Objectives. Positioning the Bariatric Patient in the OR. Goals of Positioning. Airway challenges 6/9/2014

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1 Objectives To identify proper positioning of Bariatric patients for surgery Barbara Lawrence RN MEd ONC Clinical Education Specialist Magee-Womens Hospital of UPMC To recognize patients who are more vulnerable to position-related injuries during surgery To list devices used for Bariatric positioning patients the Bariatric Patient in the OR Barbara Lawrence RN MEd As previously disclosed, there are no companies with which I have a financial or other relationship Surgical care and safe operative positioning of the morbidly obese patient requires thought, teamwork and a methodology that promotes dignity and respect. Hunt (2007) Goals of To maintain patient s airway Avoid constriction/pressure on the chest cavity To maintain circulation To prevent nerve injury To prevent skin injury To provide adequate exposure of the operative site To provide comfort and safety to the patient Challenges: Vocal chord visualization is more difficult Lack of cervical neck mobility Partial airway obstruction due to fat pads in the oral pharynx Sleep apnea Reduced oxygen reserves oxygen consumption 1

2 Lying flat: Increases intraabdominal pressure Impairs diaphragmatic movement lung volume Hypoxemia Compression of the inferior vena cava venous return to the heart Time from induction to intubation needs to be minimized because of increased rate of oxygen desaturation Difficult intubation equipment/trache tray should be readily available lying flat often difficult Awake intubation HELP position to intubate Ramped position Extubation: Extubation should be done in reverse Trendelenberg or in a semi-upright position Patient should be fully awake prior to extubation (alert oriented and cooperative Patients with morbid obesity have an increased risk of post extubation hypoxia Oxygen therapy should be closely monitored CPAP may be necessary to maintain oxygen levels Risk of Aspiration Bariatric patients: Greater risk for aspiration Increased risk of significant damage if aspiration does occur gastric pressure aspiration risk H2 antagonist may be given pre-op to decrease gastric fluids and ph Cardiac Challenges Compression of the abdomen on the vena cava and aorta may impede circulation of oxygenated blood Patient may experience or heart rate Slowed conduction Ischemia Poor ECG tracing due to excess chest tissue Vascular Challenges risk of DVT/PE SCDs Tourniquet effect of gowns, linens & SCDs 2

3 Additional challenges Anxiety Foley catheter placement may need additional help to visualize meatus while keeping insertion procedure sterile IV access may be difficult Using a blood pressure cuff instead of a tourniquet may help distend the veins better Use of ultrasound may be necessary Skin prep pay special attention to skin folds and under the pannus AORN Recommendation II: During the planning phase of patient care, the perioperative registered nurse should anticipate the positioning equipment needed for the specific operative or invasive procedure Proper positioning is essential to prevent skin and nerve injury Foot board/props prevent patient from sliding Prevents shearing Knees and ankles can bend when the position of the patient is changed (reverse Trendelenburg) Bariatric patients require OR beds that can safely accommodate up to 1,000 pounds OR Tables must allow safe transition of the patient from the supine position into deep reverse Trendelenburg Pads and bolsters made of viscoelastic polymers reduce pressure and provide support Foam products are not as effective as they may be compressed and bottom out providing little relief of pressure Padding is essential Cotton cast padding may be placed under straps used to secure extremities Ulnar and brachial nerve pads to protect arms and elbows Pillow placed under knees can reduce back strain Pillows/wedges to prevent ankles and knees from contact/rubbing Safety straps may cause nerve damage if too tight The circulating nurse: Ensures availability of special equipment and padding material to prevent muscle, bone, nerve and skin injuries Ensure patient s weight is distributed evenly over the center of the OR bed Ensure legs, knees and ankles are in proper body alignment Applies safety straps across the upper thighs and lower legs 3

4 The circulating nurse: Ensures all pressure points are well padded and supported Ensure no metal is touching the patient s skin Secures patient s arms on padded arm boards ensuring < 85⁰ abduction from the OR bed Ensure elbow to hand does not hang over the edge of the OR table Attaches electrosurgical grounding pad to patient Apply sequential compression devices Legs can be wrapped in a blanket to support legs and keep in position of thigh adduction Temperature regulating blanket can be applied to prevent hypothermia Move away from the OR table and take a last look to make sure positioning looks OK Continues to assess extremity pulses throughout the case Continue to assess positioning throughout the case (especially if OR table position changed) Postioning The patients weight should be evenly distributed on the table without parts of the torso and limbs hanging over the side AORN Recommendation III: and transporting equipment should be periodically inspected and maintained in properly functioning condition Compromises in patient safety may result when proper equipment is not available/maintained When a procedure is scheduled, the availability of special equipment should be verified The correct patient position and related equipment should be verified during the time out period Transfers AORN Recommendation VI Potential hazards associated with patient transport and transfer activities should be identified, and safe practices should be established Immediate post-op Assess skin integrity Assess extremities for circulatory compromise Move the patient to the appropriate sized bed (lateral transfer device) Maintain airway Continue sequential compression devices Assess dressings/incisions 4

5 Intra-abdominal injury or anastomosis leak Bowel, blood vessels or organs may be inadvertently injured during surgery Insufflating the abdomen with pressure that is too high can cause respiratory or cardiac compromise Gastric band can rupture if overinflated Circulating nurse also records gastric band implant information Type of implant -- serial number Model number -- sterilization and expiration date Retained foreign body Obese patients at higher risk for retained foreign bodies due to the increased abdominal cavity size, large abdominal pannus and increased omental fat Circulating nurse ensures all sponge, instrument, sharps and accessories are accounted for and recorded on the count sheet Anesthetic emergence Oxygen levels can desaturate quickly Patient may wake slowly or resedate as medications stored in fatty tissue are metabolized Patient may be unable to support their airway due to excess nasopharyngeal tissue Treat nausea and prevent vomiting to decrease risk of aspiration and anastomotic leak At the end of surgery Assess and document patient s status and give patient hand off report to PACU nurse Skin assessment: monitor skin folds and pressure points Fluid status Oxygenation Cardiac status Incision/dressings Any complications References AORN. (2013). Perioperative Standards and Recommended Practices. Denver: AORN Publications. Ide, P; Fitzerald-O Shea; and Lautz, D (2013) Implementing a Bariatric Surgery Program. AORN JOURNAL 97(2), Neil, J; (2013) Perioperative Nursing Care of the patient undergoing Bariatric Revision Surgery. AORN Journal 97(2) Graham, D; Faggionato, E; Timberlake, A (2011) Preventing Perioperative Complications in the Patient with a High Body Mass Index. AORN Journal 94(4) AORN Bariatric Surgery Guidelines. Association of Perioperative Registered Nurses. AORN Journal. 2004; 79 (5): Walsh, A; Albano, H; and Jones, D (2008) A Perioperative Team Approach to Treating Patients Undergoing Laparoscopic Bariatric Surgery. AORN Journal 88(1) Hunt, D. Evaluating Equipment and Techniques for Safe Perioperative of the Morbidly Obese Patient. Bariatric Nursing and Surgical Patient Care. 2007; 2 (1): Ide et al, Perioperative Nursing Care of the Bariatric Surgical Patient. AORN Journal: July 2008; 88 (1): Jones, S. Airway management in Bariatric Surgery. Bariatric Times 2012;9(2): Mulligan et al. Best Practices for Perioperative Nursing Care for Weight Loss Surgery Patients. Obesity Research. February 2005; 13 (2):