NCM 118: Responses to Alterations/Problems and its Pathophysiologic Basis in Life-Threatening Conditions, Acutely Ill/Multi-Organ Problems, High Acuity and Emergency Situation Responses to Metabolic-Gastrointestinal and Liver AlterationsI, ASSESSMENTonalteredGIfunction 1. GeneralNutritionalStatusInterview + Should begin with questions regarding client's dietary habits + Questions should elicit information about average daily intake of food and liquids, types and quantities consumed, where and when food is eaten, and any conditions or diseases that affect intake of absorption Questions: « Food intake history, time, food/ drink, amount, method of preparation 2. Health History + Elicit a description of present illness and chief complaint or symptoms through COLDSPA (Characteristics, Onset, Location, Duration, Precipitating Factors, and Alleviating Factors) + Family history, prenatal history, medications, use of tobacco and alcohol + Complete nutritional history including 24-hour dietary intake Onaltered Hepato-Biliary and Pancreatic Disorders + Elicit description of present illness and chief complaint © Onset, course, duration, location, and precipitating and alleviating factors © Cardinal signs and symptoms indicated altered hepatic, biliary, and pancreatic function include: = Jaundice, pruritus + Changes in urine and stool color * Vaguetosevereabdominalpainespeciallyaftereatingfattyfoods * Abdominal tenderness and distention * Easy bruising and bleeding+ Alcohol consumption + Diet high in fat + Infectious agents (transmitted through nonsterile needle puncture, unprotected sexual activity,ingestion of potentially contaminated food, etc.) + Recent blood transfusion + Medications and herbal remedies 0 Some sample drugs with high potential for hepatotoxicity ‘+ NSAIDS (ibuprofen, acetaminophen, etc.) + Antiseizure medications (phenytoin, valproic acid) = TB drugs (isoniazid, pyrazinamide)3. Physical Assessment + The general physical assessment is IPPA (inspection, palpation, percussion, auscultation). * But for abdominal physical assessment, have it in this order: Inspection, auscultation, percussion, palpationa. Inspection a.__ Inspection Body part Results Skin, mucosa & sclerae '* Jaundice (yellow skin and sclera) Petechiae or ecchymotic area Spider angiomas ‘+ _ Palmar erythema Extremities Muscle atrophy Edema ‘Skin excoriation due to scratching ‘Abdomen Contour Girth Pigmentation Color Sears Striae Visible masses Peristalsis Pulsations Cognitive and neurologic statusb, Auscultation + Auscultate bowel sounds before percussion and palpation (5-30 clicks/ min using diaphragm of stethoscope for 5 min) + Normal bowel sounds occur 5-30 times a min or every 5-15 seconds + Auscultate in all abdominal quadrants + Auscultate for vascular sounds (bruits, hepatic friction rub) c. Percussion + Percuss all 4 quadrants noting tympany and dullness d.Palpation + Palpate deeply over all 4 quadrants for any masses and note location, size and shape, pulsation + Palpate liver, spleen, kidneys, aorta for enlargement + Always palpate tender areas last, because if you start there, you may aggravate the pain and make the patient uncomfortable.DIAGNOSTIC ASSESSMENT NON-INVASIVE 1, GUAIAC TEST + Looks for hidden (occult/ old) blood in a stool sample + Detect GI bleeding (GI cancer) + ncreasefiber diet (48-72 hours) + No red meats, poultry, fish, turnips, horse radish, melons, salmon, sardines © Avoid red/ colorful food that may alter stool color for examination) + Withhold 48 hours: iron, steroids, indomethacin, colchicine, vitamin C © These will cause stool discoloration and may cause false positive results Three stool specimens (3 successive days) Hydrogen peroxide will be placed. 