Care of the obese patient undergoing bariatric surgery

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45 Care of the obese patient undergoing bariatric surgery

Theresa L. Clifford, MSN, RN, CPAN

Definitions

Bariatrics:  Branch of medicine dealing with the causes, prevention, and treatment of obesity.

Biliopancreatic Diversion (BD):  Surgical procedure that involves reducing the size of the stomach and allowing food to bypass part of the small intestine to change the normal process of digestion.

Body Mass Index (BMI):  A measure of body fat derived from a formula using a person’s weight and height.

Laparoscopic Adjustable Gastric Banding (LAGB):  One of the most common weight loss surgical procedures, it involves placing an adjustable silicone band around the upper portion of the stomach to restrict the size of the stomach. The band is tightened by adding saline through a port that is placed under the skin in the abdomen.

Malabsorptive Procedures:  Weight loss surgeries combining the reduction of stomach size, with redirection of the digestive process causing poor absorption of nutrients and calories.

Metabolic Syndrome:  A syndrome characterized by several common factors, including abdominal obesity and insulin resistance in which the body cannot use insulin efficiently.

Morbid Obesity:  Generally involves a state of being 50% to 100% over normal weight, being more than 100 pounds (45.5 kg) over normal weight, having a BMI of 40 or higher, or being sufficiently overweight to severely interfere with health or normal function.

Obstructive Sleep Apnea (OSA):  A sleep-disordered breathing; the risk increases with increased body weight.

Obesity:  A condition involving an excess proportion of total body fat. A person is considered obese when his or her weight is 20% or more above normal weight.

Restrictive Procedures:  Weight loss surgeries reducing the stomach size limiting the capacity of the stomach to hold food.

Roux-En-Y (RNY):  Common gastric bypass surgery that divides the stomach into a small upper pouch leaving a much larger, lower remnant pouch and then rearranges the small intestine into a Y configuration to enable outflow of food from the small upper stomach pouch, via a Roux limb.

Sleeve Gastric Resection (SGR):  A newer weight loss surgery that creates a thin, vertical sleeve of stomach using a stapling device, removing the rest of the stomach, thus limiting the amount of food eaten without causing any malabsorption.

Vertical Banded Gastroplasty (VBG):  Weight loss surgery also known as stomach stapling, using both a band and staples create a small stomach pouch to restrict food volume.

Weight Loss Surgery (WLS):  Procedures that either limit the amount of food a stomach can hold or restrict the amount of food digested.

Obesity is the most common nutritional disorder in the world today. Current estimates suggest that more than one third of the adult population in the United States is affected by excess weight. Approximately 33.3% of adult males, 35.3% of adult females, and 10% to 16.5% of teenagers and children are clinically obese.1 Weight loss surgery is one treatment option for patients who are overweight. Bariatric surgeries increased during 1993 to 2005 from 9189 to more than 140,000 per year.2 Caring for the patient with bariatric concerns presents a number of challenges for the perianesthesia nurse.

Defining obesity

The most useful anthropometric index for determination of obesity is the body mass index (BMI). This measurement describes the relationship between height and weight using one of the following calculations:

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or

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The higher the BMI, the greater the weight associated with a given height (Table 45-1). Recent studies have demonstrated that the patient who is considered overweight and one who is considered moderately obese usually experience minimal risks in the perioperative period.3 Underweight patients, as well as patients with a BMI greater than 30, are found to have increased perioperative mortality rates. Although obesity is not equally distributed across gender or race, the incidence of obesity in a given community is relevant and clinically important. Patients in the obese and morbidly obese categories are seen in perianesthesia services for a wide variety of conditions for a wide variety of services, including surgery.

Table 45-1 Classification of Body Mass Index

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Physiologic considerations in obesity

Pulmonary

Preoperative evaluation of obese patients reveals that 85% have exertional dyspnea and some degree of orthopnea. Periodic breathing, especially when sleeping, may also be present.

Obese patients tend to develop some degree of thoracic kyphosis and lumbar lordosis because of a protuberant abdomen. In addition, the layers of fat on the chest and abdomen reduce the bellows action of the thoracic cage. The overall lung-thorax compliance is reduced and thus leads to increased elastic resistance of the system. Usually the diaphragm is elevated, and the total work of breathing is increased as a result of the deposition of abdominal fat. Because of these factors, the oxygen cost of breathing is threefold or greater than normal, even at rest.

The primary respiratory defect of obese patients is a marked reduction in the expiratory reserve volume. The reason for the decrease in expiratory reserve volume and other lung volumes is that the obese patient is unable to expand the chest in a normal fashion. As a result, diaphragmatic movement must account for the changes in lung volume to a much greater extent than thoracic expansion does. As discussed previously, the diaphragmatic movement is moderately limited by the anatomic changes of obesity, which account for the decreased lung volumes.

