Term
| Why is proper positioning important in regards to the airway? |
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Definition
| Without proper support and alignment of the oropharynx and trachea, ventilation may be obstructed and visualization of the laryngeal structures may be obscured. |
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Term
| What are some considerations during induction? |
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Definition
Pts desaturate quickly, so you need to preoxygenate
They may be difficult to mask, you will need to lift the weight off the thorax, and may need to people.
May be high aspiration risk, so will need to be tubed.
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Term
| Why do obese patients do better with controlled ventilation vs spontaneous? |
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Definition
| Controlled ventilation with increased tidal volume leads to better oxygenation than shallow spontaneous breaths. |
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Term
| What are considerations for maintenance? |
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Definition
Ensure adequate muscle relaxation
Provide optimum oxygenation
Use full reversal of muscle relaxation
Use appropriate intraop and postop tidal volume |
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Term
| What are considerations for regionals? |
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Definition
Many technical limitations, such as obscure landmarks, difficult position, and extensive layers of adipose tissue
Make sure you have a long enough spinal needle
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Term
| Why is epidural anesthesia along with a light general utilized? |
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Definition
| Light general can facilitate management of the airway, ventilation, and the pts level of consciousness, whereas the epidural provides surgical analgesia and anesthesia. The epidural catheter can be used for postop analgesic administration and will enhance earlier resumption of deep breathing and coughing manuevers. |
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Term
| What are problems encountered during post-op? |
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Definition
Weaning can be difficult because of increased WOB, decreased lung volumes, and V/Q mismatching
The decision to extubate depends on evaluation of the ease of mask ventilation and intubation, the length and type of surgery, and the presence of preexisting medical conditions, such as OSA |
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Term
| What are the criteria for extubation? |
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Definition
Awake state
tidal volume and respiratory rate and pre-op levels
ability to sustain head lift for at least 5 seconds
strong constant hand grip
effective cough
adequate vital capacity of at least 15 ml/kg
inspiratory force of at least -25-30 cm H2O |
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Term
| What are the most common causes of death following surgery for severe obesity, and what predisposes the patient for that? |
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Definition
1. Pulmonary embolism/Thromboembolism
-immobility
-increased blood viscosity from polycythemia, hypovolemia
-increased abdominal pressure
-abnormalities in serum procoagulants and anticoagulants
2. Anastamotic breakdown |
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Term
What should be done to reduce the risk of PE/clot?
How does the incidence of wound infection and PE change for the obese population? |
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Definition
minidose heparin/low-molecular weight heparin
antiembolic stockings and pneumatic compression boots (correctly fitting!)
early ambulation
maintenance of vascular volume
Wound infections and PE are 50% higher in obese patients than normal weight pts! |
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Term
What is the most common post-op complication in the obese?
How long does this last? |
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Definition
Respiratory problems, especially with surgery involving the thorax or upper abdomen
The risk of hypoxia extends for several days into the post-op period
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Term
What is the medical treatment for obesity?
How effective is this? What is done next? |
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Definition
Diet
Behavior modification
Exercise
Medications (lots listed)
Diet therapy is relatively ineffective in the long term.
Surgical options include gastric banding and Roux-en-Y gastric bypass |
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Term
| What makes an ideal candidate for bariatric surgery? |
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Definition
failed other modalities
psychological stability
knowledgeable about the procedure and sequale
motivated
comorbidities that do not preclude likely periop and long term survival
Age 18-60
BMI > 40
BMI > 35 with medical problems |
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Term
| Of the bariatric surgeries, what is a restrictive procedure, and why is it used? |
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Definition
Gastric banding, or vertical banded gastroplasty--they decrease the size of the gastric pouch, limiting the amount of food that can be consumed at one time.
These surgeries have fewer side effects. It is the only reversible, non-destructive bariatric operation, and it allows the stomach opening to be tightened or loosened over time |
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Term
How do malabsorptive procedures work?
Which procedure is more effective: malabsorptive or restrictive? |
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Definition
They bypass most of the small bowel and create a state of chronic malabsorption.
Malabsorptive are more effective, but are not reversible.
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Term
| The Roux-en-y gastric bypass is the most commonly performed procedure in the US. How does this surgery work? |
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Definition
Both restrictive and malabsorptive.
Extremely small gastric pouch has minimal acid secretion, and a large portion of the stomach and duodenum are bypassed. The Roux limb may be lengthened to provide an element of malabsorption. |
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Term
| What are typical results after bariatric surgery? |
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Definition
Weight loss--61% at 1-2 years after surgery
Resolution of diabetes in 75% of patients
Hyperlipidemia, hypercholesterolemia, and hypertriglyceridemia were significantly improved
Hypertension significantly improved (61% resolution)
OSA significantly improves (85% resolution) |
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Term
| What are complications associated with bariatric surgery? |
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Definition
Infection
DVT
Wound dehiscence
Anastomotic leaks
IBS, rectal problems
Operative mortality at 30 days or less:
0.1% for restrictive
0.5% for gastric bypass
1.1% for biliopancreatic diversion or duodenal switch procedures. |
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