GI, GU, Integumentary, and Obesity
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Questions and Answers

What is the recommended time period for avoidance of breast milk before induction in an otherwise healthy patient?

  • 2 hours
  • 6 hours
  • 4 hours (correct)
  • 8 hours

    • Which of the following 2 medications poses a risk in patients with alpha-gal syndrome?

  • Rectal aspirin
  • Fentanyl
  • Heparin (correct)
  • Lidocaine patches (correct)

    • What is an important anesthetic consideration for patients taking a GLP1 agonist? (select 2)

  • Inhibited gastric emptying (correct)
  • Lowered blood glucose (correct)
  • Increased glucose uptake in peripheral tissues
  • Reduced glucagon secretion

    • What is the recommended duration for holding daily GLP1 agonist doses before surgery?

    <p>1 day</p> Signup and view all the answers

    Which of the following medications is SAFE for use in patients with alpha-gal syndrome?

    <p>Rectal aspirin</p> Signup and view all the answers

    What is the primary cause of increased gastric acid secretion in peptic ulcer disease?

    <p>H.Pylori infection</p> Signup and view all the answers

    What is the complications of peptic ulcer disease if left untreated?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of firing a band around esophageal varices during treatment?

    <p>To scar over the varicosity</p> Signup and view all the answers

    What is the most common location of carcinoid tumors?

    <p>Gastrointestinal (GI) tract</p> Signup and view all the answers

    What is the percentage of patients who develop carcinoid syndrome?

    <p>10%</p> Signup and view all the answers

    What is normally secreted in the GI tract when we eat and is excreted by the lungs?

    <p>Serotonin</p> Signup and view all the answers

    What is the most common cause of upper GI bleed?

    <p>Peptic Ulcer Disease (PUD)</p> Signup and view all the answers

    What is the significance of melena in GI bleeding?

    <p>Bleeding has occurred above the cecum</p> Signup and view all the answers

    What is the definition of Acute Kidney Injury (AKI)?

    <p>Increase in serum Cr &gt;0.3 mg/dl within 48 hours or &gt;50% over 7 days</p> Signup and view all the answers

    What is the primary cause of post-renal Acute Kidney Injury (AKI)?

    <p>Obstruction</p> Signup and view all the answers

    What is the primary complication of Chronic Kidney Disease (CKD)?

    <p>Hyperkalemia</p> Signup and view all the answers

    What is the primary cause of carcinoid syndrome?

    <p>Excess serotonin production by tumors reaching the systemic circulation</p> Signup and view all the answers

    What is the causes of pancreatitis?

    <p>All of the above</p> Signup and view all the answers

    Which of the following is a common complication of pancreatitis?

    <p>ARDS</p> Signup and view all the answers

    What is the primary cause of hypotension in pancreatitis?

    <p>Sequestration of fluid in the peripancreatic space</p> Signup and view all the answers

    Which of the following is a characteristic of carcinoid syndrome?

    <p>Flushing secondary to histamine release</p> Signup and view all the answers

    What is the primary risk factor for death in pancreatitis?

    <p>Shock</p> Signup and view all the answers

    What is the mortality rate associated with infection of pancreatic necrotic material or abscess formation?

    <p>50%</p> Signup and view all the answers

    Which of the following patients should have RSI? (select all that apply)

    <p>Trauma patients</p> Signup and view all the answers

    What is the most likely cause of metabolic acidosis in a patient with diarrhea?

    <p>Loss of bicarbonate</p> Signup and view all the answers

    What is the definition of dysphagia?

    <p>Difficulty swallowing</p> Signup and view all the answers

    What is the most common subjective symptom of GERD?

    <p>Heartburn</p> Signup and view all the answers

    What is the best method for evaluating mechanical causes of dysphagia?

    <p>Esophagogastroduodenoscopy (EGD)</p> Signup and view all the answers

    What is the cause of achalasia (outflow obstruction)?

    <p>Poor relaxation of the lower esophageal sphincter and hypomotile esophagus</p> Signup and view all the answers

    What is the primary mechanism of GERD?

    <p>All of the above</p> Signup and view all the answers

    A patient with a history of vomiting presents for elective surgery. What metabolic derangement is likely to occur?

    <p>Metabolic alkalosis due to loss of gastric acid</p> Signup and view all the answers

    What is the primary mechanism underlying dysphagia in patients with esophageal motility disorders?

