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Care of the Bariatric Patient
Objectives
 Define the classifications of obesity and explain
  the impact and costs related to obesity

 Explain the considerations in caring for the
  obese patients due to their pathophysiology

 Identify health and safety risks associated with
  the obese patient

 Discuss treatment options for obesity and how to
  provide weight sensitive care

                                                      2
What do we mean by the bariatric patient?


Bariatric comes from the Greek word baros
            which means weight.

  This means the patient of greater size,
   usually a body mass index of >30.



                                            3
Classifications of Obesity using
       Body Mass Index (BMI)

Uses Patient’s Height and Weight

Correlates with Total Body Fat Content

Go to
http://www.sharp.com/tools/bmi.cfm
to calculate your own BMI




                                         4
Morbid Obesity Defined
         80-100 lbs Overweight
         Body Mass Index=BMI

Acceptable Range         18.5 – 24.9
Overweight               25 – 29.9
Obese                    30 – 34.9
Severe Obesity           35 – 39.9
Morbid Obesity           40 – 49.9
Super-Morbid Obesity     50 – +++
                                       5
Measures to Assess Health Risks Related to
                 Obesity
Neck circumference: > 16-17 inches is related to greater risk
              Obstructive Sleep Apnea (OSA).




              Increased waist circumference
   >40 inches for men or >35 inches for women is related to
                   greater metabolic risks.
                                                                6
Impact of Morbid Obesity
 Causes 300,000 deaths per year in
  the United States

 Smoking and obesity are the leading
  preventable causes of death in the
  United States

 Modern worldwide epidemic


        American Obesity Association
                                       7
Prevalence of Obesity
Over 67% of adult Americans are overweight
     26% are obese or morbidly obese

 In 2010, adult obesity rates increased and
       reached 30 % in eight states




 High BMI in the U.S. is approximately
    10 % for infants and toddlers
    18 % for adolescents and teenagers
      Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008
                                                                                     8
      http://healthyamericans.org/reports/obesity2010/
High Cost of Obesity
 Currently, 9 % of all health care dollars are spent
for the treatment of obesity and its complications

Some estimate it will climb to 21% of all health care
dollars by 2018

Undetermined costs related to hospital worker
 injury




                                                                                      9
              http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
Test Your Knowledge
Currently, approximately 2/3 of Americans
 are considered overweight or obese


                True

                False
                                            10
What is Morbid Obesity?
Chronic multi-factorial metabolic
 disease

   Life-long
   Progressive
   Degenerative
   Life-threatening
   Genetically related
            http://win.niddk.nih.gov/statistics/index.htm
                                                            13
Morbid Obesity is a
               Metabolic Disease
 As BMI increases, adipose tissue becomes metabolically active
  and secretes hormones

 These hormones influence insulin resistance, hyperlipidemia,
  inflammation, thrombosis, and hypertension

 The mucosa of the stomach of obese persons secretes higher
  levels of the hormone Ghrelin which increases appetite




                                                            14
The Disease of Morbid Obesity
 Neuropeptides and neurotransmitters in the brain, mainly the hypothalamus, and
  other hormones affect satiety, appetite and weight regulation




 Interestingly, Leptin, a hormone that is secreted by adipose tissue and
  decreases hunger, is found in higher levels for obese persons but it is believed
  they are “leptin resistant”
  The next two slides will demonstrate the complexity of this
  disease!




                                                                              15
Obesity and Neurohormonal Influences

                                         Located in the brain


  Orexogenic Mediators               Anorexic Mediators
   Affects hunger                      Affects satiety
     Conserves energy              Increases energy expenditure
 Cannabinoid receptor activation          POMC + α MSH
           Orexin A                      Leptin receptors
       MCH and AGRP                       CRH/Urocortin
       Neuropeptide Y                CNS Vagus nerve activation
          Dynorphin                         Serotonin
           Galanin                          Dopamine
    Beacon gene activation           CART (Cocaine Associated
CNS Sympathetic nerve activation        Receptor Transcript)
                                                                  16
Adipose Tissue Affects Many
 Stomach                   Pancreas
              Organs
CCK                                           Reduced glucose,
Enterostatin                                  Insulin, glucagon
Peptide YY (3-36)      Adipose Tissue         and GLIP
                           Secretes:
                    Tumor Necrosis Factor α        Skeletal
                         Interleukin-6
   Liver                                           Muscle
                            Leptin



                                              Uncoupling
Reduced hepatic glucose                       proteins 2 and 3
                                                            17
Pathogenesis of Obesity
 Behavior and lifestyle habits are often determinants
           in the development of the disease




 But, it is also extremely important to also
  understand the metabolic mechanisms that
  influence body weight
 For persons who are overweight and mildly obese,
  dieting and exercise are very effective for weight
  loss
                                                       18
Challenges for the Morbidly Obese
Changes with hormones and the central nervous system
make it VERY CHALLENGING to sustain weight loss long
           term by dieting and exercise alone.




At least 85 % regain their weight and more over time
                                                  19
Key Points
• Morbid Obesity is a chronic metabolic disease


• Diet and exercise are very effective for weight loss
  for those who overweight and mildly obese

• Neurohormonal changes for the morbidly obese
 make it very challenging for them to sustain
 weight loss long term by dieting and exercise
 alone

                                                    20
Test Your Knowledge
Ghrelin is a hormone which is secreted by
 adipose tissue and decreases hunger


                True

                False
                                            21
Co-Morbidities of Obesity
Co-morbidities are conditions or diseases
 caused by or made worse by obesity

For example, asthma, gout, and arthritis may be
 made worse due to the chronic inflammation
 associated with obesity

It is important to educate patients about their
   health risks associated with obesity
                                                  24
Metabolic Syndrome X is linked to Obesity
 Insulin resistance

 Hyperinsulinemia

 Hyperglycemia

 Hyperlipidemia
                                    IR= Ins ulin
                                    Res istan ce
                                    ROS=Rea ctiv e
                                    Oxy gen Species

 Hypertension

 Heart Disease

                                                      25
American Heart Association
 Definition of Metabolic Syndrome
Increased waist circumference: > 40 inches for men or > 35
inches for women

Elevated triglycerides: Equal or > 150 mg/dL

Reduced HDL (“good”) cholesterol: < 40 mg/dl for men and
< 50 mg/dL for women

Elevated blood pressure: Equal to or greater than
130/85 mm Hg or use of medication for hypertension

Elevated fasting glucose: Equal to > 100 mg/dL
(5.6 mmol/L) or use of medication for hyperglycemia
                                                        26
Stroke
 Increased risk for ischemic stroke in both men and women




