Perioperative Care of Patients Undergoing Bariatric Surgery

Perioperative Care of Patients Undergoing Bariatric Surgery

SUPPLEMENT ARTICLE PERIOPERATIVE CARE FOR BARIATRIC SURGERY Perioperative Care of Patients Undergoing Bariatric Surgery BRIAN P. MCGLINCH, MD; FLORE...

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SUPPLEMENT ARTICLE

PERIOPERATIVE CARE FOR BARIATRIC SURGERY

Perioperative Care of Patients Undergoing Bariatric Surgery BRIAN P. MCGLINCH, MD; FLORENCIA G. QUE, MD; JOYCE L. NELSON, RN; DIANE M. WROBLESKI, RN, PHD; JEANNE E. GRANT, RD; AND MARIA L. COLLAZO-CLAVELL, MD

The epidemic of obesity in developed countries has resulted in patients with extreme (class III) obesity undergoing the full breadth of medical and surgical procedures. The popularity of bariatric surgery in the treatment of extreme obesity has raised awareness of the unique considerations in the care of this patient population. Minimizing the risk of perioperative complications that contribute to morbidity and mortality requires input from several clinical disciplines and begins with the preoperative assessment of the patient. Airway management, intravenous fluid administration, physiologic responses to pneumoperitoneum during laparoscopic procedures, and the risk of thrombotic complications and peripheral nerve injuries in extremely obese patients are among the factors that present special intraoperative challenges that affect postoperative recovery of the bariatric patient. Early recognition of perioperative complications and education of the patient regarding postoperative issues, including nutrition and vitamin supplementation therapy, can improve patient outcomes. A suitable physical environment and appropriate nursing and dietetic support provide a safe and dignified hospital experience. This article reviews the multidisciplinary management of extremely obese patients who undergo bariatric surgery at the Mayo Clinic.

Mayo Clin Proc. 2006;81(10, suppl):S25-S33 BMI = body mass index; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; RYGB = Roux-en-Y gastric bypass

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he vast majority of patients with extreme (class III) obesity who undergo surgical procedures do not undergo bariatric procedures. The epidemic of obesity in developed countries has resulted in patients with extreme obesity undergoing the full breadth of medical and surgical procedures, from childbirth to cardiopulmonary bypass– assisted heart surgery to emergent repairs of ruptured abdominal aortic aneurysms. Bariatric surgery, however, should always be viewed as an elective procedure. As such, preoperative planning must take into account the unique needs of this patient population and all aspects of their care. PREOPERATIVE MEDICAL EVALUATION In another article in this supplement, Collazo-Clavell et al1 detail the assessment of patients to determine their candidacy for bariatric surgery. Preoperative risk is reviewed in that article. This article reviews preoperative evaluation and focuses in depth on perioperative risks and management. The purpose of a preoperative clinical evaluation is to identify unrecognized disease that may increase the risk of Mayo Clin Proc.



surgery above that expected. Most patients undergoing bariatric surgery have completed a comprehensive medical evaluation conducted by a primary care physician. Underlying pulmonary, cardiovascular, and endocrine disorders have usually been identified, and therapies have been initiated to stabilize existing conditions. Before surgery, a health questionnaire should be completed by the patient to ensure that underlying medical conditions are stable and that no symptoms of new disease have developed. The questionnaire should also document anesthetic and surgical histories. Several versions of preoperative health questionnaires are available (Appendix).2 The patient seeking bariatric surgery rarely has a “negative” health questionnaire. Ramaswamy et al3 prospectively studied 193 patients, with a mean ± SD age of 42±10 years, who had undergone bariatric surgery. More than half of the patients had hypertension, a third had obstructive sleep apnea (OSA), and a quarter had diabetes, all of which had been identified previously and treated by primary care physicians. The authors concluded that further preoperative evaluations were unnecessary because of the participation of a primary care physician in the patient’s medical management before referral for bariatric surgery. Despite relatively higher prevalence in bariatric surgical candidates, weight-related comorbidities, when identified and managed preoperatively, do not appear to increase major surgical risk.4,5 Although performing routine studies in the absence of physical findings is controversial, a list of commonly recommended tests is detailed in Table 1.6 Many obese patients contemplating bariatric surgery do not perform adequate daily physical activity. Assessment of their exercise tolerance provides important information. Patients with low exercise capacity have twice the risk of serious postoperative complications compared to those with unlimited exercise tolerance. The inability to walk 4 blocks on level ground or climb 2 flights of stairs without

