What actions would you or the team need to undertake in preparation for the second patient, who is morbidly obese and scheduled for a laparoscopic cholecystectomy and intraoperative cholangiogram (IOC)?

Question

You are waiting for a RN Rosie has been working as an anaesthetic nurse for several months and she is in the anaesthetic room with Mrs A, who is to undergo a total knee replacement. Mrs A has had a premedication, which has made her drowsy, but she is clearly still very anxious and holding firmly onto Rosie's hand. Rosie notices that Mrs A's healthcare record It is the commencement of your morning shift and you have been assigned to work in the general surgery operating theatre. The operative list comprises of two adult patients for elective surgical procedures: the first patient has an allergy to latex; the second patient is morbidly obese (BMI 70, height 166 cm, weight 193 kg).

What will be an ideal response?

Answer 1

Answer:
Operating table's weight capacity accommodates the patient's weight (Rowen, Hunt & Johnson, 2012). Consideration must be given to the weight capacity as some operating tables may be manipulated so that the head of the table is positioned at the feet end to move the the pedestal or table support vertical beam away from the patient's abdominal site, enabling the positioning of the Imaging Intensifier for the IOC during the procedure.
Operating table accessories: foot side supports, extensions (sides) and fixation devices to prevent the patient's position from altering intraoperatively as they will be positioned in Trendelenburg with a lateral tilt (Rowen, Hunt & Johnson, 2012). Patients positioned for a laparoscopic cholecystectomy are generally in a Trendelenburg position and tilted laterally (right side up), using gravity to remove the abdominal contents from the patient's upper right quadrant and therefore optimising the surgeon's visualisation of the gallbladder and surrounding structures (Rowen, Hunt & Johnson, 2012).
Transferring devices must be used to assist the team in moving the patient between various surfaces (hospital bed and operating table) (ACORN, 2016; Hignett & Griffiths, 2009; Idzik, Troeleman & Mielke, 2013; Rowen, Hunt & Johnson, 2012).
Additional team members to assist with patient transfer (ACORN, 2016; Idzik, Troeleman & Mielke, 2013; Rowen, Hunt & Johnson, 2012).
Additional pillows may be used to position the patient in a semi-recumbent position to optimise pre-oxygenation and visualisation during intubation (Idzik, Troeleman & Mielke, 2013). Morbidly obese patients may store weight in the abdominal and chest areas, which places additional pressure on the chest and inhibits chest movement. By positioning the patient in a semi-recumbent position, the abdominal contents and pressure they may exert on the patient's chest cavity is minimised.
Bariatric SCD stockings: bariatric patients are at a higher risk of developing venous thromboembolism (VTE). Unless contraindicated, prophylaxis should be implemented. (Idzik, Troeleman & Mielke, 2013).
Bariatric blood pressure (BP) cuffs are applied (Idzik, Troeleman & Mielke, 2013).
Additional instrumentation or consumables, such as extra-long laparoscopic instruments and long laparoscopic ports are available (Idzik, Troeleman & Mielke, 2013). Have available open laparotomy equipment with bariatric or deep retractors at hand (Idzik, Troeleman & Mielke, 2013).
Steps for surgical team members to stand on: due to patient girth and limitations to lower the operating table, the surgical team may need a sturdy wide step which will raise them above the patient and accommodate the ESU foot pedal (Idzik, Troeleman & Mielke, 2013).
Difficult intubation equipment/trolley (fibre-optic intubation devices): intubating a morbidly obese patient could be difficult as a result of the physical barriers imposed by the larger chest and shorter neck space (high Mallampati classification, thyromental distance and external neck circumference) or the existence of obstructive sleep apnoea (OSA), which impedes oxygenation (Graham, Faggionato & Timberlake, 2011; Idzik, Troeleman & Mielke, 2013).
Assess whether the patient has his or her own BIPAP or CPAP machine: having these items accompany the patient are advantageous. BIPAP or CPAP machines may be used to optimise pre-oxygenation and minimise the patient's risk of de-saturating pre- and postoperatively.