 Ischemic stroke increases progressively and is doubled in
  those with a BMI > 30 when compared to those having a
  BMI < 25

 Obesity is not proven to be an increased risk for
  hemorrhagic strokes                                           27
                      J. La State Med Soc. 2005, 156, S42-49.
Cardiovascular


   Considerations
 Increased total blood volume

 Left ventricular hypertrophy and decreased ventricular
  contractility can occur

 About 75 % of individuals with hypertension have an
  obesity link

                                                                                                       28
            American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1818
ECG Considerations
 Increased fat deposits around the heart may lead to
   degeneration of the conduction system which causes
   lethal heart rhythms

 Large body mass may cause difficulty with landmarks
   for lead placement and inconsistent or decreased
   voltage

 Prolonged QT intervals

 Non-specific flat/inverted T waves
    in inferior leads
 Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804.
 Zacharias, A. Schwann. T. Riordan, C. et al (2005) Obesity and risk of new-onset of atrial fibrillation after cardiac surgery. Circulation 112 (32), 3247-3255

                                                                                                                                                                  29
Diabetes Mellitus
 Type 2 diabetes mellitus (DM) is strongly associated with
      overweight and obesity in both genders and in all ethnic
      groups

       90 % of all patients with type 2 DM are overweight or obese

     The risk for type 2 DM also increases in individuals with a
      more central distribution of body fat (abdominal)

 Modest weight loss (medical or surgical weight loss), even 5-
      10% loss can have significant improvement of type 2 DM
Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and
Obesity-Related Health Risk Factors, JAMA, (289),76-79.

                                                                                                                                                                    30
Renal Impact
 Some drugs may impact the renal system
      in high BMI patients due to high glomerular
      filtration rates


 Increased intra-abdominal pressure may
      lead to hypertension and insult to the kidney


 If BMI is more than 30, nearly twice the risk for kidney failure
      If BMI of 40 or above, seven times the risk of kidney failure


Blackwell Publishing Ltd. (2006, December 26). Obese Kidney Transplant Patients Twice As Likely To Die In The First Year Or Suffer Organ
Reference: June Journal of the American Society of Nephrology (2006) http://www.sciencedaily.com/releases/2006/01/060105082226.htm

                                                                                                                                           31
Nonalcoholic Fatty Liver
If BMI > 40, the prevalence of:

Nonalcoholic fatty liver disease (NAFLD) is more than 95%
Nonalcoholic steatohepatitis (NASH) may be as high as 25%.




Sustained liver injury leads to progressive fibrosis and cirrhosis in
  10% to 25% of affected individuals.
                 http://bariatrictimes.com/2010/01/21/nutrition-in-the-management-of-nonalcoholic-fatty-liver/
                 http://www.ccjm.org/content/71/8/657.full.pdf
                                                                                                                 32
Obesity Related Cancer

 Obesity related cancer death rates are 14% for men
  and 20% for women

 Obese women have a 50% increase risk for breast
  cancer after menopause

 Obese men are 30-50% more likely as lean men to
  develop colon cancer

 Obesity related cancers include prostate, lymphoma,
  liver, pancreas, and gallbladder

                 American Cancer Society
                 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119
                                                                                     33
Reproductive Impact
Imbalance of the sex hormones especially androgens
                and estrogen leads to:




Irregular menstrual cycles
Increased androgenization and facial hair
Polycystic ovarian syndrome (PCOS)
Decreased conception rates after fertility treatments
                                                    34
Physiological changes in the obese patient
increases their risk for adverse events and
         potential complications




It is extremely important to consider these
    changes in the way you provide care!

                                              35
High Risk for Blood Clots
Obesity is characterized by:

Chronic inflammation
Decreased immunity
Hypercoagulability


This is due to:

•   Decreased antithrombin-III
•   Increased tumor necrosis factor α and interleukin-6
•   Impaired neutrophil function
•   Increased blood volume

                                                                        36
                      Critical Care Medicine 2006 Jun;34(6):1796-804.
Prevent Blood Clots by Early
               Ambulation
Mobilize patients early and frequently
 The efficacy of sequential
  compression devices and TED hose
  for obese individuals is unknown
 Chronic inflammation and
  hypercoagulation increase the clot
  risk
 There are limited studies about
  anticoagulation and the obese
 The weight of the large pannus
  (abdominal fold) creates pressure
  on the deep vessels and increases
  the risk
                      Critical Care Medicine 2006 Jun;34(6):1796-804.
                                                                        37
Test Your Knowledge
Which statement is not true about the increased risk for blood
 clots and the obese individual?

     A. The weight of the abdomen on deep vessels increases
  the risk

    B. Little is known about the efficacy of SCDs and TED
  hose

     C. Studies on anticoagulation and obesity are limited

     D. There is no increased risk
                                                             38
Pulmonary Considerations
  Obese patients desaturate very rapidly due to decreased
            respiratory reserve and lung capacity.

Assess reasons oxygen saturation levels are less than 92 %.
            Immediate intervention is critical.

The reverse trendelenberg position is the optimal position as
  it drops the pannus (abdominal fold) from the diaphragm.




        Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal
                                                                                                                              41
        volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106.
Pulmonary Considerations
Preoxygenate before procedures such as suctioning. It is vital.




Keep upright or semi-recumbent as long as possible before
procedures.
Plan rest periods during most activities as dyspnea is common.
                                                            42
Obstructive Sleep Apnea (OSA)
Rates of OSA are high, about 71-77% if morbidly obese If also
  diabetic, it is about 86% and often undiagnosed

Assess if patient has symptoms of OSA:
• Snoring
• Patient has been told they stop breathing for periods of time
  during sleep
• Daytime sleepiness
Ask the patient if they use a CPAP machine at home




                                                            43
OSA and Obesity
 Obtain order for Pulmonary Services if patient
               uses CPAP at home




           Patients may also require:
• continuous oxygenation saturation monitoring
• planning for difficult airway management
                                              44
RAMP (Rapid Airway Management
    Position) for Procedures
Align the top of the ear with the sternal notch

Ramp up or raise
the occipital area
using pillows or towels

Form a trapezoid shape
beneath the back of the head
            Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260                                  45
            Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni
Regional Anesthesia
              Considerations
Increased abdominal pressure may decrease cerebral
      spinal fluid volume which may lead to higher
                    neuroaxial blockade

Monitor patients closely for respiratory compromise




                                                      46
Weight and Drugs
Caution must be used for drugs highly soluble
 in fat, especially with extended time duration,
 > 12-24 hours include:

   Opiate analgesics (Morphine, Dilaudid, etc)
   Carbamazepine (Tegretol)
   Propofol
   Fentanyl
   Midazolam (Versed)

                                                  47
Pain Management
 Avoid Intramuscular injections

 Pain medication in the obese patient is largely
  unknown

 Narcotics may lead to “Resedation Phenomenon”
 Adipose tissue leads to unpredictable absorption
 and a delayed response of these drugs

 Assess sedation levels and for respiratory
  depression very closely especially if patient has
  OSA

                                                      48
Drugs and the Obese Patient
 Pharmacodynamic and kinetic data are not available for
  many medications such as antibiotics, pain medications, etc.