From the Department of Anesthesiology (B.P.M.), Division of Gastroenterologic and General Surgery (F.G.Q.), Department of Nursing (J.L.N., D.M.W.), and Division of Endocrinology, Diabetes, Metabolism, and Nutrition (J..E.G., M.L.C.-C.), Mayo Clinic College of Medicine, Rochester, Minn. Address correspondence to Brian P. McGlinch, MD, Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected]). © 2006 Mayo Foundation for Medical Education and Research

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TABLE 1. Suggested Preoperative Testing6 Laboratory Hemoglobin/hematocrit Serum creatinine Patients >50 y Serum electrolytes Diuretic use Electrocardiography Men >45 y Women >55 y Patients with known heart disease Patients with suspected heart disease Patients at high risk for heart disease (diabetes mellitus, hypertension) Patients at risk for electrolyte abnormalities (diuretic use) Chest radiography Patients with suspected heart or lung disease Patients >60 y

pulmonary, cardiac, or vascular symptoms correlates with poor exercise tolerance.7,8 Bariatric surgical candidates with poor exercise tolerance and symptoms or clinical evidence of heart disease should be examined by a cardiologist and possibly undergo functional cardiac assessment. Dobutamine stress echocardiography is a useful functional study for bariatric surgical candidates with known or suspected cardiovascular disease because of its ability to induce physiologic stress on the heart in the presence of serious underlying medical conditions that make treadmill evaluations difficult or impossible.9 In obese patients with coronary artery disease, dobutamine stress echocardiography may provide information regarding hemodynamic parameters associated with ischemia, allowing interventions to be made in the perioperative period to avoid these hemodynamic thresholds. Our experience is that patients with known coronary artery disease can safely undergo bariatric surgery without a major increase in perioperative mortality and cardiac complications provided a thorough preoperative cardiovascular evaluation has been completed.10 Many bariatric surgical candidates have OSA. Obesity is the most important cofactor contributing to the severity of this disorder.11 Although OSA is prevalent in patients undergoing bariatric surgery, little evidence exists linking it with bariatric surgical morbidity and mortality.12-14 The American Society of Anesthesiologists endorsed practice parameters for the perioperative assessment and management of patients with OSA15 but recognized the insufficient evidence in the medical literature linking OSA with perioperative complications. Therefore, a reasonable approach for patients with established OSA being treated with continuous positive airway pressure (CPAP) is to continue using CPAP throughout the perioperative period of any surgical procedure, particularly when sleep is likely (eg, in the recovery room or at night). Sleep studies S26

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and CPAP therapy should be pursued in individuals with clinically important symptoms associated with OSA who might benefit from CPAP therapy independent of any anticipated surgery. THE ROLE OF OBESITY IN PERIOPERATIVE RISKS PULMONARY SYSTEM The greatest perioperative concern in caring for patients with extreme obesity is the respiratory system. Fortunately, thorough preoperative evaluations have resulted in better identification and initiation of therapy for OSA and reactive airway disease, as well as treatment to help patients stop smoking. Preoperative interventions designed to optimize pulmonary function may modify the physiologic effects of obesity on the pulmonary system during the perioperative period. In obese patients, particular concerns are decreased chest wall and lung compliance, increased airway resistance, lower expiratory reserve volumes, and decreased functional residual capacity.4,16-18 Conversely, the negative effect of chest wall and abdominal adipose tissue on lung compliance, functional residual capacity, and blood oxygenation is exacerbated by position changes from upright to supine and further worsened with initiation of general anesthesia and mechanical ventilation. After awake positioning of the obese patient to optimize tracheal intubation, preoxygenation and intubation are performed with the patient in a 25° reverse Trendelenburg position. Dixon et al19 showed that this head-up position was associated with greater lung volumes, a reduced tendency for atelectasis and intrapulmonary shunting, and a 23% increase in mean arterial oxygen tensions. Using this position, a more prolonged apneic period was necessary before oxygen saturations declined to 92% when compared to similar patients anesthetized in the supine position. These authors also noted that once mechanical ventilation was initiated, no advantage for oxygenation in the head-up position could be shown. These findings are consistent with observations in both normal-weight and obese patients reported by Sprung et al20,21 that arterial oxygen tensions during laparoscopy could be improved only with higher inspired oxygen fractions, not with patient position or mechanical ventilation parameters (positive end-expiratory pressures, tidal volumes, or respiratory rates). FLUID MANAGEMENT Perioperative intravenous fluid therapy influences cardiac and pulmonary function postoperatively, but no evidencebased studies have detailed the most prudent method for fluid replacement in patients with extreme obesity undergoing bariatric surgery. Recently, Nisanevich et al22 reported that both restrictive fluid therapy (4 mL/kg per hour)