0 Positive bleeding: BLUE colorHEMoccuLT (STOOL GUAIAC TEST) © Timing of a guaine test: + Interpretation must be pert + Buc color will likely develop within the first 10-20 ned within 60 necomda seconds of placing the developer © Thercoler can begin to eke after: o comple of ixinnton ter 0 seconde 2mmaten ater2. HEPATOBILIARY SCAN/ LIVER SCAN + Non-invasive nuclear medicine study using radioactive materials to show size and shape of liver tissue and visualize replacement of liver tissue with scars, cysts, and tumors + Radioactive agent is injected IV which is taken up by the liver/ hepatocytes and excreted rapidly through the biliary tract + Patient is placed on NPO and NO opioids given 4H before procedure 3, RADIONUCLIDE IMAGING/ CHOLESCINTOGRAPHY + Procedure is more or less the same with liver scan but this time, images of the gallbladder and biliary tract are obtained after IV administration of radioactive agent. 4, BARIUM SWALLOW. + An examination of the upper GIT under fluoroscopy after the client drinks a contrast medium: barium. sulfate (BaSO4) + To visualize the esophagus, stomach, duodenum, and jejunum PRE-OP POST OP © NPO PM (post-midnight) | ¢ Laxative before the day of test * Encourage oral fluids * Withhold opioids 24H | * Monitor for passage of before test barium (chalky white stools for 24-72 hours)5. BARIUM ENEMA * An examination of the lower GIT + A fluoroscopic and radiographic examination of large intestine is performed after rectal instillation of BaSO4 + Indicated for detecting bowel obstruction and cause of diarrhea and constipation *Contraindication © Patients with color perforation or fistula PRE-OP POST OP © Lowresidue diet 1-2days | ¢ EOF (early oral feeding) * Clear liquid diet and a | ¢ Administer mild laxative as laxative the evening prescribed before test * Monitor passage of * _NPOPM before the day of barium and __— notify test physician if bowel does © Suppository/ cleansing not occur 2 days after enema on the morning of testINVASIVE 1. COMPLETE BLOOD GLUCOSE (CBG) MONITORING + Convenient way of monitoring blood glucose patterns and can be useful aid in guiding treatment changes in patients with Type 1 and Type 2 diabetes, especially during periods of illness or frequent hypoglycemia + Let Patient fast prior to extraction 2-3 hours prior to getting CBG. Collect before lunch. + rotate sites + discard first drop of blood because it is considered as “dirty blood” 2. ESOPHAGOGASTRODUODENOSCOPY (EGD) + An upper GI fibroscopy = Done with fiberscopes + After sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters, and duodenum + Tissue specimens can be obtained for direct visualization of esophagus, stomach, and duodenum + Esophagus ~ stomach ~* duodenumPRE-OP POSTOP . Obtain written consent NPO 6-8H or 12H before test Sedatives, narcotics, tranquilizers as prescribed (diazepam, — meperidine hydrochloride) Atropine sulfate (S04) to reduce salivation and glucagon as ordered Remove dentures or prevent airway obstruction Airway patency —_is monitored during the test Apply mouthguard Patient is positioned on left side (to allow secretions to flow and avoid asphyxia) NPO until gag reflex returns Monitor for signs of perforation Maintain bedrest for the sedated patient until alert and advise to avoid driving 12H if sedative was used Lozenges, saline, gargle, or oral analgesics can relieve minor sore throat, after the gag reflex returns3. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) “Endoscopic visualization of common bile, pancreatic, and hepatic ducts with a flexible fiber-optic endoscope inserted into the esophagus, passed through the stomach and into the duodenum + The common bile duct and the pancreatic duct are cannulated and contrast medium is injected ducts, into the permitting visualization and radiographic evaluation. PRE-OP. POST OP ‘* Assess for allergies to iodine, | * Monitor and seafood, or contrast media document vital ‘+ Place patient on NPO 4H before signs procedure © Monitor ‘© Remove dentures and instruct to complications gargle and swallow topical {esophageal anesthetic to decrease