Care of the Bariatric Patient

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.

2
 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
Thesesecretes hormones
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
CNS Sympathetic nerve activation Associated 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= Insulin

Resistance
ROS=Reactive
Oxygen Species

Hypertension

Heart Disease

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

26
(5.6 mmol/L) or use of medication for hyperglycemia
 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

obesity link
an

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
the riskdeep vessels and increases
on the
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
Obtain order Obesity
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 and kinetic data are not available for
Pharmacodynamic
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.
 Musculoskeleta
l
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
If BMI isObesity
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
75
venues
 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
76
Phone 858-939-3010, Thomas.hayes@sharp.com
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
thinkand 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 (6th 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
Tanna Thomason, RN, MSN, Clinical Nurse Specialist,
Paul
SMH Neves, RN, BSN, ONC, Acute Care Nursing Specialist, SGH
81
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