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and liberal fluid therapy (a bolus of 10 mL/kg followed by 12 mL/kg per hour) were associated with decreased oxygen saturations on the third postoperative day, but this detrimental effect did not differ between the 2 regimens. Our approach to fluid management during bariatric procedures has evolved to more restricted fluid administration based on ideal rather than actual body weight. In our clinical experience, this approach appears to have reduced the incidence of postoperative pulmonary dysfunction, specifically hypoxia, and shortened hospital stays. Invasive monitoring of arterial blood pressure or central venous pressure during laparoscopic Roux-en-Y gastric bypass (RYGB) surgical procedures is uncommon. Patients arrive for bariatric surgery relatively euvolemic because preoperative bowel preparations are not used. Blood loss during bariatric surgery is minimal, particularly in relationship to the obese patient’s blood volume. Invasive arterial monitoring is reserved for patients undergoing open surgical procedures with epidural anesthesia, for those whose arm and forearm morphology prevents proper fit of blood pressure cuffs, in circumstances in which blood glucose samples are required to manage intravenous insulin therapy, or when underlying medical conditions warrant invasive cardiovascular monitoring. PNEUMOPERITONEUM The most clinically important hemodynamic consequence during laparoscopic RYGB occurs during abdominal insufflation. Establishing a pneumoperitoneum increases systemic vascular resistance, decreases cardiac index, and transiently increases mean arterial pressure.23,24 Patients with underlying cardiovascular dysfunction may have limited ability to tolerate these hemodynamic changes. Although infrequent, reflex bradycardia (a vagal response to peritoneal stretching during insufflation of the abdomen) and hypotension (a combined result of decreased venous return from the pneumoperitoneum and relative hypovolemia from steep reverse Trendelenburg positioning) may occur. Prompt release of abdominal pressure and a return to the supine position may be necessary. Intravenous fluid therapy (to improve cardiovascular preload) and administration of an anticholinergic agent (to counter increased vagal tone) usually allow subsequent abdominal insufflation without incident. Pneumoperitoneum may be responsible for transient intraoperative oliguria resulting from pressure compression of the renal cortex and inferior vena cava during laparoscopic procedures.25-28 Nguyen et al29 reported a 64% lower urinary output 1 hour after surgical incision in patients undergoing laparoscopic RYGB compared to similar patients undergoing open RYGB procedures. Urinary output in the laparoscopic group was less than that observed in Mayo Clin Proc.