gag reflex, bleeding, Gl as ordered perforation, * Verify informed consent before pancreatitis, sedation sepsis) ‘* Establish baseline vital signs and | ¢ — Monitor for return IVaccess of gag reflex ‘* Administer antibiotic prophylaxis, glucagon and anticholinergics as ordered4, PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) +A fluoroscopic examination of the intrahepatic and extrahepatic biliary ducts after injection of contrast medium into the biliary tree through percutaneous needle injection + Useful for distinguishing jaundice caused by liver disease (hepatocellular jaundice) from that caused by obstruction, for investigating the gastrointestinal symptoms of a patient whose gallbladder has been removed, for locating stones within the bile ducts, and for diagnosing cancer involving biliary system. PRE-OP POST OP Assess allergies to iodine | * Monitor and document and seafood vital signs. * Place patient on NPO 4H | Assess puncture site for prior to procedure bleeding, hematoma, or © Verify informed consent bile leakage before sedation * Monitor for signs of * Establish baseline vital peritonitis and sepsis signs and ensure | «Report present of pain coagulation parameters immediately and platelet count is within normal limits * Establish IV access and administer prophylactic antibiotics as ordered5. LIVER BIOPSY + Sampling liver tissue by needle aspiration for histologic analysis + Can establish a diagnosis of specific liver disease + Physician inserts biopsy needle by way of transthoracic (intercostal) or transabdominal (subcostal) routePRE-OP POST OP > Establish Baseline | * Positioning immediat hemoglobin Tevel, after biopsy: right lateral/ hematocrit and PLT count ide lying with — smal + Make sure PT is within pillow or folded towel normal limits Placed under costal + Verify informed consent + Establish baseline vital signs = Positioning for liver biopsy: supine/__lefe lateral with right of upper abdomen exposed and with patient's right arm. extended over left. shoulder behind head + Tell patient that cooperation during the procedure is important + He/ she is instructed to exhale and hold breath at the end of expiration for at least 10 seconds as the biopsy needie is: troduced margin of puncture site (patient is instructed to remain immobile and maintain position for at east 3h) + Monitor vital signs and biopsy site for hemorrhage and drainage + Instruct patient to avoid coughing or straining + Instruct patient to avoid heavy ifting and strenuous activity for 2 week6. _ LIVER FUNCTION TESTS ‘SERUM ENZYMES ‘Composition Definition Normal values a. Alkaline In absence of bone disease, | 13-19 Phosphatase | it is a sensitive measure of | units/L (ap) biliary tract obstruction b. Lactate May be increased in liver | 100-120 Dehydrogenase | damage units (LDH) Aminotransferase/ Transaminases Enzyme which are increased in liver cell damage as damaged liver cells primarily release these liver enzymes * Previously called | 5-35 units serum glutamic pyruvic transaminase (SGPT) * Levels are increased primarily in liver disorderAspartate Amine Transferase (AST) Previously serum oxaloacetic transaminase (SGOT) Not ase ive index of liver function since levels are also high in damage to skeletal muscle and kidney heart, units Gamma Glutamyl Transferase (GGT) Also called G-glutamyl transpeptidase levels are high in alcohol-induced liver damage Also a indicator cholestasis of sensitive biliary 10-48 IU/L.