Bariatric Patients: Intraoperative Care (Perioperative) - CE

ALERT

Obesity increases the risks of morbidity from hypertension; dyslipidemia; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; and endometrial, breast, prostate, and colon cancers.^{undefined#ref2">2,9} A high body weight is also associated with increases in all-cause mortality.

The Trendelenburg and lithotomy positions can cause respiratory and circulatory compromise to the patient who is obese.²

Use lifting and transfer devices when available.⁸

OVERVIEW

Many issues and obstacles are involved in caring for a patient who is obese. Obesity adversely affects most body systems. Obesity is defined as a body mass index (BMI) equal to or more than 30, and a BMI of more than 40 indicates morbid obesity.^2,4 To derive a patient’s BMI, the patient’s weight in kilograms is divided by his or her height in meters squared (kg/m²).⁴ For example, an adult who weighs 70 kg and is 1.75 m tall has a BMI of 22.9 (Table 1).

To maintain the patient’s dignity and safety, many factors must be considered. The unscrubbed perioperative team member, together with the other perioperative team members, must address the patient’s psychological well-being in addition to his or her physical status. The patient undergoing bariatric surgery relies on the compassion and expertise of the perioperative team to provide a safe and caring environment. The goals of bariatric surgery are to provide sustained weight loss, reversal of comorbidities, and improved quality of life.

To achieve the goal of permanent weight loss, the patient opts for one of these types of bariatric surgeries:⁶

• Restrictive surgeries, (e.g., gastric band, gastric sleeve): result in limitations in the amount of food intake and include the vertical-banded gastroplasty, laparoscopic adjustable banding, and the vertical sleeve gastrectomy.
• Restrictive with malabsorbtive combination procedures (e.g., Roux-en-Y, biliopancreatic diversion): bypass portions of the small intestine and reduce the number of calories and nutrients absorbed by the body and include the biliopancreatic diversion with duodenal switch surgeries.

The bariatric patient may have a number of comorbidities, including diabetes, cardiopulmonary disease, hypertension, hyperlipidemia, bone and joint problems, atherosclerosis, gastroesophageal reflux disease, and obstructive sleep apnea.^2,6 Increased stress on the cardiopulmonary system increases the risk of sudden death and stroke in obese patients.² The unscrubbed perioperative team member should consider the patient’s comfort and safety and assess the circulatory, respiratory, integumentary, musculoskeletal, and neurologic systems.² All comorbidities should be assessed by the entire perioperative team.

Positions such as Trendelenburg or lithotomy increase the patient’s intraabdominal pressure, causing reduced cardiopulmonary function.² Preventing positioning injuries requires selecting the necessary positioning equipment based on the patient’s individual needs and the planned operative procedure. Traditional foam positioning products may be ineffective due to compression from the patient’s weight.² Routine skin condition assessments may be difficult because of the patient’s size.

All bariatric preprocedure requirements, including a psychological evaluation, should be met before surgical intervention.⁶

PATIENT AND FAMILY EDUCATION

• Explain that privacy is maintained as much as possible while still allowing access to the surgical site.
• Explain the basic information about positioning.
• Encourage the family to participate in the patient’s treatment plan.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Perform a thorough preoperative assessment to identify the patient’s risk factors and any specific precautions related to his or her surgical procedure.
1. Assess the patient’s mobility, and musculoskeletal and nerve function.
2. Assess the patient’s ability to tolerate the position necessary for the procedure.
3. Assess the patient for any chronic or preexisting medical conditions or comorbidities (e.g., diabetes, obstructive sleep apnea, hyperlipidemia, hypertension).
4. Determine the patient’s height, weight, BMI, and age.
5. Assess the patient’s skin condition and nutritional status.
6. Assess the patient’s risk for skin breakdown using the Braden scale (Table 2) or another organization-approved assessment tool, such as the Norton scale or Scotts Trigger tool.^2,7,10
7. Determine whether the patient is at risk for nerve injury.

   Rationale: A focused preoperative assessment identifies patients at risk for skin breakdown and peripheral nerve injuries.

