SPECIAL CONSIDERATIONS IN WORKING WITH

GASTRIC BYPASS PATIENTS FOR THE

EMERGENCY NURSE

Author: Noel Stevens, RN, BSN, CCRN, CEN, Baltimore, MD

Earn Up to 6.5 CE Hours. See page 492.

While functioning as an emergency nurse, alter-ations in basic nursing procedures need to bemade when working with certain patient popu-

lations, such as pediatric or geriatric patients. These modi-fications hold especially true for bariatric patients who haveundergone gastric bypass surgery for the treatment of mor-bid obesity. Performing the same procedure on them as ona person who has normal anatomy may lead to the devel-opment of complications, the need for emergency surgery,or potentially death. This article will help demystify thecare of patients who have undergone gastric bypass andprovide a basic understanding of how to safely performroutine nursing procedures for these patients.

The World Health Organization has described obesityas an epidemic. Obesity is defined as the deposition of excessfat in the body as a result of the ingestion of larger amountsof calories (food) than the body requires or uses.1 It is a com-plex disease that arises from numerous interactions involvinggenetic, physiological, metabolic, cellular, molecular, cul-tural, socioeconomic, and behavioral factors. Its effects canbe seen in virtually all body systems and can be traced as aroot cause of countless disease processes. Most importantly,if left unmanaged, obesity will increase morbidity and mor-tality, possibly shortening a person’s life expectancy.2

Prevalence of Obesity

Body mass index (BMI) is a medical standard that classifiesweight status in adults. Overweight is defined as a BMI of

25.0 kg/m2 to 29.9 kg/m2, and obesity is defined as a BMIof 30.0 kg/m2 or greater. The category of obesity is furthersubdivided into 3 classes. Obesity, class I, is defined as aBMI of 30.0 kg/m2 to 34.9 kg/m2; class II is a BMI from35.0 kg/m2 to 39.9 kg/m2; and class III is a BMI greaterthan 40 kg/m2. The risk of co-morbidities directly corre-lates to the BMI; as one increases, so does the other.3

The prevalence of obesity is rising at alarming rates.The National Health and Nutrition Examination Surveyconducted by the Centers for Disease Control and Preven-tion in 2003-2004 indicated that two thirds of the UnitedStates’ population is either overweight or obese. In the past20 years, the number of obese people (BMI > 30 kg/m2)has more than doubled from 15% in 1976 to 32.9% in2003.4 This disturbing trend has prompted the US Depart-ment of Health and Human Services in its Healthy People2010 report to make the reduction in the prevalence ofobesity a national health objective for the nation.5

In 1991, the National Institutes of Health issued aconsensus statement on the growing trend of obesity aftergathering a group of professionals from the medical andscientific disciplines. They concluded that conventionaltreatment with diet, exercise, and medical therapy has notbeen shown to be effective for long-term treatment of obe-sity. The only proven method to have a long-term signifi-cant impact on the diseases of obesity (eg, sleep apnea anddiabetes) is surgical intervention. The National Institutes ofHealth also set the criteria for bariatric surgery eligibility,which are still followed today. A person should have aBMI greater than 40 kg/m2 without any co-morbidities ora BMI of 35 kg/m2 or higher with co-morbidities such asdiabetes, obstructive sleep apnea, osteoarthritis, or hyper-tension to be eligible for bariatric surgery.6

Surgical Procedure for Roux-en-Y Gastric Bypass

As the incidence of obesity continues to climb and thetechnology becomes more advanced, the demand for bar-iatric surgery has dramatically risen despite the risks andlifestyle changes required. In 1990, about 5000 bariatricsurgical procedures were performed in the United States.

Noel Stevens is Acute Care Nurse Practitioner Student, University ofMaryland School of Nursing, and Staff Nurse, Adult Emergency Department,University of Maryland Medical Center, Baltimore, MD.

For correspondence, write: Noel Stevens, RN, BSN, CCRN, CEN, 186 StoreyCreek Ln, Rocky Mount, VA 24151; E-mail: cstev004@aol.com.

J Emerg Nurs 2009;35:434-6.

Available online 5 December 2008.