 Generally, dose to a patient’s ideal body weight plus 40% of
  the excess body weight

 Start “low and go slow” is the best approach




                                                             49
Venous Access
Landmark vessels may be hard to palpate or visualize.

 Consider Infusion Services to avoid multiple IV
  sticks. Midline and PICC catheters may be a better
  option depending on the length of therapy.

 Assess carefully for signs of phlebitis due to excess
  skin, subcutaneous fat and moisture in skin folds.

 Assess if standard 1.5-in needles are long enough.




                                                       50
GI Impact
Monitor for greater aspiration risk due to high:
   gastric fluid volume
   GI reflux
   incidence of Hiatal Hernia

High Incidence of Gallstones
   Normally, acids in bile keep cholesterol from
     forming into stones

   With obesity, cholesterol in the bile increases
    beyond the ability of acids to maintain the
    cholesterol in suspension, the cholesterol
    crystallizes and form stones

                                                     51
Skin Care Considerations
 Inspect for moisture and irritation in skin folds as this may lead
  to infection

 Ask the patient if they are able to perform their personal
  hygiene:
    Obtain adaptive supplies and consult skin team if needed
    Offer assistance

 Move all lines, tubes, catheters (if possible) and the pannus
  (abdominal fold) every 2 hours to prevent atypical ulcers




 Assess for wound healing since adipose tissue less
  vascularized
                                                                                                                               52
           Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.
Musculoskeletal
      Considerations
Patients have increased:

 joint trauma/pain
 disuse and atrophy of musculature



Prevent injury to yourself and the patient by using size
  appropriate equipment. Obtain order for Physical Therapy
  as needed.

Look for the weight capacity labels on patient equipment to
  help select the right equipment (coming soon)


                                                              53
Test Your Knowledge
Obesity is linked to certain types of cancer

                    True

                   False

                                               54
Treatment of Obesity
 If BMI is 25-26.9 with co-morbidities:
    Advise patient of treatment options for diet, physical
     activity, and behavioral change

 If BMI is 27-29.9 with co-morbidities or 30-34.9
  without co-morbidities:
    Consider pharmacotherapy in addition to diet, physical
     activity, and behavioral change

 If BMI 35 or greater with two co-morbidities or BMI
  >40:
    Consider Bariatric or Weight Loss Surgery in addition
     to above noted treatments
                                                              57
Important Points
 Morbid obesity is a chronic disease. Conventional
  dieting is often not effective long term for the
  morbidly obese patient.
 Currently, medications are successful for about a
  5-10% decrease of excess body weight.
 Surgical weight loss overall results in a decrease in
  at least 50-60% and more of excess body weight
  and a profound resolution of serious co-morbidities.
 Surgery is a “tool” for weight loss success, not a
  cure.
                                                       58
Does this make you feel sad?




                               59
What do you think?




                     60
Weight Bias in Healthcare
 A recent study reported that only 2% of the
  dietitian students had a neutral or positive attitude
  about obese persons



 In one study among nurses:

  31% “would prefer not to care for obese patients”
  24 % agree that obese patients “repulsed them”
  12 % “would prefer not to touch obese patients”
           Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society


                                                                                                61
Physicians and Weight Bias
 In several anonymous self report surveys, they view obese
  patients as:
 “Noncompliant, lazy, lacking self control, unsuccessful,
  unintelligent, and dishonest”

 In a large study, 2,449 overweight and obese women
  reported that 52% had been stigmatized more than once by
  their physician

 Overall, physicians:
       spent less time with patients
       assigned more negative symptoms
       had reluctance to perform certain screenings
               Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society

                                                                                                    62
Impact on Patient Care
 Patients may delay seeking or cancel
  preventative health services and exams

 Discrimination in every social aspect leads to
  depression, low self esteem, and more

 Fear of worker injury and extra time to mobilize
  leads to resentment, impatience, and less
  mobilization by providers

           Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society


                                                                                                63
Providing Weight Sensitive Care
 Ask permission from the patient when you:
      discuss their weight or BMI
      weigh them

 Acknowledge the challenges of losing weight
  with the patient

 Briefly explain why morbid obesity is a disease.
  Many patients are not aware.

                                                     64
Providing Weight Sensitive Care
 Avoid demeaning phrases such as “fluffy”, “fat”,
  etc

 Use the term “bariatric” or “extended capacity
  equipment” instead of “big boy” equipment

 Provide the appropriate sized equipment and
  supplies


                                                     65
Patient Education
If a patient is interested in weight loss options
  at Sharp, the patient may attend an out-
  patient class. These are two options:

Go to www.sharp.com, classes and events
then bariatrics-weight loss or

 Register at 1-800-82-Sharp, ask for medical
 or surgical weight loss classes
                                               66
Test Your Knowledge
Since the topic of obesity is frequently in the
  news, weight bias is rare among health
  care providers
                    True

                    False

                                              67
Claims of Negligence
Failure to:

    Educate medical providers about risks of obesity

    Provide policies about care of the obese patient

    Obtain essential bariatric equipment




                                                    70
Claims of Negligence
Failure to:

    Provide nonjudgmental, weight sensitive care

    Adequately prepare for emergencies of the obese
     patient

    Educate patients about appropriate weight loss
     resources


                                                      71
How are we providing the
       best care
 at Sharp Healthcare?



                           72
System Task Force
            Safe Care of the Bariatric Patient
 Recommended and supported by CNOs and System
  Safety Steering Committee based on identified risks of
  this patient population
 Comprised of representatives across the system:
      SMH
             Cheryl Holsworth RN, Senior Specialist, Bariatric Surgery
             Michael Drafz RN, Lead, Vascular Access Services
             Judd Feiler, Lead, Physical Therapy
      SGH
             Bethanie Martin RN, Lead 5 East
             Ron Owen, Manager, Pulmonary Services
      SCOR
             Bryn Hogan RN, Lead ACC
      MBHWN
             Ellen Fleischman RN, RD, Manager MIS
             Bernadette Bongato RN, Nursing Specialist OR
      SCVMC
             Deanna White RN, Manager, Acute Care
             Marquet Johnson RN, CNS, PCU
      System Representatives
            Albert Rizos, PharmD, System Senior Clinical Pharmacy Specialist
            Cheryl Dailey RN, Director, Patient Safety
            Francine Parent RN, Senior Specialist, System Supply Chain Services