8. Assess the patient’s circulatory, respiratory, and neurologic systems.
9. Assess for the presence of implanted, corrective, or prosthetic devices.
10. Assess the patient’s risk for venous thromboembolism (VTE).
5. Ensure that all bariatric preprocedure requirements have been met, including a psychological evaluation.⁶
6. Identify any patient considerations that may require additional precautions (e.g., broken bones, contractures, obesity, limited range of motion).²
7. Assess for the presence of tubes, invasive lines, or equipment (e.g., traction).
8. Ask the patient about any jewelry present and ask him or her to remove it.
9. Assess the need for additional staff assistance, support devices, equipment, or padding.

Preparation

1. Ensure that appropriate-size specialty equipment and supplies are correctly functioning, clean, available, and in the operating room (OR) suite. Assemble the necessary equipment in advance.^2,6
1. A large transport stretcher with a mechanical transfer aid, such as an air powered lateral transfer device (Figure 1), designed to reduce friction and shear to the patient’s skin and protect perioperative team members from injury⁵
2. Oversized gowns, oversized blood pressure cuffs, and oversized sequential compression device hose
3. Appropriate scale if needed
4. Verify the OR bed can support the patient’s weight per the manufacturer’s instructions for use (IFU). The OR bed should be able to articulate and support a patient who weighs up to 363 to 454 kg (800 to 1000 lb).^1,9 The mattress must be able to provide sufficient support and padding and should not bottom out.¹
5. Positioning aids and side attachments, arm sleds, or toboggans for the OR bed
6. Bariatric bed for transport to the postanesthesia care unit or intensive care unit
7. Anesthesia monitoring equipment, including a difficult airway cart and hemodynamic monitoring
8. Any other specialty OR equipment for the specific procedure (e.g., extra long laparoscopic graspers)
2. Ensure that the appropriate number of available health care personnel are available to assist with transferring the patient to and from the OR safely.
3. Initiate the appropriate VTE prophylaxis therapies. Apply graduated compression stockings or an intermittent pneumatic compression (IPC) device or position the patient properly if unable to apply VTE prophylaxis therapies per the practitioner’s orders.

   Rationale: The use of mechanical devices and graduated compression stockings reduce the risk of deep vein thrombosis. ³

4. Comply with Universal Protocol.
1. Use a standardized list to verify that all required items, including informed consent, are available.
2. Mark the procedure site when required.

PROCEDURE

1. Perform hand hygiene and don head covering, mask, eye protection, and lead apron if indicated.
2. Verify the correct patient using two identifiers.
3. Transfer the patient to the OR suite. Use proper body mechanics when moving, lifting, and positioning the patient.

   Rationale: Maintaining correct body alignment while supporting the patient’s extremities and joints decreases the potential for injury during the transfer.

4. Encourage the patient to move to the OR bed on his or her own, if able, or transfer the patient from the transport stretcher to the OR bed.

Ensure that the stretcher wheel locks are engaged.

1. Ensure that the perioperative team members remain at the patient’s bedside until all safety belts and other safety devices are removed, and the patient is ready for positioning.
2. Use an appropriate lateral transfer device if the patient cannot move by himself or herself safely (e.g., an air-assisted device, a friction-reducing device, or a mechanical or powered lateral aid).⁵
5. If a urinary catheter is required, ensure that additional perioperative team members are available to assist with positioning during catheterization.
6. Place the patient in the appropriate position based on the practitioner’s preference for the surgery or invasive procedure being performed. If the supine position is required, a modification of supine, the reverse Trendelenburg position, may be preferable.

   Rationale: The reverse Trendelenburg position reduces gastric reflux, provides easier mask ventilation, and decreases thoracic pressure by improving respiratory mechanics and residual lung capacity. ²

7. Use additional appropriate positioning devices to support and protect the patient.

Rationale: A patient who is obese is difficult to position and is prone to positioning injuries from the strain the excess weight puts on the musculoskeletal and nervous systems. ⁵

1. Place pillows under the patient’s lower legs.
2. Use the appropriate OR bed attachments, such as additional oversized arm boards, arm sleds, footboards, side extensions, and padded footrests as needed for the planned surgery or invasive procedure.

