Bariatric Surgery Care Pathway
Bariatric Care Pathway
OU Metabolic and Bariatric Surgery Program
University of Oklahoma Health Sciences Center
1000 N Lincoln Boulevard, Suite 3200
Oklahoma City, OK 73104
Phone: (405) 271-9448
Indications:
1. Clinically severe (morbid) obesity
a. BMI ≥ 40
b. BMI ≥ 35 with obesity-related comorbidities (e.g. DM II, HTN, HLD, OSA, cardiomyopathy, asthma, GERD, osteoarthritis, DVT, immobility, etc.)
Procedures:
1. Laparoscopic Roux-en-Y Gastric Bypass (RYGB)
2. Laparoscopic Sleeve Gastrectomy (LSG)
3. Laparoscopic Revision (including band removal, band-to-sleeve, band-to-RYGB, VBG-RYGB, etc.)
4. We do not currently offer Laparoscopic Gastric Band (LAP-BAND®) placement or the Balloon (e.g. ORBERA®, ReShape®, etc.)
Potential Complications:
1. Anastomotic Leak
2. Hemorrhage
3. Stricture
4. Marginal Ulcer
5. Perforation
6. Bowel obstruction
7. Internal hernia (RYGB only)
8. Dehydration requiring infusion vs readmission
9. Infection (e.g. UTI, pneumonia, SSI, etc.)
10. DVT / PE
11. Dumping Syndrome
12. Malnutrition
13. Alcohol or Substance Abuse
14. Eating Disorders (e.g. Binge eating, Bulimia, Anorexia, etc.)
Pre-operative Optimization
1. Nurse Practitioner history and physical
2. Dietitian consultation with personal diet plan
3. Psychological consultation with recommendations for treatment as needed
4. Physical therapy consultation with personal exercise plan
5. Cessation of all nicotine products for a minimum of 4 weeks
6. Pre-operative weight loss through diet and exercise
a. BMI 35-39.9 – 0% TBW required
b. BMI 40-49.9 – 5% TBW required
c. BMI 50+ – 10% TBW required
7. Pre-operative evaluation and treatment of obesity-related diseases
a. Obstructive sleep apnea – sleep study if STOP-BANG score ≥ 3
b. Coronary artery disease – cardiac clearance if history of MI, stent, or CABG
i. TTE
ii. Nuclear medicine stress test
c. Congestive heart failure – cardiac clearance if any history of CHF
i. TTE
ii. Nuclear medicine stress test
d. COPD / Emphysema – PFTs and a pulmonary consult with any history
e. Hypertension – ensure well-controlled on current medications; refer to PCP PRN
f. Hyperlipidemia – ensure patient is on a statin, if applicable; refer to PCP PRN
g. Diabetes mellitus – ensure Hgb A1c < 8.0; refer to Endocrinology PRN
Day Prior / Morning of Surgery:
1. Discharge medications ordered at pre-op clinic visit and Rx sent to OU Pharmacy
2. Clear liquid diet 24 hours prior to surgery
3. NPO at midnight
4. Chlorhexidine preparatory bath
Preoperative Care
1. Prophylactic antibiotics ordered
a. First line: Ancef 3g
b. Clindamycin 900mg for penicillin allergy
c. Vancomycin 1g for penicillin allergy + history of MRSA
d. Dosing amount and timing per infectious disease protocols and weight-based dosing guidelines
2. 1000 mL Lactated Ringer’s bolus in pre-operative area
3. Aprepitant 40 mg oral – must be given 1 hour prior to OR start time
4. Sleeve gastrectomy patients must void just prior to transfer to OR
Intraoperative Care
1. Ambulatory patients to walk from transfer bed outside of operating room and will lie down on operating table with nursing assistance (no transfer while awake)
2. Hovermat to be used for all patient transfers after induction of anesthesia
3. Foley catheter to be used for Roux-en-Y gastric bypass and revisions only – not sleeve
a. Sterile catheter placement should be followed by urinalysis to rule out asymptomatic bladder colonization and/or catheter-associated urinary tract infection
4. Arms and legs to be supported and padded appropriately
5. 1000 mL Lactated Ringer’s bolus to be given at the initiation of the case
Inpatient Post-operative Care
1. Continuous IV fluids
a. Non-diabetic: D5-0.45% NaCl with 20 mEq/L KCL at 150 mL/hr
b. Diabetic: 0.45% NaCl with 20 mEq/L KCL at 150 mL/hr
c. Continue IVF until discharge. Do NOT discontinue.
