Monday, December 3, 2007

Postoperative nursing care and complications related to gastric bypass

As the number of morbidly obese people increases with each year, bariatric (weight loss) surgery is becoming more popular. Bariatric surgery is a relatively new type of treatment for obesity that has been evolving since the 1950s (Gallagher, 2004, p. 60). Although a lot of research has been done on the surgical management of morbid obesity, a big controversy regarding success and mortality rates of gastric bypass still exists. Studies have shown that operative mortality (thirty days postoperative or more) is 0.5% for gastric bypass surgery (M. Grindel & C. Grindel, 2006, p. 133). On the other hand, surgeon M.S. Srikanth from St. Francis Hospital, Federal Way, WA states that gastric bypass mortality rate varies from 0.5 to 1.9% (personal communication, June 18, 2007). Although a person’s overall health condition can lead to his or her post procedural deterioration, nursing care remains a direct link between a gastric bypass and its outcome. A patient’s success rate can be improved by understanding the nature of gastric bypass, using preventive measures in the immediate postoperative period, and providing the patient with adequate discharge instructions.
Gastric bypass is designed to reduce excess body weight by limitation of food intake and altering digestion (Grindel M. & Grindel C., 2006, p.131). In other words, the weight loss effect is reached by malabsorption. Gastric bypass is defined as a Roux-en-Y gastroenterostomy that is done by making a one to two ounce pouch in the proximal part of the stomach, which normally can hold thirty to fifty ounces (Nettina, 2006, p. 731). It can be performed as an open procedure or laparoscopically, by horizontal stapling of the smaller proximal part, which is separated from the larger distal stomach. The proximal jejunum is anastomosed to the distal jejunum, while the distal jejunum is connected to the proximal pouch, bypassing the inferior part of the stomach (et al, p. 731). As a result of the procedure, the small gastric pouch serves as food storage. Whereas, the distal part (90 % of the stomach) remains functional. Because of the narrowed outlet of the proximal pouch, its empting is delayed. Consequently, the patient is feeling sated for longer period of time (Grindel, M. & Grindel, C., 2006, p.130-131). Although gastric bypass is one of the most commonly used bariatric surgeries, it can’t be performed on any morbidly obese person.
Weight loss surgery can be an option for the clinically severely obese with a body mass index (BMI) >40 or BMI >35 with co-morbid conditions (American Nurse Association, 2000, p. 48). Despite the fact that patients who are about to have their weight loss surgery are undergoing comprehensive health evaluation, mostly all of the bariatric patients present with a coexisting disease. The research data by Snow, Barry, Fitterman, Qaseem, and Weiss (2005) states that bariatric surgery is the first choice of treatment, for the patients who have not had any success with other methods of therapy and are presenting with co-existing conditions such as hypertension, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea, OSA (Harrington, 2006, p. 357). For instance, 193 patients, who had undergone bariatric surgery, were studied. They found out that more than 50% of the patients had hypertension, a third had OSA, and 25 % had diabetes (McGlinch, Que, Nelson, Wrobleski, Grant & Collazo-Clavell, 2006, p. S25). Therefore, nursing care of the bariatric patient should not only focus on monitoring for immediate postoperative complication but should also be meticulous in evaluating a patient for other potential complications related to the patient’s health history.
As the nature of the gastric bypass and the co-morbidity related to obesity offer quite a big challenge for nurses, the nursing care requires deep knowledge of in pathophysiology of bariatric patient. Unfortunately, the data reveals a relatively big complication incidence among these patients. According to the Centers for Disease Control and Prevention, between 1998 and 2003, 10% of gastric bypass patients developed a complication during a hospital stay (CDC, 2006). Moreover, about one fifth of the patients are readmitted to the hospital within the first year of their procedure, some of them are experiencing serious complications such as wound infection, bowel obstruction, and hernia. Since the nurses are responsible for complications monitoring and infection control, they can be accountable for inappropriate postoperative care. In fact, most of the life threatening complications can be detected, and action can be taken for its avoidance, in the early postoperative period (Srikanth, personal communication, June 18, 2007).
Nurses that are giving postoperative care to a bariatric patient should consider a few major concerns the person may be at risk for. They may be inclusive but not exclusive to anastamotic leak, thrombotic disorders, dumping syndrome, and pulmonary system complications (Grindel, M. & Grindel, C., 2006, p.137).