‘SERUM PROTEINS * Measures ability of liver to synthesize proteins Albumin ~ 4055 g/d Globulin = 1733 g/d Albumin/ Globulin | low in chronic liver disease _| Normally (a/c) 21 PIGMENT STUDIES * Measures ability of the liver to conjugate and excrete bilirubin * — Abnormal in liver and biliary tract disease associated with jaundice clinically Total Bilirubin * Used as screening test | < is for liver or biliary | ml/dL dysfunctionDirect (Conjugated) Increased in bile | 0.03 Bilirubin obstruction mg/dL Indirect Increased in | 0.1-1.1 (Unconjugated) hepatocellular failure | mg/dL Bilirubin and hemolytic jaundice Urine Bilirubin High if direct bilirubin is | also high SERUM AMMONIA Serum ammonia Increased in _ liver | 35-65 failure meg/dl Indicated decreased ability of liver to convert ammonia to ureaBLOOD COAGULATION STUDIES + _ Prolonged in liver failure (PT, APTT) Prothrombin time 10-40 seconds or 90% of control International = 09-13 Normalized Ratio (INR) Partial “ 25-40 Thromboplastin seconds Time (PTT)III, METABOLIC-GI AND LIVER ALTERATIONS 1. ACUTE GI BLEEDING + Gastrointestinal bleeding - refers to any bleeding that starts in the GI tract + Bleeding may come from any site along the GI tract, but is often divided into: © Upper GI Bleeding - The upper GI includes the esophagus (tube from mouth to stomach), stomach, and first part of the small intestine © Lower GI Bleeding - the lower GI includes much of the small intestine, large intestine or bowels, rectum, and anus Etiology Upper GIT disorders Lower GIT disorders © Peptic ulcer disease © Anal fissures * Duodenal ulcer (20-30%) | © Colitis; Radiation, * Gastric ulcer (10-20%) ischemic, infectious Colonic sarcoma Colonic polyps Diverticular disease IBD (ulcerative colitis, Crohn's disease) * _ Internal hemorrhoids * Gastric or duodenal erosions (20-30%) * Gastroesophageal varices (15-20%)Signs and Symptoms/ Clinical Presentation + Hematemesis + Melena ~ black stools; old blood; upper GIT bleeding + Hematochezia ~ red stools; fresh blood; lower GIT bleeding + Syncope + Dyspepsia (indigestion) + Epigastric pain + Heartburn + Diffuse abdominal pain + Dysphagia + Weight loss + Signs of shock o Hypotension © Decreased pulses o Decreased urine output + Jaundice Diagnostic Exams + Endoscopy — considered the GOLD STANDARD for diagnosis of GI bleeding +EGD + Colonoscopy + Radiographic procedures + Serum blood studiesTreatment: Fluid resuscitation + Adequate resuscitation and stabilization is essential + Px with active bleeding should receive IVF (e.g. 500 mL of NS or RL over 30 minutes) while being crossmatched for blood transfusion + Blood transfusion o Must be individualized ‘0 Approach is to initiate BT if hemoglobin is <7 g/dL (70 mg/L) + Hemostasis. o Early intervention to control bleeding is important to minimize mortality, particularly in elderly px + Airway o€ndotracheal intubation should be considered in px whohave inadequate gag reflexes or are obtunded or unconscious, particulary if they will be undergoing upper endoscopy + Active variceal bleeding ‘Can be treated with endoscopic banding, injectionsclerotherapy, or transjugular intrahepatic portosystemic shunting (TIPS) procedure + General support ‘0 Supplemental oxygen via nasal cannula oNPO 0 PIVC (16G / 18G) or a central venous line should be inserted Placement of a pulmonary artery catheter 0 Elective endotracheal intubationNursing Management + All critically ill px should be considered at risk for stress ulcers and therefore GI hemorthage. gastric Maintaining fluid pH 3.5-4.5 is a goal of prophylactic therapy + Major nursing interventions are: 0 Administering volume replacement © Controlling bleeding © Maintaining surveillance for complications © Educating family and px hemorthagic shock) 2. INTRA-ABDOMINAL HYPERTENSION (IAH) AND ABDOMINAL COMPARTMENT SYNDROME (ACS) + Intrabdominal pressure - pressure concealed within the abdominal cavity + Intraabdominal hypertension (IAH) © Sustained pathological elevation of IAP greater than or equal to12 mmHg Grade IAP Values Grade! IAP between 12-15 mmHg Grade II IAP between 16-20 mmHg Grade lll__| IAP between 21-25 mmHg GradelV__| IAP >25 mmHg+ Abdominal Compartment Syndrome (ACS) © Organ dysfunction caused by intraabdominal pressure >20 mmHg o This MBDICAL EMERGENCY + Prevalence 0 IAH and ACS are not only r/t trauma + IAH and ACS are equally