2. Medications
a. Cut tablets into small pieces (smaller than M&M) or crush to swallow
b. Open capsules and empty into a sugar-free liquid
c. Sleeve: If extended release medications are larger than size of M&M – reorder for smaller immediate release option
d. RYGB: All extended release medications must be converted to immediate release due to change in gastrointestinal absorption
3. Diabetes
a. Continue all oral home medications
b. If patient takes any SUBCUTANEOUS diabetes medications at home –
i. Order Endocrinology Consult for inpatient insulin management plan
1. Please discourage use of insulin infusion – will delay discharge
ii. Blood sugar checks AC & HS
iii. Do NOT place on dextrose containing fluids
iv. Do NOT check blood glucose on non-diabetic patients
4. Hypertension
a. Continue home anti-hypertensive medications with hold parameters
b. Diuretics
i. Hydrochlorothiazide
1. If daily dose ≤ 25 mg à discontinue
2. If daily dose > 25 mg à half dose
ii. Furosemide
1. If daily dose ≤ 40 mg à discontinue
2. If daily dose > 40 mg à half dose
5. Pain Management
a. Hydromorphone (Dilaudid) 0.5-1 mg IV every 1 hour PRN severe pain
b. Oxycodone (immediate release) liquid or tablets 5-15 mg PO every 4 hours PRN moderate pain
c. Acetaminophen 1000 mg PO every 6 hours SCHEDULED
d. Ketorolac (Toradol) 30 mg IV every 6 hours SCHEDULED
i. Not recommended for age > 70, renal insufficiency, or bleeding tendency
6. Nausea Management
a. Ondansetron (Zofran) 4 mg IV every 12 hours X 4 doses SCHEDULED
i. Followed by 4 mg IV every 12 hours PRN
b. Metoclopramide (Reglan) 10 mg IV every 6 hours x 6 doses SCHEDULED
i. Followed by 10 mg IV every 6 hours PRN
c. Prochlorperazine (Compazine) suppository 12.5 – 25 mg PR every 12 hours PRN
7. Bowel Management
a. Colace 100 mg PO every 12 hours SCHEDULED
b. Miralax 17 g PO every 12 hours PRN constipation
c. Glycerin suppository PRN severe constipation
d. Do not use senna (stimulating) products
8. GI Prophylaxis
a. Omeprazole (Prilosec) capsule 20 mg PO once daily
i. Instruct patient to open capsule and dissolve in small amount of sugar-free liquid or yogurt/pudding
ii. Discharge on 90 day supply
iii. PPI usage will be re-evaluated in clinic at the 3 month post-operative visit
iv. If on H2B prior to surgery, please discontinue and start PPI as above
9. VTE Prophylaxis
a. Enoxaparin 40 mg SQ every 12 hours while hospitalized
i. FIRST DOSE IN PACU
b. Patients with a BMI ≥ 55 (or any of the following criteria) will discharge home on Enoxaparin 40 mg every 12 hours for seven days
i. BMI ≥ 55
ii. Any history of DVT / PE regardless of presence of IVC filter
iii. Chronic immobility (scooter, bed-bound)
iv. Active cancer diagnosis
v. Operative time > 180 minutes
vi. Active smoker
10. Other Medications
a. Simethicone (Mylicon) chew tablet 80 mg PO TID PRN for gas pain/bloating
b. Thiamine (Vitamin B1) 100 mg IV once on POD#1
c. Cyanocobalamin (Vitamin B12) 1000 mcg SQ once on POD#1
d. Aspirin 81 mg PO daily ONLY if patient was taking prior to admission. Enteric coted only. Swallow whole. Do not crush.
e. Flu shot – administer if indicated by screening.
11. Labs
a. CBC, BMP, Mg, Phos on POD#1 only
b. No other routine labs unless otherwise indicated
c. No blood glucose monitoring in non-diabetic patients
12. Activity
a. OOB within 2 hours of arrival to ward
b. Ambulate in hallway every 2 hours while awake
c. Abdominal binder can be used as needed when OOB – not required
d. Physical therapy evaluation on if needed
13. Respiratory
a. Incentive spirometry 10 times per hour while awake
b. Encourage cough and deep breathing
c. CPAP must be used if OSA diagnosis with CPAP use prior to admission
14. Wound Care
a. No dressings needed. Instruct patient to shower on POD#1 and pat incisions dry. Do not scrub incisions. No bathing or swimming for 2 weeks.
