Criteria consider to perform obese pt in outpatient facility?
- Potential for undx OSA 2. Anatomical physiological abnormalities 3. Extent and severity of coexisting disease and how optimized 3. Nature of surgery (superficial, abdominal, peripheral) 4. Intraop anesthetic requirement (local, regional, sedation, general), and anticipated post operative opioid requirement 5. Age 6. Capabilities of outpatient facility: emergency airway, lab and radiology, transfer agreement with inpatient facility
How to decide if obese pt should be preformed in outpt facility
- H&P to determine extent and severity of coexisting dz (including potential for OSA) 2. OSA not suspected: medically optimized proceed 3. OSA suspected: proceed if facility capability and post discharge care was adequate and patients post op pain could be managed predominately using non opioids (local, regional, NSAIDs)
BMI qualifies as obese and superobese
o >30 obese o >50 kg/m^2 superobese
How to identify patients with undx OSA?
STOP BANG: >3 high risk for OSA, <3 low risk of OSA 5-8 mod-severe OSA o Snoring (loud enough to be heard through closed door o Tired o Observed apnea o High blood pressure o BMI>35 o Age>50 o Neck circumference >40cm o Gender Male
Head to toe potential complications with obesity
o Anesthesia: difficult airway management, patient positioning, altered drug effects (sensitivity)
neuro: stroke, obesity hypoventilation syndrome,
CV: difficulty eval cardipulm status 2/2 sedentary lifestyle, HTN, CAD, phtn,
Pulm: rapid desat w apnea (decreased FRC), OSA, post op apnea,
GI: nonalcoholic fatty liver, GERD w abdomen pushing belly up
Endocrine: DM o
Heme: DVT/PE, wound infection
How to evaluate for patients cardiac status? RCI factors? Risk % by # of factors. Flow sheet on decision to proceed to surgery?
- Determine if any active cardiac conditions: unstable or severe angina, decompensated heart failure, severe arrhythmia, severe valvular disease 2. Assess periop risk for major adverse cardiac event (MACE) via revised cardiac risk index o Hx ischemic heart dz (MI, active + stress test, unstable angina, use nitrate, path q wave), TIA/CVA, history of compensated or prior HF, IDDM, creatinine >2, or supraingunal vascular, intraperitoneal, intrathoracic surgery (SMIRCH) o 0-0.4%, 1-1%, 2-6.6%, 3-11% o Decision to proceed to proceed to surgery Emergencysurgery Elective + ACScardiology RCRI Elective +MACE <1% PROCEED MACE>1 but >4 METS proceed MACE>1 + <4 mets or unknownchange plan? If yes test
How to dose drugs in obese pts
obesity effect on pharmacology can be hard to predict. LBW: induction prop, fent/remi TBW: total succ, maintenance of prop IBW paralytics from there titrate additional dose to effect
How is lean and ideal body weight calculated
-Lean body weight: based on an individual’s height and weight, -ideal body weight is based only on height Female: deal 45.5. +2.3kg/inch over 5 ft Male: 50kg + 2/3/inch over 5 ft
causes of desaturation? in extubated pt?
- Insufflation atelectasis, pleural effusion 2. Pulm edema, aspiration 3. PTX, hemothorax, chylothorax, capnothorax 4. PE 5. Bronchospasm, mainstem, secretions 6. Tube kinked, machine issue extubated: obstruction (OSA, airway edema, resp depression, aspiration, atelectasis, PE
How to respond to desaturation
o 100% oxygen o manual ventilation-feel compliance o Listen to lungs(PTX)-confirm b/l breath sounds, adequate tube placement o Check BP EKG pulse ox, ETCO2, airway pressures(Increase capnothorax, decrease PTX, PE, CO2 embolism) o TX: Suction (aspiration, mucus), inhaler, recruitment, PEEP
How to treat suspected bronchospasm
o 100% oxygen o Increase depth anesthesia o B2 agonist like albuterol o Refractory: epi, ketamine
How to monitor OSA pt post op?
provide supplemental oxyhgen untilthey can maintain baseline sat on RA in quiet environment.
use home CPAP
multimodal, try to avoid opiods,
Maintain on continuous pulse ox until they can maintain sat >90% during sleep
If have apneic/hypoxemic episode monitor closely for at least ~7 hrs after last apnea episode,
What is MELD and what does it include? What does score indicate?
o model for end stage liver disease-use to prioritize liver allocation to pts. o Range 6-40 (higher score = higher short term morality Does not include fulminant hepatic failure or life expectancy <7 daysthey get status 1 (priority) o Serum creatinine, INR, and bilirubin
Dyspnea ddx in a cirrhotic pt?
o Cards: alcoholic cardiomyopathy, cirrhotic cardiomyopathy o Pulm: 1. COPD (smoker), 2. Ascites 3. pleural effusion 4. Portopulmonary syndrome 5. Hepatopulm syndrome,
How to dx hepatopulmonary syndrome
- liver disease 2. decreased oxygenation (A-a gradient >20 or Pa02<70 on RA), 3. intrapulm vascular dilation (contrast enhanced echo, perfusion lung scanning, pulm angio) • Orthodexia (arterial deoxygenation upright); platypnea (Dyspnea upright) • Indication for liver transplantation unless complexly unresponsive to oxygen
Head to toe concern in liver disease
o Neuro: 1. Wernicke encephalopathy (ETOH thiamine def) 2. hepatic encephalopathy (production ammonia by intestinal bacteria) o Pulm: 1. ascites decrease FRC 2. portopulmonary HTN 3. HPS o GI; increased risk aspiration o Renal: hepatorenal syndrome o Heme: 1. SBP 2. plt dysfunction 3. coagulopathy
Defination apnea
hypoapnea
OHS
Pickwickean
- apnea cessation airflow >10 sec w >4% drop sat, >5 per hr
- hypoapnea >50% cessation in airflow, >4% drop sat, >15/ hr
- OHS 2/2 obesity/OSA: BMI>30, daytime arterial hypercapnea >45 nocternal hypoxia, polycythemia
- Pickwickian: severe form OHS chronic hypovent –>pulm HTN and RVF
how much should BP bladder cuff encircle arm
75%
