Perioperative nursing care of the bariatric surgical patient

AORN Journal, July, 2008 by Patricia Ide, Elliott S. Farber, David Lautz

Approximately 60% of the US population is overweight and 30.5% of the population is obese. (1,2) Obesity ranks second to cigarette smoking as a preventable cause of death in the United States. (3) Approximately 300,000 adult deaths each year are attributable to unhealthy diets, physical inactivity, and sedentary behavior. (4) The prevalence of obesity and overweight has steadily increased in both genders, all ages, all racial and ethnic groups, all educational levels, and all geographical locations across the United States. (5)

As the prevalence of obesity and overweight has increased, so have related direct and indirect health care costs. (4) Direct health care costs refer to preventive, diagnostic, and treatment services, such as physician visits, medications, and hospital and nursing home care. Indirect costs are the value of wages lost by people unable to work because of illness or disability, as well as the value of future earnings lost because of premature death. The total annual cost of overweight and obesity is estimated to be $117 billion, with direct costs of $61 billion and indirect costs of $56 billion. (4) This is comparable to the health care costs for cigarette smoking. (4)

Currently, the most effective means of losing substantial weight and maintaining that weight loss is bariatric surgery. (6-8) The term bariatric comes from the Greek words baros (ie, weight) and iatreia (ie, medical treatment). Bariatrics is the branch of medicine concerned with the prevention and control of obesity and allied diseases. (9) Bariatric surgery is gastrointestinal surgery that alters the normal digestive process. The number of bariatric surgical procedures is increasing steadily each year, with approximately 144,000 surgeries being performed in 2004. (10,11) The success of weight loss after bariatric surgery has resulted in greater acceptance of surgery as a treatment for morbid obesity.

In 2006, the Centers for Medicare & Medicaid Services (CMS) officially recognized obesity as a disease and bariatric surgical procedures as an allowable benefit, providing opportunities for financial support to obese patients for obesity-related medical and surgical treatments. (12) Medical attempts at weight loss have a high long-term failure rate. Even if these approaches initially are successful, results from medical weight-loss treatments usually are not durable, do not result in a decrease of weight-related health problems, and do not improve survival rates. (13) Pharmaceutical treatment regimens also have been largely unsuccessful, with relatively low levels of average excess weight loss maintained over time. Bariatric surgery has been successful in the treatment of morbid obesity by achieving both weight loss and reversal of comorbidities. (14)

Caring for obese patients has created a new area of learning needs for health care professionals. Both patients and health care providers must be educated about the risks and complications associated with bariatric surgery. Policies and procedures are needed to guide health care providers who are caring for these patients. Gastric bypass procedures should be considered major surgery because they are performed on a high-risk population. (15) For example, 16 patients died after weight-loss surgery in Massachusetts between March 1, 2003, and October 31, 2004. (15)

   Sepsis and pulmonary emboli were contributing
   factors or the cause of death in 10 out of
   16 cases. The number one trend noted in the
   review of all 16 mortalities was knowledge-based
   deficits of caregivers. (15)(p1)

As a result of these deaths, the Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Bariatric Surgery reviewed all medical literature available on bariatric surgery and published best practice guidelines for clinicians and facilities performing such procedures. (16) Despite these efforts, there remains a need for better education of caregivers who are treating the increasing number of bariatric surgical patients. The purpose of this article is to assist perioperative nurses in providing safe and appropriate care for bariatric patients.

DEFINING OVERWEIGHT AND OBESITY

The term overweight refers to an excess of body weight compared to set standards. The excess weight may come from muscle, bone, fat, water, or any combination of these. The term obesity refers specifically to having an abnormally high proportion of fat. A person can be overweight without being obese, such as an athlete who has developed significant muscle mass. (17,18)

FAT DISTRIBUTION. Typically, fat distribution is different in men and women, although either type of fat distribution can be found in either gender. Central obesity or android distribution of upper body fat (ie, apple shape) is the predominant type of fat distribution in men. Conversely, women typically exhibit a lower body or gynoid distribution of fat (ie, pear shape).

CALCULATING BODY MASS INDEX. Levels of obesity can be estimated using a patient's height and weight. Body mass index (BMI) has become the medical standard to measure overweight and obesity. Although BMI cannot distinguish between muscle and body fat, this mathematical calculation generally is a good indicator of obesity and is closely associated with measures of body fat. It also predicts the development of health problems related to excess weight; however, if a person (eg, an older adult) loses muscle mass, the BMI measurement may indicate a weight is healthy when in fact it is not. (18,19)