15. Urinary Retention Protocol
a. If patient is unable to void for 6 hours AND has the urge to void, check a post-void bladder scan to measure urine volume.
i. If volume > 500 mL wait 30 minutes. If patient still unable to void, straight catheterize patient and record amount. Restart 6 hour protocol for second voiding attempt.
ii. If volume < 500 mL wait 1 hour. If patient still unable to void, re-scan bladder and continue until volume > 500 mL or 8 hour has passed since indwelling catheter was discontinued. Contact primary team for further instructions.
b. If unable to void after 2 straight catheterizations, contact primary team. Continue straight cath protocol until otherwise instructed by primary team.
16. Diet
a. Nutrition consult on all bariatric patients
b. POD#0 please order: Clear liquid diet but place in comments “Bariatric Clear Liquid” and mark the box “NO” for room service appropriate question.
i. Provide measuring cups for accurate measurement of intake
ii. Record intake at minimum every 4 hours.
c. Sleeve can progress to stage 2 Full Liquids on POD#1 if tolerating clears and no evidence of nausea / vomiting
i. Please order: Full liquid diet but place in comments “Bariatric Full Liquid, No oatmeal” and mark the box “NO” for room service appropriate question.
ii. Supplement order for High Protein Low Carbohydrate (Premier) protein shake QID and PRN
iii. One liter of total fluid intake required prior to discharge
iv. Cannot discharge with nausea or vomiting
v. Patient is discharge home on full liquid diet
d. Roux-en-Y gastric bypass can progress to stage 2 Full Liquids on POD#2 if tolerating clears, no tachycardia, and no evidence of nausea / vomiting
i. Please order: Full liquid diet but place in comments “Bariatric Full Liquid, No oatmeal” and mark the box “NO” for room service appropriate question.
ii. Supplement order for High Protein Low Carbohydrate (Premier) protein shake QID and PRN
iii. One liter of total fluid intake required prior to discharge
iv. Cannot discharge with nausea or vomiting
v. Patient is discharge home on full liquid diet
e. General diet instructions
i. No straws
ii. No carbonated beverages
iii. Have patient sit upright while drinking
iv. Patient should be instructed to take small, frequent sips
v. Avoid sugar and concentrated sweets such as juice, soda, table sugar, jam, etc. Nutrasweet and Splenda are okay.
vi. Patient should be instructed to drink at least 64 oz of fluid every day on discharge – ok to have ice, sugar-free popsicles, crystal light, broth, tea
17. Discharge Criteria
a. Stable vital signs, no tachycardia
b. At least 1L fluid intake (from time of surgery to discharge) with no nausea or vomiting
c. Tolerating a full liquid (bariatric stage 2) diet
d. Dietary counseling prior to discharge
e. Incisions clean, dry, and intact with no signs of infection
f. Pain is well controlled on oral medications
g. Patient is able to ambulate (or at baseline)
h. Patient is voiding without difficult (or at baseline)
Discharge Care
1. Discharge medications
a. Patients may take medication tablets ≤ 1.30 cm (0.5 inch) – approximate size of an M&M. Otherwise, break pill into that size. If medication is a capsule, open capsule and mix with sugar-free liquid.
b. Stagger medications over 1-2 hours.
c. For RYGB, if meds are XL or XR, reorder for immediate release.
d. Pain
i. 5-15 mg Oxycodone tablet PO Q4hrs PRN
ii. 650 mg Acetaminophen tablet PO Q6hrs PRN (cut, do not crush)
e. Nausea – Zofran 4 mg PO Q6hrs PRN
f. Gas pain / bloating – 80 mg Simethicone chewable tablet TID PRN
g. VTE prophylaxis – discharge on 40mg BID x 7 days if:
i. BMI > 55
ii. BMI < 55 with following risk factor: history of DVT/PE, chronic immobility, active cancer dx, operative time > 180 min
h. GI prophylaxis – 20 mg omeprazole PO daily before breakfast x 90 days. Instruct patient to open capsule and sprinkle in small amounts of sugar-free liquid.