                                                                                   73
Focus Areas of Bariatric Task Force
 Ensure that our clinical staff have ready access to
  supplies, products and equipment which are weight
  and size appropriate

 Label weight capacity of equipment using weight
  sensitive stickers. (Implementation has begun at
  SMH and planned for all of Sharp Healthcare)

 Offer comprehensive programs for medical and
  surgical weight loss (Surgical programs offered at
  SMH and SCV)

 Implement use of difficult airway kits

                                                        74
Focus Areas
 Provide education to our staff, patients,
  employees, and physicians for the management
  and care of this patient population

 Provide education about ways to provide weight
  sensitive care

 Spread entity best practices across the
  organization

 Provide educational and resource information
  available to staff via Sharp Intranet and other
  venues
                                                    75
Bariatric Resources
Bariatric Website (under construction)
http://sharpnet/hospitals/memorial/bariatricProgram/index.cfm

  www.sharp.com go to classes and events, look for
  bariatrics

  Resource Experts

   Cheryl Holsworth, RN, MSA, CBN
   Senior Specialist Bariatric Program
   Phone 858-939-3083, Cheryl.holsworth@sharp.com

   Thomas Hayes
   Administrative Coordinator Bariatric Program
   Phone 858-939-3010, Thomas.hayes@sharp.com
                                                                76
Conclusions about Morbid Obesity
 It is a metabolic disease

 It results in multisystem problems

 Care of the patient requires customization
 of care and thoughtfulness

 Refer patients to out-patient resources for
 medical/surgical weight loss options
                                               77
Remember how we
think and how we feel
is reflected in our eyes

                           78
References
   American Society of Metabolic and Bariatric Surgery
   American Cancer Society
   American Journal of Respiratory and Critical Care Medicine (2004). (169), 557-561.
   Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6 th edition). Saunders
    Elsevier: St. Louis, MO.
   Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital
    Environment. Clinical Nurse Specialist, 15(5): 219-223.
   Hahler, B. (2002). Morbid Obesity: A Nursing Care Challenge. Medsurg Nursing, 11(2): 85-90.
   Hurst, S., Blanco, K., Boyle, D. Douglass, L. & Wikas, A. (2004). Bariatric Implications of Critical Care
    Nursing. Dimensions of Critical Care Nursing, 23(2): 76-83.
   Marik, P. & Varon, J. (1998). The Obese Patient in the ICU. Chest, 113, 492-498.
   National Institutes of Health. (2000). The Practical Guide: Identification, Evaluation and Treatment of
    Overweight and Obesity in Adults. National Institutes of Health national Heart, Lung, and Blood
    Institute North American Association for the Study of Obesity.
   Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care
    Medicine, 34(6), 1796-1804.
   Reto, C.S. (2003). Psychological Aspects of Delivering Nursing Care to the Bariatric Patient. Critical
    Care Nurse Quarterly, 26(2), 139-149.
   Vachharajani, V. & Vital, S. (2006). Obesity and Sepsis. Journal of Intensive Care Medicine, 21, 287-
    295.
   Varon, J. & Marik, P. (2001). Management of the Obese Critically Ill Patient. Critical Care Clinics ,
    17(1).
   Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse
    Quarterly, 26(2), 119-132.
   Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical
    Communications: Edgemont, PA.
                                                                                                         79
References Continued
   http://emedicine.medscape.com/article/123702-treatment
   Bagchi, D. & Preuss, H. (2007) Obesity: Epidemiology, Pathophysiology, and Prevention. (CRC
    Press, Taylor & Francis Group, LLC). Boca Raton, Fl.
   http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
   American Obesity Association
   http://win.niddk.nih.gov/statistics/index.htm
   Simoni, R. Brazilian Journal of Anesthesiology (2005). Tracheal Intubation of Morbidly Obese
    Patients, (55)2, 256-260.
   Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea
    (May 2006). Anesthesiology (104) 5, 1081-93.
   Bell, R. & Rosenblum, S. (2005). Postoperative Considerations for Patients with Obesity and Sleep
    Apnea, Anesthesiology Clin. N. America (23), 493-500.
   www.cdc.gov/obesity
   Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory
    Rate and Tidal volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal
    of Critical Care, (3), 102-106.
   L. Ben-Noun, A. Laor. (January, 2003). Relationship of neck circumference to cardiovascular risk
    factors. Obesity Research (11), 226-231.
   Frey, W.C. & Pilcher, J. (2003) Obstructive Sleep Apnea in Patients evaluated for Bariatric Surgery,
    Obesity Surgery, (13), 676-683.
   Pływaczewski R, Bieleń P, Bednarek M, Jonczak L, Górecka D, Sliwiński P. (2008). Pneumonol Alergol Pol.
    (76)5, 313-320.
   Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales,
    & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk
    Factors, JAMA, (289),76-79.
   http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119
                                                                                                              80
Author Information
                     Cheryl Holsworth, RN, MSA, CBN
                    Senior Specialist Bariatric Program
                         Sharp Memorial Hospital


    Special thanks to the following SHC specialists for their valuable input:

    Rossanne Decastro, RN, PHN, MSNc, Acute Care Specialist, SCVMC
    Karen Harmon, RNC, MSN, CNS, Perinatal Clinical Nurse Specialist,
     SMBHW
    Steve Leary, RN, MSN, Senior Specialist Acute Care, SMH
    Susan Moore, RN, MSA, Senior Specialist Acute Care, SMH
    Paul Neves, RN, BSN, ONC, Acute Care Nursing Specialist, SGH
    Tanna Thomason, RN, MSN, Clinical Nurse Specialist, SMH


                                                                           81
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Care of the bariatric patient for the OR Nurse