    <p>Impaired peristalsis in the esophagus</p> Signup and view all the answers

    What is the primary indication for rapid sequence induction (RSI) in patients undergoing elective surgery?

    <p>Risk of aspiration due to decreased gastric emptying</p> Signup and view all the answers

    What is the characteristic of chronic kidney disease?

    <p>GFR &lt;60 for 3+ months</p> Signup and view all the answers

    What is the risk factor for acute kidney injury?

    <p>All of the above</p> Signup and view all the answers

    What is the definition of oliguria?

    <p>Decrease in urine output to &lt; 0.5 mg/dL</p> Signup and view all the answers

    What is the medication that provokes mediator release in carcinoid tumors?

    <p>All of the above</p> Signup and view all the answers

    What is the main characteristic of achalasia?

    <p>Outflow obstruction caused by poor relaxation of the lower esophageal sphincter and hypomotile esophagus</p> Signup and view all the answers

    What is the primary mechanism of carcinoid syndrome?

    <p>Secretion of large amounts of serotonin and vasoactive substances</p> Signup and view all the answers

    What is the primary substance secreted by carcinoid tumors?

    <p>All of the above</p> Signup and view all the answers

    What are the primary symptoms of carcinoid syndrome?

    <p>All of the above</p> Signup and view all the answers

    Which of the following is NOT a characteristic of metabolic syndrome?

    <p>Hypotension</p> Signup and view all the answers

    What is the primary function of leptin in the body and what is its concentration in obesity?

    <p>Appetite control, reduced</p> Signup and view all the answers

    What is the recommended approach to airway management in obese patients?

    <p>Ramping position to align pharyngeal axes</p> Signup and view all the answers

    What is the primary reason for using recruitment maneuvers in obese patients?

    <p>To open collapsed alveoli</p> Signup and view all the answers

    What is the primary effect of opioids, propofol, and benzodiazepines on patients with OSA?

    <p>Exaggerated responses</p> Signup and view all the answers

    What is the primary advantage of using desflurane in obese patients?

    <p>Rapid and consistent recovery profile due to its low solubility in blood</p> Signup and view all the answers

    What is the primary factor influencing the dosing of propofol, vecuronium, rocuronium, and remifentanil in obese patients?

    <p>Ideal body weight</p> Signup and view all the answers

    What is the primary mechanism by which visceral adipose tissue contributes to metabolic syndrome?

    <p>Release of proinflammatory cytokines</p> Signup and view all the answers

    What is the purpose of using a BP cuff with a width 20% greater than arm diameter or 40% of circumference in obese patients?

    <p>To ensure accurate blood pressure measurement</p> Signup and view all the answers

    What are the complications of obesity that result in rapid decreases in SPO2 during apnea?

    <p>All of the above</p> Signup and view all the answers

    What are the NPO guidelines for clear liquids before surgery?

    <p>2 hours</p> Signup and view all the answers

    What are the NPO guidelines for formula, non-human milk, or light meals before surgery?

    <p>6 hours</p> Signup and view all the answers

    What are the NPO guidelines for a full meal before surgery?

    <p>8 hours</p> Signup and view all the answers

    What type of esophageal disorder causes dysphagia with solid food and liquids?

    <p>Motility disorders</p> Signup and view all the answers

    What type of esophageal disorder causes dysphagia with solid food only?

    <p>Structural disorders</p> Signup and view all the answers

    What is characterized by the reflux of GI contents into the pharynx without nausea or vomiting?

    <p>Regurgitation</p> Signup and view all the answers

    What is the main difference between odynophagia and globus sensation?

    <p>Globus sensation is a feeling of food stuck in the throat, while odynophagia is a painful swallowing</p> Signup and view all the answers

    Most esophageal disorders represent an aspiration risk

    <p>True</p> Signup and view all the answers

    What are the esophageal disorders related to motility? (select 2)

    <p>Achalasia</p> Signup and view all the answers

    What is distal esophageal spasm?

    <p>Spastic distal portion of the esophagus</p> Signup and view all the answers

    What is unique about peptic ulcer disease symptoms?

    <p>They can be relieved by food</p> Signup and view all the answers

    What are the common causes of esophageal varices? (select 2)

    <p>Portal hypertension</p> Signup and view all the answers

    What is the mechanism of action of pancreatitis?

