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118 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Studies have found that persons who are obese contend experienced, such as during re-positioning, if the activity
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with a negative bias within a social context but this is not arranged competently and with sensitivity.
same negative bias from health professionals including VTE prophylaxis in bariatric patients is vital especially for
nurses may then interfere with their ability to obtain those patients having bariatric surgery. Routine prophy-
quality healthcare. 112-114 According to Susan Bejciy-Spring, laxis is recommended with weight adjusted dosing
the key to providing quality, patient-centred, sensitive of medications. 81,111 Combining pharmacological and
care to the bariatric patient is R-E-S-P-E-C-T: Rapport, mechanical prophylaxis is recommended for this high
Environment/Equipment, Safety, Privacy, Encourage- risk group. The application of leggings or sleeves for
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ment, Caring/Compassion and Tact. Simple things sequential compression devices or pneumatic venous
such as an appropriately sized gown and suitable bed pumps can often be easier than applying graduated com-
linen which provide the patient with adequate covering pression stockings in any patient when they are supine in
are often not well-organised for this patient group, unless bed. Care must be taken with measuring the limb to
the nurse takes the time to arrange specific supplies if they obtain the correct size legging or stocking. Careful moni-
are not routinely available.
toring of the limb for signs of skin deterioration from
Sedation in the bariatric patient needs to be carefully moisture, or pressure from an ill-fitting legging, sleeve or
managed to avoid the resultant risk of respiratory stocking must be undertaken diligently in the bariatric
failure and need for ventilation. Reducing narcotic usage patient. The insertion of a removable inferior vena cava
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through use of combinations of other analgesia along (IVC) filter as a component of pulmonary embolism pro-
with sedatives will also reduce risk for respiratory failure. phylaxis for patients undergoing bariatric surgery may
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Bispectral index monitoring can be used to assist in occur in some institutions. 111
the titration of sedations during procedures where levels
of sedation that eliminates awareness and recall is The post-operative management of the bariatric patient
necessary. 115 will include nutrition to support tissue repair. The use of
postpyloric enteral nutrition may be of benefit in reduc-
The use of arterial monitoring rather than non-invasive ing the risk of aspiration in the bariatric patient, as these
blood pressure measurements for patients receiving patients often experience post-operative vomiting and
titrated vaso-active infusions should be considered, nausea. 115
because of the difficulty in obtaining accurate readings if
the cuff is not sized or positioned correctly. Use specific INFECTION CONTROL IN THE CRITICAL
bariatric equipment and techniques to move patients CARE UNIT: GENERAL PRINCIPLES
safely for both the patient and the staff involved. It is
important to be aware of the weight capacities of various Effective infection control is vital in the critical care
facilities, such as lifts and equipment, that may be setting to prevent further health risks to critically ill
required in the care of the bariatric patient. patients already compromised by their disease or trauma
(Box 6.3). Critically ill patients often require multiple
Overweight patients can be challenging in any setting,
and it is important to consider the health and safety of invasive devices and therapies to manage their illness and
the staff involved in lifting and moving patients. Equally these increase the potential risk for infection to the
important is maintaining the patients’ dignity and feel- patient. While using therapeutic medical devices is often
ings of safety and minimising their self-consciousness vital to the management of the patient, they are not
during repositioning, irrespective of the method required. without risk. Ventilator associated pneumonia (VAP),
Lifts and hoists and other equipment that are designed catheter associated urinary tract infections (CAUTIs) and
for heavier people should be used. 116,117 A well-thought- central line associated bacteraemia (CLAB) are all aligned
out strategy by an inter-disciplinary group can work with invasive device use and form a significant source of
through the local issues within a hospital or unit and healthcare acquired infections (HAIs) within critical
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produce a Bariatric Kit, containing a range of equipment care. Critical care staff themselves need to protect
appropriate to the needs of the bariatric patients in against contracting infections while providing care for
various settings including the ICU. 117 their patients.
When patients are admitted to critical care it is impossi-
A major concern in the ICU is the positioning of the
morbidly obese patient with respect to airway manage- ble to identify whether or not they are newly colonised
ment and oxygenation. Boyce et al found no differences with bacteria, or are carrying an infection, without further
in the difficulty of airway management when patients investigation. Standard Precautions are applied in the
were in the 30-degree reverse Trendelenburg (head up, management of all patients regardless of the reason for
feet down), supine-horizontal, or 30-degree back-up their admission. Standard Precautions include hand
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position. However, when patients were positioned in hygiene, respiratory hygiene and cough etiquette, the use
the reverse Trendelenburg position, their oxygen satura- of appropriate personal protective equipment, safe han-
tion dropped the least and took the shortest time to dling of sharps, waste and used linen, appropriate clean-
recover. Consult with the patient about techniques that ing and environmental controls, appropriate re-processing
work for them at home when re-positioning and mobilis- of re-usable equipment and the use of aseptic non-touch
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ing. As with all patients, bariatric patients are vulnerable techniques during procedures.
to fears and anxieties resulting from their illness, however With the advent of Influenza H1N1 outbreaks, there has
additional concerns for their physical safety may be been an emphasis on respiratory hygiene and cough