  • 1. Care of the Bariatric Patient
  • 2. Objectives  Define the classifications of obesity and explain the impact and costs related to obesity  Explain the considerations in caring for the obese patients due to their pathophysiology  Identify health and safety risks associated with the obese patient  Discuss treatment options for obesity and how to provide weight sensitive care 2
  • 3. What do we mean by the bariatric patient? Bariatric comes from the Greek word baros which means weight. This means the patient of greater size, usually a body mass index of >30. 3
  • 4. Classifications of Obesity using Body Mass Index (BMI) Uses Patient’s Height and Weight Correlates with Total Body Fat Content Go to http://www.sharp.com/tools/bmi.cfm to calculate your own BMI 4
  • 5. Morbid Obesity Defined 80-100 lbs Overweight Body Mass Index=BMI Acceptable Range 18.5 – 24.9 Overweight 25 – 29.9 Obese 30 – 34.9 Severe Obesity 35 – 39.9 Morbid Obesity 40 – 49.9 Super-Morbid Obesity 50 – +++ 5
  • 6. Measures to Assess Health Risks Related to Obesity Neck circumference: > 16-17 inches is related to greater risk Obstructive Sleep Apnea (OSA). Increased waist circumference >40 inches for men or >35 inches for women is related to greater metabolic risks. 6
  • 7. Impact of Morbid Obesity  Causes 300,000 deaths per year in the United States  Smoking and obesity are the leading preventable causes of death in the United States  Modern worldwide epidemic American Obesity Association 7
  • 8. Prevalence of Obesity Over 67% of adult Americans are overweight 26% are obese or morbidly obese In 2010, adult obesity rates increased and reached 30 % in eight states High BMI in the U.S. is approximately 10 % for infants and toddlers 18 % for adolescents and teenagers Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008 8 http://healthyamericans.org/reports/obesity2010/
  • 9. High Cost of Obesity  Currently, 9 % of all health care dollars are spent for the treatment of obesity and its complications Some estimate it will climb to 21% of all health care dollars by 2018 Undetermined costs related to hospital worker injury 9 http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
  • 10. Test Your Knowledge Currently, approximately 2/3 of Americans are considered overweight or obese True False 10
  • 11. What is Morbid Obesity? Chronic multi-factorial metabolic disease  Life-long  Progressive  Degenerative  Life-threatening  Genetically related http://win.niddk.nih.gov/statistics/index.htm 13
  • 12. Morbid Obesity is a Metabolic Disease  As BMI increases, adipose tissue becomes metabolically active and secretes hormones  These hormones influence insulin resistance, hyperlipidemia, inflammation, thrombosis, and hypertension  The mucosa of the stomach of obese persons secretes higher levels of the hormone Ghrelin which increases appetite 14
  • 13. The Disease of Morbid Obesity  Neuropeptides and neurotransmitters in the brain, mainly the hypothalamus, and other hormones affect satiety, appetite and weight regulation  Interestingly, Leptin, a hormone that is secreted by adipose tissue and decreases hunger, is found in higher levels for obese persons but it is believed they are “leptin resistant” The next two slides will demonstrate the complexity of this disease! 15
  • 14. Obesity and Neurohormonal Influences Located in the brain Orexogenic Mediators Anorexic Mediators Affects hunger Affects satiety Conserves energy Increases energy expenditure Cannabinoid receptor activation POMC + α MSH Orexin A Leptin receptors MCH and AGRP CRH/Urocortin Neuropeptide Y CNS Vagus nerve activation Dynorphin Serotonin Galanin Dopamine Beacon gene activation CART (Cocaine Associated CNS Sympathetic nerve activation Receptor Transcript) 16
  • 15. Adipose Tissue Affects Many Stomach Pancreas Organs CCK Reduced glucose, Enterostatin Insulin, glucagon Peptide YY (3-36) Adipose Tissue and GLIP Secretes: Tumor Necrosis Factor α Skeletal Interleukin-6 Liver Muscle Leptin Uncoupling Reduced hepatic glucose proteins 2 and 3 17
  • 16. Pathogenesis of Obesity  Behavior and lifestyle habits are often determinants in the development of the disease  But, it is also extremely important to also understand the metabolic mechanisms that influence body weight  For persons who are overweight and mildly obese, dieting and exercise are very effective for weight loss 18
  • 17. Challenges for the Morbidly Obese Changes with hormones and the central nervous system make it VERY CHALLENGING to sustain weight loss long term by dieting and exercise alone. At least 85 % regain their weight and more over time 19
  • 18. Key Points • Morbid Obesity is a chronic metabolic disease • Diet and exercise are very effective for weight loss for those who overweight and mildly obese • Neurohormonal changes for the morbidly obese make it very challenging for them to sustain weight loss long term by dieting and exercise alone 20
  • 19. Test Your Knowledge Ghrelin is a hormone which is secreted by adipose tissue and decreases hunger True False 21
  • 20. Co-Morbidities of Obesity Co-morbidities are conditions or diseases caused by or made worse by obesity For example, asthma, gout, and arthritis may be made worse due to the chronic inflammation associated with obesity It is important to educate patients about their health risks associated with obesity 24
  • 21. Metabolic Syndrome X is linked to Obesity  Insulin resistance  Hyperinsulinemia  Hyperglycemia  Hyperlipidemia IR= Ins ulin Res istan ce ROS=Rea ctiv e Oxy gen Species  Hypertension  Heart Disease 25
  • 22. American Heart Association Definition of Metabolic Syndrome Increased waist circumference: > 40 inches for men or > 35 inches for women Elevated triglycerides: Equal or > 150 mg/dL Reduced HDL (“good”) cholesterol: < 40 mg/dl for men and < 50 mg/dL for women Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension Elevated fasting glucose: Equal to > 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia 26
  • 23. Stroke  Increased risk for ischemic stroke in both men and women  Ischemic stroke increases progressively and is doubled in those with a BMI > 30 when compared to those having a BMI < 25  Obesity is not proven to be an increased risk for hemorrhagic strokes 27 J. La State Med Soc. 2005, 156, S42-49.
  • 24. Cardiovascular Considerations  Increased total blood volume  Left ventricular hypertrophy and decreased ventricular contractility can occur  About 75 % of individuals with hypertension have an obesity link 28 American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1818
  • 25. ECG Considerations  Increased fat deposits around the heart may lead to degeneration of the conduction system which causes lethal heart rhythms  Large body mass may cause difficulty with landmarks for lead placement and inconsistent or decreased voltage  Prolonged QT intervals  Non-specific flat/inverted T waves in inferior leads Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804. Zacharias, A. Schwann. T. Riordan, C. et al (2005) Obesity and risk of new-onset of atrial fibrillation after cardiac surgery. Circulation 112 (32), 3247-3255 29
  • 26. Diabetes Mellitus  Type 2 diabetes mellitus (DM) is strongly associated with overweight and obesity in both genders and in all ethnic groups  90 % of all patients with type 2 DM are overweight or obese  The risk for type 2 DM also increases in individuals with a more central distribution of body fat (abdominal)  Modest weight loss (medical or surgical weight loss), even 5- 10% loss can have significant improvement of type 2 DM Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, JAMA, (289),76-79. 30
  • 27. Renal Impact  Some drugs may impact the renal system in high BMI patients due to high glomerular filtration rates  Increased intra-abdominal pressure may lead to hypertension and insult to the kidney  If BMI is more than 30, nearly twice the risk for kidney failure If BMI of 40 or above, seven times the risk of kidney failure Blackwell Publishing Ltd. (2006, December 26). Obese Kidney Transplant Patients Twice As Likely To Die In The First Year Or Suffer Organ Reference: June Journal of the American Society of Nephrology (2006) http://www.sciencedaily.com/releases/2006/01/060105082226.htm 31
