Perioperative Nursing Care of the Bariatric Surgical Patient

1
Perioperative Nursing Care of the Bariatric
Surgical Patient

• Patricia Ide, RN, MS, CNOR
• Elliott Farber, MD
• David Lautz, MD

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Background

• 60 of the US population is overweight
• 30.5 of the population is obese
• 300,000 deaths per year
• Prevalence is steadily increasing in
• Both genders
• All ages
• All ethnic and racial groups
• And all geographical locations across the US

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Bariatric Surgery

• Currently the most effective means of losing
  substantial weight and maintaining the weight
  loss is Bariatric Surgery
• From the Greek words
• Baros, that is weight and
• -iatreia, that is medical treatment

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Knowledge Deficits of Caregivers

• 16 Patients died in Massachusetts between March
  1, 2003 and October 31, 2004
• Sepsis and pulmonary emboli were contributing
  factors or the cause of death in 10 of the 16
  cases
• Number one trend noted in the review of all 16
  mortalities was knowledge deficit

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Defining Overweight and Obesity

• Body Mass Index (BMI) has become the medical
  standard to measure overweight and obesity
• Calculation to determine BMI
• Weight in kilograms divided by the square of the
  patients height in meters
• Many BMI tables are also available

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Weight Categories by Body Mass Index

• Underweight lt18.5
• Normal 18.5-24.99
• Overweight 25-26.99
• Mild Obesity 27-30
• Moderate Obesity gt30
• Severe Obesity gt35
• Morbid Obesity gt40
• Super Obesity gt50

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Patient Selection

• gt 18 years old
• Fully understand the surgery, required life style
  changes and lifetime medical care
• Have made numerous attempts at medical weight
  loss
• Severely obese
• BMIgt35 with at least one co morbidity
• BMIgt40

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Most Common Bariatric Procedures

• Roux-en-Y Gastric Bypass
• Laparoscopic Adjustable Gastric Banding

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Roux-en-Y Gastric Bypass
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Laparoscopic Adjustable Gastric Banding
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RYGBP Benefits/Disadvantages

• Initial rapid weight loss
• Higher total weight loss is reported
• 2/3 of patients will lose 2/3 of their excess
  weight
• 1/3 of patients will achieve ideal weight

• Dumping syndrome
• Cannot evaluate
• Nutritional Deficiencies
• Extremely difficult to reverse
• Mild weight gain gt2yr
• Higher mortality
• Other complications

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LAGB Advantages/Disadvantages

• Lowest mortality and complication rates
• Least invasive
• Reversible/adjustable
• Less malnutrition
• Less hospitalization and faster recovery

• Initial weight loss is slower and variable
• Requires implant of a surgical device and its
  management
• Band slippage and erosion
• Band intolerance
• Inadequate weight loss

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The Obese Patient High Risk

• Preoperative evaluation includes an evaluation of
  the medical consequences of the patients morbid
  obesity, in particular the cardiovascular and
  respiratory systems

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Cardiovascular Concerns

• Increased cardiac afterload, decreased oxygen
  supply, increased risk of CAD, all lead to left
  ventricular hypertrophy
• Right ventricular failure can be caused by
  chronic hypoxemia, hypercarbia, polycythemia, and
  pulmonary hypertension
• The patients body is forced to do more with less

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Cardiac Concerns

• Prone to heart disease
• Weight of abdominal wall on aorta and vena cava
  may impede circulation of oxygenated blood
• Heart rate can be increased/decreased
• Slowed conduction
• Ischemia
• Past MI

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Cardiac Concerns

• Assure proper defibrillator is available
• Be aware of patients HX, normal heart rhythm, HCT

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Respiratory Concerns

• Little respiratory reserves and O2 desaturates
  quickly
• Increased oxygen consumption and increased CO2
  production require increased ventilation
• SOB due to increased metabolic needs
• Often have sleep apnea or asthma
• Should bring CPAP to hospital

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Respiratory Concerns

• Assess patients ability to lie flat and optimal
  position
• May experience asphyxiation or gastric reflux
• Cricoid pressure may be necessary to assist with
  view and prevent aspiration

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Respiratory Concerns

• Failed intubation is one of gravest risks
• Sleep apnea usually indicates a low chance of
  successful masking of patient
• Pre-induction includes prolonged pre-oxygenation
  to maximize O2 reserves
• Vocal cord visualization is difficult
• Lack cervical neck mobility
• May require awake intubation

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Respiratory Concerns

• Contingency planning is costly
• Assure entire team is present and aware of plan
• Difficult airway cart available
• Patients inhalers
• Laryngeal intubating mask/bronchoscopes
• Trach kit and tubes available

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Vascular Concerns

• Increased risk for DVT/PE
• IV access is difficult
• Apply compression boots
• Assure no tourniquet effects
• Administer preop SQ Heparin
• Ambulate patient DOS

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Musculoskeletal and Nervous System Concerns