In the obese patient, the functional residual capacity may be less than the closing capacity in the sitting and supine positions; therefore the dependent lung zones may be effectively closed throughout the respiratory cycle. Consequently, inspired gas is distributed mainly to the upper or nondependent lung zones. The resulting mismatch of ventilation to perfusion produces systemic arterial hypoxemia. The hypoventilation and ventilation-perfusion abnormalities that contribute to systemic arterial hypoxemia also contribute to retention of carbon dioxide and thus lead to hypercarbia.

In the general population, undiagnosed obstructive sleep apnea (OSA) is common in obese patients despite awareness that increased abdominal girth is a significant risk factor. Reportedly more than 70% of patients undergoing weight loss surgery have been clinically diagnosed with sleep apnea.4 OSA can occur in patients with redundant pharyngeal tissue. Obstructive sleep apnea is characterized by excessive episodes of apnea (approximately 10 seconds), apneic episodes occurring more than five times per hour, and a 50% reduction in airflow or a reduction sufficient to lead to a 4% decrease in oxygen saturation during sleep as a result of a partial or complete upper airway obstruction. Clinically significant apnea episodes of more than five episodes in 1 hour or 30 per night result in hypoxia, hypercapnia, systemic and pulmonary hypertension, and cardiac arrhythmias. In obese patients with OSA, there is an increased risk of difficult intubations as well as postextubation complications.4

Cardiovascular

Thirty pounds of fat are estimated to contain 25 miles of blood vessels, and the increased body mass in obesity leads to increased oxygen consumption and carbon dioxide production. It is not surprising that the cardiac output and the total blood volume are increased in the obese state. This increase in cardiac output is a result of an increase in stroke volume rather than an increase in heart rate; the latter usually remains normal.

The transverse cardiac diameter has been shown to be greater than normal in approximately two thirds of obese patients. A linear relationship seems to exist between cardiac diameter and body weight.

Obesity has been suggested to predispose one to electrocardiographic changes. The Q-T interval is often prolonged, and the QRS voltage is reduced because of the increased distance between the heart and the electrodes. Finally, the likelihood of ventricular arrhythmias is increased in the obese patient. These arrhythmias are believed to be a result of myocardial hypertrophy, hypoxemia, coronary artery disease, and fatty infiltration of the conducting and pacing systems.

A positive correlation exists between an increase in body weight and increased arterial pressure. Hypertension is a known risk factor for the development of coronary artery disease. A weight gain of 28 lb (12.75 kg) can increase the systolic and diastolic blood pressure by 10 and 7 torr, respectively. Systemic hypertension is tenfold more likely in the obese patient. The increase in blood pressure is probably caused by the increased cardiac output.

Chronic heart failure, although uncommon, can occur in persons with long-standing morbid obesity with or without hypertension. It is usually characterized by high output and biventricular dysfunction, with the left ventricle predominating. Clinically, heart failure can be difficult to diagnose because pedal edema may be chronically present.

Cerebral blood flow in obese persons does not differ significantly from that in persons of normal weight. Oxygen uptake of the brain remains normal in the obese person; however, the fraction of the total body oxygen represented in the cerebral metabolism is less than normal, because the total body oxygen requirement is increased. Although the kidneys of obese subjects weigh more than those of nonobese counterparts, renal blood flow is the same as or slightly lower than that of patients of normal weight.

Psychological

There are a number of contributing factors associated with obesity such as environment, genetics, highly processed and energy-dense foods, lack of exercise, ethnic culture, in addition to numerous psychological and social issues. Often eating has nothing to do with hunger. Many people eat in response to emotions such as boredom, sadness, or anger. Disordered eating may also be a symptom of depression and low self-esteem. Some individuals use food to fill emptiness, provide good feelings, and sooth job pressures and personal conflicts. Socially, obese people are perceived as lazy and lacking self-discipline and willpower, which can lead to a cycle of self-blame, guilt, shame, depression, and social withdrawal. Body image, along with the ability to interact with others, may be a problem for obese patients. Many bariatric patients have avoided routine medical care for fear of being judged and disrespected.

Integumentary

The presence of multiple skin folds can lead to impaired hygiene in the patient who may have difficulty seeing or reaching areas that need cleaning. Retained moisture on this redundant skin can lead to excoriations or rashes if not kept clean and dry. Problem areas tend to be found in the groin, perineum, or axilla, beneath the breasts, and in large skin folds. Wound infections can develop and commonly include yeast and fungi. Adipose tissue is poorly vascularized and can cause delayed wound healing.