   Rationale: If applicable, place the patient’s feet flat against a padded footboard to prevent rotation and increased pressure on the ankle.

3. Place a safety belt across the patient’s abdomen. Use an extra long, extra wide belt for a patient who exceeds length limits for regular safety belts.²
4. Fasten an extra wide, extra long safety belt above the patient’s knees with enough space to slide two fingers comfortably under the belt.² A second safety belt may be used below the patient’s knees if needed for the surgery or invasive procedure.

   Rationale: A tight belt places pressure on nerves and restricts venous return. ¹ Additional safety belts may be needed. An obese patient’s calves may be close to the sides of the OR bed if he or she is unable to close his or her legs. ⁹

5. Use gel rolls, axillary rolls, and pillows for a patient in the lateral or prone position and heavy-duty footrests or boots for a patient in the lithotomy position.

   Avoid the Trendelenburg position, if possible, because of the added pressure against the diaphragm and increased vascular congestion. ²

6. Place foam padding, foam wedges, and gel pads under pressure points.

   Rationale: Obese patients are at increased risk of pressure injuries. ⁵

7. Place an appropriate-size headrest under the patient’s head. The anesthesia provider may need blankets to create a “ramp” that elevates the head, neck, and shoulders, supporting airway alignment² (Figure 2).
8. Obtain approval to move the patient from the anesthesia provider before initiating the surgical site preparation.
9. Check the patient’s position once it is made final by the practitioner, before draping, and intraoperatively after any repositioning of the patient, OR bed, or equipment that attached to the OR bed.

   Rationale: Changing position may expose or damage otherwise protected body tissue. The safety belt may shift and cause increased pressure when the patient is repositioned or extra padding is added. ¹

10. Ensure that the preparation of the patient’s surgical site is completed using the appropriate solution and following the manufacturer’s instructions for use (IFU). Ensure that there is no pooling of preparation solution underneath the patient. If using an alcohol-based preparation solution, ensure that it dries completely before the patient is draped.

    Rationale: Pooling of preparation solution may cause irritation and increase the likelihood of infection. The preparation agent remains flammable until completely dry. Vapors trapped under the drapes increase the risk of fire or burn injury. ¹

11. Comply with Universal Protocol: Perform a time-out to verify correct patient, correct site, and correct procedure.
12. Perform a postoperative skin assessment at the completion of the surgery or procedure.¹

    Be aware that pressure injuries that originate during surgery have a distinguishing purple appearance that may look like a burn and fail to blanch when compressed. ⁷

13. Discard supplies, remove gloves, and perform hand hygiene.
14. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor body alignment, arms, legs, safety belt, and padding after the initial positioning and after any movement of the patient, OR bed, or any equipment that attaches to the OR bed.^1,2

   Rationale: Changing the patient’s position may expose or damage otherwise protected body tissue. The safety belt may shift and apply increased pressure when the patient is repositioned or extra padding is added.

2. Ensure adequate padding and support material between the patient’s body and any hard or metal surface of the OR bed.
3. Assess arms and legs periodically during the procedure to ensure circulatory and neurologic function.
4. Monitor devices, invasive lines, and catheters periodically during the procedure to ensure that they are working correctly.
5. Ensure that appropriate preventive maintenance and repair of positioning devices have been performed per the manufacturer’s IFU.

EXPECTED OUTCOMES

• Normal peripheral neurovascular function is maintained.
• Patient experiences no tingling, numbness, or pain unrelated to the surgical procedure or positioning.
• Normal skin and tissue integrity is maintained.
• Patient resumes preprocedure patterns of mobility.
• Patient experiences no circulatory or respiratory compromise.