0099-1767/$36.00

Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

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Three years later, the number of surgeries had tripled, andby 2004, it was estimated at more than 140,000, a 10-foldincrease in 15 years. The projection is that a quarter millionprocedures will be performed each year by 2010.7

At this time, the most common bariatric surgical pro-cedure performed in the United States is the Roux-en-Ygastric bypass (RYGB). The RYGB has both restrictiveand malabsorptive aspects that are the basis for its successin sustained weight loss. A gastric pouch (15-30 mL in size)is transected from the rest of the stomach, typically using astapler. The foundation for the restriction is that the pouchfills quickly, causing early satiety and decreased food con-sumption. The small pouch produces much less gastric acidand, overall, has a higher pH level than does the stomachas a whole. The continuity of the digestive tract is then re-stored by the creation of a Roux limb. The Roux limb isformed when the small intestine is severed on average45 cm from the Ligament of Treitz and reconnected tothe pouch. The connection (gastric outlet) is about 1 cmin diameter, a size that deters emptying of the pouch,thereby completing the restriction. The portion of thesmall intestine still connected to the stomach (commonlimb) is reconnected to the Roux limb (about 75-150 cmfrom the pouch), allowing digestive enzymes from the pan-creas and gallbladder to facilitate the digestion process.This procedure bypasses a majority of the small intestine,causing the malabsorption and preventing bile reflux. Thelength of the common limb determines the degree of mal-absorption. Today, the RYGB procedure is typically per-formed using a laparoscopic approach.3

Nursing Procedures

When taking a history on an ED patient, discovery of asurgical history of gastric bypass is critical because of thesurgical alteration of the internal anatomy. Special consid-erations need to be made during routine nursing proce-dures for patients who have undergone gastric bypass.

The most common procedure an emergency nursedoes is obtain and trend vital signs. Because physical ex-amination can be limited and radiologic tests may be un-available because of the body habitus of morbidly obesepatients, subtle changes in vital signs often can be the onlyindication that life-threatening complications are develop-ing. A gastrointestinal leak is a complication that is usuallyseen in early postoperative RYGB patients and is oftensubtle and difficult to detect. If left undetected, a gastro-intestinal leak can progress into sepsis. The 2 most sensitiveindicators of a gastrointestinal leak are respiratory distressand a heart rate exceeding 120 beats per minute. In thepresence of a gastrointestinal leak at the anastomosis sites,

often no pain is reported or fever measured. Physical ex-amination is unreliable in the presence of a leak. Close ob-servation and critical thinking are the best tools for anemergency nurse.8

Another procedure that an emergency nurse performsfrequently is medication administration, which cannot bedone in the usual fashion with RYGB patients. For a while(usually about 6 weeks) after the surgery, all oral medica-tions need to be liquid or crushed. As a result, substitutionsmay be necessary when giving ordered medication. Whenthe patient can tolerate whole pills, the physical size of thepill becomes relevant. If the pill is too large (greater than1 cm in diameter), it can become lodged and lead to a gas-tric pouch outlet obstruction. Also, bear in mind that somepatients are never able to tolerate swallowing whole pillsafter surgery. This information is usually ascertained whiletaking a medication history.9

RYGB patients are advised to avoid certain medica-tions indefinitely because of the reduction in the size ofthe stomach and gastric acid production. The most notableare oral nonsteroidal anti-inflammatory drugs (eg, ibuprofen),salicylates, steroids, and bisphosphonates. Minimal amountsof these medications can lead to marginal ulcer formationand potentially perforation. The consequences can be fatalif these recommendations are not followed. Options for paincontrol include acetaminophen, opioids, or tramadol.9

In addition, the gastric bypass procedure affects drugsolubility and surface area for absorption. The decreasedintestinal length and surface area result in the reducedabsorption of extended-release drug preparations. Thesedrugs typically are formulated to absorb over 2 to 12 hoursthrough the course of a normal intestinal tract. However,because of a reduction in the functional length of the intes-tines in RYGB patients, the drug will have passed throughbefore absorption is completed. This result also applies tomedications that are enteric coated, film coated, or delayedrelease. To overcome this issue and the fact these medica-tions cannot be crushed, immediate-release formulationsshould be substituted, possibly resulting in an increase inthe frequency of administration.9

The site of absorption for medication also should beconsidered. Drugs that are rapidly and primarily absorbedin the stomach or duodenum are likely to have reduced effi-cacy (eg, enalapril, olanzapine, and ketoconazole). If appro-priate doses have little to no effect, reduced absorptionshould be considered. Alternative delivery mechanisms,such as intravenous or subcutaneous, may need to be con-sidered. Another major category of medications that havereduced absorption in RYGB patients are oral contraceptives.Therefore, non-hormonal contraceptives, barrier contracep-tion, or an intrauterine device should be recommended.9