the open RYGB group throughout the procedure. Postoperatively, serum urea nitrogen and creatinine levels were not adversely affected. The reversibility of the relationship among pneumoperitoneum, renal cortex compression, and oliguria must be considered when making intraoperative decisions about fluid management. Additional fluid will not appreciably improve urinary output and may result in postoperative pulmonary complications. Impaired renal function after laparoscopy-induced oliguria during bariatric procedures has not been reported. ANESTHETIC CONSIDERATIONS Obesity may be associated with an increased risk of intraoperative awareness during general anesthesia. Once absorbed into the circulation by the lungs, the uptake of volatile anesthetic by various body tissues is influenced by tissue blood flow and body mass. Although blood flow to adipose tissue is only a small percentage of cardiac output, the capacity of fat for absorbing volatile anesthetics is substantial, particularly with lipid-soluble anesthetic agents in patients with increased stores of adipose tissue. This capacity for absorption of volatile anesthetic may contribute to a delay in reaching equilibrium between anesthetic uptake by the lungs and delivery to the brain.30 The use of less soluble volatile anesthetics (eg, desflurane or sevoflurane) allows faster times to steady state and reduces the influence of adipose volume.31 Patients anticipating bariatric surgery can be reassured that the risk of intraoperative awareness associated with bariatric procedures is not increased above the recognized baseline risk of 0.4% for all patients undergoing general anesthesia.32 PERIPHERAL NERVE INJURIES Peripheral nerve injuries represent the second most frequent cause of professional liability in anesthetic practice.33 Stretch injuries of the brachial plexus and compression of the ulnar nerve can result from excessive arm abduction, inadequate support of the outstretched arms, or prolonged flexion of the elbow.34,35 Warner et al36 assessed a single institution’s 35-year experience with perioperative ulnar neuropathy and found that 29% of patients with such injuries had a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) greater than 38 kg/m2, and 70% were male. Interestingly, ulnar neuropathies also occur in hospitalized nonsurgical patients, suggesting that patient positioning (eg, supine position, hands resting on chest or abdomen, or elbows resting on bed rails) also contributes to this condition.37 The combination of large BMI, male sex, and hospitalization for any reason places the patient at increased risk of ulnar neuropathies. Extended-width beds (to prevent arms from resting on side rails) and education (directed toward pa-

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tients, nurses, and physicians) about arm positions while the patient is in bed appear warranted. If postoperative polyneuropathies are discovered, malnutrition (particularly vitamin B deficiencies), rather than intraoperative positioning, should be thoroughly investigated.38 PERIOPERATIVE MORBIDITY AND MORTALITY Patients with extreme obesity have comorbidities that potentially influence the risks associated with any surgery. Complications unique to bariatric surgical procedures add to their surgical risk. In addition, both surgeon and facility expertise in bariatric procedures are important aspects that must be considered when referring patients for bariatric surgery. Each of these factors may contribute to perioperative morbidity and mortality in patients undergoing bariatric surgery. PATIENT FACTORS Obesity-related comorbidities (eg, diabetes mellitus, hypertension, OSA) increase the perioperative risks of pulmonary, cardiovascular, and thromboembolic complications associated with any surgical procedure. O‘Rourke et al12 and Fernandez et al13 retrospectively studied their individual practices for indicators of morbidity and mortality specifically related to bariatric surgery (both open and laparoscopic procedures). Age, sex, BMI, hypertension, diabetes mellitus, OSA, and obesity-hypoventilation syndrome were among the factors included in the analyses in one or both studies. In both studies, only age (>55 years) was found to be an independent patient-related risk factor for increased morbidity and mortality after bariatric surgery. Age was also cited as a significant risk for increased 30-day mortality in a study by Flum et al,14 who reviewed mortality after bariatric surgery in Medicare patients. These results suggest the importance of primary care interventions in identifying and stabilizing existing medical conditions before surgery, leaving only that which cannot be modified—age—as the greatest patient risk factor for bariatric surgery. CARDIOPULMONARY COMPLICATIONS Death immediately after bariatric surgery is rare, particularly death from myocardial infarction. The low death rate (<1%) is likely due to the preoperative evaluation and optimization of therapies for underlying disease in this patient population. Postoperative cardiopulmonary-associated deaths (except those associated with pulmonary emboli) may be related to lethal cardiac arrhythmias occurring in the setting of OSA. During apneic spells, arterial hypoxemia can be profound. Awakening in response to apnea is associated with significant sympathetic discharge.39 This S28

