morbidObesityGastricBypass
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Transcript morbidObesityGastricBypass
Morbid Obesity and Gastric
Bypass
Fun Facts
61% of adults in US have
BMI >25 in ’99
13% of children 6-11
14% of adolescents aged
12-19
How many deaths in the
US are associated with
obesity?
Economic Cost?
National Institute of Health. Call to
Action Report
Deaths and Cost
300,000 deaths per year
BMI >30 have a 50%-100% increased risk
of premature death.
117 BILLION dollars in 2000
National Institute of Health. Call to Action Report
More Fun Facts
More non-Hispanic white women(23%)
are obese compared to non-Hispanic white
men(21%)
Most affected-women are of low
socioeconomic.
National Institute of Health. Call to Action Report
Taco Bell?
Mexican american
boys tend to have
higher prevalence of
overweight.
National Institute of Health. Call to
Action Report 1998
Heart Disease
Hypertension twice as
common
Increased risk: MI,
CHF, Sudden Death,
Arrythmias.
Diabetes
A gain of 11-18 lbs
increases the risk of
developing Type 2 to
twice that of normal
individuals
Over 80% of people
with DM type 2 are
overweight or obese
Respiratory
Sleep Apnea
Obesity Hypoventilation Syndrome
Asthma
Decreased FRC
Increased risk of aspiration from GERD
Difficult airways (ventilate and intubate)
Other
Arthritis
Reproductive complications
Gallbladder disease.
Depression, Social Discrimination
What is BMI?
Body Mass Index
BMI=weight (kg) /
height (m2)
BMI=pounds/inches 2
x 703
Why BMI?
Classification
Healthy Weight 18.524.9
Overweight 25.0-29.9
Obesity
Class I 30.0-34.9
Class II 35-39.9
Class III >40
Limitations to BMI….really?
Overestimate body fat
in persons who are
very muscular i.e.
body builders
Underestimate body
fat in persons who
have lost muscle
mass i.e. elderly
Surgery Aspect
Indications
Types
Results
Complications
Indications
Age 18-60
BMI > 40
BMI > 35 with
medical problems
Exhausted other
venues of weight loss
Types of Surgery
How do they work?
Restrictive
Malabsorption
Behavioral modification
Results
Weight Loss- 66% at 1 to
2 years after surgery
60% at 5 years
50% at 10 years
African-american lose
significantly less
weight…why?
Improvement in
comorbities
Complications
Akin to any surgery i.e. infection, DVT,
wound deshicense, anastomotic leaks, etc.
Death 1%-2% after surgery, but higher
with other comorbities.
Irritable bowel syndrome ….can lead to
rectal problems
Anesthesia
Pre-Op
Intra-Op
Post-Op
Pre-Op/ History
History and Physical
ROS
Airway
Heart
Lungs
Eyes… eyes?… yes
eyes
Previous anesthesia
Airway
Mallampati, mouth opening, tongue size,
thyromental distance, sternomental distance,
neck circumference
Predictibility of difficult intubation: neither
obesity or BMI predicted problems with tracheal
intubation… BUT HIGH MALLAMPATI SCORE >3
and LARGE NECK CIRCUMFERENCE MAY
INCREASE THE POTENTIAL FOR DIFFICULT
LARYNGOSCOPY AND INTUBATION
Anesthesia and Analgesia, Mar 2002. 732-736
Cardiovascular
HTN: multiple
medications difficult
to control
Cardiomyopathy,
CHF, Ischemia, CVA,
Pulmonary HT, DVT,
PE,
Hypercholesterolemia,
Hypertriglyceridimia
Obesity Cardiomyopathy
Patients with severe and long standing
obesity
LVH, left ventricle dilation and LV diastolic
dysfunction.
Left Ventricle Failure and Right Ventricle
Failure = Obesity Cardiomyopathy
Causes of death are CHF and sudden
cardiac death
Lungs/ OSA
OSA- hypersomnolence, loud snoring,
apnea and hypopnea during sleep
Physiologic changes:
Arterial hypoxemia
Polycythemia
Arterial Hypercarbia
HTN
Pulmonary hypertension
Lungs/ OSA
Risk Factors:
Male
Middle Age
Obesity
Alcohol
Drug Induced Sleep
Lungs/OHS
Obesity Hypoventilation Syndrome is
defined as:
PaO2 < 70
PaCO2 > 45
BMI > 30 kg/m2
No other respiratory disease of explaining the
gas anomaly
Lungs/OHS
Why is there
hypoventilation?
1. High cost of work
of respiration
2. Dysfunction of the
respiratory center
3. Repeated episodes
of nocturnal
obstructive apnea
Lungs/OHS
Physiologic Changes:
Hypersomnolence (also
OSA)
Arterial Hypoxemia (also
OSA)
Polycythemia (also OSA)
Hypercarbia (also OSA)
Respiratory acidosis
Pulmonary hypertension
(also OSA)
RV Failure (also OSA)
Lungs/OHS
Some say that OHS progress into OSA
Some say that they are different entities.
Who is right?
OHS are usually:
Older, more obese, more deranged daytime
ABG values, more restricted lung volume,
more severe desaturation during sleep.
Chest, 2001:120:336-339
Lungs/ OSA vrs OHS
Chicken or the egg?
A spectrum of the
same disease?
Eyes
Hypoxia and
hypercarbia as a sign
of angiogenesis
Case Report , Elia J.
Duh, AMA-Assn.org
Intra Operative
GA vrs TIVA
GA supplemented with regional
Fast onset and fast offset medication
Good muscle paralysis
Calculate drug doses according to IBW
Best choice of maintenance is….
NOT KNOWN
Post Op
Extubation
Post Op Pain
OSA and OHS
Cardiac
Post Op/Extubation
Fully awake
Recover in head up
positioning
Monitoring very
important if OSA or
OHS
Post Op/Extubation
Maximun decrease in PaO2 is 2-3 days post
op.
Mechanical weaning can be difficult b/c:
1. Increased work of breathing
2. Decresed lung volumes
3. V/Q mismatch
Pain Control and OSA
Pt with OSA have a exquist sensibility to
narcotics, even when used in regional
techniques.
Narcotics can have depressive effects up
to 2-3 days post op
Post Op/ Others
Others:
DVT early ambulation/ heparin
Wound infection is twice as common
Guillain-Barre
Case Report: Chang; Obes Surg 2002 Aug; 12(4) 592-97