• Strain of the weight impacts positioning
• Risk for nerve injury--lt85 degree abduction of
  arms
• Risk of injury due to steep reverse
  trendelenburg, need foot props
• Assure OR bed meets manufacturers
  recommendations
• Risk of dislocation of knees and ankles

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Musculoskeletal and Nervous System Concerns

• Arrange for postop bariatric bed if greater than
  350 lbs, if patient cannot move well, or needs
  additional space to turn side to side
• Fat tissue delays medication absorption and is
  later stored in the fat
• May require more meds
• Avoid IM injectionsmay not be muscle

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Musculoskeletal and Nervous System Concerns

• Highly varied rate of medication absorption
• May contribute to unpredictable emergence and
  re-emergence from anesthesia

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Skin Injuries

• Patients are obese but may be malnourished
• Assure mattresses are in good condition
• No sliding on the bedcreates shearing
• Keep skin crevices clean and dry
• Feet snug against foot supports
• Pad pressure points

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Fluid Management Concerns

• Pneumoperitoneum may be responsible for transient
  oliguria during surgeryby placing pressure on
  the renal cortex and inferior vena cava
• Therefore fluid management can be difficult

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Psychosocial Concerns

• Preop medication is minimized
• Anxiety is increased
• Stay with patient and have knowledge of bariatric
  surgery
• Be prepared
• Provide warmth and comfort

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Sensitivity Training

• It is said that obesity is the last social
  acceptable form of prejudice
• Society values slenderness and equates it to
  youth, success, happiness and social
  acceptability

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Nursing Survey Related to Obesity

• Nurses self reported agreement with the following
  beliefs
• Obese are not successful (24)
• Obese are overindulgent (43)
• Obese are lazy (22)
• Obese experience unresolved anger (33)

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Other Nursing Beliefs

• Obesity can be prevented with self-control (63)
• Felt uncomfortable caring for an obese patient
  (48)
• Would prefer not to care for obese patients (31)
• Hospital nurses do not experience with the
  patient their recovery, weight loss and
  improvement of health and quality of life

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Strategies for Obesity Bias

• Recognize complex etiology of obesity and its
  multiple contributors
• Acknowledge the difficulty of achieving and
  sustaining weight loss
• Recognize many patients have had many attempts to
  lose weight
• Recognize that patients have had negative
  experiences with healthcare providers

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Strategies

• Explore all causes of patients presenting health
  problems and do not attribute all problems to the
  patients weight
• Emphasize importance of behavioral changes and
  not just weight loss
• Recognize that small weight losses can result in
  meaningful health results
• Patients deserve to receive non-discriminatory,
  appropriate treatment and care

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Modest Goals Help

• 5-10 weight loss decreases HTN
• 5-7 weight loss can prevent Type II Diabetes for
  people at high risk

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Outlook

• View patient as suffering from a chronic disease
  with bariatric surgery seen as a treatment option
  for that chronic disease

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OR Complications

• Hypothermia
• Intra-abdominal injury
• Anastomotic leaks
• Retained foreign bodies
• Postop Infections
• Anesthesia complications

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Postoperative Complications

• Worsening abdominal pain
• Chest pain
• Shortness of breath
• Leg pain
• Swelling/redness of incisions
• Fever
• Persistent tachycardia

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Postoperative Complications

• Nausea and vomiting
• Inability to swallow
• Something wrong, patient not acting like self

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Post Anesthesia Care

• Standard handoff report
• BMI
• Optimal positioning
• Management of risky airway
• IV narcotics and PCA for pain control

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Long Term Care is for Life

• Management of complications
• Prevention of nutritional deficiencies
• Assistance with psychological adjustments
• Management of co morbid conditions
• Medication management
• Prevention and management of long term weight loss

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Conclusions

• Many surgeons report that bariatric patients are
  among the happiest and most appreciative
• Patients return to the hospital usually for life
• Some patients do have buyers remorse
• Patients experience marked improvement in health
  and often can stop medications

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Conclusions

• Study (Hager) measured quality of life and found
  improvement in
• Physical functioning
• Self esteem
• Sexual life
• Work

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Further Research

• Bariatric surgery has endless opportunities for
  research
• New field
• Further study is needed to support, guide or
  change current standards of care for the
  bariatric patient

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For More Information

• Weight Control Information Network, US Dept of
  Health and Human Services, http//win.niddk.nih.go
  v/publications
• Commonwealth of Massachusetts Betsy Lehman Center
  for Public Safety and Medical Error Reduction
  Expert Panel on Weight Loss Surgery Executive
  Report Obes Res. 200513(2)205-305

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For More Information

• AORN bariatric surgery and guideline. In
  Perioperative Standards and Recommended
  Practices, AORN, 200867-85
• Gregory Crum BS. Practicing safe care of the
  bariatric population. Perioperative Nursing
  Clinics. 20061(1)67-71.
• Ide, Farber, Lautz. Perioperative Nursing Care of
  the Bariatric Surgical Patient. AORN 2008
  88(1)30-58