The research data by Podnos, Jimenez, Wilson, Stevens, and Nguyen states that the number one cause of death following bariatric surgery is intra-abdominal infection, which is a result of an anastamotic leak at the site. The most common symptoms of the leak are unexplained tachycardia, dyspnea, and restlessness (Harrington et al, 2006, p. 359). Unexplained tachycardia is the only symptom that can be indicative of the anastamotic leak for the first 24 hours after the procedure (McGlinch, et al. 2006, p. S28). So, the frequent monitoring of the heart rate and blood pressure is required in the immediate postoperative period, because changes in those values can point toward anastamotic leak or hemorrhage (Grindel, M. & Grindel, C., 2006, p. 137). However, if the patient presents with low hemogram, high serum potassium, metabolic acidosis upon arterial blood gas examination, complaining of non-incisional abdominal pain, it should alert the nurse to anastamotic leak as well (Gallagher, 2004, p. 62). In this case the surgeon should be notified immediately, so that computed tomography scans and upper gastrointestinal series with gastrographin can be performed to rule out the leak (Harrington, 2006, p. 361).
Bariatric patients are also at risk for thrombotic disorders such as deep vein thrombosis and pulmonary embolism. Therefore, heparin therapy and sequential compression devices (SCD) or antiembolic stockings should be used as the preventative measures in the immediate postoperative period. Furthermore, it is essential to do frequent checks for positive Holman’s sign, change in the pulse pattern, redness, unilateral edema, or pain to the extremities. If any of the above symptoms present, the physician should be notified immediately (M. Grindel and C. Grindel, 2006, p. 137). Finally, early and frequent ambulation is the most effective method of prevention of the deep vein thrombosis (McGlinch et al., 2006, p. S29).
Dumping syndrome is another common complication that can affect patient following gastric bypass surgery, because the pylorus sphincter is bypassed and stomach contents can rapidly pass into intestine. An increased amount of water is forced down to the intestine, which increases intestinal peristalsis as it propels food down the lower gastrointestinal tract. As the result of increased peristalsis, a patient may exhibit tachycardia, sweating, dizziness, diarrhea, and abdominal pain (Grindel, M. & Grindel, C., 2006, p. 142). On the other hand, consumption of the simple sugars can lead to dumping syndrome as well (Gallagher, 2004, p.63). Therefore, it is highly recommended for the patient to have sugar free popsicles, gelatin, and non-carbonated beverages starting on the first postoperative day and up to discharge (Grindel et al., 2006, p. 139).
The pulmonary system is one the greatest postoperative concerns in caring for a bariatric client due to the fact that a heavy weight of fatty tissue on the rib cage prevents the chest wall from full expansion (Gallagher, 2004, p.62). Moreover, anesthesia adds stress on the respiratory system, which makes the patient more vulnerable to hypoxia. Therefore, nursing care should also be focused on encouraging the patient to use incentive spirometry at least ten times every hour and keeping record of all of the readings. Oxygen saturation should be monitored frequently including a night time for those with history of OSA (M. Grindel and C. Grindel, 2006, p.137). Patients with OSA, should also continue using the continuous positive airway pressure (CPAP) machine (if they have one) as the preventative measure of apnea in the times when they are about to fall asleep. A 25° reverse Trendelenburg position of the bed is highly recommended as well since this position is associated with greater lung volumes and a reduced tendency for atelectasis (McGlinch et al., 2006, p. S26). Dr. Srikanth is simply explaining the importance of mandatory 14° reverse Trendelenburg position by the need of the obese patients to get “weight off their lungs” (personal communication, June 18, 2007). Finally, nursing care should be meticulous regarding monitoring patient’s breath sounds and frequent ambulation in order to reduce his or her risk for any pulmonary complication. In fact, M. Grindel and C. Grindel (2006) alone with other researchers suggest that the patient should be ambulating as early as two to twenty-four hours after surgery (p. 137).
Although it is essential for the client to receive the best possible nursing care, the discharge instructions are becoming more important because stays are getting shorter. Adequate postoperative teaching is a one more step towards the patient’s success following gastric bypass surgery. When teaching bariatric patient, it is essential to cover the great risks for wound infection, dehiscence, nutritional balance, and the need in life long supplementation.