  • 28. Nonalcoholic Fatty Liver If BMI > 40, the prevalence of: Nonalcoholic fatty liver disease (NAFLD) is more than 95% Nonalcoholic steatohepatitis (NASH) may be as high as 25%. Sustained liver injury leads to progressive fibrosis and cirrhosis in 10% to 25% of affected individuals. http://bariatrictimes.com/2010/01/21/nutrition-in-the-management-of-nonalcoholic-fatty-liver/ http://www.ccjm.org/content/71/8/657.full.pdf 32
  • 29. Obesity Related Cancer  Obesity related cancer death rates are 14% for men and 20% for women  Obese women have a 50% increase risk for breast cancer after menopause  Obese men are 30-50% more likely as lean men to develop colon cancer  Obesity related cancers include prostate, lymphoma, liver, pancreas, and gallbladder American Cancer Society http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119 33
  • 30. Reproductive Impact Imbalance of the sex hormones especially androgens and estrogen leads to: Irregular menstrual cycles Increased androgenization and facial hair Polycystic ovarian syndrome (PCOS) Decreased conception rates after fertility treatments 34
  • 31. Physiological changes in the obese patient increases their risk for adverse events and potential complications It is extremely important to consider these changes in the way you provide care! 35
  • 32. High Risk for Blood Clots Obesity is characterized by: Chronic inflammation Decreased immunity Hypercoagulability This is due to: • Decreased antithrombin-III • Increased tumor necrosis factor α and interleukin-6 • Impaired neutrophil function • Increased blood volume 36 Critical Care Medicine 2006 Jun;34(6):1796-804.
  • 33. Prevent Blood Clots by Early Ambulation Mobilize patients early and frequently  The efficacy of sequential compression devices and TED hose for obese individuals is unknown  Chronic inflammation and hypercoagulation increase the clot risk  There are limited studies about anticoagulation and the obese  The weight of the large pannus (abdominal fold) creates pressure on the deep vessels and increases the risk Critical Care Medicine 2006 Jun;34(6):1796-804. 37
  • 34. Test Your Knowledge Which statement is not true about the increased risk for blood clots and the obese individual? A. The weight of the abdomen on deep vessels increases the risk B. Little is known about the efficacy of SCDs and TED hose C. Studies on anticoagulation and obesity are limited D. There is no increased risk 38
  • 35. Pulmonary Considerations Obese patients desaturate very rapidly due to decreased respiratory reserve and lung capacity. Assess reasons oxygen saturation levels are less than 92 %. Immediate intervention is critical. The reverse trendelenberg position is the optimal position as it drops the pannus (abdominal fold) from the diaphragm. Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal 41 volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106.
  • 36. Pulmonary Considerations Preoxygenate before procedures such as suctioning. It is vital. Keep upright or semi-recumbent as long as possible before procedures. Plan rest periods during most activities as dyspnea is common. 42
  • 37. Obstructive Sleep Apnea (OSA) Rates of OSA are high, about 71-77% if morbidly obese If also diabetic, it is about 86% and often undiagnosed Assess if patient has symptoms of OSA: • Snoring • Patient has been told they stop breathing for periods of time during sleep • Daytime sleepiness Ask the patient if they use a CPAP machine at home 43
  • 38. OSA and Obesity Obtain order for Pulmonary Services if patient uses CPAP at home Patients may also require: • continuous oxygenation saturation monitoring • planning for difficult airway management 44
  • 39. RAMP (Rapid Airway Management Position) for Procedures Align the top of the ear with the sternal notch Ramp up or raise the occipital area using pillows or towels Form a trapezoid shape beneath the back of the head Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260 45 Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni
  • 40. Regional Anesthesia Considerations Increased abdominal pressure may decrease cerebral spinal fluid volume which may lead to higher neuroaxial blockade Monitor patients closely for respiratory compromise 46
  • 41. Weight and Drugs Caution must be used for drugs highly soluble in fat, especially with extended time duration, > 12-24 hours include:  Opiate analgesics (Morphine, Dilaudid, etc)  Carbamazepine (Tegretol)  Propofol  Fentanyl  Midazolam (Versed) 47
  • 42. Pain Management  Avoid Intramuscular injections  Pain medication in the obese patient is largely unknown  Narcotics may lead to “Resedation Phenomenon” Adipose tissue leads to unpredictable absorption and a delayed response of these drugs  Assess sedation levels and for respiratory depression very closely especially if patient has OSA 48
  • 43. Drugs and the Obese Patient  Pharmacodynamic and kinetic data are not available for many medications such as antibiotics, pain medications, etc.  Generally, dose to a patient’s ideal body weight plus 40% of the excess body weight  Start “low and go slow” is the best approach 49
  • 44. Venous Access Landmark vessels may be hard to palpate or visualize.  Consider Infusion Services to avoid multiple IV sticks. Midline and PICC catheters may be a better option depending on the length of therapy.  Assess carefully for signs of phlebitis due to excess skin, subcutaneous fat and moisture in skin folds.  Assess if standard 1.5-in needles are long enough. 50
  • 45. GI Impact Monitor for greater aspiration risk due to high:  gastric fluid volume  GI reflux  incidence of Hiatal Hernia High Incidence of Gallstones Normally, acids in bile keep cholesterol from forming into stones With obesity, cholesterol in the bile increases beyond the ability of acids to maintain the cholesterol in suspension, the cholesterol crystallizes and form stones 51
  • 46. Skin Care Considerations  Inspect for moisture and irritation in skin folds as this may lead to infection  Ask the patient if they are able to perform their personal hygiene:  Obtain adaptive supplies and consult skin team if needed  Offer assistance  Move all lines, tubes, catheters (if possible) and the pannus (abdominal fold) every 2 hours to prevent atypical ulcers  Assess for wound healing since adipose tissue less vascularized 52 Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.
  • 47. Musculoskeletal Considerations Patients have increased:  joint trauma/pain  disuse and atrophy of musculature Prevent injury to yourself and the patient by using size appropriate equipment. Obtain order for Physical Therapy as needed. Look for the weight capacity labels on patient equipment to help select the right equipment (coming soon) 53
  • 48. Test Your Knowledge Obesity is linked to certain types of cancer True False 54
  • 49. Treatment of Obesity  If BMI is 25-26.9 with co-morbidities:  Advise patient of treatment options for diet, physical activity, and behavioral change  If BMI is 27-29.9 with co-morbidities or 30-34.9 without co-morbidities:  Consider pharmacotherapy in addition to diet, physical activity, and behavioral change  If BMI 35 or greater with two co-morbidities or BMI >40:  Consider Bariatric or Weight Loss Surgery in addition to above noted treatments 57
  • 50. Important Points  Morbid obesity is a chronic disease. Conventional dieting is often not effective long term for the morbidly obese patient.  Currently, medications are successful for about a 5-10% decrease of excess body weight.  Surgical weight loss overall results in a decrease in at least 50-60% and more of excess body weight and a profound resolution of serious co-morbidities.  Surgery is a “tool” for weight loss success, not a cure. 58
  • 51. Does this make you feel sad? 59
  • 52. What do you think? 60
  • 53. Weight Bias in Healthcare  A recent study reported that only 2% of the dietitian students had a neutral or positive attitude about obese persons  In one study among nurses: 31% “would prefer not to care for obese patients” 24 % agree that obese patients “repulsed them” 12 % “would prefer not to touch obese patients” Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society 61