    <p>Autodigestion of pancreatic tissue by activated enzymes r3esulting in acute inflammatory changes</p> Signup and view all the answers

    Which of the following symptoms are associated with pancreatitis?

    <p>All of the above</p> Signup and view all the answers

    What are the causes of shock in pancreatitis?

    <p>All of the above</p> Signup and view all the answers

    What are some possible complications of pancreatitis? Select 3

    <p>Renal failure</p> Signup and view all the answers

    At what percentage of estimated blood volume loss do tachycardia and hypotension typically occur?

    <p>&gt;25%</p> Signup and view all the answers

    What are common causes of lower GI bleeding?

    <p>Diverticulosis or tumors</p> Signup and view all the answers

    What do the majority of fatalities from GI bleeds usually result from?

    <p>Multi-organ dysfunction syndrome (MODS)</p> Signup and view all the answers

    A hematocrit below what percentage is likely to be associated with orthostatic hypotension?

    <p>30%</p> Signup and view all the answers

    What is a normal GFR (glomerular filtration rate)?

    <p>90-120 mL/min</p> Signup and view all the answers

    What is the relationship between age and GFR?

    <p>GFR decreases with age by 1% per year after 20</p> Signup and view all the answers

    What clinical test is the best measure of glomerular filtration rate and why?

    <p>Creatinine clearance, because Cr production is constant, Cr is filtered in the blood, and Cr is not reabsorbed</p> Signup and view all the answers

    What urine specific gravity suggests urine concentrating ability is adequate?

    <p>&gt;1.018</p> Signup and view all the answers

    AKI requiring dialysis is associated with an increased rate of mortality

    <p>True</p> Signup and view all the answers

    How is prerenal acute kidney injury caused?

    <p>Impaired blood supply to kidney</p> Signup and view all the answers

    What is are the leading causes of Chronic Kidney Disease (CKD)?

    <p>Hypertension</p> Signup and view all the answers

    At what level of GFR is dialysis usually required?

    <p>GFR &lt;25 mL/min</p> Signup and view all the answers

    Which of the following are complications of acute kidney injury?

    <p>All of the above</p> Signup and view all the answers

    What is asterixis?

    <p>A type of hand tremor</p> Signup and view all the answers

    Because skin turgor is a late sign of dehydration, what else should be assessed?

    <p>All of the above</p> Signup and view all the answers

    Slow to very slow skin retraction indicates what level of body weight loss in dehydration?

    <p>5-10% or more</p> Signup and view all the answers

    At what level of deoxygenated hemoglobin (hgb) and/or oxygen saturation does central cyanosis occur?

    <p>3-5 g/dL, 85%</p> Signup and view all the answers

    Central cyanosis is suggestive of a cardiopulmonary etiology

    <p>True</p> Signup and view all the answers

    Why does pulse oximetry misread methemoglobin and carboxyhemoglobin?

    <p>Because they have similar absorption spectra to oxyhemoglobin</p> Signup and view all the answers

    What is the main cause of jaundice?

    <p>Buildup of bilirubin in the blood</p> Signup and view all the answers

    What is the byproduct of the recycling of red blood cells?

    <p>Bilirubin</p> Signup and view all the answers

    What is jaundice frequently a symptom of?

    <p>All of the above</p> Signup and view all the answers

    Peripheral edema is a symptom of which of the following?

    <p>Active or impending fluid overload</p> Signup and view all the answers

    What is the likely cause of nailbed clubbing?

    <p>Chronic respiratory disease</p> Signup and view all the answers

    What rank is obesity as a preventable cause of death?

    <p>Second</p> Signup and view all the answers

    What must exist in order to be diagnosed with metabolic syndrome?

    <p>At least three of the above</p> Signup and view all the answers

    What is true about the incidence of metabolic syndrome?

    <p>It increases with age and male gender.</p> Signup and view all the answers

    What are some health risks associated with obesity?

    <p>All of the above</p> Signup and view all the answers

    What are the known effects of obesity on the immune system? (select 2)

    <p>Depression of natural killer cell cytotoxic activity</p> Signup and view all the answers

    What is obesity hypoventilation syndrome characterized by?

    <p>Impaired central ventilatory drive that is characterized by an awake, chronic hypoxemia (PaO2&lt;65 mmHg) without a diagnosis of lung disease</p> Signup and view all the answers

    What is the greatest risk factor for the development of obstructive sleep apnea-hypoventilation syndrome?