Endocrine

Metabolic syndrome, also known as insulin resistance, is related to the effect of chronically high-normal serum blood sugars. The body has consistently high levels of glucose requiring the pancreas to secrete greater and greater amounts of insulin in order to keep blood sugar regulated. Eventually the cells no longer respond to insulin, and glucose begins to accumulate in the blood, leading to diabetes. Diabetes mellitus has been associated with obesity and metabolic resistance. It is the third most prevalent preoperative pathologic condition found in obese patients. Hypertension and dyslipidemia frequently occur concurrently and in association with resistance to insulin-stimulated glucose metabolism. When these risk factors cluster, the risks for CHD, stroke, diabetes, and cardiovascular disease mortality are further increased. This clustering of risk factors is frequent, but not invariably associated with obesity, particularly abdominal obesity. Insulin resistance is also associated with an unfavorable imbalance in the endothelial production of mediators that regulate platelet aggregation, coagulation, fibrinolysis, and vessel tone.

Other disorders

Other problems associated with clinical obesity include abnormal liver function tests, fatty infiltration of the liver (nonalcoholic steatohepatitis), gallstones, hiatal hernia, stress incontinence, and varicose veins. Gastroesophageal reflux is prevalent among the obese. Overweight patients are at higher risk for deep vein thrombosis and pulmonary emboli because of the limited or lack of mobility, stasis, and polycythemia related to chronic respiratory insufficiency. Obese individuals will also have some degree of degenerative joint disease affecting mobility.

Bariatric procedures

For centuries, standard diet and exercise was the usual prescription for weight loss. With the increase in incidence of obesity and obesity-related health concerns, weight-related issues have become a priority in the health fields and the media. Multiple venues for managing weight have been established and newer, safer techniques in weight loss surgery are among the many treatment options for reducing excess body fat.

Evidence-Based Practice

According to the extensive literature reviews conducted by Schumann and colleagues, safe pain management strategies for the patient undergoing weight loss surgery include a well-planned multimodal approach. Postoperative pain management options for the obese patient should include the use of preemptive agents including epidural or patient-controlled analgesia, surgical technique (open versus laparoscopic), the use of local anesthesia, and the use of nonopioid analgesics when indicated.

Implications for practice

Perianesthesia nurses caring for the bariatric patient can actively advocate for optimal pain management. This includes engaging multidisciplinary support for the development of appropriate order sets and policies and procedures for monitoring the postoperative bariatric patient, as well as soliciting active patient participation in postoperative pain management.

Source: Schumann R et al: Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, Obes Res 13(2):254−266, 2005.

There are two basic types of bariatric surgery. Restrictive procedures are aimed at reducing the stomach size to limit the capacity of the stomach to hold food and to induce a state of satiation quickly. Malabsorptive procedures may include reducing the size of the stomach and redirecting the digestive process, causing an alteration in the body’s ability to absorb and process nutrients and calories.

Two of the most common restrictive procedures include the laparoscopic adjustable gastric banding (LAGB; Fig. 45-1, C) and the vertical banded gastroplasty (VBG; see Fig. 45-1, B). The LAGB procedure involves the placement of an inflatable silicone band around the upper portion of the stomach. When in place, an access port is implanted just under the skin. This port allows for the injection or withdrawal of fluid into the band’s lumen to either increase or decrease the diameter of the band. The end result is a smaller volume of food consumed with an early and longer sensation of fullness.

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FIG. 45-1 Bariatric surgical procedures. A, Gastric bypass. B, Vertical banded gastroplasty. C, Laparoscopic adjustable gastric banding.

(From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 5, St. Louis, 2006, Saunders.)

The second restrictive procedure is the VBG. In this procedure, the upper stomach near the esophagus is stapled vertically to create a small pouch (capable of holding approximately 30 mL) along the inner curve of the stomach. The outlet from the pouch to the rest of the stomach is restricted by a band, which delays the emptying of food from the pouch, causes an early feeling of fullness, and limits the volume of food consumed.

The most common malabsorptive weight loss procedure is known as the Roux-en-Y gastric bypass (see Fig. 45-1, A). Either open or laparoscopic, this procedure involves making the stomach smaller by creating a small pouch at the top of the stomach using surgical staples or a plastic band. The smaller stomach is then connected directly to the middle portion of the small intestine (jejunum), bypassing the rest of the stomach and the upper portion of the small intestine (duodenum). The smaller stomach reduces the amount of food taken in, and the bypass of the intestines result in fewer calories being absorbed.

