Can you recognize problems from gastric procedures?

(Editor’s note: This is the second of a two-part series on improving care of obese patients in the ED. This month’s story addresses complications of surgical treatment for morbid obesity you may be seeing in your ED. Last month, we covered special considerations for assessment and supplies.)

If you haven’t treated a patient for complications related to a gastric procedure in your ED, prepare yourself. You probably will, and very soon.

"The number of procedures being done has increased exponentially, so you will be seeing more of this population coming through the doors, not only for problems related to the surgery, but other ailments as well," says Jane Lashock, RN, BSN, CEN, ED nurse and bariatric nurse coordinator at Greater Hazleton (PA) Health Alliance and Drs. Butt, Carrato, and Bono Surgical Practice, also based in Hazleton.

Many surgical interventions for weight loss are available, but the most common is the "roux en y," which makes the stomach a 1- to 2-oz. pouch and reroutes the intestines, she says.

Since demand for weight loss surgery has risen quickly due to a dramatic increase in morbid obesity, potentially unscrupulous practitioners may offer these procedures, warns Lashock.

"The safety nets of patient education with a designated dietitian may not always be in place," she says. "Some patients may not be receiving basic information about dietary restrictions and other limitations such as medications, which can be dangerous and lead to adverse side effects."

To effectively manage complications related to gastric procedures, take the following steps:

• Be aware of typical complications.

"The main complications we see in the ED are nausea, vomiting, diarrhea, and abdominal pain due to slow gastric emptying," says Stephanie J. Baker, RN, BSN, CEN, MBA/HCM, director of emergency services at Paradise Valley Hospital in National City, CA.

The most common thing ED nurses are likely to see is vomiting, says Lashock. "The vast majority is dietary-related, either resulting from noncompliance with their diet, eating too fast, or the patient has introduced new foods that don’t agree with them," she says. Although vomiting usually can be resolved with a dietary adjustment, you must be alert for vomiting as a sign of bowel obstruction, adds Lashock.

Possible interventions include supportive care, intravenous therapy due to electrolyte imbalance or dehydration, antiemetics, anti-diarrheals, or laxatives, says Baker.

• Understand dietary restrictions.

After undergoing gastric procedures, patients have severe dietary restrictions that you must be aware of, says Lashock. For example, avoid carbonated beverages since these can cause irritation and bloating to the new stomach pouch, she notes. Also, sugar is contraindicated for these patients, Lashock says. "The safest thing is to give patients clear broths or sugar-free [gelatin dessert] and tea," she advises.

• Assess for surgical site infections and adhesions in the abdominal wall.  

Patients may experience abdominal pain, fever, purulent drainage, and general malaise, says Baker. "Sites should be checked daily for redness and/or drainage, and patients need thorough instructions regarding dressing changes and wound care management," she says.

When in the ED, these patients may need intravenous or oral antibiotics, wound cultures, antipyretics, and pain medications, says Baker.

Remember that morbidly obese patients are more prone to infection because of decreased circulation to the skin, and some are diabetic as well, says Lashock. "Also, healing could be an issue because of decreased protein in their diet," she says. "Look for drainage, redness, swelling, and hard, distended abdomens."

• Avoid medications that can cause stomach irritation.

"Nonsteroidal anti-inflammatories are irritating to the normal stomach and are even more irritating to these patients, with the stomach reduced to a 2-oz. pouch," says Lashock. "These should be avoided unless cleared by their surgeon."

Acetaminophen is a good option, but consider possible interactions with other over-the-counter remedies, says Lashock. "Alcohol and other components are rapidly absorbed and can lead to a magnified response to side effects," she explains.

• Watch for ulcerations.

Ulcers can be life-threatening, warns Lashock. "There are multiple areas around the new stomach pouch and intestine that are stapled and can open with the assistance of an ulcer," she notes. "Ulceration can cause a gastric leak or gastrointestinal bleed, which can present as severe abdominal pain or shock symptoms," she says.

Warning signs include tachycardia, hypotension, abdominal pain, or hemoccult-positive stools, Lashock advises.

• "Dumping" syndrome can occur.

This syndrome results from the patient eating or drinking foods high in sugar, and it occurs because the stomach is so small that sugars are absorbed quickly through the intestine, explains Lashock. It may cause vomiting, abdominal pain, extreme fatigue, flushing, palpitations, and diarrhea, she says.

"The patient usually gets dry heaves because their stomach pouch is so tiny that anything that was in there is already absorbed," Lashock says. 

Sources

For more information about management of complications resulting from gastric procedures, contact:

  • Stephanie Baker, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Telephone: (619) 470-4386. E-mail: StephanieRN1@cox.net.
  • Jane Lashock, RN, BSN, CEN, Bariatric Nurse Coordinator, Drs. Butt, Carrato, and Bono, Greater Hazleton Health Alliance, 668 N. Church St., Suite 104, Hazleton, PA 18201. Telephone: (570) 459-5607. Fax: (570) 459-1140. E-mail: janern@ptd.net.