    <p>Obesity</p> Signup and view all the answers

    What is the consequence of increased adipose tissue around airways in terms of airway management?

    <p>Increased risk of severe airway obstruction and anticipated difficult mask ventilation and DL</p> Signup and view all the answers

    What is the main difference between obstructive sleep apnea and obstructive sleep hypopnea?

    <p>Apnea refers to a complete cessation of airflow, while hypopnea refers to a partial reduction in airflow.</p> Signup and view all the answers

    Obstructive sleep apnea = cessation of airflow for 10+ seconds with 5+ more episodes per hour of sleep with a decrease in SaO2 of +4%

    <p>True</p> Signup and view all the answers

    Obstructive sleep hypopnea = more than 50% reduction of airflow lasting at least 10 seconds occurring 15+ times an hour with a decrease in SaO2 of +4%

    <p>True</p> Signup and view all the answers

    What is a normal apnea-hypopnea index (AHI)?

    <p>5-10 events/hour</p> Signup and view all the answers

    During a polysomnography sleep study, the patient was reported to have >30 apneic events per hour. What is the patient's severity on the AHI (Apnea-Hypopnea Index) and how does this impact induction?

    <p>Severe, risk of desaturation during anesthesia induction</p> Signup and view all the answers

    What is the definition of moderate AHI in terms of events per hour?

    <p>15-30</p> Signup and view all the answers

    Which of the following anatomic features could increase airway management difficulty for patients with OSAHS?

    <p>All of the above</p> Signup and view all the answers

    Identify the CPAP value suggestive of difficult mask ventilation with the induction of anesthesia.

    <p>Greater than 10 cmH2O</p> Signup and view all the answers

    Is obesity alone an independent risk factor for gastric aspiration or an indication for invasive monitoring

    <p>No</p> Signup and view all the answers

    When inducing an obese patient with T2D and performing epidural anesthesia, what precautions should you take?

    <p>Consider the use of a histamine antagonist or PPI</p> Signup and view all the answers

    Which of the following are predictors of difficult endotracheal intubation in obese patients?

    <p>Mallampati score 3 or 4</p> Signup and view all the answers

    What strategies can be used to reduce desaturation and improve gas exchange after intubation of the obese patient?

    <p>All of the above</p> Signup and view all the answers

    What strategies can be used to reduce the risk of desaturation at the conclusion of general anesthesia?

    <p>All of the above</p> Signup and view all the answers

    Which of the following medications use actual body weight (total body weight) for dosing?

    <p>All of the above</p> Signup and view all the answers

    Obese patients breath at abnormally elevated lung volumes

    <p>False</p> Signup and view all the answers

    Study Notes

    NPO Guidelines for Elective Surgery

    • Clear liquids allowed up to 2 hours before induction
    • Breast milk allowed up to 4 hours before induction
    • Infant formula/non-human milk and light meal allowed up to 6 hours before induction
    • Heavy solids and fatty foods not allowed within 8 hours before induction

    GLP1 Agonists

    • Physiologically lower blood sugar, increase sense of fullness, and delay gastric emptying
    • Recommendation: stop taking GLP1 agonists for 1 week before parental dose and 1 day before daily (enteral) dose

    Alpha Gal Syndrome

    • Caused by Lone star tick bite, resulting in hypersensitivity to animal proteins
    • Non-contagious
    • Allergic reaction symptoms can be immediate or delayed
    • Medications that pose a risk include heparins, gelatin capsules, vaccines, and lidocaine patches
    • Unsafe medications include propofol, hydromorphone, acetaminophen, clevidipine, milrinone, and all antiplatelets except rectal aspirin

    Patients with Full Stomach/Delayed Gastric Emptying

    • Diabetic patients due to gastroparesis
    • Pregnant women in labor
    • Trauma patients
    • Patients treated with opioids, resulting in decreased gastric motility
    • All these patients require RSI (rapid sequence induction)

    Routine Testing

    • Not recommended unless specific disease, comorbidities, or risks to anesthesia are present

    Goal of Preoperative Evaluation

    • Discover diseases/disorders
    • Verify or assess known diseases influencing anesthesia care
    • Support the formulation of a specific care plan