Obesity itself predisposes patient to the wound infection because of the poor blood supply to the skin and large subcutaneous spaces (McGlinch et al., 2006, p. S28). Also, the wound that is hiding within a skin fold may harbor more bacteria due to excess moisture and may heal slowly (Gallagher, 2004, p. 62). However, if a gastric bypass is done laparoscopically, it has a 3% incidence of incisional infection; whereas, if it is done as an open procedure, it has a 7% incidence (McGlinch et al. 2006, p. S28). Nevertheless the prevalence of infection depends on the type of a surgical incision; nurses remain responsible for educating a bariatric patient about the infection prevention. The person may be taught about the normal drainage characteristics, its reasonable amount, and about signs and symptoms of infection. For instance, he or she should be informed that serosanguineous drainage from the noninfected wound may be indicative of dehiscence not infection (McGlinch et al., 2006, p. S28). When giving the discharge instruction on infection control, the nurse should remember that it is negligent to assume that patient knows something. In other words, a repetition will not hurt but benefit the patient later on.
Another important topic, to be covered in the patient teaching, is life long need in the supplementation. Because of the nature of gastric bypass surgery, people following the procedure have decreased absorption of vitamin B 12, iron and calcium (Grindel, 2006, p. 131). Therefore, a multiple vitamin and mineral supplementation alone with a low calorie diet (800-1000 cal/day) is essential in order to avoid deficiencies (Nettina, 2006, p. 731). Furthermore, gastric bypass patients are at risk for secondary hyperthyroidism due to the sufficient calcium levels. Although non-compliant clients usually are more prone to this complication since it can be easily corrected by vitamin D intake, it is highly recommended that the patients have their bone density monitored closely (Srikanth, personal communication, June 18, 2007).
As a final point, it is important to stress that the diet regimen slowly progresses from clear liquids on the first postoperative day, to regular diet starting the sixth week following the procedure (Grindel, 2006, p.139-141). So, the patient should be instructed how to transition to the regular diet correctly. First of all, the nurse should let the client know that the paced fluid intake with one to two ounce sip at a time can alleviate discomfort and prevent complications. Secondly, it should be emphasized that daily fluid intake is gradually increased to 48 ounces to keep self well hydrated. Finally, it is highly recommended that the patient drinks his or her fluids from 30 ounce medicinal cup in order to learn the right intake in the small amounts (Grindel, 2006, p.137).
Taking care of morbidly obese patients that are undergoing weight loss surgery can be quite a challenge. Especially with increased popularity of bariatric procedures, nurses have a greater need in understanding of the nature of gastric bypass in order to use preventive measures and providing patient with adequate postoperative teaching. As the result of continuing nursing education, the operative mortality rates can be reduced, with a significant increase in a patient’s success rate.
a. Intervention 1 (Utilization of CPAP machine in the immediate postoperative period).
I. Disadvantage 1 (A one strap mask also called a nuisance mask can’t protect a patient in the postoperative period from Farmer’s Lung disease).
Utilization of continuous positive airway pressure (CPAP) is highly recommended for bariatric clients with obstructive sleep apnea (OSA) (Harrington, 2006, p. 360). According, to Centers for Disease Control and Prevention (2002), these masks that can be seen on some CPAP machines are helpful for very large particles, whereas tiny particles that cause Farmer’s Lung still can invade the patient.
Farmer’s Lung is caused by the invasion of microscopic sized particles into the body’s natural filtering mechanisms (nose, hair and throat mucous). As they accumulate in lungs, an allergic type of pneumonia can result (Farm Safety Association, 2002). Manifestations can be similar to severe cases of flu in the early period. However, as the disease progresses, it affects ability to breathe, laboring inspirations as well as expirations. Consequently, in about five years patient will have permanent scarring of lung tissue that is irreversible (CDC, 2002).
Therefore, in order for CPAP machine to be safe and effective, the mask should have two straps, which are meeting NIOSH standards. Although one strap masks are relatively inexpensive and remain popular among general public, they predispose patients to Farmer’s Lung disease. Thus, they should not be used due to the inadequate protection against the microscopic particles (CDC, 2002). Moreover, only two strap mask can properly fit the nose in order to promote adequate ventilation. In fact, Farm Safety Association (2002) states that it is important to improve air circulation within the mask in order to prevent the growth of mold spores or limit the damage that they can cause. Failure to adjust mask can labor breathing, hit the air inside of the mask, and decrease protection (CDC, 2002).
