As obesity rates rise, providers ask: How obese is too obese for outpatient?

Difficulties can be a setup for disaster. . . a perfect storm’

The obesity rate has risen dramatically, from 13% of men and 17% of women in 1980 to 28% of men and 34% of women in 1999-2000.1 Increasingly, outpatient surgery providers are faced with the question: Can we handle these people as outpatients?

"The answer is many times obese patients can be taken care of in an outpatient setting, especially within the walls of a hospital-like facility," says F. Dean Griffen, MD, FACS, chair of the committee on patient safety and professional liability at the Chicago-based American College of Surgeons, and general surgeon at Highland Clinic in Shreveport, LA.

"Marked individualization is required, especially if the patient is in a freestanding facility, such as a doctor’s office or surgery center, because the frustration of transport by ambulance or whatever arrangements that have been made with that hospital of choice can be stressful at best, and may not be totally safe," he explains.

Obesity in and of itself should not be a contraindication to day surgery in any facility, Griffen emphasizes. However, obese patients are more likely to have comorbidities including diabetes mellitus, sleep apnea, asthma, hypertension, heart disease, venous statis ulcers, and gastro-esophageal reflux disease.

The most irresponsible behavior is to send a morbidly obese patient home who has sleep apnea, says Rebecca S. Twersky, MD, medical director of the Ambulatory Surgery Unit at Long Island College Hospital and professor of anesthesiology at State University of New York Down-state, both in Brooklyn. "There have been deaths," she says.

In one recent study, anesthesiologists were surveyed on which patients they were willing to include in their selection criteria for ambulatory surgery.2 More than 75% who responded said that sleep apnea patients with postoperative narcotics, as well as morbidly obese patients with comorbidities and no patient escort, were unsuitable for ambulatory anesthesia. More than 75% said they would include patients with morbid obesity without comorbidities and patients with sleep apnea without use of narcotics.

Another issue is the mobility of the patients at home and how well they can care for themselves, says Janey S.A. Pratt, MD, FACS, bariatric surgeon at MGH Weight Center, assistant surgeon in the division of general surgery at Massachusetts General Hospital, and instructor of surgery at Harvard Medical School, all in Boston.

In terms of the operation, obese patients often are difficult to intubate, Griffen says. "It creates a setup for disaster. It’s like a perfect storm," he adds.

These indeed are high-risk patients, explains Ramona Conner, RN, MSN, CNOR, perioperative nursing specialist at the Center for Nursing Practice at the Association of periOperative Registered Nurses in Denver. "Very often they don’t have just one or two comorbidities," she says. "They often have a complex array of physical problems."

The most important key is individualized care, Conner says.

Twersky says she doesn’t believe outpatient surgery should be performed on patients with a body mass index (BMI) of more than 35 with significant comorbidities (sleep apnea, cardiac, endocrine, and/or respiratory) for general anesthesia.

"It is critical to assess the patient for comorbidities and the condition of those comorbidities," she continues. "If patients have sleep apnea and require general anesthesia, is the facility prepared to monitor the patient for an extended period of time, e.g., 23 hours?"

Another comorbidity that should be on the assessment radar is malnutrition, Pratt says. "Believe it or not, the obese tend to be fairly malnourished," she notes. Typically, these patients have a long history of dieting, Pratt says. Often, they’re on high-protein or low-fat diets, she says. "When you cut out a major food group, that’s the best way to get malnourished," Pratt adds.

In addition to comorbidities, consider these areas when determining whether obese patients can undergo outpatient surgery:

  • Body type.

Men who are obese frequently are more problematic than women because they carry more weight in their midsection, Griffen explains. "This increases pulmonary issues," he says. "There’s more risk of pneumonia and more risk of aspiration."

In comparison, women often carry weight in their hips and thighs, he says. "A woman who weighs 280 pounds who has all her added weight below the waist is a much safer anesthesia risk and safer outpatient than a man with a beer gut," Griffen explains.

  • Anesthesia.

Consider the extent of the procedure, the type of anesthetic, and the anesthetic risk, sources advise. Breast biopsy or similar procedures can be rationalized more easily for obese patients and can be performed much more safely than procedures that require a deeper level of sedation, such as gallbladder, Griffen notes. At issue is the total dose and the aftereffects, he says.