    Health History for GI Assessment

    • Nausea and vomiting lead to metabolic alkalosis due to loss of gastric acid
    • Diarrhea leads to metabolic acidosis due to loss of bicarbonate

    Esophageal Disease

    • Dysphagia: difficulty swallowing
      • Structural: common with solid food
      • Functional/Motility: common with liquids and solid food
    • Heartburn common with GERD
      • Acid in distal esophagus causing discomfort
    • Regurgitation: reflux of GI contents into the pharynx without nausea/vomiting
    • Odynophagia: pain with swallowing
    • Globus sensation: feeling of a lump in the throat
    • Esophagogastroduodenoscopy (EGD): best method for evaluating mechanical causes of dysphagia
    • Most esophageal disorders represent an aspiration risk

    Esophageal Disorders

    • Achalasia: outflow obstruction caused by poor relaxation of the lower esophageal sphincter and hypomotile esophagus
    • Distal esophageal spasm: spastic distal portion of the esophagus

    Esophageal Disorders (Structural)

    • Diverticula
    • Hiatal hernia
    • Tumors

    GERD

    • Gastric contents re-enter the esophagus due to:
      • Transient relaxation of the lower esophageal sphincter (LES)
      • Poor LES tone
      • Anatomic distortion of the GE junction (e.g., hiatal hernia)

    Peptic Ulcer Disease

    • H. Pylori: offending agent, causing an increase in gastric acid secretion
    • Symptoms: epigastric pain relieved by eating and worsened by fasting
    • Common disease affecting men slightly more than women
    • Complications:
      • Bleeding
      • Perforation
      • Obstruction

    Esophageal Varices

    • Dilations and weakening in the wall of the esophagus
    • Due to cirrhosis and scar tissue/portal hypertension
    • Treatment: fire band around varicosity to scar it over
    • Esophageal gastrectomy: can be used to treat esophageal cancer, 33% mortality

    Carcinoid Tumors

    • Occur most commonly in the GI tract
    • Known to secrete vasoactive substances (ACTH, serotonin precursor, growth hormone factor)
    • Types of secretory substances vary depending on tumor location
    • Carcinoid syndrome occurs in approximately 10% of patients
    • Serotonin is normally secreted in the GI tract when we eat and excreted by the lungs; carcinoid tumors cause an increase in serotonin due to secretion by the tumor

    Carcinoid Syndrome

    • Occurs due to secretion of large amounts of serotonin and vasoactive substances reaching the systemic circulation
    • Symptoms: flushing, diarrhea, dehydration, and electrolyte abnormalities
    • Carcinoid crisis: life-threatening, characterized by flushing, diarrhea, abdominal pain, tachycardia, and hypertension/hypotension
    • Drugs provoking mediator release: Succs, mivacurium, atracurium, tubocurarine, epi, NE, dopamine, isoproterenol, thiopental

    Pancreatitis

    • Pancreas manufactures and secretes numerous digestive enzymes (proteases)
    • Gallstones and alcohol abuse are the etiologic antecedents in 60-80% of cases
    • Hypercalcemia and pancreatic ductal hypertension lead to intrapancreatic release of digestive enzymes and acute inflammatory changes
    • Symptoms: excruciating pain, nausea/vomiting, ileus, dyspnea
    • Complications: shock, ARDS, renal failure, GI hemorrhage, coagulopathy, and DIC

    GI Bleeding

    • Upper GI bleeding is more common than lower GI bleeding
    • Upper GI bleeding is usually caused by PUD
    • Tachycardia and hypotension are common when EBL > 25% of EBV
    • Lower GI bleeding is usually caused by diverticulosis or tumors
    • Melena suggests bleeding has occurred above the cecum
    • Orthostatic hypotension typically occurs when Hct < 1.018, suggesting urine concentrating ability is adequate
    • Urinalysis detects proteins, glucose, acetoacetate, blood, and leukocytes
    • Hematuria may be the result of bleeding anywhere between the glomerulus and urethra

    AKI

    • Defined as an increase in serum Cr > 0.3 mg/dl within 48 hours or > 50% over 7 days
    • Causes: sepsis, cardiovascular dysfunction, pulmonary complications
    • Pre-renal, intra-renal, and post-renal causes
    • Risk factors: pre-existing renal disease, CV disease, respiratory disease, post-op reliance on inotropes, post-op diuretic use, sepsis, nephrotoxic drug administration
    • Complications: Asterixis, polyneuropathy, uremic pericarditis, hyperkalemia, metabolic acidosis