II. Disadvantage 2 (The cost of the CPAP machine is one of the greatest obstacles for patients to begin such treatment).
For instance, the machine’s cost ranges somewhere from $ 239.99 to $ 579.99 depending on brand and retailer (CPAP Auction, 2007). Moreover, American Academy of Sleep Medicine (2007) is offering sleep education series from S 125.00 to 200.00. As the result, a lot of people remain not educated about OSA, are not yet diagnosed, or not sure how to use CPAP machine properly. American medical news have reported that medicare premiums for outpatient services (which include OSA studies) will rise 3.1% in 2008 due to the fact that that physician rates are set to be cut by 10% in January 2008 (October 22/29, 2007). Therefore, it will decrease a chance of been diagnosed and treated for OSA in people who are using this type of insurance.
b. Intervention 2 (Patient’s education regarding new diet regimen).
I. Disadvantage 1 (Mortality incidence still existing even if people are closely following the diet in the postoperative period).
As the clear liquid diet progresses to regular diet starting sixth week following the procedure, bariatric patients require more personalize attention and teaching (Grindel, 2006, p.139-141). On November 1, 2005 Swedish obese subjects were studied. Among 1338 cases, which were followed for at least ten years, the frequencies of re-operations or conversion surgeries not including the surgeries caused by postoperative complications was 17 % for gastric bypass The study have found that the most common cardiovascular causes of death were myocardial infarction, sudden death, and cerebrovascular damage. Cancer was listed as the most common cause of death from non-cardiovascular causes. (Sgostrom, L., Narbro, C., el al, 2007, p. 748).
II. Disadvantage 2 (Because of the nature of gastric bypass surgery, people following the procedure are on life long multiple vitamin and mineral supplementation).
The Rounx-en-Y gastric bypass (the most common type) causes iron, vitamin B-12, and calcium deficiencies as a result of bypassing a large portion of jejunum (Grindel, 2006, p. 131). Therefore, a multiple vitamin and mineral supplementation alone with a low calorie diet (800-1000 cal/day) is essential in order to avoid deficiencies (Nettina, 2006, p. 731). Furthermore, gastric bypass patients are at risk for secondary hyperthyroidism due to the sufficient calcium levels. So, it is very important for patients to have their bone density monitored closely (Srikanth, personal communication, June 18, 2007).
References:
American Academy of Sleep Medicine. (2007). Sleep Education Series. Retrieved November 2, 2007, from http://www.aasmnet.org/store/products.aspx?depid=19
Centers for Disease Control and Prevention. (2002). Farmer's Lung - Physical Simulation, University of Kentuky. Retrieved November 1, 2007, 2007, from http://www.cdc.gov/nasd/docs/d000101-d000200/d000153/lung3.html
Centers for Disease Control and Prevention. (2006). Women’s Health. Hyattsville, MD: National Center for Health Statistics. Retrieved July 5, 2007,from http://www.cdc.gov/nchs/products/pubs/pubd/hus/women.htm
CPAP Auction. (2007). Retrieved November 2, 2007, from http://www.cpap.com/?gclid=CKX61I3jvo8CFSFaagodmiHgYw
Farm Safety Association (2002). Farmer’s Lung. Retrieved December 2, 2007, from http://www.cdc.gov/nasd/docs/d001601-d001700/d001609/d001609.pdf
Grendinning, D. (2007). Medicare 2008 premium hike low, but doctor’s pay remains
unresolved. Retrieved November 2, 2007 http://www.ama-assn.org/amednews/2007/10/22/gvl11022.htm
Grindel, E.G., & Grindel, C.G. (2006). Nursing Care of the Person Having Bariatric Surgery. MedSurg Nursing, 15(3), 129-143. Retrieved July 5, 2007, from Academic Search Premier database (AN 21110332).
Harrington L. (2006). Postoperative Care of Patients Undergoing Bariatric Surgery. MedSurg Nursing, 15(6), 357-363. Retrieved June 23, 2007, from Academic Search Premier database (AN26359832).
Nettina, S. M. (2006). The Lippincott manual of nursing practice. (8th ed.). Ambler, PA: Lippincott Williams and Wilkins.h vice
Sjostrom, L., Narbo, K, Sjorstrom, D, Karason, K., Larsson, S., Bengtsson, C., Dahlgren, S., Gummeson, A., Jacobson, P., Karlsson, J., Lindroos, A., Lonroth, H., Naslund, I., Olbers, T., Stenlof, K., Torgerson J., agren, G., and Carlsson, L. (2007). Effects of bariatric surgery on mortality in swedish obese subjects. The New England Journal of Medicine. August 23, 1007. 357 (8), pp. 741-751.

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