  • 54. Physicians and Weight Bias  In several anonymous self report surveys, they view obese patients as: “Noncompliant, lazy, lacking self control, unsuccessful, unintelligent, and dishonest”  In a large study, 2,449 overweight and obese women reported that 52% had been stigmatized more than once by their physician  Overall, physicians: spent less time with patients assigned more negative symptoms had reluctance to perform certain screenings Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society 62
  • 55. Impact on Patient Care  Patients may delay seeking or cancel preventative health services and exams  Discrimination in every social aspect leads to depression, low self esteem, and more  Fear of worker injury and extra time to mobilize leads to resentment, impatience, and less mobilization by providers Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society 63
  • 56. Providing Weight Sensitive Care  Ask permission from the patient when you:  discuss their weight or BMI  weigh them  Acknowledge the challenges of losing weight with the patient  Briefly explain why morbid obesity is a disease. Many patients are not aware. 64
  • 57. Providing Weight Sensitive Care  Avoid demeaning phrases such as “fluffy”, “fat”, etc  Use the term “bariatric” or “extended capacity equipment” instead of “big boy” equipment  Provide the appropriate sized equipment and supplies 65
  • 58. Patient Education If a patient is interested in weight loss options at Sharp, the patient may attend an out- patient class. These are two options: Go to www.sharp.com, classes and events then bariatrics-weight loss or Register at 1-800-82-Sharp, ask for medical or surgical weight loss classes 66
  • 59. Test Your Knowledge Since the topic of obesity is frequently in the news, weight bias is rare among health care providers True False 67
  • 60. Claims of Negligence Failure to:  Educate medical providers about risks of obesity  Provide policies about care of the obese patient  Obtain essential bariatric equipment 70
  • 61. Claims of Negligence Failure to:  Provide nonjudgmental, weight sensitive care  Adequately prepare for emergencies of the obese patient  Educate patients about appropriate weight loss resources 71
  • 62. How are we providing the best care at Sharp Healthcare? 72
  • 63. System Task Force Safe Care of the Bariatric Patient  Recommended and supported by CNOs and System Safety Steering Committee based on identified risks of this patient population  Comprised of representatives across the system:  SMH Cheryl Holsworth RN, Senior Specialist, Bariatric Surgery Michael Drafz RN, Lead, Vascular Access Services Judd Feiler, Lead, Physical Therapy  SGH Bethanie Martin RN, Lead 5 East Ron Owen, Manager, Pulmonary Services  SCOR Bryn Hogan RN, Lead ACC  MBHWN Ellen Fleischman RN, RD, Manager MIS Bernadette Bongato RN, Nursing Specialist OR  SCVMC Deanna White RN, Manager, Acute Care Marquet Johnson RN, CNS, PCU  System Representatives  Albert Rizos, PharmD, System Senior Clinical Pharmacy Specialist  Cheryl Dailey RN, Director, Patient Safety  Francine Parent RN, Senior Specialist, System Supply Chain Services 73
  • 64. Focus Areas of Bariatric Task Force  Ensure that our clinical staff have ready access to supplies, products and equipment which are weight and size appropriate  Label weight capacity of equipment using weight sensitive stickers. (Implementation has begun at SMH and planned for all of Sharp Healthcare)  Offer comprehensive programs for medical and surgical weight loss (Surgical programs offered at SMH and SCV)  Implement use of difficult airway kits 74
  • 65. Focus Areas  Provide education to our staff, patients, employees, and physicians for the management and care of this patient population  Provide education about ways to provide weight sensitive care  Spread entity best practices across the organization  Provide educational and resource information available to staff via Sharp Intranet and other venues 75
  • 66. Bariatric Resources Bariatric Website (under construction) http://sharpnet/hospitals/memorial/bariatricProgram/index.cfm www.sharp.com go to classes and events, look for bariatrics Resource Experts Cheryl Holsworth, RN, MSA, CBN Senior Specialist Bariatric Program Phone 858-939-3083, Cheryl.holsworth@sharp.com Thomas Hayes Administrative Coordinator Bariatric Program Phone 858-939-3010, Thomas.hayes@sharp.com 76
  • 67. Conclusions about Morbid Obesity It is a metabolic disease It results in multisystem problems Care of the patient requires customization of care and thoughtfulness Refer patients to out-patient resources for medical/surgical weight loss options 77
  • 68. Remember how we think and how we feel is reflected in our eyes 78
  • 69. References  American Society of Metabolic and Bariatric Surgery  American Cancer Society  American Journal of Respiratory and Critical Care Medicine (2004). (169), 557-561.  Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6 th edition). Saunders Elsevier: St. Louis, MO.  Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital Environment. Clinical Nurse Specialist, 15(5): 219-223.  Hahler, B. (2002). Morbid Obesity: A Nursing Care Challenge. Medsurg Nursing, 11(2): 85-90.  Hurst, S., Blanco, K., Boyle, D. Douglass, L. & Wikas, A. (2004). Bariatric Implications of Critical Care Nursing. Dimensions of Critical Care Nursing, 23(2): 76-83.  Marik, P. & Varon, J. (1998). The Obese Patient in the ICU. Chest, 113, 492-498.  National Institutes of Health. (2000). The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Institutes of Health national Heart, Lung, and Blood Institute North American Association for the Study of Obesity.  Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804.  Reto, C.S. (2003). Psychological Aspects of Delivering Nursing Care to the Bariatric Patient. Critical Care Nurse Quarterly, 26(2), 139-149.  Vachharajani, V. & Vital, S. (2006). Obesity and Sepsis. Journal of Intensive Care Medicine, 21, 287- 295.  Varon, J. & Marik, P. (2001). Management of the Obese Critically Ill Patient. Critical Care Clinics , 17(1).  Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse Quarterly, 26(2), 119-132.  Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA. 79
  • 70. References Continued  http://emedicine.medscape.com/article/123702-treatment  Bagchi, D. & Preuss, H. (2007) Obesity: Epidemiology, Pathophysiology, and Prevention. (CRC Press, Taylor & Francis Group, LLC). Boca Raton, Fl.  http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf  American Obesity Association  http://win.niddk.nih.gov/statistics/index.htm  Simoni, R. Brazilian Journal of Anesthesiology (2005). Tracheal Intubation of Morbidly Obese Patients, (55)2, 256-260.  Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea (May 2006). Anesthesiology (104) 5, 1081-93.  Bell, R. & Rosenblum, S. (2005). Postoperative Considerations for Patients with Obesity and Sleep Apnea, Anesthesiology Clin. N. America (23), 493-500.  www.cdc.gov/obesity  Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106.  L. Ben-Noun, A. Laor. (January, 2003). Relationship of neck circumference to cardiovascular risk factors. Obesity Research (11), 226-231.  Frey, W.C. & Pilcher, J. (2003) Obstructive Sleep Apnea in Patients evaluated for Bariatric Surgery, Obesity Surgery, (13), 676-683.  Pływaczewski R, Bieleń P, Bednarek M, Jonczak L, Górecka D, Sliwiński P. (2008). Pneumonol Alergol Pol. (76)5, 313-320.  Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, JAMA, (289),76-79.  http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119 80
  • 71. Author Information Cheryl Holsworth, RN, MSA, CBN Senior Specialist Bariatric Program Sharp Memorial Hospital Special thanks to the following SHC specialists for their valuable input:  Rossanne Decastro, RN, PHN, MSNc, Acute Care Specialist, SCVMC  Karen Harmon, RNC, MSN, CNS, Perinatal Clinical Nurse Specialist, SMBHW  Steve Leary, RN, MSN, Senior Specialist Acute Care, SMH  Susan Moore, RN, MSA, Senior Specialist Acute Care, SMH  Paul Neves, RN, BSN, ONC, Acute Care Nursing Specialist, SGH  Tanna Thomason, RN, MSN, Clinical Nurse Specialist, SMH 81
  • 72. Exit Click the Take Test button on the left side of the screen when you are ready to complete the requirements for this course. Choose the My Records button to view your transcript. Select Exit to close the Student Interface. 82