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A complaint of abdominal pain may land RYGB pa-tients in the emergency department. Consequently, a con-trasted abdominal/pelvis computed tomography scan willbe ordered to rule out various potential pathologies. Becausethe stomach is reduced to a pouch that can hold only afew ounces, giving oral contrast can be problematic. Typi-cally, oral contrast is mixed in a large volume of fluid (∼750-1000 mL) that the patient must drink in a short amount oftime, causing bowel loop dilation. However, this routine isnot physically possible for RYGB patients. The radiologistsat the hospital should have protocols in place for RYGB pa-tients. Nevertheless, if no such guidelines are available, thefollowing is a possible approach. The patient should drinkthe same amount of volume but slowly and continuouslywhile waiting for the contrast to transverse the intestines,which is approximately 2 hours.

One of the most common complaints that brings aRYGB patient in to the emergency department is abdomi-nal pain, which can be accompanied by nausea and/orvomiting. A procedure that emergency nurses are likelyto use with a patient having these complaints is the place-ment of a nasogastric tube (NGT). A NGT should neverbe placed in RYGB patients, regardless of when their sur-gery was performed. Even when an experienced emergencynurse performs this procedure with the best technique, therisk of pouch rupture is substantial, leading to potentiallyfatal sequelae. If it is determined by the surgeon that aNGT is needed, it must be placed under fluoroscopy toavoid pouch rupture and ensure proper placement. Subse-quently, any further adjustments or repositioning must bedone under fluoroscopy as well.

A challenge to most emergency departments today iscrowding and admission holding, which results in the needto provide meals for patients. The meals provided to anRYGB patient should be high in protein and low in concen-trated sugar and fat. If a large amount (more than 10 gm) ofconcentrated sugar or fat is ingested during a meal, the pa-tient is at risk of having dumping syndrome, which resultsfrom rapid emptying of gastric pouch contents into thesmall intestines, causing fluid shifts within the gut. Symp-toms of early dumping syndrome (usually within 30 minutesof food ingestion) include vertigo, tachycardia, syncope, dia-phoresis, palpitations, and the feeling of wanting to lie down.Late dumping syndrome, which can occur from 90 minutesto 3 hours after eating, is caused by a release of an excessiveamount of insulin in response to a high carbohydrate load inthe jejunum. The symptoms are similar to early dumping

syndrome. In both cases, the symptoms will resolve sponta-neously with time.

Hydration is crucial for RYGB patients. Because of thesurgical alteration in their anatomy, the satiety level is changed,making them prone to dehydration. Non-sweetened, non-carbonated beverages should always be available unlessmedically contraindicated. RYGB patients are instructed,as part of their change in lifestyle, not to drink liquid fora half hour before a meal, during the meal, and for at leastan hour afterward, to limit washout of the pouch contents.

With a projected quarter million procedures being per-formed annually, the chance of an ED nurse tending to apatient who has had a gastric bypass is likely. Caring forthese patients can be unfamiliar and intimidating to anemergency nurse, but with a few alterations in nursing pro-cedures, nurses can provide safe, effective treatment withpositive outcomes for the patient and themselves.

REFERENCES1. World Health Organization. Obesity and overweight. Available

at: http://www.who.int/mediacentre/factsheets/fs311/en/print.html.Accessed July 28, 2008.

2. Hanson D. Complications of weight loss surgery: implications forcritical care nursing. Crit Care Nurs Clin North Am 2004;16:553-8.

3. Buchwald H. Consensus Conference Statement Bariatric surgeryfor morbid obesity: health implications for patients, health pro-fessionals, and third-party payers. Surg Obes Related Dis 2005;200:593-604.

4. National Center for Health Statistics. Prevalence of overweightand obesity among adults: United States, 2003-2004. Availableat: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_adult_03.htm. Accessed April 2, 2008.

5. United States Department of Health andHuman Services. Healthypeople 2010. Available at: http://www.healthypeople.gov/document/html/objectives/19-02.htm. Accessed July 28, 2008.

6. National Institutes of Health. Gastrointestinal surgery forsevere obesity. Available at: http://consensus.nih.gov/1991/1991GISurgeryObesity084html.htm. Accessed July 28, 2008.

7. Virji A, Murr MM. Caring for patients after bariatric surgery. AmFam Physician 2006;73:1403-8.

8. Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB,Provost DA. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003;17:679-84.

9. Miller AD, Smith KM. Medication and nutrient administrationconsiderations after bariatric surgery. Am J Health Syst Pharm2006;63:1852-7.

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