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spike in sympathetic tone in the presence of hypoxemia may induce lethal arrhythmias and death in the absence of coronary artery disease. Bariatric surgical patients with a risk or diagnosis of OSA need CPAP therapy and continuous cardiorespiratory monitoring beginning in the recovery room and extending into the postoperative period until pulse oximetry readings during sleep exceed 90% while the patient breathes room air and the need for intravenous narcotics is eliminated.15 Given the increased incidence of OSA in bariatric surgical candidates, preoperative evaluations should include assessment of OSA risk and preoperative institution of CPAP therapy when indicated. SURGICAL FACTORS Surgical complications related to bariatric procedures can be grouped into the following categories: anastomotic leaks, wound-related problems, internal hernia, thrombotic disorders, and death.40 Anastomotic Leak. The incidence of anastomotic leak from the gastrojejunostomy, a staple line, or the jejunostomy is 2% and does not differ between open and laparoscopic techniques, particularly when the surgeon is experienced in laparoscopic gastric bypass.41 Detection of an anastomotic leak postoperatively is difficult in the bariatric population, and unexplained tachycardia presenting more than 24 hours after bariatric surgery may be the only symptom. Classic physical findings of fever, abdominal pain, and peritonitis are often absent. Prompt exploration of the abdomen rather than continued observation is indicated, particularly if an anastomotic leak is highly suspected. Wound Complications. Large subcutaneous spaces and poor blood supply to the skin predispose bariatric surgical patients to wound infections. Wound infection weakens the surgical incision site and may lead to an incisional hernia. Incisional infections are significantly less common after laparoscopic bariatric procedures than open procedures (3% vs 7%).41 Incisional hernias are substantially less common after laparoscopic than after open bariatric surgical procedures (0.45% vs 9%).41 Although rarely life threatening, wound infections after bariatric surgery are associated with considerable morbidity because of the prolonged time necessary to treat the infection and the increased risk for incisional hernia. Finally, fascial dehiscence is a rare (<1%) but important postoperative event that requires immediate surgical attention. It should be considered when serosanguineous drainage occurs in noninfected surgical wounds after bariatric surgery. Internal Hernia. Internal herniation of bowel occurs rarely in patients undergoing open RYGB but has an incidence of 2% to 3% in patients undergoing laparoscopic RYGB.42,43 Laparoscopic RYGB is associated with far

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fewer intra-abdominal adhesions than open RYGB. Without adhesions to fix the bowel in place, the bowel is mobile and can herniate into intra-abdominal defects. Internal herniation may occur within the first 3 postoperative days, and a second period of risk occurs 1 to 3 years after surgery as major weight loss occurs. Detection of this complication is difficult because abdominal symptoms may be intermittent and nonspecific. However, this complication must be considered when abdominal pain develops after laparoscopic RYGB regardless of the interval from the original surgery. Abdominal exploration is warranted if the patient appears ill or sepsis is suspected. Thrombotic Disorders. Deep venous thrombosis is uncommon after bariatric surgery, and its incidence does not differ between open or laparoscopic procedures.41,44 Patients with a history of venous stasis disease (chronic leg edema, venous insufficiency, stasis dermatitis) preoperatively are at higher risk of perioperative deep venous thrombosis and pulmonary embolism.44,45 Prophylaxis for thrombotic disorders in bariatric surgical patients remains controversial, but prudence suggests the use of a combination of mechanical devices (sequential alternating compressive devices on the lower extremities), prophylactic low-dose anticoagulation (heparin or a fractionated heparin compound), and early, frequent ambulation.46 Prophylactic placement of a vena caval filter (temporary or permanent) before bariatric surgery is recommended for patients with documented venous stasis disease, previous pulmonary embolism, or known hypercoagulable conditions.44,45,47 Death. In the United States, death within 30 days after bariatric surgery is lower than 1%.48 This cited incidence is somewhat deceiving because it includes all bariatric procedures performed at all US institutions. Courcoulas et al49 reported a 30-day mortality of 0.3% in patients treated at a high-volume bariatric center. However, Flum and Dellinger50 identified a 4-fold higher 30-day mortality after gastric bypass operations performed by surgeons in lowvolume bariatric surgical practices compared with procedures performed by experienced surgeons (>100 laparoscopic bariatric procedures) and in high-volume bariatric centers. Clearly, both surgeon and facility experience with bariatric procedures are directly related to postoperative complication and death rates. SURGEON EXPERTISE Laparoscopic bariatric surgery is considered one of the most challenging procedures performed by general surgeons. Three recent studies that evaluated outcome after bariatric surgical procedures41,48,51 concluded that surgeon experience with laparoscopic gastric bypass directly contributed to the incidence of postoperative complications. Complications unique to laparoscopic bariatric procedures Mayo Clin Proc.