i. If patient was previously on H2B, stop H2B and start PPI
i. Bowel prophylaxis – Colace 100 mg PO BID while taking narcotics
i. Miralax 17g up to TID PRN (second line)
ii. Glycerin suppository PRN (third line)
j. Biliary prophylaxis – Ursodiol 300 mg PO BID x 6 months if patient has a gallbladder with no evidence of gallstones (do not give if patient has had cholecystectomy or has known gallstones)
k. Diuretics –
i. Hydrochlorothiazide – if ≤ 25 mg daily, discontinue; if > 25 mg daily, then send home with half-dose
ii. Furosemide – if ≤ 40 mg daily, discontinue; if > 40 mg daily, half dose
l. Diabetes
i. If patient is on subcutaneous insulin at home, obtain endocrinology consult and follow their recommendations for discharge
ii. Continue all oral diabetes medications, unless instructed otherwise by endocrine
iii. Educate patient to follow-up with PCP in 1-2 weeks
iv. Instruct patient on signs/symptoms of hypoglycemia
v. Educate patient to monitor blood glucose at home and keep a log
m. Hypertension
i. Continue medications at previously scheduled dose.
ii. Instruct patient on signs/symptoms of hypotension and orthostatic hypotension
iii. Educate patient to follow-up with PCP in 1-2 weeks
iv. Educate patient to monitor blood pressure at home and keep a log
n. Aspirin
i. Gastric bypass: enteric coated only, swallow whole, do not crush
ii. Sleeve: can take any form of aspirin
o. NSAIDs – NONE for gastric bypass patients at discharge; sleeve may take without restriction
p. Vitamins – do not order at discharge. They should have been purchased by patient pre-operatively. If not, this will be addressed at their one week post-op check.
2. Activity
a. No weight lifting restrictions. Use common sense. If activity causes pain, then do not do it.
b. Move frequently throughout the day. Instruct patient to walk at least every two hours while awake. Gradually increase activity daily.
c. Do not drive while on narcotic medications.
d. Return to work clearance is based on individual patient and their specific job requirements. Most patients are able to return within two weeks.
e. Sex is ok as long as it does not increase pain.
f. Follow abdominal precautions.
3. Diet
a. Discharge on stage 2 bariatric FULL liquid diet. Liquids should be of thin consistency and patients should be able to pour from cup to cup. Aim for 60-80 g of protein per day. Do NOT advance diet until you are seen in clinic.
b. Nausea/vomiting/difficulty swallowing – this could be from ingesting inappropriate foods/drink, eating too much, or eating too fast. Do not drink with meals. Allow 30 minutes between eating and drinking to decrease overfilling your stomach. Take nausea medication provided if you feel nauseous. It is important to meet your fluid intake goal (> 64 oz daily).
4. Wound care
a. No dressing needed.
b. Patient may shower. No bathing or soaking in water for seven days.
c. Allow warm soap and water to run over incisions. Do not rub. Do not apply lotions or creams. Allow clear glue dressing to peel off over 2-3 weeks.
5. Primary Care Follow-up
a. Instruct patient to follow-up with PCP within TWO weeks of surgery to manage chronic medications.
6. Dehydration
a. The most common reason for readmission is dehydration. It is CRITICAL that the patient stay hydrated at home. They must be taking in 64 oz of fluid at a minimum, taking small sips continuously throughout the day. Thirst is the first sign of dehydration and should be avoided. Nausea is a late sign of dehydration and should be treated aggressively with medication. Educate the patient that they should be urinating at least four times per day and the urine should be light yellow in color. Instruct the patient to please call the office if they think they are dehydrated. We can arrange for IV fluids to be administered as an outpatient.
7. Pain and constipation
a. Educate the patient that post-operative pain is expected and should gradually diminish as healing occurs.
b. Educate the patient to reduce narcotic medications as pain decreases.
c. Educate the patient on the risk of constipation with narcotic use.
8. When to call provider
a. Fever over 101C
b. Vomiting
c. Signs / symptoms of infection
d. Pain in one or both legs
e. Shortness of breath
f. Increasing levels of pain, uncontrolled with prescribed pain medications
9. Surgery follow-up
a. Appointment should be made prior to surgery
b. One week – Nurse Practitioner, Judy Vorheis at bariatric clinic
c. Two weeks – PCP
d. One month – Surgeon at bariatric clinic
10. Discharge summary
a. Complete discharge summary and route to PCP and any specialty providers patient may be seeing
02/27/18—Partial gastrectomy is NOT a PSH case. Spoke to Dr. Fischer’s nurse, who asked & confirmed.