    NPO Guidelines for Elective Procedures

    • Clear liquids: 2 hours
    • Breast milk: 4 hours
    • Infant formula/non-human milk: 6 hours
    • Light meal (e.g. crackers): 6 hours
    • Solid/fatty foods: 8 hours

    Rapid Sequence Induction

    • Diabetic patients
    • Bowel obstructions
    • Pregnant women in labor
    • Trauma patients
    • Patients treated with opioids
    • Patients who just ate a heavy meal

    Preoperative Evaluation

    • Four sources of information:
      • Medical records
      • Physical examination
      • Patient history
      • Tests/labs
    • Three goals:
      • Discovery of disease/disorders
      • Verification/assessment of known diseases influencing anesthesia care
      • Support the formulation of a specific plan of care

    Metabolic Derangements

    • Nausea and vomiting: metabolic alkalosis due to loss of gastric acid
    • Diarrhea: metabolic acidosis due to loss of bicarbonate

    GI Terms

    • Dysphagia: difficulty swallowing
    • Regurgitation: reflux of GI contents into the pharynx without nausea/vomiting
    • Odynophagia: pain with swallowing
    • Globus sensation: feeling of a lump in the throat

    Dysphagia

    • Two etiologies: structural and functional/motility
    • Best method for evaluation: Esophagogastroduodenoscopy (EGD)

    Esophageal Disorders

    • Motility-related:
      • Achalasia: outflow obstruction caused by poor relaxation of the lower esophageal sphincter and hypomotile esophagus
      • Distal esophageal spasm: spastic distal portion of the esophagus
    • Structure-related:
      • Diverticula (e.g. Zenker's diverticula)
      • Hiatal hernia
      • Tumors

    Gastroesophageal Reflux Disease (GERD)

    • Three causes:
      • Transient relaxation of the lower esophageal sphincter (LES)
      • Poor LES tone
      • Anatomic distortion of the GE junction (e.g. hiatal hernia)

    Peptic Ulcer Disease

    • Bacterium most often associated: H. pylori
    • Three complications:
      • Bleeding: common without treatment and can cause mortality
      • Perforation: increased mortality when accompanied by shock
      • Obstruction: edema and inflammation may lead to an outlet obstruction

    Carcinoid Tumors

    • Common location: GI tract
    • Three substances commonly secreted:
      • ACTH
      • 5-hydroxytryptophan (serotonin precursor)
      • Growth hormone releasing factor
    • Secretory substances tend to vary depending on the location of the tumor

    Carcinoid Syndrome

    • Occurs in about 10% of patients
    • Symptoms:
      • Flushing
      • N/V/D
      • Excess serotonin with dehydration
      • Electrolyte abnormalities
      • Fibrosis (endocardial, retroperitoneal, pelvic)
      • Respiratory sx (cough, wheezing, dyspnea)
      • Cyanosis
      • Pulmonic and tricuspid valve thickening and stenosis
      • Hepatomegaly
    • In carcinoid crisis: life-threatening and characterized by flushing, diarrhea, abdominal pain, tachycardia, hypertension/hypotension

    Pancreatitis

    • Symptoms:
      • Excruciating pain
      • N/V
      • Ileus
      • Dyspnea
    • Two most common causes:
      • Gallstones
      • Alcohol abuse
    • Six complications:
      • Shock
      • Hypotension secondary to sequestration of fluid in peri-pancreatic space
      • ARDS
      • Renal failure
      • GI hemorrhage
      • Coagulopathy and DIC

    GI Bleeding

    • Melena: suggests bleeding has occurred above the cecum (stomach, small intestine)
    • Bright red bleeding and clots: from the rectum, distal colon, or sigmoid colon
    • Upper GI bleeds: commonly associated with gastric ulcers
    • Tachycardia: likely to occur when estimated blood loss exceeds 25% of the patient's blood volume

    Hematocrit and Orthostatic Hypotension

    • Hematocrit below 18%: likely to be associated with orthostatic hypotension

    Acute Kidney Injury

    • Six risk factors:
      • Pre-existing renal disease
      • Cardiovascular disease
      • Aortic cross clamping
      • Respiratory disease
      • Post-operative reliance on inotropes
      • Post-operative diuretic use
      • Sepsis
      • Nephrotoxic drug administration
    • Chronic kidney disease: characterized as a GFR < 60 mL/min/1.73m² for > 3 months

    Obesity

    • Obesity is the second leading preventable cause of death, only surpassed by smoking.
    • BMI is directly associated with health risk, with higher BMI indicating higher health risk.
    • Obesity is linked to early death and is associated with metabolic syndrome.

