Line 2: Due to adipose tissue, there is an increase in blood volume, preload of the heart, stroke volume, cardiac output and myocardial workload to meet perfusion demands. Line 3: With increased blood volume, there is increased RBC’s thus increased viscosity of the blood, so increased risk for thrombophlebitis. A BMI >29 heightens the prevalence of Pulmonary Embolism. DVT appears twice as often in Obese patients compared to nonobese patients. (Gallagher 2006). Baylor College in Texas confirmed that at one year, CHF patients at 1 year who died were less likely to be obese or have metabolic syndrome. U of M at Ann Arbor, MI reported that obese individuals had more than 3 X the risk for the composite end point of death, cardiac transplant or ventricular assist devices
One cause of arrhythmias with persons of higher BMI may be the increased sympathetic activity caused by leptin. Leptin is shown to increase mean arterial pressure and heart rate in laboratory rats. It appears to sensitize adrenergic receptors to catecholamines.
Obese individuals are twice as likely to die after the first year after a transplant and have organ failure. It becomes greater after 5 years. There is accumulating evidence that the sympathetic nervous system plays a role in the development of obesity-related hypertension. Both animal and human studies have shown that excess weight gain is associated with increased renal sympathetic activity, resulting in sodium retention. An activated RAS also contributes to enhanced oxidative stress,vascular remodeling, and pressor response to exercise.The sympathetic nervous system activation associated with obesity is mediated in part by the adipocyte-derived hormone, leptin, which increases in proportion to the degree of adiposity.An increase of leptin in hypertensive individuals is associated with elevated plasma renin activity, aldosterone, andangiotensin concentrations.
Scientists at Geneva University in Switzerland conducted a population-based study in which they evaluated the impact of obesity on presentation, diagnosis and treatment of breast cancer. Among all women diagnosed with invasive breast cancer in Geneva between 2003 and 2005, they identified those with available information on body mass index and categorized them into groups they identified as normal/underweight (BMI <25kg/m), overweight (BMI >/=-30kg/m), and obese (BMI >30kg/m). They compared tumor, diagnosis and treatment characteristics between the groups. They found that obese women presented significantly more often with stage III and stage IV disease, with an odds ratio of 1.8. This means they were 180% more likely to have later stage breast cancer than those women in the normal/underweight group. Women in the obese group were 240% more likely to have tumors that were equal to or greater in size than 1 centimeter compared to the women in the normal/underweight group. They were also a whopping 510% more likely to have positive lymph nodes suggesting their cancers may have spread to other parts of their bodies. In another study, obese women were 20 percent more likely to have false-positive results from mammograms -- readings that can lead to unnecessary biopsies and anxiety. Being overweight can get in the way of effective cancer treatment, too, experts say. The problem: under dosing. "Oncologists usually base chemo on patients' ideal weight rather than their true weight, partly because chemo is so toxic and partly because drug trials typically include only average women, so we don't know the correct dose for bigger women," says Kellie Schneider, M.D., a gynecologic oncologist at the University of Alabama at Birmingham. "But underdosing can mean the difference between life and death."
Obese patients normally have smaller cerebrospinal fluid (CSF) volumes than normal weight patients, and these changes are further exaggerated in the obese parturient. Decreased CSF volume due to increased abdominal pressure (obesity or pregnancy) may produce more-extensive neuraxial blockade due to diminished dilution of anesthetic. The mechanism by which increased abdominal pressure decreases CSF volume is probably inward movement of soft tissue in the I Intervertebral foramen displacing CSF. The epidural space volume is also reduced, due to adipose I infiltration and increased venous distension from aortocaval compression and increased intra-abdominal pressure, resulting in higher spread of local anesthetic and in higher risk of hypotension and respiratory difficulty.
Care of the bariatric patient for the OR Nurse
Care of the Bariatric Patient
Objectives Define the classifications of obesity and explain the impact and costs related to obesity Explain the considerations in caring for the obese patients due to their pathophysiology Identify health and safety risks associated with the obese patient Discuss treatment options for obesity and how to provide weight sensitive care 2
What do we mean by the bariatric patient?Bariatric comes from the Greek word baros which means weight. This means the patient of greater size, usually a body mass index of >30. 3
Classifications of Obesity using Body Mass Index (BMI)Uses Patient’s Height and WeightCorrelates with Total Body Fat ContentGo tohttp://www.sharp.com/tools/bmi.cfmto calculate your own BMI 4
Morbid Obesity Defined 80-100 lbs Overweight Body Mass Index=BMIAcceptable Range 18.5 – 24.9Overweight 25 – 29.9Obese 30 – 34.9Severe Obesity 35 – 39.9Morbid Obesity 40 – 49.9Super-Morbid Obesity 50 – +++ 5
Measures to Assess Health Risks Related to ObesityNeck circumference: > 16-17 inches is related to greater risk Obstructive Sleep Apnea (OSA). Increased waist circumference >40 inches for men or >35 inches for women is related to greater metabolic risks. 6
Impact of Morbid Obesity Causes 300,000 deaths per year in the United States Smoking and obesity are the leading preventable causes of death in the United States Modern worldwide epidemic American Obesity Association 7
Prevalence of ObesityOver 67% of adult Americans are overweight 26% are obese or morbidly obese In 2010, adult obesity rates increased and reached 30 % in eight states High BMI in the U.S. is approximately 10 % for infants and toddlers 18 % for adolescents and teenagers Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008 8 http://healthyamericans.org/reports/obesity2010/
High Cost of Obesity Currently, 9 % of all health care dollars are spentfor the treatment of obesity and its complicationsSome estimate it will climb to 21% of all health caredollars by 2018Undetermined costs related to hospital worker injury 9 http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
Test Your KnowledgeCurrently, approximately 2/3 of Americans are considered overweight or obese True False 10
What is Morbid Obesity?Chronic multi-factorial metabolic disease Life-long Progressive Degenerative Life-threatening Genetically related http://win.niddk.nih.gov/statistics/index.htm 13
Morbid Obesity is a Metabolic Disease As BMI increases, adipose tissue becomes metabolically active and secretes hormones These hormones influence insulin resistance, hyperlipidemia, inflammation, thrombosis, and hypertension The mucosa of the stomach of obese persons secretes higher levels of the hormone Ghrelin which increases appetite 14
The Disease of Morbid Obesity Neuropeptides and neurotransmitters in the brain, mainly the hypothalamus, and other hormones affect satiety, appetite and weight regulation Interestingly, Leptin, a hormone that is secreted by adipose tissue and decreases hunger, is found in higher levels for obese persons but it is believed they are “leptin resistant” The next two slides will demonstrate the complexity of this disease! 15
Obesity and Neurohormonal Influences Located in the brain Orexogenic Mediators Anorexic Mediators Affects hunger Affects satiety Conserves energy Increases energy expenditure Cannabinoid receptor activation POMC + α MSH Orexin A Leptin receptors MCH and AGRP CRH/Urocortin Neuropeptide Y CNS Vagus nerve activation Dynorphin Serotonin Galanin Dopamine Beacon gene activation CART (Cocaine AssociatedCNS Sympathetic nerve activation Receptor Transcript) 16
Pathogenesis of Obesity Behavior and lifestyle habits are often determinants in the development of the disease But, it is also extremely important to also understand the metabolic mechanisms that influence body weight For persons who are overweight and mildly obese, dieting and exercise are very effective for weight loss 18
Challenges for the Morbidly ObeseChanges with hormones and the central nervous systemmake it VERY CHALLENGING to sustain weight loss long term by dieting and exercise alone.At least 85 % regain their weight and more over time 19
Key Points• Morbid Obesity is a chronic metabolic disease• Diet and exercise are very effective for weight loss for those who overweight and mildly obese• Neurohormonal changes for the morbidly obese make it very challenging for them to sustain weight loss long term by dieting and exercise alone 20
Test Your KnowledgeGhrelin is a hormone which is secreted by adipose tissue and decreases hunger True False 21
Co-Morbidities of ObesityCo-morbidities are conditions or diseases caused by or made worse by obesityFor example, asthma, gout, and arthritis may be made worse due to the chronic inflammation associated with obesityIt is important to educate patients about their health risks associated with obesity 24
Metabolic Syndrome X is linked to Obesity Insulin resistance Hyperinsulinemia Hyperglycemia Hyperlipidemia IR= Ins ulin Res istan ce ROS=Rea ctiv e Oxy gen Species Hypertension Heart Disease 25
American Heart Association Definition of Metabolic SyndromeIncreased waist circumference: > 40 inches for men or > 35inches for womenElevated triglycerides: Equal or > 150 mg/dLReduced HDL (“good”) cholesterol: < 40 mg/dl for men and< 50 mg/dL for womenElevated blood pressure: Equal to or greater than130/85 mm Hg or use of medication for hypertensionElevated fasting glucose: Equal to > 100 mg/dL(5.6 mmol/L) or use of medication for hyperglycemia 26
Stroke Increased risk for ischemic stroke in both men and women Ischemic stroke increases progressively and is doubled in those with a BMI > 30 when compared to those having a BMI < 25 Obesity is not proven to be an increased risk for hemorrhagic strokes 27 J. La State Med Soc. 2005, 156, S42-49.
Cardiovascular Considerations Increased total blood volume Left ventricular hypertrophy and decreased ventricular contractility can occur About 75 % of individuals with hypertension have an obesity link 28 American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1818
ECG Considerations Increased fat deposits around the heart may lead to degeneration of the conduction system which causes lethal heart rhythms Large body mass may cause difficulty with landmarks for lead placement and inconsistent or decreased voltage Prolonged QT intervals Non-specific flat/inverted T waves in inferior leads Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804. Zacharias, A. Schwann. T. Riordan, C. et al (2005) Obesity and risk of new-onset of atrial fibrillation after cardiac surgery. Circulation 112 (32), 3247-3255 29
Diabetes Mellitus Type 2 diabetes mellitus (DM) is strongly associated with overweight and obesity in both genders and in all ethnic groups 90 % of all patients with type 2 DM are overweight or obese The risk for type 2 DM also increases in individuals with a more central distribution of body fat (abdominal) Modest weight loss (medical or surgical weight loss), even 5- 10% loss can have significant improvement of type 2 DMAli H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, andObesity-Related Health Risk Factors, JAMA, (289),76-79. 30
Renal Impact Some drugs may impact the renal system in high BMI patients due to high glomerular filtration rates Increased intra-abdominal pressure may lead to hypertension and insult to the kidney If BMI is more than 30, nearly twice the risk for kidney failure If BMI of 40 or above, seven times the risk of kidney failureBlackwell Publishing Ltd. (2006, December 26). Obese Kidney Transplant Patients Twice As Likely To Die In The First Year Or Suffer OrganReference: June Journal of the American Society of Nephrology (2006) http://www.sciencedaily.com/releases/2006/01/060105082226.htm 31
Nonalcoholic Fatty LiverIf BMI > 40, the prevalence of:Nonalcoholic fatty liver disease (NAFLD) is more than 95%Nonalcoholic steatohepatitis (NASH) may be as high as 25%.Sustained liver injury leads to progressive fibrosis and cirrhosis in 10% to 25% of affected individuals. http://bariatrictimes.com/2010/01/21/nutrition-in-the-management-of-nonalcoholic-fatty-liver/ http://www.ccjm.org/content/71/8/657.full.pdf 32
Obesity Related Cancer Obesity related cancer death rates are 14% for men and 20% for women Obese women have a 50% increase risk for breast cancer after menopause Obese men are 30-50% more likely as lean men to develop colon cancer Obesity related cancers include prostate, lymphoma, liver, pancreas, and gallbladder American Cancer Society http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119 33
Reproductive ImpactImbalance of the sex hormones especially androgens and estrogen leads to:Irregular menstrual cyclesIncreased androgenization and facial hairPolycystic ovarian syndrome (PCOS)Decreased conception rates after fertility treatments 34
Physiological changes in the obese patientincreases their risk for adverse events and potential complicationsIt is extremely important to consider these changes in the way you provide care! 35
High Risk for Blood ClotsObesity is characterized by:Chronic inflammationDecreased immunityHypercoagulabilityThis is due to:• Decreased antithrombin-III• Increased tumor necrosis factor α and interleukin-6• Impaired neutrophil function• Increased blood volume 36 Critical Care Medicine 2006 Jun;34(6):1796-804.
Prevent Blood Clots by Early AmbulationMobilize patients early and frequently The efficacy of sequential compression devices and TED hose for obese individuals is unknown Chronic inflammation and hypercoagulation increase the clot risk There are limited studies about anticoagulation and the obese The weight of the large pannus (abdominal fold) creates pressure on the deep vessels and increases the risk Critical Care Medicine 2006 Jun;34(6):1796-804. 37
Test Your KnowledgeWhich statement is not true about the increased risk for blood clots and the obese individual? A. The weight of the abdomen on deep vessels increases the risk B. Little is known about the efficacy of SCDs and TED hose C. Studies on anticoagulation and obesity are limited D. There is no increased risk 38
Pulmonary Considerations Obese patients desaturate very rapidly due to decreased respiratory reserve and lung capacity.Assess reasons oxygen saturation levels are less than 92 %. Immediate intervention is critical.The reverse trendelenberg position is the optimal position as it drops the pannus (abdominal fold) from the diaphragm. Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal 41 volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106.
Pulmonary ConsiderationsPreoxygenate before procedures such as suctioning. It is vital.Keep upright or semi-recumbent as long as possible beforeprocedures.Plan rest periods during most activities as dyspnea is common. 42
Obstructive Sleep Apnea (OSA)Rates of OSA are high, about 71-77% if morbidly obese If also diabetic, it is about 86% and often undiagnosedAssess if patient has symptoms of OSA:• Snoring• Patient has been told they stop breathing for periods of time during sleep• Daytime sleepinessAsk the patient if they use a CPAP machine at home 43
OSA and Obesity Obtain order for Pulmonary Services if patient uses CPAP at home Patients may also require:• continuous oxygenation saturation monitoring• planning for difficult airway management 44
RAMP (Rapid Airway Management Position) for ProceduresAlign the top of the ear with the sternal notchRamp up or raisethe occipital areausing pillows or towelsForm a trapezoid shapebeneath the back of the head Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260 45 Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni
Regional Anesthesia ConsiderationsIncreased abdominal pressure may decrease cerebral spinal fluid volume which may lead to higher neuroaxial blockadeMonitor patients closely for respiratory compromise 46
Weight and DrugsCaution must be used for drugs highly soluble in fat, especially with extended time duration, > 12-24 hours include: Opiate analgesics (Morphine, Dilaudid, etc) Carbamazepine (Tegretol) Propofol Fentanyl Midazolam (Versed) 47
Pain Management Avoid Intramuscular injections Pain medication in the obese patient is largely unknown Narcotics may lead to “Resedation Phenomenon” Adipose tissue leads to unpredictable absorption and a delayed response of these drugs Assess sedation levels and for respiratory depression very closely especially if patient has OSA 48
Drugs and the Obese Patient Pharmacodynamic and kinetic data are not available for many medications such as antibiotics, pain medications, etc. Generally, dose to a patient’s ideal body weight plus 40% of the excess body weight Start “low and go slow” is the best approach 49
Venous AccessLandmark vessels may be hard to palpate or visualize. Consider Infusion Services to avoid multiple IV sticks. Midline and PICC catheters may be a better option depending on the length of therapy. Assess carefully for signs of phlebitis due to excess skin, subcutaneous fat and moisture in skin folds. Assess if standard 1.5-in needles are long enough. 50
GI ImpactMonitor for greater aspiration risk due to high: gastric fluid volume GI reflux incidence of Hiatal HerniaHigh Incidence of Gallstones Normally, acids in bile keep cholesterol from forming into stones With obesity, cholesterol in the bile increases beyond the ability of acids to maintain the cholesterol in suspension, the cholesterol crystallizes and form stones 51
Skin Care Considerations Inspect for moisture and irritation in skin folds as this may lead to infection Ask the patient if they are able to perform their personal hygiene: Obtain adaptive supplies and consult skin team if needed Offer assistance Move all lines, tubes, catheters (if possible) and the pannus (abdominal fold) every 2 hours to prevent atypical ulcers Assess for wound healing since adipose tissue less vascularized 52 Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.
Musculoskeletal ConsiderationsPatients have increased: joint trauma/pain disuse and atrophy of musculaturePrevent injury to yourself and the patient by using size appropriate equipment. Obtain order for Physical Therapy as needed.Look for the weight capacity labels on patient equipment to help select the right equipment (coming soon) 53
Test Your KnowledgeObesity is linked to certain types of cancer True False 54
Treatment of Obesity If BMI is 25-26.9 with co-morbidities: Advise patient of treatment options for diet, physical activity, and behavioral change If BMI is 27-29.9 with co-morbidities or 30-34.9 without co-morbidities: Consider pharmacotherapy in addition to diet, physical activity, and behavioral change If BMI 35 or greater with two co-morbidities or BMI >40: Consider Bariatric or Weight Loss Surgery in addition to above noted treatments 57
Important Points Morbid obesity is a chronic disease. Conventional dieting is often not effective long term for the morbidly obese patient. Currently, medications are successful for about a 5-10% decrease of excess body weight. Surgical weight loss overall results in a decrease in at least 50-60% and more of excess body weight and a profound resolution of serious co-morbidities. Surgery is a “tool” for weight loss success, not a cure. 58
Weight Bias in Healthcare A recent study reported that only 2% of the dietitian students had a neutral or positive attitude about obese persons In one study among nurses: 31% “would prefer not to care for obese patients” 24 % agree that obese patients “repulsed them” 12 % “would prefer not to touch obese patients” Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society 61
Physicians and Weight Bias In several anonymous self report surveys, they view obese patients as: “Noncompliant, lazy, lacking self control, unsuccessful, unintelligent, and dishonest” In a large study, 2,449 overweight and obese women reported that 52% had been stigmatized more than once by their physician Overall, physicians: spent less time with patients assigned more negative symptoms had reluctance to perform certain screenings Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society 62
Impact on Patient Care Patients may delay seeking or cancel preventative health services and exams Discrimination in every social aspect leads to depression, low self esteem, and more Fear of worker injury and extra time to mobilize leads to resentment, impatience, and less mobilization by providers Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society 63
Providing Weight Sensitive Care Ask permission from the patient when you: discuss their weight or BMI weigh them Acknowledge the challenges of losing weight with the patient Briefly explain why morbid obesity is a disease. Many patients are not aware. 64
Providing Weight Sensitive Care Avoid demeaning phrases such as “fluffy”, “fat”, etc Use the term “bariatric” or “extended capacity equipment” instead of “big boy” equipment Provide the appropriate sized equipment and supplies 65
Patient EducationIf a patient is interested in weight loss options at Sharp, the patient may attend an out- patient class. These are two options:Go to www.sharp.com, classes and eventsthen bariatrics-weight loss or Register at 1-800-82-Sharp, ask for medical or surgical weight loss classes 66
Test Your KnowledgeSince the topic of obesity is frequently in the news, weight bias is rare among health care providers True False 67
Claims of NegligenceFailure to: Educate medical providers about risks of obesity Provide policies about care of the obese patient Obtain essential bariatric equipment 70
Claims of NegligenceFailure to: Provide nonjudgmental, weight sensitive care Adequately prepare for emergencies of the obese patient Educate patients about appropriate weight loss resources 71
How are we providing the best care at Sharp Healthcare? 72
System Task Force Safe Care of the Bariatric Patient Recommended and supported by CNOs and System Safety Steering Committee based on identified risks of this patient population Comprised of representatives across the system: SMH Cheryl Holsworth RN, Senior Specialist, Bariatric Surgery Michael Drafz RN, Lead, Vascular Access Services Judd Feiler, Lead, Physical Therapy SGH Bethanie Martin RN, Lead 5 East Ron Owen, Manager, Pulmonary Services SCOR Bryn Hogan RN, Lead ACC MBHWN Ellen Fleischman RN, RD, Manager MIS Bernadette Bongato RN, Nursing Specialist OR SCVMC Deanna White RN, Manager, Acute Care Marquet Johnson RN, CNS, PCU System Representatives Albert Rizos, PharmD, System Senior Clinical Pharmacy Specialist Cheryl Dailey RN, Director, Patient Safety Francine Parent RN, Senior Specialist, System Supply Chain Services 73
Focus Areas of Bariatric Task Force Ensure that our clinical staff have ready access to supplies, products and equipment which are weight and size appropriate Label weight capacity of equipment using weight sensitive stickers. (Implementation has begun at SMH and planned for all of Sharp Healthcare) Offer comprehensive programs for medical and surgical weight loss (Surgical programs offered at SMH and SCV) Implement use of difficult airway kits 74
Focus Areas Provide education to our staff, patients, employees, and physicians for the management and care of this patient population Provide education about ways to provide weight sensitive care Spread entity best practices across the organization Provide educational and resource information available to staff via Sharp Intranet and other venues 75
Bariatric ResourcesBariatric Website (under construction)http://sharpnet/hospitals/memorial/bariatricProgram/index.cfm www.sharp.com go to classes and events, look for bariatrics Resource Experts Cheryl Holsworth, RN, MSA, CBN Senior Specialist Bariatric Program Phone 858-939-3083, Cheryl.firstname.lastname@example.org Thomas Hayes Administrative Coordinator Bariatric Program Phone 858-939-3010, Thomas.email@example.com 76
Conclusions about Morbid Obesity It is a metabolic disease It results in multisystem problems Care of the patient requires customization of care and thoughtfulness Refer patients to out-patient resources for medical/surgical weight loss options 77
Remember how wethink and how we feelis reflected in our eyes 78
References American Society of Metabolic and Bariatric Surgery American Cancer Society American Journal of Respiratory and Critical Care Medicine (2004). (169), 557-561. Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6 th edition). Saunders Elsevier: St. Louis, MO. Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital Environment. Clinical Nurse Specialist, 15(5): 219-223. Hahler, B. (2002). Morbid Obesity: A Nursing Care Challenge. Medsurg Nursing, 11(2): 85-90. Hurst, S., Blanco, K., Boyle, D. Douglass, L. & Wikas, A. (2004). Bariatric Implications of Critical Care Nursing. Dimensions of Critical Care Nursing, 23(2): 76-83. Marik, P. & Varon, J. (1998). The Obese Patient in the ICU. Chest, 113, 492-498. National Institutes of Health. (2000). The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Institutes of Health national Heart, Lung, and Blood Institute North American Association for the Study of Obesity. Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804. Reto, C.S. (2003). Psychological Aspects of Delivering Nursing Care to the Bariatric Patient. Critical Care Nurse Quarterly, 26(2), 139-149. Vachharajani, V. & Vital, S. (2006). Obesity and Sepsis. Journal of Intensive Care Medicine, 21, 287- 295. Varon, J. & Marik, P. (2001). Management of the Obese Critically Ill Patient. Critical Care Clinics , 17(1). Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse Quarterly, 26(2), 119-132. Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA. 79
References Continued http://emedicine.medscape.com/article/123702-treatment Bagchi, D. & Preuss, H. (2007) Obesity: Epidemiology, Pathophysiology, and Prevention. (CRC Press, Taylor & Francis Group, LLC). Boca Raton, Fl. http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf American Obesity Association http://win.niddk.nih.gov/statistics/index.htm Simoni, R. Brazilian Journal of Anesthesiology (2005). Tracheal Intubation of Morbidly Obese Patients, (55)2, 256-260. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea (May 2006). Anesthesiology (104) 5, 1081-93. Bell, R. & Rosenblum, S. (2005). Postoperative Considerations for Patients with Obesity and Sleep Apnea, Anesthesiology Clin. N. America (23), 493-500. www.cdc.gov/obesity Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106. L. Ben-Noun, A. Laor. (January, 2003). Relationship of neck circumference to cardiovascular risk factors. Obesity Research (11), 226-231. Frey, W.C. & Pilcher, J. (2003) Obstructive Sleep Apnea in Patients evaluated for Bariatric Surgery, Obesity Surgery, (13), 676-683. Pływaczewski R, Bieleń P, Bednarek M, Jonczak L, Górecka D, Sliwiński P. (2008). Pneumonol Alergol Pol. (76)5, 313-320. Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, JAMA, (289),76-79. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119 80
Author Information Cheryl Holsworth, RN, MSA, CBN Senior Specialist Bariatric Program Sharp Memorial Hospital Special thanks to the following SHC specialists for their valuable input: Rossanne Decastro, RN, PHN, MSNc, Acute Care Specialist, SCVMC Karen Harmon, RNC, MSN, CNS, Perinatal Clinical Nurse Specialist, SMBHW Steve Leary, RN, MSN, Senior Specialist Acute Care, SMH Susan Moore, RN, MSA, Senior Specialist Acute Care, SMH Paul Neves, RN, BSN, ONC, Acute Care Nursing Specialist, SGH Tanna Thomason, RN, MSN, Clinical Nurse Specialist, SMH 81
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