If you are performing general or deep intravenous sedation, you need a trained anesthesia provider on site, Pratt emphasizes. Regional anesthetics are more variable in the obese population, she says.

"If you’re doing a spinal for knee surgery, for example, you may want to be in a facility with a trained [anesthesia provider] who feels comfortable managing the airway because the regional may not last as long or may not be as good as with a thin person, so the patient may end up needing anesthesia in the middle of the procedure," Pratt says.

An office may not have an anesthesia machine or vaporizers, Twersky points out. "Patients who will require significant postoperative opioids for pain also present with risks for postoperative respiratory depression and respiratory arrest, so it’s not over just when the surgery is over," she says.

  • Facility preparation.

Outpatient facilities must be prepared to handle obese patients by having large gowns, operating room beds and stretchers that are weighted correctly for patients, appropriately sized equipment — such as anesthesia monitors with extra large cuffs, a difficult-airway cart, scales that can handle large weights, and sometimes, longer instruments, sources says.

Pratt is aware of day surgery units that don’t have doorways large enough for large stretchers to go through, she says. When those facilities have a very unhealthy or unambulatory obese patient, they have to perform surgery in the main OR, not the day unit, Pratt notes.

  • Staff training.

Ask some physical therapists to train your staff on how to move overweight patients, she suggests. To avoid inappropriate behavior or prejudice toward obese patients, train staff so they obtain a sense of what it’s like to be overweight, Pratt advises.

"This is so they understand that people aren’t overweight of their own volition; it’s a disease," she says. "It’s not laziness or just because they overeat. They probably were born with it."

Massachusetts General brought in former gastric bypass patients to share things that were said them before they lost weight, and then they described how they were treated differently after the surgery. Also, nurses did role-playing in which they played the part of obese patients who were being told how to wipe themselves after having bowel movements. "Even being aware of that difficulty is very important for nurses to know about patients, especially one who has had abdominal surgery," Pratt says.

The hospital had its staff wear "obesity empathy suits" that weighed 40 pounds and changed a person’s anatomy to resemble an obese person. "You wear this for a while, and it gives you a true sense of what it’s like to be overweight," Pratt says. "The nurses thought it was incredibly useful in terms of understanding obesity from a personal perspective."

So what’s the bottom line for ambulatory surgery providers? Be prepared.

"It’s perfectly OK to handle obese patients as outpatients, especially in a hospital, especially if they are individualized in terms of keeping with their body habitus — weight below the waist, keeping with their comorbidities: diabetes and esophageal reflux, and the extent of surgery planned," Griffen says.

"I don’t think we should categorically say that big people can’t have outpatient surgery, because they can. But we need to be alert to these possibilities with them, especially extubation considerations with anesthesia, that dictate most should be done in a hospital setting," he notes. Hospitals have broader options for the post-anesthesia period, including ventilator care, admission, and safe transport on a gurney to a room, Griffen says.

"With the increasing prevalence of obesity in the U.S.," Twersky adds, "it is critical that both the anesthesiologist and surgeon be honest in assessing the risks of the procedure and the patient, and if the outpatient facility can handle not only the intraoperative care, but the postoperative care as well."

References

1. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health and Nutrition Examination Survey. Web: www.cdc.gov/nchs/data/nhanes/databriefs/adultweight.pdf#search=’National%20Health%20and%20Nutrition%20Surveys%20Data%20obesity’.

2. Friedman Z, Chung F, Wong DT. Ambulatory surgery adult patient selection criteria — a survey of Canadian anesthesiologists. Can J Anaesth 2004; 51:437-443.

Sources

For more on handling obese patients, contact:

  • Ramona Conner, RN, MSN, CNOR, Perioperative Nursing Specialist, Center for Nursing Practice, Association of periOperative Registered Nurses, Denver. E-mail: consult@aorn.org.
  • F. Dean Griffen, MD, FACS, General Surgeon, Highland Clinic, 1455 E. Bert Kouns, Shreveport, LA 71105. Phone: (318) 798-4546.
  • Janey S.A. Pratt, MD, FACS, Bariatric Surgeon, MGH Weight Center; Assistant Surgeon, Division of General Surgery, Massachusetts General Hospital; Instructor of Surgery, Harvard Medical School, Boston. E-mail: jpratt@partners.org.