(eg, anastomotic leaks, internal hernia) were highest when the surgeon had performed fewer than 75 laparoscopic bariatric operations. As surgeon experience exceeds 100 cases, major complication rates become comparable between laparoscopic and open bariatric techniques. This information should be considered when primary care physicians refer patients for bariatric surgical procedures. HOSPITAL FACILITY EXPERTISE Hospitals with high-volume bariatric surgical practices have overall mortality rates of 0.5%.41,52 This observation was supported by Nguyen et al,40 who evaluated a health system database for the outcomes of all patients who underwent RYGB between 1999 and 2002 (N=24,166). Mortality was significantly less in high-volume (>100 procedures per year) compared to low-volume (<50 procedures per year) facilities (0.3% vs 1.2%; P<.01). In patients older than 55 years (the highest-risk patient population for bariatric procedures), high-volume facilities again had significantly less mortality than lower-volume facilities (0.9% vs 3.1%; P<.01). Along with lower mortality, high-volume facilities had significantly lower overall complication rates (10.2% vs 14.5%; P<.01) and shorter hospital stays (3.8+2.9 days vs 5.1+4.0 days; P<.01) compared to lowvolume facilities. In light of this information, limiting bariatric procedures to high-volume bariatric centers, although controversial, may be indicated. NURSING CARE Planning and communication are key elements for nursing care that honors patient wishes, preserves patient dignity, and can be amended as hospital stay progresses. Planning begins before the patient arrives at the nursing unit. Without adequate equipment to support the challenges of caring for markedly obese patients, simple functions such as patient mobilization, transfers, ambulation, and even positioning in bed can be considered as problems at best or threats at worse by nursing and other allied health staff. Specially built nursing units with overhead lifts, wider doorways, and sturdy fixtures designed to meet the needs of this patient population are essential. Nursing units should have access to portable hydraulic lifts, transfer mattresses that support patients with a cushion of air, and extended-width and weight-rated beds, commodes, and chairs. Extended-size gowns, pants, and robes should be available. Respiratory support with CPAP and bilevel positive airway pressure therapy should also be readily available. All these factors promote a safe and dignified environment. The plan of care can result from care conferences and/or daily focused conversations with the patient. Instructions

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for safe patient transfers and equipment and personnel needs should be addressed. Physical therapists can help coach nursing staff on safe transfer techniques, and occupational therapists can teach patients how to make routine daily activities easier. Clinical nurse specialists can offer skin care support. Discharge planners and social workers can help the nursing staff plan for care after discharge. Assessment of the patient for early signs of complications is an important part of good nursing care. Postoperative assessments for hypovolemia, electrolyte imbalances, deep venous thrombosis, anastomotic leaks, and cardiopulmonary dysfunction are critical. Explanation of the need for early postoperative ambulation and performance of deep-breathing/coughing exercises, instructions regarding the 0 to 10 pain assessment scale, and the use of a patientcontrolled analgesia device improve patient participation in the healing process. We have also found that the use of preemptive-type pain control with early postoperative continuous epidural analgesia promotes ambulation and deep breathing without producing systemic narcotization. Management of postoperative analgesia with conversion from intravenous to oral agents warrants the assistance of a pharmacist to provide equianalgesic agents and doses to ensure that the patient is comfortable during breathing exercises and ambulation. Limiting the number of caregivers increases patient privacy, safety, and comfort through continuity of care and promotes a positive patient attitude toward planning for discharge. Moreover, focusing the care of bariatric surgical patients on specific nursing units allows staff to develop both the expertise and the sensitivity needed to care for such patients.

cups (equivalent to 1 fluid ounce or 2 tablespoons). With the pureed diet, patients are advised to consume 6 medicine cups of protein-rich food per day at the beginning of each meal. Typically, the patient receives a pureed diet for at least 1 day before hospital dismissal. Tolerance to the diet is monitored closely, with particular emphasis on adequate fluid intake to prevent dehydration. The patient is instructed to take 2 chewable multivitamin/multimineral supplements daily in addition to daily calcium supplements and to consume 1500 to 2000 mg of calcium per day from a combination of calcium-rich food/ liquids and calcium supplements. At our institution, a registered nurse instructs the patient on self-administration of subcutaneous vitamin B12 injections, which are prescribed monthly. After bariatric surgery, we provide patients with a restaurant card that requests that patients be allowed to order special meals or even reduced (eg, children’s) portions to better meet their dietary needs. Before discharge, an appointment can be arranged for the patient to receive follow-up care by a registered dietitian, preferably coordinated with other follow-up appointments. CONCLUSION For patients to experience the potential health benefits of bariatric surgery, risks imposed by their obesity and the planned bariatric operation must be managed carefully. Preparation with communication and coordination of services by all disciplines involved in the patient’s care becomes a critical part of providing a safe and dignified environment while working to minimize the risk of postoperative complications during and after the patient’s hospital stay.

NUTRITIONAL THERAPY Educating bariatric surgical patients about nutritional therapy should begin early in the assessment process, as described elsewhere in this supplement by Collazo-Clavell et al.1 An in-hospital registered dietitian experienced in bariatric surgical counseling should reinforce the dietary restrictions explained initially in the preoperative period because they are introduced during the patient’s hospitalization. Despite the brief hospital stay associated with bariatric surgery, the dietitian should meet with the patient regularly to discuss specific nutritional guidelines and review postdischarge dietary progression, which is optimally outlined in printed patient education materials. Dietary progression after bariatric surgery consists of 1 or 2 days of clear and/or full liquids before initiation of pureed foods (see Table 2 in the article by McMahon et al53 elsewhere in this supplement). Patients are instructed to measure, not weigh, pureed foods using small medicine S30

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30. Eger EI II, Saidman LJ. Illustrations of inhaled anesthetic uptake, including intertissue diffusion to and from fat. Anesth Analg. 2005;100:10201033. 31. Domino KB, Posner KL, Caplan RA, Cheney FW. Awareness during anesthesia: a closed claims analysis. Anesthesiology. 1999;90:1053-1061. 32. Sebel PS, Bowdle TA, Ghoneim MM, et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg. 2004; 99:833-839. 33. Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: a closed claims analysis. Anesthesiology. 1999;90:10621069. 34. Abir F, Bell R. Assessment and management of the obese patient. Crit Care Med. 2004;32(4 suppl):S87-S91. 35. Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia. 2000;55:980-991. 36. Warner MA, Warner ME, Martin JT. Ulnar neuropathy: incidence, outcome, and risk factors in sedated or anesthetized patients. Anesthesiology. 1994;81:1332-1340. 37. Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. Ulnar neuropathy in medical patients. Anesthesiology. 2000;92:613-615. 38. Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, Norell JE, Dyck PJ. A controlled study of peripheral neuropathy after bariatric surgery. Neurology. 2004;63:1462-1470. 39. Kaw R, Michota F, Jaffer A, Ghamande S, Auckley D, Golish J. Unrecognized sleep apnea in the surgical patient: implications for the perioperative setting. Chest. 2006;129:198-205. 40. Nguyen NT, Paya M, Stevens CM, Mavandadi S, Zainabadi K, Wilson SE. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg. 2004;240:586-593. 41. Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. 2003;138:957-961. 42. Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13:596-600. 43. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-enY gastric bypass: incidence, treatment and prevention. Obes Surg. 2003;13: 350-354. 44. Prystowsky JB, Morasch MD, Eskandari MK, Hungness ES, Nagle AP. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery. 2005;138:759-763. 45. Sapala JA, Wood MH, Schuhknecht MP, Sapala MA. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg. 2003;13:819-825. 46. Agnelli G. Prevention of venous thromboembolism in surgical patients. Circulation. 2004;110(suppl):IV4-IV12. 47. Keeling WB, Haines K, Stone PA, Armstrong PA, Murr MM, Shames ML. Current indications for preoperative inferior vena cava filter insertion in patients undergoing surgery for morbid obesity. Obes Surg. 2005;15:10091012. 48. Nguyen NT, Silver M, Robinson M, et al. Result of a national audit of bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project. Arch Surg. 2006;141:445449. 49. Courcoulas A, Schuchert M, Gatti G, Luketich J. The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. Surgery. 2003;134:613-621. 50. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543-551. 51. Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243:181-188. 52. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235:640-645. 53. McMahon MM, Sarr MG, Clark MM, et al. Clinical management following bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc. 2006;81(10, suppl):S34-S45.

October 2006;81(10, suppl):S25-S33

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PERIOPERATIVE CARE FOR BARIATRIC SURGERY

APPENDIX. REPRESENTATIVE PREOPERATIVE HEALTH QUESTIONNAIRE THAT SHOULD BE COMPLETED BARIATRIC SURGICAL CANDIDATES SHORTLY BEFORE HOSPITAL ADMISSION

BY

Patient's Name ______________________________________________________________ Age ______________ Sex __________________ Planned Operation ____________________________________________________________________ Date of Surgery ___________________ Surgeon ____________________________ Primary Doctor _______________________________ Here before:

Yes

No

Cardiologist? _________________ When last seen ______________ Is your cardiologist at this institution?