Notes de l'éditeur

  1. Line 2: Due to adipose tissue, there is an increase in blood volume, preload of the heart, stroke volume, cardiac output and myocardial workload to meet perfusion demands. Line 3: With increased blood volume, there is increased RBC’s thus increased viscosity of the blood, so increased risk for thrombophlebitis. A BMI &gt;29 heightens the prevalence of Pulmonary Embolism. DVT appears twice as often in Obese patients compared to nonobese patients. (Gallagher 2006). Baylor College in Texas confirmed that at one year, CHF patients at 1 year who died were less likely to be obese or have metabolic syndrome. U of M at Ann Arbor, MI reported that obese individuals had more than 3 X the risk for the composite end point of death, cardiac transplant or ventricular assist devices
  2. One cause of arrhythmias with persons of higher BMI may be the increased sympathetic activity caused by leptin. Leptin is shown to increase mean arterial pressure and heart rate in laboratory rats. It appears to sensitize adrenergic receptors to catecholamines.
  3. Obese individuals are twice as likely to die after the first year after a transplant and have organ failure. It becomes greater after 5 years. There is accumulating evidence that the sympathetic nervous system plays a role in the development of obesity-related hypertension. Both animal and human studies have shown that excess weight gain is associated with increased renal sympathetic activity, resulting in sodium retention. An activated RAS also contributes to enhanced oxidative stress,vascular remodeling, and pressor response to exercise.The sympathetic nervous system activation associated with obesity is mediated in part by the adipocyte-derived hormone, leptin, which increases in proportion to the degree of adiposity.An increase of leptin in hypertensive individuals is associated with elevated plasma renin activity, aldosterone, andangiotensin concentrations.
  4. Scientists at Geneva University in Switzerland conducted a population-based study in which they evaluated the impact of obesity on presentation, diagnosis and treatment of breast cancer. Among all women diagnosed with invasive breast cancer in Geneva between 2003 and 2005, they identified those with available information on body mass index and categorized them into groups they identified as normal/underweight (BMI &lt;25kg/m), overweight (BMI &gt;/=-30kg/m), and obese (BMI &gt;30kg/m). They compared tumor, diagnosis and treatment characteristics between the groups. They found that obese women presented significantly more often with stage III and stage IV disease, with an odds ratio of 1.8. This means they were 180% more likely to have later stage breast cancer than those women in the normal/underweight group. Women in the obese group were 240% more likely to have tumors that were equal to or greater in size than 1 centimeter compared to the women in the normal/underweight group. They were also a whopping 510% more likely to have positive lymph nodes suggesting their cancers may have spread to other parts of their bodies. In another study, obese women were 20 percent more likely to have false-positive results from mammograms -- readings that can lead to unnecessary biopsies and anxiety. Being overweight can get in the way of effective cancer treatment, too, experts say. The problem: under dosing. &quot;Oncologists usually base chemo on patients&apos; ideal weight rather than their true weight, partly because chemo is so toxic and partly because drug trials typically include only average women, so we don&apos;t know the correct dose for bigger women,&quot; says Kellie Schneider, M.D., a gynecologic oncologist at the University of Alabama at Birmingham. &quot;But underdosing can mean the difference between life and death.&quot;
  5. Obese patients normally have smaller cerebrospinal fluid (CSF) volumes than normal weight patients, and these changes are further exaggerated in the obese parturient. Decreased CSF volume due to increased abdominal pressure (obesity or pregnancy) may produce more-extensive neuraxial blockade due to diminished dilution of anesthetic. The mechanism by which increased abdominal pressure decreases CSF volume is probably inward movement of soft tissue in the I Intervertebral foramen displacing CSF.[55] The epidural space volume is also reduced, due to adipose I infiltration and increased venous distension from aortocaval compression and increased intra-abdominal pressure, resulting in higher spread of local anesthetic and in higher risk of hypotension and respiratory difficulty.[54]