Bariatric Surgery Patient After the Roux-En-Y Operation

57 yo CF with PMH of morbid obesity is seen just after Roux-En-Y gastric bypass surgery (RYGB).

PMH:
Morbid obesity, HTN, GERD, Depression, OSA on CPAP, DM2, HPL, DJD

Medications:
Mavik, Metoprolol, Nexium, Zoloft, Zocor, ASA, Relafen, NPH insulin, Metformin

Physical examination:
Obese lady in NAD
VS 36.7-16-72-140/85 SpO2 96% 0n 5L
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: surgical dressing
Extremities: no c/c/e

Where should this patient go after surgery - regular floor or ICU?
First, ask how long she had been on CPAP for OSA.
If more than 7 days and VSS, she can go to RMF.
If less than 7 days, she needs to go to the unit for an overnight stay.

What else should you do?
Check the CPAP settings. Most patients know the settings of their CPAP machine. Usually it is 5-20 cm H2O (not mm Hg).

If the patient does not know her CPAP setting, you can initially use a dynamic CPAP machine which adjusts the pressure automatically.

Always try to get the correct CPAP setting. To make a presumption is just like saying "hmmm...we do not know the Dig dose but let's try 0.25 mg..."

What should we do with all those pills she was taking before the surgery?
Restart the antidepressant and PPI.
Start SSI with Accuchecks qid.
Do not restart the NPH insulin, statin and BP medications automatically. Wait to see what this patient's PO intake will be.

Most patients have a significant weight loss after surgery and they may not need medications for their insulin resistance, HTN and hypercholesterolemia because these problems either resolve ot improve.

You cannot use extended release tablets because in the first few weeks they have to be crushed. Bariatric surgery patients are fed pureed diet for 2-3 weeks.

Incentive Spirometry
There is another key question to ask: How much do you do on the incentive spirometer?
The baseline value is determined prior to surgery. After the operation, the patient is expected to reach at least 30% of the baseline.

If the patient blew out 2000 cc on the spirometer before the surgery, she is are expected to reach 700 cc now. Most patients perform much better though.

Incentive spirometry is important to prevent atelectasis and then unnecessary work-up for fever.

Key Points of Interest After RYGB:
CPAP setting and duration of the treatment
Incentive Spirometry
Change in the medications
Diet

What did we learn from this case?
There is a list of 4 medical problems seen very commonly in bariatric patients: HTN, DM 2, DJD and depression.

After extubation, and before transferring the patient to the floor, make sure that she does not
have stridor due to glottic edema or wheezing/crackles due to pulmonary edema.

Incentive spirometry is essential in the postoperative period. If the patient did 2000 cc pre-op, they have to reach at least 30 percent of this after surgery (1000 cc is great).

References:
Patient Education for Incentive Spirometry - University of Utah Health Sciences Center
Incentive Spirometry - AARC Clinical Practice Guideline
Preventing respiratory problems after abdominal surgery - BMJ 1996, Tips from Other Journals - AFP
Obesity: Assessment and Management in Primary Care - AFP 06/01

The Risks of Bariatric Surgery - Other Perils of Overweight - NY Times 05/05

A case of gastric bypass surgery that went wrong. Struggling with Body Image During the Holidays - NPR 11/05