Yes

No

Your height _______________ Your weight: ______________ Your weight at age 21: ______________ 1.

Please list ALL OPERATIONS (and approximate dates)

a. _____________________________________________________

d. ______________________________________________________

b. _____________________________________________________

e. ______________________________________________________

c. _____________________________________________________

f. _______________________________________________________

2.

Please list ALLERGIES to medicines, latex or other (and your reaction to it)

a. _____________________________________________________

c. ______________________________________________________

b. _____________________________________________________

d. ______________________________________________________

3.

Please list ALL MEDICATIONS you have taken in the last month (include OVER THE COUNTER drugs, inhalers, herbals, dietary supplements, vitamins, and aspirin)

Name of Drug

Dose & Frequency

a. ____________________________________________________

Name of Drug

Dose & Frequency

f. ______________________________________________________

b. ____________________________________________________

g. ______________________________________________________

c. ____________________________________________________

h. ______________________________________________________

d. ____________________________________________________

i. ______________________________________________________

e. ____________________________________________________

j. ______________________________________________________

(Please check YES or NO and circle specific problems) 4. 5.

YES NO

Have you taken steroids (prednisone or cortisone) in the last year? Have you ever smoked? (quantify in ________ packs/day for _______ years) Do you still smoke? Do you drink alcohol? (if so, when was your last drink? __________________) If so, have you ever had a problem drinking? Do you use any illegal drugs?

6.

Can you walk up TWO flights of stairs without stopping?

7.

When did you last walk up two flights of stairs _____________ or walk 6 blocks

8.

Have you had any problems with your heart? (circle) (chest pain or pressure, heart attacks,

without stopping _____________________ ?

abnormal EKG, skipped beats, heart murmur, palpitation, heart failure {fluid in the lungs}, require antibiotics before routine dental care) 9.

Do you have or have you ever had high blood pressure?

10. Have you had any problems with your lungs or your chest? (circle) (shortness of breath, emphysema, bronchitis, asthma, TB, abnormal chest x-ray) 11. Are you ill or were you recently ill with a cold, fever, chills, flu or productive cough? Describe recent changes 12. Have you or anyone in your family had serious bleeding problems? (circle) (prolonged bleeding from nosebleed, gums, tooth extractions, or surgery) 13. Have you had any problems with your blood (anemia, leukemia, sickle cell disease, blood clots, transfusions)? If yes, when 14. Have you ever had problems with your: (circle) Liver (cirrhosis, hepatitis, jaundice)? Kidney (stones, failure, dialysis)? Digestive system (frequent heartburn, hiatus hernia, stomach ulcer)? Back, neck or jaws (TMJ, rheumatoid arthritis)?

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October 2006;81(10, suppl):S25-S33



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PERIOPERATIVE CARE FOR BARIATRIC SURGERY

(Please check YES or NO and circle specific problems)

YES NO

15. Have you ever had: (circle) Seizures, epilepsy, or fits Stroke, facial, leg or arm weakness, difficulty speaking? Cramping pain in your legs with walking? Problems with hearing, vision or memory? 16. Have you ever been treated for cancer with chemotherapy or radiation therapy? (circle) 17. Women: could you possibly (even remotely) be pregnant? Last menstrual period began: 18. Have you ever had problems with anesthesia or surgery? (circle) (severe nausea or vomiting, malignant hyperthermia (in blood relatives or self), prolonged drowsiness, anxiety, breathing difficulties) 19. Do you have any chipped or loose teeth, dentures, caps, bridgework, braces, problems opening your mouth, swallowing or choking? (circle) 20. Do your physical abilities limit your daily activities? 21. Do you snore? 22. Please list any medical illnesses not noted above: _____________________________________________________________________________ _____________________________________________________________________________ 23. Additional comments/questions for nurse or anesthesiologist _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

From Elsevier,2 with permission.

Mayo Clin Proc.



October 2006;81(10, suppl):S25-S33



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For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.

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