Bariatric surgery: Intensive care unit management of the complicated postoperative patient
- Kevin Thornton, MD
Kevin Thornton, MD
- Assistant Clinical Professor of Anesthesia
- University of California San Francisco School of Medicine
- Richard H Savel, MD, FCCM
Richard H Savel, MD, FCCM
- Professor of Clinical Medicine
- Albert Einstein College of Medicine
- Michael A Gropper, MD, PhD
Michael A Gropper, MD, PhD
- Professor and Chair
- Department of Anesthesia and Perioperative Care
- University of California, San Francisco
- Section Editors
- Daniel Jones, MD
Daniel Jones, MD
- Section Editor — Bariatric and Metabolic Surgery
- Professor of Surgery
- Harvard Medical School
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
Most obese patients with uncomplicated medical comorbidities following a bariatric operation are managed on the standard in-patient postoperative surgical unit. However, patients with severe obesity (body mass index >60 kg/m2) and/or severe comorbid illnesses (eg, refractory diabetes) may require intensive care unit (ICU) management prior to transfer to the in-patient surgical floor [1-7]. Parallels can be drawn from the management of the complicated postoperative patient undergoing a bariatric operation and applied to management of a complicated postoperative obese patient undergoing a different elective operation.
The intensive care unit management of the complicated postoperative bariatric surgical patient will be reviewed here. A description of specific bariatric operations, indications for surgery, short-term and long-term complications and outcomes, morbidity and mortality, and management of the uncomplicated postoperative patient are reviewed as separate topics, including:
- Steinbrook R. Surgery for severe obesity. N Engl J Med 2004; 350:1075.
- El-Solh AA. Clinical approach to the critically ill, morbidly obese patient. Am J Respir Crit Care Med 2004; 169:557.
- Brolin RE. Gastric bypass. Surg Clin North Am 2001; 81:1077.
- Gonzalez R, Bowers SP, Venkatesh KR, et al. Preoperative factors predictive of complicated postoperative management after Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003; 17:1900.
- El-Solh A, Sikka P, Bozkanat E, et al. Morbid obesity in the medical ICU. Chest 2001; 120:1989.
- Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg 2004; 188:105.
- El Shobary H, Backman S, Christou N, Schricker T. Use of critical care resources after laparoscopic gastric bypass: effect on respiratory complications. Surg Obes Relat Dis 2008; 4:698.
- van den Broek RJ, Buise MP, van Dielen FM, et al. Characteristics and outcome of patients admitted to the ICU following bariatric surgery. Obes Surg 2009; 19:560.
- Abir F, Bell R. Assessment and management of the obese patient. Crit Care Med 2004; 32:S87.
- Barr J, Cunneen J. Understanding the bariatric client and providing a safe hospital environment. Clin Nurse Spec 2001; 15:219.
- Miller AH, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002; 9:800.
- Gann M Jr, Sardi A. Improved results using ultrasound guidance for central venous access. Am Surg 2003; 69:1104.
- den Herder C, Schmeck J, Appelboom DJ, de Vries N. Risks of general anaesthesia in people with obstructive sleep apnoea. BMJ 2004; 329:955.
- Koenig SM. Pulmonary complications of obesity. Am J Med Sci 2001; 321:249.
- Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg 2003; 13:676.
- Williamson JA, Webb RK, Szekely S, et al. The Australian Incident Monitoring Study. Difficult intubation: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:602.
- Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94:732.
- Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg 2003; 97:595.
- Biring MS, Lewis MI, Liu JT, Mohsenifar Z. Pulmonary physiologic changes of morbid obesity. Am J Med Sci 1999; 318:293.
- Ladosky W, Botelho MA, Albuquerque JP Jr. Chest mechanics in morbidly obese non-hypoventilated patients. Respir Med 2001; 95:281.
- Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301.
- Brower RG, Ware LB, Berthiaume Y, Matthay MA. Treatment of ARDS. Chest 2001; 120:1347.
- Pelosi P, Ravagnan I, Giurati G, et al. Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. Anesthesiology 1999; 91:1221.
- Kress JP, Gehlbach B, Lacy M, et al. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med 2003; 168:1457.
- Gehlbach BK, Kress JP. Sedation in the intensive care unit. Curr Opin Crit Care 2002; 8:290.
- Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471.
- Vaughan RW, Bauer S, Wise L. Effect of position (semirecumbent versus supine) on postoperative oxygenation in markedly obese subjects. Anesth Analg 1976; 55:37.
- Masa JF, Celli BR, Riesco JA, et al. The obesity hypoventilation syndrome can be treated with noninvasive mechanical ventilation. Chest 2001; 119:1102.
- Kessler R, Chaouat A, Schinkewitch P, et al. The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases. Chest 2001; 120:369.
- Liesching T, Kwok H, Hill NS. Acute applications of noninvasive positive pressure ventilation. Chest 2003; 124:699.
- Hida W, Okabe S, Tatsumi K, et al. Nasal continuous positive airway pressure improves quality of life in obesity hypoventilation syndrome. Sleep Breath 2003; 7:3.
- Watters M, Waterhouse P. Percutaneous tracheostomy in morbidly obese patients. Anaesthesia 2002; 57:614.
- Mansharamani NG, Koziel H, Garland R, et al. Safety of bedside percutaneous dilatational tracheostomy in obese patients in the ICU. Chest 2000; 117:1426.
- Black IH, Blosser SA, Murray WB. Central venous pressure measurements: peripherally inserted catheters versus centrally inserted catheters. Crit Care Med 2000; 28:3833.
- Griffiths VR, Philpot P. Peripherally inserted central catheters (PICCs): do they have a role in the care of the critically ill patient? Intensive Crit Care Nurs 2002; 18:37.
