CICM SAQ 2015.2 Q13

Question

Outline the key issues in the post-operative management of a super-obese (BMI 59) patient with type 2 diabetes following sleeve gastrectomy.

Answer

Answer and interpretation

Maintain ABCs

  • Monitoring of vital signs
  • SpO2 and ABGs for PCO2
  • Use of CPAP post op if required. May use patient’s own CPAP device but issues with leak, need for
    oxygen supplementation, etc. may require ICU machine usage
  • Monitor electrolytes especially K+, urine output

Maintain hydration

  • Appropriate fluids can be Hartmanns, 5% glucose, dextrose saline all of which will provide an
    energy substrate and avoid starvation ketosis

Maintain euglycaemia (BSL 4-10)

  • Insulin either as an intravenous infusion or intermittent sub-cut bolus to maintain BSL 4-10. No
    evidence even in this group to support tight BSL control

Avoid starvation ketosis

  • Post-operative oral fluids or diet should be discussed with surgical team and appropriate diet
    commenced as soon as practical

Housekeeping

  • Adequate analgesia avoiding opioids
  • DVT prophylaxis- mechanical prophylaxis for all with low molecular weight heparin if no
    contraindications.

Positioning

  • Ensure appropriate posture/positioning in bed to optimize respiratory function and minimize gastro-
    oesophageal reflux and for pressure care
  • Early mobilization is essential. Goals should be set in conjunction with physiotherapy staff including,
    for example, sitting out of bed within 18 hours, walking within the next 24 hours.
  • Special bariatric beds required and may also need large chairs so patients can be sat out of bed.
  • Hoists etc. / manual handling training for staff

Surgical

  • Test for leak as per surgical protocol e.g. ice water test, gastrograffin swallow.
  • Pass rate: 75%
  • Highest mark: 8.3

Additional Examiners’ Comments:

  • Candidates who scored well mentioned specific challenges and considerations (rather than just generic “ABCs”) and suggested strategies to address these.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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