The least commonly performed weight loss surgery is biliopancreatic diversion (BPD). BPD removes approximately three fourths of the stomach to produce both restriction of food intake and reduction of acid output. The small intestine is then divided with one end attached to the stomach pouch to create what is called an alimentary limb. All the food moves through this segment, but not much is absorbed. The bile and pancreatic juices move through the biliopancreatic limb, which is connected to the side of the intestine close to the end to supply digestive juice in the section of the intestine now called the common limb. The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat, and fat-soluble vitamins.

Perianesthesia care of the obese patient

Equipment

Securing proper equipment throughout the continuum of care for the bariatric patient ensures patient comfort and safety. Properly sized blood pressure cuffs, gowns, bedside commodes, and transfer devices, such as wheelchairs and crutches, may be needed for the morbidly obese patient. In addition, special bariatric beds or stretchers for the operating room and postoperative care are also necessary. Adequate padding should be used to avoid pressure injuries that result in neurologic injury or rhabdomyolysis, a result of compartment syndrome and associated muscle necrosis. Because of problems associated with central lines in these patients, checking with the anesthesia care team to see what monitoring equipment is in use is important so that it can be continued in the postanesthesia phase.

Respiratory

Significant problems arise in the PACU phase of the perioperative care of the obese patient. In fact, the problems associated with the rising incidence of obesity are becoming more apparent to all perianesthesia nurses, regardless of the reason for the surgical event. A direct correlation exists between the incidence rate of postoperative pulmonary complications and the degree of obesity. Expansion of the chest wall is restricted by the compression of weight. The mortality rate after upper abdominal operations in morbidly obese patients is 2.5 times that of the normal-weight counterparts.

Functional residual capacity (FRC) decreases with increasing BMI. The restriction of movement and crowding of structures within the chest because of weight contribute to this decreased FRC. In addition, expiratory reserve volume (ERV) decreases, and the residual volume (RV) stays the same. Thus, the FRC is reduced (ERV + RV = FRC) and the result is that the closing volume (CV) is increased, which leads to an increase in the alveolar-arterial oxygen (a-A PO2) difference, resulting in hypoxemia. Therefore, the a-A PO2 increases as the BMI increases. The bariatric patient is more susceptible to rapid desaturation and progressive hypercapnia. Vigilance to ventilation and oxygenation is crucial.

Positioning can be a valuable therapeutic tool for improving arterial oxygenation. Vigorous pulmonary toileting, including coughing, deep breathing, and the use of an incentive spirometer in the awake patient are also important nursing interventions. Position has been shown to significantly affect PaO2 levels for 48 hours after surgery. The obese patient should be cared for in a semi-Fowler position unless cardiovascular instability exists. Routine use of the supine position should be avoided, because the functional residual capacity can decrease to less than the closing capacity and thus reduce the number of ventilated alveoli, which ultimately leads to hypoxemia. Another position that aids in relieving pressure on the diaphragm is the head-elevated laryngoscopy position, which is a modified semi-Fowler position with elevation of the head and upper body with pillows to create a horizontal line between the sternum and ear that also improves the view for reintubation, if needed. Moreover, early ambulation and mobilization in the PACU is of great value in enhancement of lung volumes of the obese patient.

In the postanesthesia period, the position of the operative incision is a factor because obese patients with a vertical incision have been shown to have a more marked postoperative hypoxemia than obese patients who receive a transverse incision. Therefore supplemental inspired oxygen may be necessary after surgery for 3 to 4 days in patients with a vertical incision. Serial arterial blood gas determinations can serve as guides to supplemental oxygen administration. Moreover, after the patient’s arterial line is in place, arterial blood gas determinations should be done to provide a baseline guide for proper ventilation. If the patient arrives in the PACU with the endotracheal tube in place, a ventilator should be started for the patient. The nurse should then auscultate for bilateral breath sounds to ensure proper placement of the endotracheal tube. Because of the many technical difficulties associated with tracheal intubation of the obese patient (e.g., size and mobility of the neck, increased tissue mass of the mouth and tongue), the perianesthesia nurse should constantly monitor the patient for proper placement of the tube. If the tube becomes displaced, the patient’s lungs should be ventilated with a bag-mask system, and the anesthesia personnel should be summoned immediately.

Many patients will have a secondary diagnosis of OSA and may require the use of a continuous positive airway pressure device (CPAP) or bilevel positive airway pressure device (BiPAP) to maintain open airways. These devices may be contraindicated depending on the type of bariatric surgery performed, because CPAP and BiPAP devices have been linked to increased risk of anastomotic leaks. Morbidly obese adult patients with severe OSA may need a tracheostomy with local anesthesia before a general anesthetic is administered. If a patient with OSA arrives in the PACU and becomes obtunded, an emergency tracheostomy may be necessary to secure an airway.

