Bariatric Patients: Intraoperative Care
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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
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
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
Rationale: A focused preoperative assessment identifies patients at risk for skin breakdown and peripheral nerve injuries.
Rationale: The use of mechanical devices and graduated compression stockings reduce the risk of deep vein thrombosis.
Rationale: Maintaining correct body alignment while supporting the patient’s extremities and joints decreases the potential for injury during the transfer.
Ensure that the stretcher wheel locks are engaged.
Rationale: The reverse Trendelenburg position reduces gastric reflux, provides easier mask ventilation, and decreases thoracic pressure by improving respiratory mechanics and residual lung capacity.
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.
Rationale: If applicable, place the patient’s feet flat against a padded footboard to prevent rotation and increased pressure on the ankle.
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.
Avoid the Trendelenburg position, if possible, because of the added pressure against the diaphragm and increased vascular congestion.
Rationale: Obese patients are at increased risk of pressure injuries.
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.
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.
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.
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.
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
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