    Metabolic Syndrome

    • Abdominal obesity, specifically visceral obesity, is a more reliable predictor of metabolic syndrome than BMI.
    • Characteristics of metabolic syndrome include:
      • Low HDL levels
      • Hyperinsulinemia
      • Glucose intolerance
      • Hypertension (HTN)
      • Proinflammatory state
      • Prothrombic state
    • Incidence of metabolic syndrome increases with age and male gender.
    • Certain medications, such as corticosteroids, antidepressants, and antipsychotics, can contribute to metabolic syndrome.

    Inflammation and Immunity

    • Adipose tissue has two primary functions:
      • Storage and release of energy-rich fatty acids
      • Release of proteins required for endocrine function and autocrine energy regulation
    • Visceral adipose tissue is a significant source of proinflammatory cytokines.
    • Chronic inflammation is linked to heart disease, diabetes, and stroke.
    • Obesity is associated with depression of natural killer cell cytotoxic activity.
    • Leptin plays a crucial role in appetite control, but its production is reduced in obesity.

    Obesity Hypoventilation Syndrome

    • Obesity hypoventilation syndrome is characterized by impaired central ventilatory drive, resulting in awake, chronic hypoxemia (PaO2 < 30 mmHg).

    Morbid Obesity

    • Preoperative evaluation for morbidly obese patients should focus on:
      • Coexisting diseases (e.g., diabetes, HTN, CVD, cerebrovascular disease, cancer, OSAHS)
      • Functional capacity
      • Airway assessment
      • Cardiopulmonary function and reserve
      • Vital signs and SaO2
      • Previous surgical and anesthetic history and complications
    • Focused evaluation should be conducted on HTN, diabetes, CHF, and obesity hypoventilation syndrome.

    Anesthesia and Obesity

    • Obesity alone is not an independent risk factor for gastric aspiration.
    • Regional-spinal or epidural anesthesia is safe for patients with a larger BMI, but may require reduced or titrated dosing.
    • Obesity alone is not an indication for invasive monitoring.
    • BP cuff width should be 20% greater than arm diameter or 40% of circumference.

    Airway Management

    • Anatomical challenges in obese patients include:
      • Short, thick neck
      • Large tongue
      • Redundant pharyngeal tissue
    • Predictors of difficult intubation include:
      • Mallampati 3 or 4
      • Neck circumference
      • Abundance of pre-tracheal soft tissue
    • Ramping position can help align pharyngeal axes.
    • Emergency airway equipment, such as LMA, fiberoptic scopes, and video laryngoscopy equipment, should be available.

    Pulmonary Abnormalities in Obese Patients

    • Obese patients are prone to rapid desaturation during apnea due to decreased lung capacities (vital capacity, inspiratory capacity, expiratory reserve volume, and functional residual capacity).
    • Lung compliance and respiratory compliance are low in obese patients.
    • Obese patients breathe at abnormally low lung volumes.
    • Strategies to reduce desaturation and improve gas exchange after intubation include:
      • Recruitment maneuvers
      • Head-up/reverse Trendelenburg position (30 degrees)
      • PEEP (10 cmH2O) to improve ventilatory mechanics

    Positioning and Anesthesia Drugs

    • Morbidly obese patients require extra care during positioning, with padding and frequent checks of pressure points being mandatory.
    • Opioids, propofol, and benzodiazepines can provoke exaggerated responses in patients with OSA.
    • Desflurane has a rapid and consistent recovery profile due to lower blood-gas coefficient (less solubility in blood).
    • Ideal body weight should be used for dosing propofol, vecuronium, rocuronium, and remifentanil, while total body weight should be used for midazolam, succinylcholine, cis-atracurium, fentanyl, and sufentanil.

    Preparation for Emergence and Extubation

    • Full reversal of neuromuscular blockade is necessary before emergence.
    • Provide PPV during emergence and spontaneous ventilation.
    • Transport morbidly obese patients with their head elevated and supplemental O2 (consider CPAP).

