Diagnosing post-discharge complications in bariatric surgical patients
Bariatric patients may present with dehydration, malnutrition and surgical site complications in the days and weeks after a bariatric surgery procedure
Treating and transporting a bariatric patient can require coordination with outside agencies, as well as specialized lifting and monitoring equipment. Bariatric patients have the right to expect professional and timely emergency care, with consideration given to their unique assessment challenges, and providers have the obligation to deliver such care without risking their own health. Learn more in this EMS1 Special Coverage series, "Bridging the gap in bariatric patient care: Pathophysiology, assessment and transport solutions."
The EMS1 Academy features "Managing Chronic Care Patients," a 1-hour course providing instruction on managing chronic care patients and their use of the EMS system. Visit the EMS1 Academy to learn more and for an online demo.
By Susan Briggs, FNP-BC, APN, EMT
Who hasn’t thought about weight loss? We all know it’s easier to pack on the pounds and a real struggle to take them off. Some say it’s all about will power until that next cookie comes along. Weight loss is a lifestyle change and not a quick fad to avoid the yo-yo dieting.
Obesity has been on the rise for quite some time, especially in the U.S. The comorbidities that accompany obesity – hypertension, stroke, cardiac disease, diabetes, just to name a few – can lead to death. Who knows better than EMS the pharmaceuticals patients take on a daily basis to keep these diseases in control?
When other weight loss methods fail, people turn bariatric surgery to reduce these risks. There have been over 225,000 bariatric surgeries performed annually for weight loss. The most common is the laparoscopic gastric sleeve procedure.
The patient has to have been medically and psychologically cleared prior to undergoing a gastric sleeve procedure, and is advised to avoid smoking and alcohol to avoid post-operative healing complications. During the procedure, the surgeon will make four holes in the abdomen to place the laparoscopic tool in order to visualize and will remove a portion of the stomach pouch. The remaining stomach then becomes a smaller pouch or “sleeve” and is closed with staples.
Typically, the next day, the patient will undergo a swallow study to ensure there is no leaking. The patient starts with liquids then advances to protein shakes and a bariatric diet with the guidance of the bariatric team. Over the course of time, patients are monitored for weight loss, nutritional deficiencies and overall wellness, and positive change results in a reduction of medications and decreases their mortality from obesity.
The success of this procedure outweighs the complications for people seeking weight loss and a better lifestyle. For a majority that undergo these types of procedures, they recover well. But, what about the few that have complications? Complications can occur immediately, to days and weeks post-operative.
Differential diagnosis for post-operative bariatric patients
Post-operative patients discharged after a bariatric surgery procedure may present with the following complications.
Dehydration. One common complication, which is minor, but must be addressed, is dehydration. It occurs frequently when patients do not have the urge to take in oral fluids of small amounts frequently throughout the day. Repletion via IV fluids, monitoring vital signs, monitoring of strict intake and output is necessary to maintain a balance. You may be called to assist dehydrated post-operative bariatric patients soon after discharge, especially during the summer months.
Malnutrition complications. All bariatric surgical patients require nutritional supplements post-operatively. Their smaller intake of food means they may not be able to take in adequate doses required for health. Their vitamin levels are monitored on an outpatient basis by the bariatric team, including vitamin A, B, C, D, E, folate and thiamine. If a patient is not taking their supplements or taking in enough of these nutrients, this can lead to malnutrition as far out at one year post-operatively. For example, a lack of thiamine can lead to Wernicke’s encephalopathy, causing neurological changes such as confusion and seizure activity.
Leaks at the incision sight. The greatest concern is for leaks at the incision site, which usually occur early on (within a few days to weeks after discharge). The symptoms can be insidious with complaints of diffuse abdominal pain, poor fluid intake, vomiting, fever, poor urine output and possible diarrhea.
These patients may present to EMS with dehydration, hypotension, tachycardia, fever and vomiting. When assessing post-bariatric surgery patients, keep a diagnosis differential of gastric incisional leak high on your list. This is considered a medical emergency and should be treated as such. An EKG may show arrhythmias from electrolyte imbalances. Hypotension and tachycardia is a sign of dehydration, with the lack of oral intake and poor output, but match it with a fever over 101 and it’s classified as sepsis.
Part of the prehospital treatment algorithm for sepsis is to provide fluids. If able to provide antiemetic’s, such as Zofran, this can reduce the risk of vomiting, which exacerbates dehydration and increases risk of aspiration. Either in a paramedicine setting or in the hospital setting, IV antibiotics and electrolyte repletion can be started. Tylenol should be given as soon as possible. The ED and bariatric teams will consider a CT of the abdomen and pelvis to rule out any leaks.
Questions to ask post-operative bariatric patients
Treating postoperative bariatric patients in the prehospital setting can be difficult. Some key assessment questions for post-bariatric surgery include:
- The type of surgery
- When the surgery was performed
- Where the pain is located
- When the pain started
- To describe the pain
- Intake and output over the past few days
- Have they been febrile at any point
- Have they taken any medication
Hopefully, this information on bariatric surgical patients can guide you to assess and treat a very special growing population.
About the author
Susan Briggs is a family nurse practitioner at a Level 1 Trauma hospital, Westchester Medical Center, Westchester County, New York, caring for trauma and surgical patients. She has enjoyed volunteering for 30 years at Valhalla Ambulance Corps as an EMT and instructor.