MIS Levy Post-Op Bariatric Management

1. ADMISSION: Admit to inpatient
2. ALLERGIES
3. CONDITION: stable

 

Treatments

• NOTIFY HOUSE OFFICER: T>: 100.0 SBP>: 180 SBP<: 90 DBP>: 100 HR>: 100 HR<: 50 UOP<: 240 ml/8h
• VITAL SIGNS q4h
• INTAKE AND OUTPUT strict q4h (measure in hat)
• SEQUENTIAL COMPRESSION DEVICE breaks to ambulate at least QID (must be worn AT ALL TIMES WHILE IN BED)
• VOLUREX INCENTIVE SPIROMETER Q1H While awake
• TURN/COUGH/DEEP BREATH q2h while awake
• NURSING: teach patient to take five deep breaths every 15 minutes (during commercials if watching TV)
• NURSING: Give tablet and capsule medications whole unless otherwise directed. Give one medication at a time with 5 minutes between each medication.
• ABDOMINAL BINDER prn measure and place on patient for comfort with ambulation and activity
• AMBULATE WITH ASSIST qid starting eve of surgery walking in hallway.

Diet

• POST OP DAY 0
  1. NPO EXCEPT ICE CHIPS 1 - 4 oz of water/ice per hour (please provide 1 oz medicine cups for patient to use)
• POST OP DAY 1
  1. BARIATRIC CLEAR LIQUID DIET daily until d/c sip 4-5 oz per hour or until pt feels full; no sugar or carbonated drinks
  2. NURSING: ensure pt has water, broth packet, sugar free jello and crystal light packets available in room now (from floor stock) DO NOT WAIT on dietary tray to be delivered
  3. NURSING: Encourage patient to sip bariatric clear liquids as often as comfortable. Goal is 64 oz fluid daily (minimum of 48 oz fluid daily).

Respiratory

• ADULT OXYGEN THERAPY PROTOCOL oxygen as needed to keep sat >93%
• MASKED CPAP THERAPY _ patient should use home CPAP or BiPAP and adjusted to home settings

Tests

• gastrograffin swallow x1 (r/o leak; assess adequacy of gastrojejunostomy - small volume gastrograffin (30 mL)) 
  1. ONLY PERFORM IF: patient has persistent HR above 120 and/or requested by operating staff but should not be routinely ordered

Labs

IV Fluids

• LR: LACTATED RINGERS ___ ml/hr iv
  1. Set at rate appropriate for patient (usually 125-150)
  2. Post-op day 1 morning should decreased to half that rate if patient drinking well
  3. Saline lock when patient tolerating at least 4 ounces of clear liquids per hour