    Obesity

    • Obesity is the second leading preventable cause of death, only surpassed by smoking.
    • BMI is directly associated with health risk, with higher BMI indicating higher health risk.
    • Obesity is linked to early death and is associated with metabolic syndrome.

    Metabolic Syndrome

    • Abdominal obesity, specifically visceral obesity, is a more reliable predictor of metabolic syndrome than BMI.
    • Characteristics of metabolic syndrome include:
      • Low HDL levels
      • Hyperinsulinemia
      • Glucose intolerance
      • Hypertension (HTN)
      • Proinflammatory state
      • Prothrombic state
    • Incidence of metabolic syndrome increases with age and male gender.
    • Certain medications, such as corticosteroids, antidepressants, and antipsychotics, can contribute to metabolic syndrome.

    Inflammation and Immunity

    • Adipose tissue has two primary functions:
      • Storage and release of energy-rich fatty acids
      • Release of proteins required for endocrine function and autocrine energy regulation
    • Visceral adipose tissue is a significant source of proinflammatory cytokines.
    • Chronic inflammation is linked to heart disease, diabetes, and stroke.
    • Obesity is associated with depression of natural killer cell cytotoxic activity.
    • Leptin plays a crucial role in appetite control, but its production is reduced in obesity.

    Obesity Hypoventilation Syndrome

    • Obesity hypoventilation syndrome is characterized by impaired central ventilatory drive, resulting in awake, chronic hypoxemia (PaO2 < 30 mmHg).

    Morbid Obesity

    • Preoperative evaluation for morbidly obese patients should focus on:
      • Coexisting diseases (e.g., diabetes, HTN, CVD, cerebrovascular disease, cancer, OSAHS)
      • Functional capacity
      • Airway assessment
      • Cardiopulmonary function and reserve
      • Vital signs and SaO2
      • Previous surgical and anesthetic history and complications
    • Focused evaluation should be conducted on HTN, diabetes, CHF, and obesity hypoventilation syndrome.

    Anesthesia and Obesity

    • Obesity alone is not an independent risk factor for gastric aspiration.
    • Regional-spinal or epidural anesthesia is safe for patients with a larger BMI, but may require reduced or titrated dosing.
    • Obesity alone is not an indication for invasive monitoring.
    • BP cuff width should be 20% greater than arm diameter or 40% of circumference.

    Airway Management

    • Anatomical challenges in obese patients include:
      • Short, thick neck
      • Large tongue
      • Redundant pharyngeal tissue
    • Predictors of difficult intubation include:
      • Mallampati 3 or 4
      • Neck circumference
      • Abundance of pre-tracheal soft tissue
    • Ramping position can help align pharyngeal axes.
    • Emergency airway equipment, such as LMA, fiberoptic scopes, and video laryngoscopy equipment, should be available.

    Pulmonary Abnormalities in Obese Patients

    • Obese patients are prone to rapid desaturation during apnea due to decreased lung capacities (vital capacity, inspiratory capacity, expiratory reserve volume, and functional residual capacity).
    • Lung compliance and respiratory compliance are low in obese patients.
    • Obese patients breathe at abnormally low lung volumes.
    • Strategies to reduce desaturation and improve gas exchange after intubation include:
      • Recruitment maneuvers
      • Head-up/reverse Trendelenburg position (30 degrees)
      • PEEP (10 cmH2O) to improve ventilatory mechanics

    Positioning and Anesthesia Drugs

    • Morbidly obese patients require extra care during positioning, with padding and frequent checks of pressure points being mandatory.
    • Opioids, propofol, and benzodiazepines can provoke exaggerated responses in patients with OSA.
    • Desflurane has a rapid and consistent recovery profile due to lower blood-gas coefficient (less solubility in blood).
    • Ideal body weight should be used for dosing propofol, vecuronium, rocuronium, and remifentanil, while total body weight should be used for midazolam, succinylcholine, cis-atracurium, fentanyl, and sufentanil.

    Preparation for Emergence and Extubation

    • Full reversal of neuromuscular blockade is necessary before emergence.
    • Provide PPV during emergence and spontaneous ventilation.
    • Transport morbidly obese patients with their head elevated and supplemental O2 (consider CPAP).

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