CARING FOR BARIATRIC PATIENTS IN PACU

MISHELLE DEHAINI RN, CCRN,GRAD. CERT HPE, GRAD. CERT PERIOP

CNE - BOX HILL OPERATING THEATRES

PHYSIOLOGICAL CHANGES

• Increased Metabolic Rate

• Increased 02 demand

• Increased CO2 production

• Increased alveolar ventilation

• Ventilation Changes

• Reduction in lung volumes:• Decreased chest wall compliance (excessive adipose tissue over thorax)

• Increased abdominal mass forces diaphragm cephalad

• Decreased FRC (risk of V/Q mismatch)

• Cardiac Changes

• Increased work load (cardiac output and blood volume rise to perfuse additional fat stores

OBSTRUCTIVE SLEEP APNEAKnown as obesity hypoventilation syndrome

• Hypercapnia

• Right heart failure

• Somnolence

• Blunted respiratory drive

• Upper airway obstruction

• Periods of apnea (pauses)

Associated with post-operative complications:• Hypertension• Hypoxia• Arrhythmias• Myocardial Infarction• Pulmonary oedema• Stroke • Death

CARDIAC CHANGES

OSA:

• Increased work load (cardiac output and blood volume rise to perfuse additional fat stores)

• SV increases instead of HR to meet demand

Hypertension leads to

• Left ventricular hypertrophy

• Pulmonary hypertension (from increase pulmonary blood flow)

Persistent hypoxia

• Pulmonary hypertension (from pulmonary artery vasoconstriction)

PRIMARY ASSESSMENT

• D – danger- environment safe to receive patient

• R - Response –Pt. awake, orientated, unconscious

• A - airway -Look, listen, feel

• B - breathing – listen and feel

• C - circulation- Color, HR, ECG, BP, capillary return, temperature

• D – disability – dressings, ‘drips’, drains, drugs, diabetes, documentation, dermatomes

• E- exposure – everything else, pressure areas, VTE prophylaxis, pain , PONV, specific observations for surgery

R IS FOR RESPONSE

• GCS – Best verbal response, best motor response, eye opening

• PUPILS - ? PEARL – What can this tell us?

• ASSESS CONSCIOUS STATE USING:

• A – awake

• V- rouses to voice, light touch

• P – rouses to painful stimuli

• U - unrousable

RESPIRATORY ASSESSMENT

AIRWAY ASSESSMENT

• Look, listen and feel for chest and air movement

• Patient colour

• Conscious state

• Oxygen saturation

RESPIRATORY ASSESSMENT

• Rate

• Rhythm

• Depth

• Chest wall symmetry

• Use of accessory muscles

• Noise (stridor/wheeze)

• Paradoxical chest

movement

• Patient position

• Pursed lips/nasal flaring

• Colour

• Oxygen Saturations

• Mental status

• Cough

• Tracheal tug

INSPECTION OF RESPIRATORY RATE

NORMAL 16-20 PER MIN, EXPANSION TO BASES OF LUNGS

TACHYNEA RATE >20 PER MIN, ^RATE AND DECREASED DEPTH OF VENTILATION

ASSOCIATED WITH RESP FAILURE, ANXIETY, PAIN, LVF, SHOCK

BRADYNEA RESP RATE <10 PER MIN

CAUSES – FATIGUE, HYPOTHERMIA, CNS DEPRESSION, NARCOTIC

OVERDOSE

HYPERVENTILATION INCREASED RESP RATE AND DEPTH OF VENTILATION

CAUSES – ANXIETY, METABOLIC ACIDOSIS

ORTHOPNEA PATIENTS MUST STAND OR SIT UPRIGHT TO BREATHE COMFORTABLY

RESPIRATORY RHYTHM

https://binged.it/2FzmIvI

RESPIRATORY ASSESSMENT

• CHEST AUSCULTATION

• ABGS OR VBGS

• CHEST X-RAY

OXYGENATION

• Consider humidified oxygen early

• Venturi masks and Nasal prong options for known CO2 retainers

• CPAP mask circuits not commonly preferred option – lead to gas build up in abdomen

AIRVO BENEFITS

• O2 and Air blend

• Flow rates up to 70litres/min

• Reduces mucosal drying

• Increases muco-ciliary clearance

• Decreases Work of breathing

• Decreases energy expenditure on breathing

• 30Litres/min and above generate CPAP

• Alveolar recruitment

AIRWAY OBSTRUCTION

No passage of air despite respiratory effort usually occurs in the very drowsy or unconscious patient

• Causes

• Pathology: tumours, clots, swelling bronchospasm

• Soft tissue (tongue)

• foreign bodies

AIRWAY OBSTRUCTIONRecognition

• Snoring, more likely in a bariatric rather than silent

• little or no air movement on auscultation of the lungs

• retraction of intercostal muscles

• Paradoxical chest movement

• decreased oxygen saturation level

• Somnolence

MANAGEMENT OF AIRWAY OBSTRUCTION

• May depend on exact cause of obstruction• 100% Oxygen

• Encourage deep breaths

• ? Lateral position- difficult with bariatric patients

• If unresponsive:

• Jaw support

• Airway

• Suction

• Prepare for possible re-intubation or trache

Is the patient trying to breathe ?