Medications

• Need to review medications with patient pre-op to fully understand the indication for medications because some weight loss medications have dual indications
• Ok to swallow all medications whole, those meds larger than 2cm can be broken in half, there is no need to crush medication
• Medications should be taken 5 minutes apart
• All extended release medications should be converted to immediate release medications unless there is no immediate release option
• Neuro
  1. Psych meds (for depression, mood stabilizers) should be restarted
     • Convert to immediate release if possible but many of them only come in an extended release version, if so continue then continue the extended release version
  2. ADHD meds can be held
  3. Migraine medicine
     • Anyone with a history of migraines should have imitrex 6mg subQ available prn migraine (unless they are allergic)
     • continue home migraine medication unless that medication has NSAID in it or caffeine in them
• Cardiac
  1. Blood pressure medication
     • Anyone who was previously on beta blockers and or calcium channel blockers prior to surgery should be continued post-op in the immediate release form
     • Ace inhibitors/ARBs should only be restarted if the patient’s blood pressure is persistently above 150mmhg (consider starting half home dose initially depending on home dose and degree to which blood pressure is elevated)
     • Diuretics should NOT be restarted without explicit permission from the operating surgeon
  2. Cholesterol medications
     • Ok  continue 
  3. Blood thinners
     • Check note from cardiology and speak with operative attending about when to resume
• Respiratory
  1. Ok to continue all inhalers if patient uses them at home
• GI meds
  1. GERD medications
     • PPI (protonix/omeprazole) 40mg PO daily x 90 days, starting POD 1
     • If someone takes PPI BID at home, ok to write for PPI BID
     • Ok to stop H2 blockers
  2. Post-operative nausea and vomiting
     • First line: Ondansetron:  4mg IV/PO Q6hr PRN
     • Second line: Haloperidol:  0.5 – 1 mg IV PRN
     • Third line: Promethazine: 6.25-­‐12.5 mg PO PRN
       • Ensure patent IV prior to promethazine injection as extravasation can cause serious tissue injury
  3. Gasx (Simethicone) and Levsin (Hyoscyamine)
     • Do not give levsin to a pt with any of these: Glaucoma; obstructive uropathy (for example, bladder neck obstruction due to prostatic hypertrophy); obstructive disease of the gastrointestinal tract (as in achalasia, pyloroduodenal stenosis); paralytic ileus, intestinal atony of elderly or debilitated patients; unstable cardiovascular status in acute hemorrhage; severe ulcerative colitis; toxic megacolon complicating ulcerative colitis; myasthenia gravis.
     • ALL SLEEVES
       • Schedule Levsin 0.25mg sublingual q4h, (Then decrease to q6h after first 3 doses) can increase to q4h if still having spasms (chest discomfort with swallowing)
       • Schedule simethicone 80mg q6h
         1. Can increase to q4h if still complain of gas pain (usually felt in the midepigastric region)
     • Bypass and Revision patients
       • Can administer levsin in same dose as listed above if patient is having esophageal spasms. If the patient answers yes to the following questions they likely have esophageal spasms.   Levsin usually takes a few doses to start working
         1. Do they have chest pain/nausea/reflux with swallowing (liquids or pills)?
         2. Do they have epigastric pain after swallowing?
         3. Do they burp every time they swallow?
       • If patient complains of gas pain then can give simethicone in same dose as listed above
  4. Weight loss medications
     • These should all be stopped
     • These medications often have dual indication so need to check with patient pre-op to determine why they are taking medications so that all weight loss medications can be stopped
     • Examples: Qsymia (Phentermine-topiramate), topiramate, Contrave (Bupropion-naltrexone), Victoza or Saxenda (Liraglutide), Adipex (phentermine)
  5. Vitamins
     • All vitamins and supplements can be held
  6. Stool softeners
     • Do not write for any stool softeners or laxatives
• GU
  1. Ok to resume bladder spasm, urinary retention and incontinence medications
• Endocrine
  1. Steroids: should discuss with operating attending if patient was on steroids
  2. Diabetics NOT ON INSULIN PRE-OP
     • All diabetic patients should be written for insulin sliding scale
     • All diabetic medications should be stopped
     • If by post-op day 1 patients have sugars that are persistently above 200, the patient needs to be written for insulin sliding scale to go home with
  3. Diabetics ON INSULIN PRE-OP
     • AUTOMATIC ENDOCRINE CONSULT
     • All diabetic patients should be written for insulin sliding scale post-op

 

• Pain
  1. ABSOLUTELY NO NSAIDS OF ANY KIND
  2. Gabapentin
     • Schedule patients on 300mg PO TID starting POD 0 until discharge
       • IF the patient is >65 years old decrease dose to 100mg TID
       • IF the patient is having significant sedation/dizziness decrease dose to 100mg TID
       • If patient is already on gabapentin at home on higher dose, resume home dose of gabapentin
       • Do not write for gabapentin and Lyrica together
  3. Tylenol:  
     • Schedule 1000 mg PO Q6hr starting POD0 until discharge (max 4000 mg in 24hrs)
       • Dose to be given as 500mg tablets cut in half.  So 1000mg dose would be two 500mg tablets each cut in half.  Do not crush medications
  4. Oxycodone:  
     • 5mg PO Q4 PRN pain >4/10.
     • If patient has persistent pain with above algorithm may schedule 5mg of oxycodone every 4hours and then have 5mg additional PRN every 4 hours
  5. Hydromorphone 
     • Consider PRN bolus for breakthrough pain (LAST LINE)
     • Contact Dr Levy to consider toradol before use of IV pain medication
• Post-op VTE prophylaxis
  1. Start POD 1
  2. If CrCl >30mL/Min:
     • Lovenox 40mg subQ Q24h
  3. If CrCl <30mL/Min: 
     • Heparin 5000u q8h
  4. If BMI >60, immobility, use of hormone therapy, obesity hypoventilation syndrome, pulmonary hypertension, venous stasis disease, prolonged operative time, history of DVT, family history of clotting disorder
     • Lovenox 40mg subQ Q12h