Bariatric Surgery. Keitha Kirkham RN, BScN

Transcription

1 Bariatric Surgery Keitha Kirkham RN, BScN

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3 Civic Campus

4 BMI Obesity Definition Underweight with BMI lower than 20 Normal weight with a BMI between 20 and 25 Overweight with a BMI between 25 and 30 Obese with a BMI between 30 and 40 Morbidly obese with a BMI greater than 40 Super morbidly obese with a BMI greater than 55

5 Statistics Canada

6 Who Qualifies for Gastric Bypass Morbid Obesity with a BMI > 40 BMI >35 with the following severe comorbidities Obstructive Sleep Apnea Coronary Artery Disease Type II Diabetes Difficult to control Hypertension

7 Weight Management Clinic Initial assessment case coordinated by APN Work up Height and weight, waist circumference, baseline health screening, blood work Seen by dietician Behaviourist Referrals as needed to Psychology Psychiatry

8 Weight Management Clinic cont Social work Upper endoscopy Abdominal Ultrasound Sleep study Endocrinology Cardiology Internal medicine

9 Weight Management continued 3 hour pre operative class meal planner booklet given Preoperative consult with surgeon (Includes assessment risk benefits optifast prescription review of optifast and medications obtain consent and surgery date) Begin discharge planning

10 Pre Admission Unit (PAU) Height/weight/BMI Seen for nursing assessment and teaching Measure teds and remind female patients of pregnancy testing one week before surgery date blood work Seen by RT re CPAP device Anaesthesia consult

11 Same Day Admit (SDA) Prep for surgery as per usual TEDS if the fit is appropriate Bariatric stretcher Significant emotional support

12 Roux en Y Gastric Bypass

13 Sleeve Gastrectomy

14 Gastric banding

15 Outcomes with Roux en Y Reduce Type II diabetes by 80 90% Reduce Hypertension by 70 80% Reduce excess weight by 50 75% Resolve OSA Correct or improve infertility Improve quality of life

16 Key Anesthesia concerns IV Access May need central line Peripheral line extension set BP monitoring Use forearm or some patients benefit from an arterial line Difficult intubation Pneumoperitoneum and positioning reduces lung capacity leading to hypovolemia Peep 10cm H2O reduces atelectasis

17 Anesthetic Drug Dosing Almost all medications need to be calculated using lean body weight to prevent overdosing

18 Anesthetic considerations cont. Dexmedetomidine (Percedex) Alpha 2 agonist similar to Clonidine Anesth Analg, 2008 Jun;106(6): Double blind ASA II III morbidly obese (80) Conclusions: Adjunctive use of intraoperative Dex infusion decreased fentanyl use, antiemetic therapy and the length of stay in the PACU Did not improve overall quality of recovery.

19 Dexmedetomidine cont. Seminars in Anesthesia, perioperative medicine and pain Volume 25, issue 2 June 2006 Results in less respiratory depression and airway compromise, less nausea and vomiting, better intestinal function and potentially make this a 24 hour admisssion

20 PACU Continuous monitoring HOB 30 degrees Teds if fit appropriate Meets PACU discharge criteria If OSA OSA protocol If no episodes of desaturation after emergence can go to the trauma unit to use CPAP machine.

21 PACU Specialty equipment Bariatric beds versus stretchers

22 POST OP specialty unit HR and Oxygen Saturation Monitoring for 24 hours Clear fluids initially sips to 100cc/hr Discharged day hrs Discharged day hrs Prior to discharge endoscopy or CT for leaks

23 Case study 39 year old female 565lbs 5 6 tall BMI 91.2 Smaller upper body Lower body weight syndrome History of being overweight since age of 2 Both parents overweight mother 250 lbs

24 3 out of 4 grandparents overweight Does walk as part of job becoming more difficult joints hurt etc No other co morbidities Expectation documented by WMC and surgeon prediction only 60% loss

25 Questions?