PRIMARY CARE OF THE BARIATRIC SURGERY PATIENT. Kristen Panther, RN APNP UW Division of General Internal Medicine 30 January 2013

Transcription

1 PRIMARY CARE OF THE BARIATRIC SURGERY PATIENT Kristen Panther, RN APNP UW Division of General Internal Medicine 30 January 2013

2 OBJECTIVES Brief review of surgical options Candidates appropriate for bariatric procedures Discuss post operative complications Identify common shortfalls in long term successful weight loss Review vitamin deficiencies and appropriate repletion

3 SURGICAL PROCEDURES

4 PRE-OPERATIVE PROCESS Multi-disciplinary visits At least 3 classes with Dietician, Health Psychologist, and PA May need further 1:1 counseling Many insurances require 3-6 month supervised diet Medical visits Medical clearance by surgeon Stress test >40 or history of diabetes/cardiac event CXR, EKG, full lab panel Perioperative anticoagulation, antibiotics

5 PRE-OPERATIVE PROCESS Pre-op weight loss is not tied to post operative success Average duration 6 months to surgery The referral form is your chance to air any concerns Supervised diet Many require documented weight loss Either dietician or MD/APP

6 SUPERVISED DIET DOCUMENTATION This is a supervised diet visit Height/weight Comorbid conditions Medications for those conditions Goals: healthy choices, behavioral modifications, activities Smart Text.kpdiet

7 HEALTH PSYCHOLOGY Scott Ritchie, PhD Odana Road John Martin, PhD Marshall Court

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9 EARLY COMPLICATIONS < 30 days post op DVT Anastomotic leak Bleeding/Hemorrhage PE Sepsis

10 LATE COMPLICATIONS Stricture / Stenosis Similar complaints to gallbladder disease Vomiting/dysphagia Post prandial pain Decreasing tolerance of foods Endoscopy, urgently Ulcers Nausea or vomiting Anemic Melena or hematemesis Smoking #1 risk factor Endoscopy, urgently. Check hemodynamic status

11 LATE COMPLICATIONS Dumping Nausea Trembling Diaphoresis Running to the bathroom Occurs after ingestion of foods higher in sugar, fat, artificial sweeteners Band slip or herniation Heartburn Bitter or sour taste in mouth Regurgitation, especially when lying supine UGI or KUB can help identify slip

12 LATE COMPLICATIONS Herniation (Peterson s hernia) Abdominal pain Laparoscopic surgical approach After significant weight loss Frequently missed on imaging CT scanning best, or if still high suspicion, diagnostic laparoscopy

13 STRATEGIES FOR LONG TERM SUCCESS Drink at least 64 ounces of sugar free, noncarbonated fluids daily Aim for at least 60gm lean protein daily Eat protein first! Hold fluids for before meals and after meals Move! Aim for at least 30 exercise daily Join a group, online or in person Take recommended vitamins

14 WEIGHT LOSS Pre-op weight IBW = Excess weight IBW usually corresponds to BMI of Expect 20-70% of excess weight to be lost in 9-24 months Most patients will gain 5-10% of their excess weight as they approach the 3 year mark Manage expectations

15 POST-OP DIET PLAN PHASE TIMING DIET TYPE Phase I Immediately post-op day 1 Sugar-free clear liquid SERVING SIZE KEY ¼ to ½ cup Go Slowly! Phase II Day 2 through 2-6 weeks after surgery Pureed (scrambled eggs, applesauce) ¼ cup 1 oz pureed meat -64 oz water -60 gm protein -No drinking fluids with meals Phase III After 6 weeks Regular ½ to ¾ cup -64 oz water -60 gm protein -No drinking fluids with meals

16 DAILY VITAMINS 500mg calcium carbonate, BID 1000 IU vitamin D, QD mg thiamine, QD mcg SL B12, QD MVI with iron, BID

17 ANNUAL LABS Albumin Prealbumin Vitamins D, B12, B1 (whole blood thiamine) Calcium, PTH Electrolyes CBC Iron with TIBC

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20 NEUROLOGIC COMPLICATIONS FOLLOWING BARIATRIC SURGERY Vitamin/Nutrient Incidence Complications Vitamin A 10% Xeropthalmia, night blindness, decreased immunity Vitamin B1 Common Wernicke s encephalopathy, Beriberi Vitamin B % Myelopathy, neuropathy, dementia, depression Folate 1-10% Macrocytic anemia, fatigue Vitamin D 50-60% Myopathy Vitamin E Rare Peripheral neuropathy, myopathy Copper Rare (because undiagnosed) Myelopathy, sensory ataxia Vitamin B2 14% Burning feet syndrome Vitamin B6 17% Polyneuropathy

21 REPLETION Nutrient Vitamin A Thiamine Vitamin B 12 Copper Vitamin K Iron Recommended Dose 5,000-10,000 IU/day 100mg/day IM x 5-10 days Base dose on symptoms 1000mg IM q3 months 1mg/day 300 mcg/day May need infusion Vitamin D D2 50,000 IU twice weekly for 3 months

22 MEDICATION CONSIDERATIONS Avoid NSAID medications, regardless of procedure If needed, may use up to 2 weeks, but with BID PPI dosing Avoid extended release medications Diabetic medications may be less effective, other than injectables and Metformin Evaluate for effectiveness of psych meds Administration timing with food/fluid intake

23 CLINIC ACCESSIBILITY Wall mounted toilets Max weight 350# Increase to 1000# with floor mount Standard exam tables 350# max, stirrups support less Standard chair and wheelchairs 250# max weight

24 CONCERNS