UNEXPECTED OUTCOMES

• Inability to resume preprocedure patterns of mobility
• Numbness, tingling, or pain unrelated to the surgical procedure or positioning
• Impaired peripheral neurovascular function
• Circulatory or respiratory compromise or failure
• Skin and tissue breakdown
• Surgical site infection

DOCUMENTATION

• Preoperative interview, assessment, and physical examination
• Intraoperative positioning, including type and location of positioning aids
• Names and titles of perioperative team members assisting in transfer and positioning
• Musculoskeletal and neurovascular changes, if any
• Intraoperative change in patient’s position or bed, if any
• Time of intraoperative repositioning
• Time-out procedure, including verification of correct patient, correct procedure, and correct site
• Serial number, settings, and any changes in settings on surgical equipment used
• Location of return electrode pad
• Placement of sequential compression devices or compression stockings
• Preoperative and postoperative skin assessment
• Unexpected outcomes and related interventions
• Patient and family education

PEDIATRIC CONSIDERATIONS

• Normothermia must be maintained because children are prone to excessive heat loss.
• Be aware that adolescent patients may have an altered perception of their body image.
• The child’s size and weight should be considered when selecting positioning aids.
• The perioperative team members should establish a rapport with the child and family.

OLDER ADULT CONSIDERATIONS

• Normothermia must be maintained and a minimum of skin exposed when the site is prepared because older adult patients are at risk for hypothermia.
• If the patient seems confused, then short, clear instructions should be given.
• The presence of arthritis or other conditions affecting an older patient’s mobility may require additional attention to positioning.
• The thin skin layer and increased incidence of arteriosclerosis make older adult patients more prone to skin breakdown due to pressure.

HOME CARE CONSIDERATIONS

• The patient should contact the practitioner if signs and symptoms of infection appear, including fever, redness, inflammation, chills, and purulent drainage.
• The patient should contact his or her practitioner if skin breakdown, numbness, or decreased motor function occur in a nonoperative area.
• After the patient is discharged, a postoperative phone call and interview should be conducted per the organization’s practice to evaluate the patient for any indication of injury related to his or her positioning.
• The patient should be advised that discoloration from preparation solution fades with time.
• The patient should be provided with nutritional information and a detailed diet plan. This information should be reviewed with him or her before discharge.
• The patient should be instructed to follow the practitioner’s orders for regular follow-up care, diet, and counseling.

REFERENCES

1. Association of periOperative Registered Nurses (AORN). (2019). Patient skin antisepsis. In Guidelines for perioperative practice (pp. 579-606). Denver: AORN. (Level VII)
2. Association of periOperative Registered Nurses (AORN). (2019). Positioning the patient. In Guidelines for perioperative practice (pp. 637-714). Denver: AORN. (Level VII)
3. Association of periOperative Registered Nurses (AORN). (2019). Venous thromboembolism. In Guidelines for perioperative practice (pp. 1123-1152). Denver: AORN. (Level VII)
4. Devolder, B.E. (2019). Chapter 11: Gastrointestinal surgery. In J.C. Rothrock, D.R. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 287-341). St. Louis: Elsevier.
5. Fawcett, D.L. (2019). Chapter 6: Positioning the patient for surgery. In J.C Rothrock, McEwen, D.R. (Eds.), Alexander’s care of the patient in surgery (17th ed., pp. 142-175). St. Louis: Elsevier.
6. Fencl, J.L., Walsh, A., Vocke, D. (2015). The bariatric patient: An overview of perioperative care. AORN Journal, 102(2), 116-131. doi:10.1016/j.aorn.2015.05.007
7. National Pressure Ulcer Advisory Panel (NPUAP). (2016). NPUAP pressure injury stages. Retrieved October 21, 2019, from https://npuap.org/page/PressureInjuryStages (Level VII)
8. Occupational Safety & Health Administration (OSHA). (n.d.). Healthcare wide hazards: Ergonomics. Retrieved October 21, 2019, from https://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html (Level VII)
9. Phillips, N. (2017). Chapter 7: The patient: The reason for your existence. In Berry & Kohn’s operating room technique (13th ed., pp. 94-117). St. Louis: Elsevier.
10. Scott, S.M. (2015). Progress and challenges in perioperative pressure ulcer prevention. Journal of Wound, Ostomy and Continence Nursing, 42(5), 480-485. doi:10.1097/WON.0000000000000161

ADDITIONAL READINGS

Association of periOperative Registered Nurses (AORN). (2019). Care of the bariatric patient in surgery tool kit. Retrieved October 21, 2019, from http://www.aorn.org

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports