Implementation of a New Standard Practice for Pain Management—Reduced Narcotic Use among Bariatric Patients—Lessons Learned by a Bariatric Clinic

| December 17, 2009

by Tracy Martinez, RN, BSN, CBN

Tracy Martinez, RN, BSN, CBN, is Program Director at the Wittgrove Bariatric Center in La Jolla, California.

Bariatric Times. 2009;6(12):16–19

Abstract

The purpose of this article is to review pain associated with morbid obesity and its related comorbidities and bariatric surgery, as well as risks associated with narcotic use in pre- and postoperative bariatric patients. The author will also review how the implementation of a localized pain management therapy following gastric bypass in a well-established bariatric program helped reduce narcotic use in bariatric patients.

Introduction
Bariatric surgery is a highly specialized surgical procedure. Along with the complexity of the disease of morbid obesity and its related comorbidities, bariatric surgery patients often present with a variety of unique medical conditions, which can make the use of narcotics more threatening than on a normal-weighted patient undergoing abdominal surgery. In this article, I will review some of the challenges the weight loss patient may experience postoperatively and how the use of narcotics may impact these challenges. I will also briefly review how laparoscopic weight loss surgery can reduce some of the postoperative risks seen with open procedures. Finally, I will share experiences of a well-established bariatric program in assessing and implementing a successful pain-management protocol while decreasing some of the more serious side effects of narcotic use after bariatric surgery.

Background information
Challenges for the weight loss surgery patient that can be complicated by narcotics. Sleep apnea. Sleep apnea, a comorbidity present in as much as 50 percent of patients with morbid obesity, can be aggravated by narcotics and anesthetics used during and after bariatric surgery.[1] Sleep apnea, at least in our clinic, often is not diagnosed until a preoperative workup and evaluation are done, especially if the person sleeps or lives alone.

Arthritis. Many patients with morbid obesity also have severe arthritic pain.[2] The Centers for Disease Control and Prevention (CDC) have established that morbid obesity can contribute to arthritis 4.4 times more when compared to a normal-weighted individual.[3] Individuals with arthritis may have a high tolerance to narcotics due to daily need of preoperative narcotics necessary for adequate relief from arthritic pain symptoms.

Hypoventilation syndrome. Patients with obesity may also present to the weight loss surgery clinic with hypoventilation syndrome due to decreased lung volume secondary to increased abdominal pressure and an elevated diaphragm.[4] Hypoventilation syndrome results in chronic shortness of breath and decreased respiratory reserve volume, increased oxygen consumption, and an increase in carbon dioxide. This chronic event can lead to heart strain and failure. Postoperatively, the risk of this condition can increase with narcotic use.[5]

Benefits of laparascopic weight loss surgery. Laparoscopic bariatric surgery, first performed in 1993, has been shown to reduce the risk of many postoperative complications compared to the open approach.[6] Those who have been in a bariatric surgical setting during the transition from open to laparoscopic bariatric procedures have seen an increase in patient mobility and a decrease in length of stay in patients who had laparoscopic bariatric procedures compared to those who underwent open procedures.[7] There is also significant reduction in incision hernias,[8] respiratory compromise,[9] wound infections, and postoperative pain[10,11] with the laparoscopic approach. Other complications, such as prolonged illeus,[12] deep venous thrombosis (DVT), and pulmonary embolism, can decrease with early ambulation and quicker return of mobility as seen in laparoscopic approach.[13]

Morbid obesity is associated with an increased risk of developing a thromboembolism postoperatively.[14] Data show a 0.4-percent incidence of DVT and a 0.8-percent incidence of pulmonary embolism in individuals with morbid obesity. The incidence of pulmonary embolism after laparoscopic Roux-En-Y gastric bypass (RYGB), specifically, ranges from 0 to 1.1 percent.[15] Shorter operating time has been shown to decrease the risk of pulmonary embolism.12 Prudent postoperative care, such as low molecular anticoagulant therapy and continuous leg compression devices with early and frequent ambulation can also decrease the risk of pulmonary embolism.[16]

Benefits of Pain Management
While it is now accepted, after years of research,[17,18] that the laparoscopic approach to bariatric surgery decreases many of the postoperative complications seen with open procedures, pain is still very much a concern among bariatric surgery patients. Although pain may be reduced when a bariatric procedure is performed laparoscopically, the procedure is not pain free.

Adequate pain management in the postsurgical bariatric patient is needed in order to increase movement and mobility and enable the patient to adequately perform deep breathing exercises. However, as reviewed earlier, systemic narcotics can increase the risk of hypoventilation, exacerbate sleep apnea, and increase sedation with lack of mental clarity. All of these events can add to the patient’s risk of falling and disruption of normal gastrointestinal function, which can interfere with a physical exam.

Implementation of a new standard practice for pain management
Like most programs, we are continually evaluating our care and results. It is our practice to ask our patients to complete evaluations both preoperatively and postoperatively.

Patients who attend our patient information seminar are asked to complete an evaluation form. Among several questions, we ask patients what concerns or worries they have when contemplating bariatric surgery. One of the most common concerns was, “How much pain will I have?” Although we addressed this issue in the seminar, most respondents felt it was not in depth enough. Because of this evaluation, we now give more information about pain in our seminar and also offer an educational pamphlet on our pain management protocol. This also prompted us to evaluate our current standard practice for pain management in our postoperative patients.

Preoperative conditions vary among our bariatric patients, causing varying levels of pain. In our practice, patients report that, postoperatively, the most painful incision is the left lower port site used for the circular stapler to create the gastrojejunostomy. Our routine was to utilize a patient-controlled analgesia (PCA) pump on all our postoperative patients. We also offer meperidine or morphine injections as needed as well as ketorolac every six hours, which is still our practice.

To better address the issue of postoperative pain among our patients, we investigated the use of a local pain pump device (LPP) (ON-Q® PainBuster Post-Op Pain Relief System, I-Flow Corporation, Lake Forest, California), which uses a continuous infusion of local anesthetic by using a slow-release bulb that “bathes” the most painful incision with the anesthetic. Although in theory this delivery system looked good, we required a study, as is our practice, before our standard practice could be changed.

We conducted a study (nonpublished) in collaboration with our bariatric unit nurses. The study observed 26 consecutive primary gastric bypass patients. Thirteen patients were given PCA only and 13 patients were given both PCA and the local pain pump. Our study showed that the LPP group used 45-percent less narcotics postoperatively when compared to the group who used the PCA only (Figure 1).

Currently, greater than 80 percent of our patients rate their pain on postoperative Day 1 a “4” or less and upon discharge a “2” or less (using a pain-scale rating of 0 to 10, 10 being severe). On postoperative evaluations, 98 percent of patients felt their pain was managed to their satisfaction. An improvement in mental clarity and alertness was noted when the LPP was initiated.

Conclusion
Ongoing assessment in a bariatric clinic program can be beneficial in order to improve care. Careful and thoughtful evaluation should be done prior to implementing change. Listen to your patients, for they can be some of our best educators. The change we implemented at our clinic has allowed our patients improved postoperative recovery by enabling them to have comparable pain control to our previous protocol while having a decreased risk of systemic narcotic use in the high-risk population of patients with morbid obesity. This one implementation enables patients to ambulate, do respiratory exercises, and have a quicker return of bowel function while minimizing postoperative complications to which sedation can contribute.

References
1.    North American Association for the Study of Obesity (NAASO) and the National Heart, Lung, and, Blood Institute (NHLBI); The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Institute of Health Pub # 00-4084. Bethesda, MD, National Institutes of Health, Oct 2000.
2.    Dietal M. Commentary: joint pains after various intestinal bypasses and secondary to obesity. Obes Surg. 1998;8:265.
3.    Mokad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289(1):76–79.
4.    Anand PK, Ralph-Edwards A, Deitel M. Pulmonary complications in obesity surgery. Obes Surg. 1992;2(4):327–331.
5.    Nachmany I, Szold A, Klausner J, et al. Resolution of bariatric comorbidities sleep apnea. In: Buchwald H, Cowan G Jr., Pories W, eds. Surgical Management of Obesity; Philadelphia: Saunders; 2007:377–382.
6.    Wittgrove AC, Clark GW. Laparoscopic gastric bypass Roux en Y: 500 patients technique and results, with 3–60 month follow up. Obes Surg. 2000; 10:233–239.
7.    Westling A, Gustavsson S. Laparoscopic versus open Roux-en-y gastric bypass: a prospective, randomized trial. Obes Surg. 2001;11:284–292.
8.    See C, Carter PL, Elliott D, et al. An institutional experience with laparoscopic gastric bypass complications seen in the first year compared to open gastric bypass complications seen during the same period. Am J Surg. 2002; 183:533–538.
9.    Nguyen NT, Ho HS, Palmer LS, et al. A comparison study of laparoscopic verses open gastric bypass for morbid obesity. J Am Coll Surg. 2000;191:149–157.
10.    Karayiannakis AJ, Makri GG, Mantzioka A, et al. Postoperative pulmonary function after laparoscopic and open cholecystectomy. Br J Anaesth. 1996;77:448–452.
11.    Joris J, Cigarini I, Legrand M, et al. Metabolic and respiratory changes after cholecystectomy performed via laparotomy or laparscopcopy. Br J Anaesth. 1992;69 341–345.
12.    Shobary H, Christou N, Beckman, et al. Effect of laparoscopic versus open gastric bypass surgery on postoperative pain and bowel function. Obes Surg. 2006;16(4):437–442.
13.    Joris, JL, Hinque VL, Laurent PE, et al. Pulmonary function and pain after gastroplasty performed via laparotomy versus laparoscopy in morbidly obese patients. Br J Anaesth. 1998; 80:283-288
14.    Clagett G, Anderson F, Geerts W, et al. Prevention of venous thromboembolism. Chest. 1998;114:531s–560s.
15.    Schneider BE, Billegas L, Blackburn GL, et al. Laparoscopic gastric bypass surgery: outcomes. J Laparoendosc Adv Surg Tech A. 2003;13(4):247–255.
16.    O’Leary JP, Paige J, Martin L. Perioperative management of the bariatric patient. In: Buchwald H, Cowan G Jr., Pories W, eds. Surgical Management of Obesity; Philadelphia: Saunders; 2007:377–382.
17.    Nguyen N, Wolfe B, Laparoscopic versus open gastric bypass. Semin Laparosc Surg. 2002;9:86–93
18.    McGrath V, Needleman B, Melvin W. Evolution of laparoscopic gastric bypass. J Laparoendosc Adv Surg Tech A. 2003: 13:221–227.

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