Cardiovascular pathophysiology can reduce cardiac reserve, especially in the older obese patient. A reduction in arterial oxygen tension caused by incision site or postoperative position causes an increase in cardiac output to facilitate tissue oxygen delivery, which could lead to cardiac decompensation in an already compromised cardiovascular system. Arterial hypoxemia should be avoided because many obese patients cannot compensate for the increased cardiac output demand and the concomitant pulmonary vasoconstriction caused by the reduced arterial oxygen tension.

Early postoperative ambulation is important not only in enhancing lung volumes but also in helping to reduce the incidence of venous thrombosis. Indeed, relatively immobile obese persons are particularly susceptible to the development of pulmonary emboli.

Cardiovascular

The obese patient has a higher incidence rate of pulmonary hypertension, right-sided heart disease, coronary artery disease, myocardial infarction, and cardiomegaly; therefore careful electrocardiographic monitoring should be used. If an arterial line was not used during surgery, an appropriately sized blood pressure cuff that covers one third to half the length of the upper arm should be used. A baseline blood pressure measurement when the patient arrives in the PACU proves valuable in comparing the intraoperative measurements for assessment of the accuracy of the blood pressure reading. The PACU nurse may need a forearm blood pressure cuff, especially if used before and during surgery, and those readings provide a baseline blood pressure measurement.

Pain and comfort management

Bariatric patients are at higher risk for resedation and slower drug metabolism because many pharmacologic agents are lipophilic. Supplemental oxygen and pulse oximetry are often warranted depending on the extent of surgery or the length of anesthesia, or both. Respiratory sensitivity to the depressive effects of opioids should be assessed, and opioids should be used with caution and close monitoring. Multimodal treatments are encouraged using oral analgesics, nonsteroidal antiinflammatory drugs, opioids, patient-controlled analgesia, local anesthesia, and the epidural route of pain management.

Other comfort measures for the bariatric patient include the prevention of hypothermia. Lowered body temperatures will increase metabolic workload, increase oxygen demand, and ultimately increase the work of the cardiovascular system. Deep vein thrombosis prophylaxis requires attention to the proper fitting of compression devices, taking care to avoid a tourniquet effect that can impede blood flow and cause nerve or skin damage. Attention to skin integrity and condition is important for the bariatric patient. In addition to tension on skin during positioning and movement, care should be taken to keep skin clean and dry. Obesity-related stress incontinence is common and should be monitored. Last, close monitoring of serum glucose levels will help to minimize wide variations in blood sugars.

Fluid dynamics

Subcutaneous fat often makes the process of initiating intravenous therapy a challenge. Careful monitoring of venous access sites should be a priority. Because fatty tissue is 6% to 10% water (compared with lean tissue, which is comprised of 70% to 80% water), fat contributes less fluid to total body water than does muscle mass. As a result, alterations in fluid requirements occur in the obese patient. In the healthy person, body water is 65%. In the obese person, the body water is approximately 40% of total weight. Calculations of fluid requirements must be adjusted to compensate for this reduction in total body water, and care taken to avoid rapid volume shifts will lessen cardiopulmonary compromise. Note that obese surgical patients have been found to have higher rates of postoperative nausea and vomiting, which will also affect fluid balance.

Psychological aspects

Psychological support of the obese patient should not be overlooked when perianesthesia care is administered. The perianesthesia personnel should establish a positive rapport with the obese patient before surgery whenever possible. In addition, the perianesthesia staff must not express any negative feelings about the patient or about morbid obesity in general. Many obese patients have struggled with quality-of-life issues and clinical depression. Attention to psychological support serves to minimize fear and anxiety and ultimately improve outcomes of obese patients.

Summary

The prevalence of obesity in patients seeking elective, bariatric, or emergency surgery has undoubtedly increased in recent years. Although patients with mild degrees of obesity pose few additional problems for perianesthesia and surgical management, those with a significant body mass index (BMI) require special consideration, equipment, and handling. Preoperative assessment is a key component of patient safety and preparation. Knowledge of the physiology of obesity is critical to understanding the implications of anesthesia and surgery on the overweight patient. In addition, the choice of anesthesia, patient positioning and handling, and postoperative care all require careful planning.

References

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3. Mullen JT, et al. The obesity paradox. Annals of Surgery. 2009;250(1):166–172.

4. Schumann R, et al. Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obesity Research. 2005;13(2):254–266.

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