NO = Apnea

YES = Obstruction

RECOGNIZING HYPOVENTILATION

• PaCO2 above 45

• Recognition

• Excessive prolonged somnolence

• Obstruction

• Tachypnea or bradypnea

• Respiratory acidosis

• Poor SaO2

CONTRIBUTING FACTORS TO HYPOVENTILATION

• Ensure to exclude the following:

• Residual depressant effects of anaesthetic

• Inadequate reversal

• Opioid-induced respiratory depression

• Splinting:

• Incisional pain

• Abdominal distention

• Tight dressing

MANAGEMENT OF HYPOVENTILATION

TREATMENT

• ABC- notify anaesthetist and team leader

• Oxygen therapy

• Identify and treat cause

• Provide stimulation to improve respiratory function

• ? Pharmacology management – Naloxone, Flumazenil, Neostigmine

• ?Intubate and ventilate

ARTIFICIAL AIRWAYS

ORAL AIRWAY – Aims to keep tongue elevated, teeth and lips apart

NASAL AIRWAYS – Better tolerated than oral airways

INDICATIONS

• Patients with decreased conscious state, unable to maintain patent airway

• Very useful in bariatric patients – excess tissue in the upper airway

• Assistance with manual ventilation

• Prevention of patient’s biting on ETT

WHEN TO RE-INTUBATE

• NOT BREATHING WELL ENOUGH

• TIRING OR NOT WAKING

• APNEIC

• CONTROL OF VENTILATION

• O2 AND CO2 LEVELS

CIRCULATION ASSSESSMENT

LOOK:

• Pink, well perfused

• Monitoring• BP, HR, Arterial line• ECG

• Monitor in V1-2 for arrhythmias• Monitor in V5-6 for ischaemia• Consider 12 Lead ECG for chest pain

• Urine output/ fluid loss from drains

LISTEN:

• Manual BP

FEEL:

• Palpate pulses

• Warmth- Peripheral vs. Central

• Neurovascular assessment of limbs

D IS FOR DISABILITYDIABETES

• Check BSL, ? Need for Actrapid infusion

DRUGS

• Check what drugs have been given & can be given to treat Pain/PONV

DOCUMENTATION

• Check all charts and ensure all care documented

DERMATOMES

• Use ice to check sensory levels; T4 –safe for discharge

• Epidural – check above and below

• Bromage – motor assessment (0-3 scale)

DRUGS

MULTI-MODAL ANALGESIA

• PCA

• Paracetamol

• NSAIDS – can be used in appropriate patients

• Judicious use of Narcotics – esp. Pain protocols

• ? Use of Low dose Ketamine infusion during surgery

DRUGS

Managing PONV

Prophylaxtic anti-emetics works best

Combination of:

• Dexamethasone

• Cyclizine

• Prochlorperazine

• Ondansetron

• Ensuring good oxygenation and BP helps reduction of PONV

E-EVERYTHING ELSE

VTE PROPHYLAXIS

• TEDS insitu – ensure well fitting

• SCDS continuously

SKIN INTEGRITY

• Check skin for tears, pressure areas

• Dress any wounds with appropriate products

• Use of pressure relieving mattresses, gel pads, etc

• Pressure care if in PACU for extended period

E-EVERYTHING ELSE

GASTRIC ASSESSMENT

• If NGT insitu – monitor drainage hourly

• Excessive pain may require a Surgical review

• Anastomotic leak – not common 2.1% , more commonly seen in the ward

• Marked by HR>120, Febrile, Pain, drop in SaO2 ,hiccups

E-EVERYTHING ELSE

RENAL ASSESSMENT

• Rhabdomyolysis occurs -1.4% of Bariatric surgery

• Risk factors include- ^Pressures on deep tissues, prolonged surgery, BMI>40

• Monitor Urine output hourly – note dark urine or blood stained

• Serum CK levels maybe checked, if suspected

DISCHARGE FROM PACU

POST OPERATIVE CARE IN WARDS

• ?need for ICU/HDU post-operatively – should be booked pre-op if possible

• Clear handover for specific co-morbidities of each pt.

• Clear post-operative orders both Anaesthetic and Surgical

• ?need for CPAP/Respiratory support in wards

BIBLIOGRAPHY

Dehaini, M, Introduction to PACU power point presentation, SVH 2018

Duke, J, Anesthesia Secrets, Mosby Elsevier 2014

Eakins, D, Primary and Secondary Patient Assessment power point presentation, Eastern Health 2018

Morgan, G, et al, Clinical Anesthesiology 3rd Edition, McGraw- Hill 2002

Nagelhout, J et al, Nurse Anesthesia 6th Edition, Elsevier 2018

Odom-Forren, J et al, Drain’s Perianesthesia Nursing – A Critical Care Approach, Elsevier 2013

BIBLIOGRAPHY

• Sollazzi, L et al, Pre-inductive use of Clonidine and Ketamine improves recovery and reduces post-operative pain after bariatic surgery, Surgery for Obesity and Related diseases, Vol.5, Iss. 1 Jan-Feb 2009, Pgs 67-71

• Bamgbade OA, Oluwole O, Khaw RR. Perioperative analgesia for fast-track laparoscopic bariatric surgery. Obes Surg. 2017;27(7):1828–34.

• Bamgbade, O.A., Oluwole, O. & Khaw, R.R. OBES SURG (2018) 28: 1296. https://doi.org/10.1007/s11695-017-3009-7