GAstric Bypass in the SICU

Gldngrl · Apr 9, 2003

Christie-

I occasionally care for gastric bypass pts in a small CCU as overflow. MSO4 PCA is our current pain management. They come to ICU because they can't be extubated,or end up being quickly reintubated, or hemodynamically unstable. Most freq. complication I've seen and heard about is leaks. The running "joke" is that the surgeons say the pt's complications is all respiratory and the pulmonary docs, etc. are saying sepsis/leak, etc...otherwise, the patient goes to PACU after surgery, gets extubated, goes to the floor and discharged in about 5 days. Hope this helps.

nowplayingEDRN · Apr 9, 2003

mmb...

Thanks for taking the time to respond. It kinda helped but yet it didn't...lol. I guess it is due the VERY small size of our facility that they spend anywhere from 3-4 days in SICU. They come from PACU, fully extubated and our pain control is a thoracic epidural of bupivicaine and fentanyl. So far we have been fortunate that our worst complication was on day 5 a patient went in to PSVT on the floor and had to be sent back to the SICU, of course this was after her NGT was dislodged the day after surgery and had to be re-placed under floroscopy (surgeon was p***'d off as you can imagine). I was just trying to get a feel for how other facilities handle their gastric bypass patients, if and when they get them. Our nurses often feel that these patients should be ward patients but the docs are afraid (sadly and unfortunately) to put their major surgical cases on the ward until about 2-3 days post op, siting unskilled and incapable nurses. But again, thanks for taking the time to answer.

Christie

Gldngrl · Apr 10, 2003

Christie-

I'm a Yankee in a Southern Community hospital where one of the surgeons wants it to be known as the "gastric bypass hospital of the region" How's that for notoriety:D I know practically nothing about gastric bypass, but thankfully my nursing friend works on the gastric bypass floor so what I've learned I owe to her. Generally, the patients don't stay in ICU like I've said and they definitely don't have NGT at all. They go to the floor drowsy and nauseated w/ MSO4 PCA and get phenergan, etc. and they are up in a chair that night, they are walking the next day, they start I think on day 2 w/ 30cc po slowly...the thing that gets me w/ these surgeries is the promises made by the surgeons, ie: it'll resolve the diabetes, the htn, etc. w/o treating the underlying problems to begin with. The surgeons here are operating on anyone, regardless of risks, up to 800 lbs! Those patients as you can imagine are in the ICU for many months and some don't ever make it. I feel for you, they are hard patients to care for because of the particular problems they present. MMB

Going80INA55 · Apr 10, 2003

I see them after they get out of the hospital, and speaking from experience I can say I have many, and I mean many who come off of ALL of their DM meds and have normal sugars. Mds even tell them to stop checking them after awhile. As for the htn,,,,seen that go down too....seen many come off of ALL their HTN meds as well.

No, that dont happen for everyone, but yes it does happen more often than I thought it would.

Gldngrl · Apr 10, 2003

Despite the fact that many lose weight and are able to attain normal blood sugars and blood pressures without the use of medications, I believe that the surgery itself has too many inherent risks and is indiscriminately used. I am living in an area where the focus is not upon exercise or healthy eating, but where people eat far too much and of the wrong items and do little to no exercise. When my 300 lb. patient comes in with his MI, he wants to know when he can eat and how many ice creams he can have. There's something wrong with this picture.

Going80INA55 · Apr 10, 2003

Yes, without question this type of procedure is very risky. Right now, depending on the area of the country it seems to be a "fad." We are seeing more and more of them done.

I, like you, don't believe that in many of the cases they are trying to get these folks to focus on proper nutrition and exercise, when it is needed, prior to having this procedure.

I did some post op care and counseling with a gentlemen two days ago who had the procedure. I was very disappointed to find that the appt for his dietician counseling was not yet scheduled. Nor was there a plan in place for a walking schedule.

He was past the fluid phase and just starting on a 1/2 cup of solids 3 times a day. However, he was not injesting nearly enough protein to keep himself from having a dehis.

Gldngrl · Apr 10, 2003

I am just glad to know that in some areas, dietary counselling is being provided as a follow-up. I do know that in my area, pts are sent home and f/u with their surgeon and PCP and do not receive any dietary/exercise counselling. I have a friend who did have the procedure and has lost a total of 110 lbs so far, but he had already lost 70 lbs preop and was exercising faithfully, keeping a food journal, and undergoing psychotherapy for underlying issues. He told me his Dr. told him he must have surgery or he would regain the weight. :eek:

nowplayingEDRN · Apr 10, 2003

Well, having the slight privilege of working in a MTF, where they put a bit higher emphasis on the care that the patients get, maybe they are going over board to keep from having trouble with the patients. I do know that they are supposed to have a well documented hx of over wieght with multi attempts to loose the wgt both through diet and exercise as well as with medication. Then they are supposed to have a throrough and extensive counseling including psych eval before the surgery. Unfortunately, the MTF where I work has a rather prestegious hx behind it and they cater very much to the wants of the population, whether or not it is medically necessary. Therefore, lately the RGBs have been more of a fad here. As far as I am aware, we have had no leaks, but they have an NGT to LCWS for 2-3 days, usually the first time out of bed is that night, the next day they get the OOB tid and that is when they tend to have a mild vasovagal with nausea that resolves rapidly. Walking by the 3rd or 4th day. They do not use a MSo4 PCA but rather the thoracic epidural, which I am sure is another reason they leave them in the unit so long because of the nerve innervation with the diaphragm and the potential for resp distress. Usually when the NGT comes out is when they start the 30cc of ice chips hourly...to see how it is tolerated and they are on clear liquids by d/c. Usually they have an intense dietary consult before d/c to ensure proper diet and hopefully prevention of N/V and dumping syndrome. We have seen improved health status in some and one has had trouble with attaining a plateau for weight but she is also the same pt that had the tube dislodge and went into PSVT 4 days post op....it is just that the doc writes so many orders and has so many tubes in these pt (including an Aline) that it gets very intensive (they even have us doing hourly I&Os. All this input has been great. Thanks

blue280 · Apr 10, 2003

I work on a med-surg floor where we recently found out that we will be getting about 10-20 lap bandings a week. The MD who does them here is well known for his work and does a good job. Lap bandings are different from gastric bypass. its done laproscopically(spl?) and a band is placed around the stomach so the capacity is smaller and the patient feels fuller faster. They come to us from PACU and usually on a MSO4 PCA for the first 24 hrs. They are ice chips only and in the morning they start a clear liquid diet. They get 6 ounces of clears every 3 hrs. They HAVE to see the dietician before discharge and most see the dietician before hospitalization. IMO I think these surgeries are done way too frequently. But I was told its good money and patients feel good about themselves so its good PR. I did see one case where the patient had problems with her opening and it healed shut. Consequently, she can no longer take anything in my mouth and needs a feeding tube for nutrition! Main side effects we have are gas pains from the lap and some nausea.

Gldngrl · Apr 10, 2003

I had wondered why NGT weren't normally kept in at my facility- was told that literature did not support it, nor do they do KUBs before discharge to make sure there's no leaks. Anyone out there have any information about that? My state passed legislation that as long as someone qualifies under the weight requirements, their MD is required to offer them gastric bypass (note that doesn't mean the insurance will pay for it and the hospital can make additional requirements).

Going80INA55 · Apr 12, 2003

Well, I also think we live in a society where some believe we can mistreat our bodies terribly and a pill or procedure will fix it.

I think the procedure is a viable answer to an overweight population, but I hope other avenues have been exausted first, such as diet, exercise and behavior modification.