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Postoperative Care Pathways for the Bariatric Patient

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The SAGES Manual of Bariatric Surgery

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Abstract

The bariatric patient population presents unique issues in postoperative management due to both the size of the patient and their multiple medical comorbidities. Implementation of postoperative bariatric care pathway, including enhanced recovery after surgery and the use of postoperative order sets, can aid in providing a uniform level of care, minimizing the risk of postoperative complications. The following chapter describes various aspects of the postoperative management of the bariatric patient with a focus on utilization of an enhanced recovery pathway.

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Author information

Authors and Affiliations

  1. Cleveland Clinic, Bariatric and Metabolic Institute, Cleveland, OH, USA

    Katherine M. Meister

  2. Department of Surgery, Cleveland Clinic, Bariatric and Metabolic Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA

    Stacy A. Brethauer

Authors
  1. Katherine M. Meister
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  2. Stacy A. Brethauer
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Corresponding author

Correspondence to Katherine M. Meister .

Editor information

Editors and Affiliations

  1. Foregut and Bariatric Surgeon, Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA

    Kevin M. Reavis

  2. Long Island Jewish Forest Hills Hospital, Department of Surgery, Hofstra-Northwell School of Medicine, Forest Hills, New York, USA

    Allison M. Barrett

  3. Institute Chief, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates

    Matthew D. Kroh

Appendix: Sample Post-Laparoscopic Gastric Bypass Order Set

Appendix: Sample Post-Laparoscopic Gastric Bypass Order Set

The following is a sample order set used as a framework for bariatric postoperative ERAS protocol:

Admission

  • Admit to inpatient

  • Diagnosis: morbid obesity s/p LRYGB/LSG

  • Condition: stable

  • Expected length of stay: for surgical procedure

  • Principle admitting diagnosis: morbid obesity

  • Location: regular nursing floor

Non-ICU continuous cardiac monitoring, routine, continuous

Vital Signs every 4 h for 24 h, then every shift

Activity

  • Up with assistance

  • Mobilization frequency: minimum of five times per day.

  • Head of bed position: 30 degrees

  • Up walking the day of surgery POD#0, every 2–3 h.

Diet

  • Bariatric Phase 1, starting the night of surgery

  • Bariatric Phase 2, on POD1 advance as tolerated from Phase 1 to Phase 2

Nursing Orders

  • Use mouth swab for oral care

  • Foley catheter; connect to constant drainage

  • Discontinue Foley catheter on POD#1

  • Record intake and every 4 h

  • Oxygen by nasal cannula, wean to SpO2 greater than 92%

  • Incentive spirometry ten times per hour while awake, please encourage

  • Maintain elevated head of bed 30 degrees or greater

  • Place intermittent sequential compression devices

  • Continuous pulse oximetry

  • Patient may be transported off unit without telemetry monitoring

  • Notify physician for:

    • Temperature greater than 101.5° F

    • Heart rate greater than 110 BPM

    • Systolic BP greater than 180 mmHg

    • Systolic BP less than 90 mmHg

    • Diastolic BP greater than 90 mmHg

    • Urine output less than 250 ml/8 h.

    • Pulse Oximetry less than 92%

    • Respiratory Therapy

    • CPAP/BiPAP for sleep apnea, if required

Labs

  • CBC, BMP morning of POD#1

Imaging

  • (Optional) esophagram with gastrografin, then barium on POD#1

IV Fluids

  • Lactated Ringers at 100 ml/h

IV Antibiotics

  • (Optional) cefazolin 2 g IV every 8 h for two doses

  • (Optional) vancomycin 1.5 g IV every 12 h for one dose, for PCN allergy

Medications

  • Ondansetron 4 mg IV every 6 h PRN nausea

  • Scopolamine 1.5 mg transdermal (1 mg over 3 days)

  • Acetaminophen 650 mg PO every 6 h

  • Ketorolac 15 mg IV every 6 h for eight doses

  • Oxycodone 5–10 mg PO every 4 h PRN nausea

  • Hydromorphone 0.2 mg IV every 4 h PRN breakthrough pain

  • Lovenox 40 mg SQ BID

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Meister, K.M., Brethauer, S.A. (2018). Postoperative Care Pathways for the Bariatric Patient. In: Reavis, K., Barrett, A., Kroh, M. (eds) The SAGES Manual of Bariatric Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-71282-6_16

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  • DOI: https://doi.org/10.1007/978-3-319-71282-6_16

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-71281-9

  • Online ISBN: 978-3-319-71282-6

  • eBook Packages: MedicineMedicine (R0)

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