- Elamin EM. Nutritional care of the obese intensive care unit patient. Curr Opin Crit Care 2005; 11:300.
- Cutts ME, Dowdy RP, Ellersieck MR, Edes TE. Predicting energy needs in ventilator-dependent critically ill patients: effect of adjusting weight for edema or adiposity. Am J Clin Nutr 1997; 66:1250.
- Pichardo-Lowden A, Gabbay RA. Management of hyperglycemia during the perioperative period. Curr Diab Rep 2012; 12:108.
- Mathison CJ. Skin and wound care challenges in the hospitalized morbidly obese patient. J Wound Ostomy Continence Nurs 2003; 30:78.
- Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet 2010; 49:71.
- Brill MJ, Diepstraten J, van Rongen A, et al. Impact of obesity on drug metabolism and elimination in adults and children. Clin Pharmacokinet 2012; 51:277.
- Levi D, Goodman ER, Patel M, Savransky Y. Critical care of the obese and bariatric surgical patient. Crit Care Clin 2003; 19:11.
- Varon J, Marik P. Management of the obese critically ill patient. Crit Care Clin 2001; 17:187.
- Erstad BL. Dosing of medications in morbidly obese patients in the intensive care unit setting. Intensive Care Med 2004; 30:18.
- Pai MP, Bearden DT. Antimicrobial dosing considerations in obese adult patients. Pharmacotherapy 2007; 27:1081.
- Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin therapeutic guidelines: a summary of consensus recommendations from the infectious diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis 2009; 49:325.
- Meyhoff CS, Lund J, Jenstrup MT, et al. Should dosing of rocuronium in obese patients be based on ideal or corrected body weight? Anesth Analg 2009; 109:787.
- Sturm AW, Allen N, Rafferty KD, et al. Pharmacokinetic analysis of piperacillin administered with tazobactam in critically ill, morbidly obese surgical patients. Pharmacotherapy 2014; 34:28.
- Bookstaver PB, Bland CM, Qureshi ZP, et al. Safety and effectiveness of daptomycin across a hospitalized obese population: results of a multicenter investigation in the southeastern United States. Pharmacotherapy 2013; 33:1322.
- Adane ED, Herald M, Koura F. Pharmacokinetics of vancomycin in extremely obese patients with suspected or confirmed Staphylococcus aureus infections. Pharmacotherapy 2015; 35:127.
- Hall RG 2nd, Payne KD, Bain AM, et al. Multicenter evaluation of vancomycin dosing: emphasis on obesity. Am J Med 2008; 121:515.
- Gan TJ. Pharmacokinetic and pharmacodynamic characteristics of medications used for moderate sedation. Clin Pharmacokinet 2006; 45:855.
- Myzienski AE, Lutz MF, Smythe MA. Unfractionated heparin dosing for venous thromboembolism in morbidly obese patients: case report and review of the literature. Pharmacotherapy 2010; 30:324.
- Schaefer DC, Hufnagle J, Williams L. Rapid heparin anticoagulation: use of a weight-based nomogram. Am Fam Physician 1996; 54:2517.
- Nutescu EA, Spinler SA, Wittkowsky A, Dager WE. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother 2009; 43:1064.
- Bauer SR, Ou NN, Dreesman BJ, et al. Effect of body mass index on bleeding frequency and activated partial thromboplastin time in weight-based dosing of unfractionated heparin: a retrospective cohort study. Mayo Clin Proc 2009; 84:1073.
- Al-Yaseen E, Wells PS, Anderson J, et al. The safety of dosing dalteparin based on actual body weight for the treatment of acute venous thromboembolism in obese patients. J Thromb Haemost 2005; 3:100.
- Hainer JW, Barrett JS, Assaid CA, et al. Dosing in heavy-weight/obese patients with the LMWH, tinzaparin: a pharmacodynamic study. Thromb Haemost 2002; 87:817.
- Correction to Endorsements in: Antithrombotic therapy and Prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines chestjournal.chestpubs.org (Accessed on May 14, 2012).
- Garcia DA, Baglin TP, Weitz JI, et al. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e24S.
- Hohner EM, Kruer RM, Gilmore VT, et al. Unfractionated heparin dosing for therapeutic anticoagulation in critically ill obese adults. J Crit Care 2015; 30:395.
- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110:e82.
- Canadian Cardiovascular Society, American Academy of Family Physicians, American College of Cardiology, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008; 51:210.
- Doherty C. Vertical banded gastroplasty. Surg Clin North Am 2001; 81:1097.
- Hirsh J, Bauer KA, Donati MB, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:141S.
- Scholten DJ, Hoedema RM, Scholten SE. A comparison of two different prophylactic dose regimens of low molecular weight heparin in bariatric surgery. Obes Surg 2002; 12:19.
- Borkgren-Okonek MJ, Hart RW, Pantano JE, et al. Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration, dose stratification, and antifactor Xa activity. Surg Obes Relat Dis 2008; 4:625.
- CRITERIA FOR ICU ADMISSION
- INTENSIVE CARE UNIT POSTOPERATIVE MANAGEMENT
- Cardiac and hemodynamic monitoring
- Respiratory management
- - Extubation
- - Ventilation management
- - Prolonged ventilation and ICU admission
- Mechanical ventilation
- Noninvasive positive pressure ventilation
- Role of tracheostomy
- Vascular access
- Pain control
- Glycemic control
- Repositioning maneuvers
- Prophylaxis for venous thromboembolic events
- MEDICATION DOSING
- Antibiotic dosing
- Sedative and analgesic dosing
- Neuromuscular blocking agent dosing
- Anticoagulant dosing
- - Unfractionated heparin
- - Low molecular weight heparins
- Cardiac medication dosing
- RISK OF COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS