrenergic or serotonergic therapy?

2 weeks for adequate catecholamine levels to be recovered

When is an A-line recommended?

In all but minor procedures in the morbidly obese.

Limitations in exercise tolerance, history of orthopnea, and paroxysmal nocturnal dyspnea may indicate?

Left ventricular dysfunction

What is your concern w/ a pt who becomes dyspneic and desaturates when recombent?

He/she will experience the same symptoms during induction in the supine position.

How do you treat an obese patient considered t have a "full stomach"?

Pretreat w/ an H2 antagonist, metoclopramide, and oral nonparticulate antacid

Re: preoperative considerations

When are PFTs necessary?

for abdominal or thoracic surgery.

-CXR will determine the presence of cardiomegaly, pulmonary infiltrates, and COPD

Re: preoperative considerations

What leads should be monitored?

Leads II and V5 (to enhance MI detection)

-Sudden cardiac death is more prevalent in morbidly obese pts w/ LV hypertrophy and ventricular ectopy

What are the two most important factors identified in morbidly obese pts in regards to airway evaluation?

Increasing neck circumference an Mallampati classification of greater than 3

A 575 lb pt is rolling into your OR, name some of your concerns in regards to equipment.

TABLE!-most newer OR tables can accommodate up to 600lbs

-you may need double arm boards, heavy duty stirrups, extra large retractors, elogated instruments (but we don't care about those-the OR nurse will =)

We do care about extra blades, emergency airway equipment, fiberoptic and bronchoscopic devices

Obese patients may have and increased incidence of nerve damage why?

-Excessive weight on the anatomic structures.

-They don't have the ROM of nonobese individuals.

What is the effect of general anesthetics on FRC in the obese patient?

50% reduction in FRC compared to 20% in nonobese

Why use PEEP in the obese?

it improves both FRC and arterial O2 tension, but at the expense of cardiac output and osygen delivery

What is the normal adult percentage of total body water? How about in the severely obese?

-Normal adult=60-65%

-Severely obese= 40%

How do you calculate estimated blood volume in the obese?

45-55 ml/kg 

(versus 70ml/kg)

Oh no! You need to replace volume in Mrs. Biggie- and your going to use Hetastarch, how much do you use?

You will not administer more than recommended volumes per kilogram of IBW (20 ml/kg)

*Use of reduced parameters for volume replacement and avoidance of rapid rehydration lessen cardiopulmonary compromise*

What can happen if I use more than the recommended volume per kilogram of IBW (20ml/kg) of Hetastarch in my obese pt?

Dilutional coagulopathy, factor VIII inhibition, and decreases plt aggregability

Do obese pts have a greater or lesser sensitivity to the respiratory effects of opioids?

They have a GREATER sensitivity to the resp. depressant effects. Use supplemental O2 and pulse oximetry monitoring are mandated.

Why is it important to have your patient properly positioned (sniffing position)?

Without proper support and alignment of the oropharynx and trachea, ventilation may be obstructed and visualization of the laryngeal structures may be obscured.

Obese patients may need to be "ramped"