prevalent in medical px + Can be found in every critical care population Effects of Increase IAP + Renal © Compression of renal veins and collecting systems © Oliguria, activation of RA system, acute tubular necrosis, and renal failure (if prolonged) = Neurological oT ICP(t BP 4 PULSE J RR) 0 4 Cerebral perfusion pressure (CPP) + Gastrointestinal o Edema o NecrosisIntra-abdominal Pressure Monitoring SY] Wintusion bag To monitor Pressure transducer 60 mL syringe Urine lamp with three stopeocks catheter Seas}+The gold standard for diagnosing intra-abdominal hypertension + Measure IAP at least q 4-6 hours. + TAP is measured by measuring bladder pressure © Requires placement of indwelling urinary catheter 0 Drainage bag clamped ‘0 Pxin flat supine position (recommended) * If not tolerated, may place in supine 30-degree reverse Trendelenburg = Note pxposition at the time of pressure measurement in medical record o Instill 25 mL of sterile 0.9% normal saline thru catheter 0 Transducer attached to catheter sample port (transducer zeroes to mid axillary line, at the level of the iliac crest) 0 Obtain pressure reading during end-expiration o Subtract instilled volume from urine output © Monitor for trends and signs of organ dysfunction Treatment + Titrate therapies for IAP <= 15 mmHg + Optimize fluid status + Optimize systemic perfusion © Goal abdominal perfusion pressure (AP) of >= 60 mmHg APP = MAP -IAP+ Evacuate intraintestinal contents + Evacuate intra-abdominal lesions + Improve abdominal wall compliance + Consider emergent abdominal decompression © Percutaneous drain to remove fluid ‘0 Decompressive Celiotomy © Bedside laparotomy 3. LIVER FAILURE *An uncommon condition in which rapid deterioration of liver function results in coagulopathy and alteration in mental status + Liver failure indicated that liver has sustained injury Types of Liver Failure + Fulminant Hepatic Failure ‘© Encephalopathy starts within 8 weeks + Non Fulminant Hepatic Failure ‘0 Encephalopathy starts between 8-26 weeksAcute Liver Failure + Isa rare condition characterized by the ABRUPT onset of severe liver injury + Loss of liver function that occurs rapidly—in days or weeks—usually in a person who has no pre-existing liver disease «It’sa thatrequireshospitalization MEDICAL EMERGENCY Signs and Symptoms + Jaundice + Hepatic encephalopathy Mental confusion o Difficulty concentrating o Disorientation + Pain and tenderness in the upper right side of the stomach Electrolyte imbalances ‘Hypoglycemia oHypokalemia © Hypomagnesemia © Hypocalcemia © Hypophosphatemia +Melena + Ascites + Ankle edema + Malaise, drowsiness, and muscle tremors + Bleeding, cerebral edema, hematemesis, comaPharmacological Management 320 mosm/kg) 0 (NV: 275-295 mOsm/kg), ohigh urine specific gravity (1.010)Implementation + volume restoration Characteristics of Diabetic Ketoacidosis (DKA) vs Hyperosmolar Hyperglycemic State (HHS) ‘Components DKA HHS History of diabetes | Type 1 Type 2 mellitus Onset Rapid Slow Respiratory rate Hyperventilation | Slightly Rapid Breath odor Acetone orsweet__| None Blood glucose | Elevated Markedly elevated elevation Serum sodium Mild hyponatremia | hypernatremia Serum ketones Positive Negative Serum potassium | Hyperkalemia Within normal initially, then | limits hypokalemia ‘Serum osmolality Slightly elevated Markedly elevated Acidosis Metabolic acidosis NegativeIMPLEMENTATION/ MANAGEMENT OF METABOLIC-GI AND LIVER ALTERATIONS MEDICAL-SURGICAL MANAGEMENT 1, NASOGASTRIC SUCTION TUBES +Nasogastric tubes = primarily inserted for decompression ofstomach Types: a. LEVIN (Single lumen) Pump © (channel within a tube or catheter) and is made of plastic/rubber. This is tube is connected to low intermittentsuction (30-40 mmHg) to avoid erosion or tearing of thestomachlining b. SALEM (Double Lumen) Pump 0 radiopaque (easily seen on x-ray), clear plastic, double-lumengastrictube. Theblueportventisalways opentoairfor continuous atmospheric irrigation; prevent reflux byhavingtheblueventportabovepatient's waist Lowe}Common Gastrointestinal (Gl) Suction Tubes LEVIN TUBE SALEM SUMP TUBE nirseslobs2. ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES *Done via placement of Sengstaken-blakemore or Minnesotatube which are multi-lumen gastric placed tubes, nasally & extended into the stomach; there are two balloons: © Esophageal balloon — at the esophageal area, when inflated, tamponades the bleeding in the esophagus 0 Gastric balloon - serves as anchor 7 tes tn \ eametatooa. Sengstaken-Blakemore tube -triple lumen gastric tube (one lumen allows inflation of esophageal balloon, the other allows inflation of gastric balloon while third lumen allows for gastric aspiration) b. Minnesota tube + quadruple tumen gastric tube; a modified Sengstaken-blakemore tube with an additional lumen for aspirating esophagopharyngeal secretions mpg on aeons sorta ge pe Pic 1 & 2 Minnesota tubeNursing Considerations: = Closely monitor patient's condition and lumen pressure + Careful surveillance of patient's vital signs, oxygen saturation, and cardiac rhythm (a change may indicate new bleeding) + Monitor respiratory status and observe for respiratory distress o If respiratory distress= CUT balloon ports and REMOVE tube. o Keep scissors at bedside + Provide support for patient + Deflate esophageal balloon for about 30 minutes every 12 hours or according to hospital policy/procedure 3. BILLROTH | AND II + Subtotal Gastrectomy = a generic term referring to any surgery that involves partial removal of the stomach, may be accomplished by either a Billroth I or a Billroth II procedure. Billroth I + Surgeon removes part of the distal portion of the stomach, including the antrum, +The remainder of the stomach is anastomosed to the duodenum “This combined procedure is more properly called gastroduodenostomy + It decreases the incidence of dumping syndrome that often occurs after a Billroth II procedure.Billroth II + Billroth II resection involves reanastomosis of the proximal remnant of the stomach to the proximal jejunum + Pancreatic secretions and bile continue to be secreted into the duodenum, even after gastrectomy + Surgeons prefer the Billroth II technique for treatment of duodenal ulcer because recurrent ulceration develops less frequently after this surgery. + WOF: Dumping Syndrome — rapid gastric emptying in which your food moves too quickly from the stomach to the duodenum = let patient lie on the LEFT SIDE DUMPING SYNDROME. “Tachycardia * Neder + Se Lining4, TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) «Involves the threading of a cannula into the portal vein via the transjugular route + an expandable stent is inserted & serves as an intrahepatic shunt between the portal circulation & hepatic vein, reducing portal hypertension. Transjugular intrahepatic oie portosystemic shunt (TIPS) yastions Hepatic vein- Stent Gallbladder Portal vein5. LIVER TRANSPLANTATION + Surgery to remove a diseased liver and replace it with a healthy one. Indications: + Liver transplantations is needed for patients who are likely to die because of liver failure + Common conditions requiring liver transplant include: © Noncholestatic cirrho: o Biliary atresia © Acute hepatic necrosis + Where does a liver for a transplant come from? Two types: a. Living donor transplantation b. Cadaveric transplantation iver transplant surgery takes between 6 and 12 hours Post-op: « Patient is advised to stay working + Patient is required to take lifetime medicines (e.g. immunosuppressive medications) and to prevent infections in the hospital for an average of 1-3 weeks to ensure that new liver is rejectionComplications: a. Rejection + Immune system works to destroy foreign substances that invades the body. The immune system, however, can’t distinguish between transplanted liver and unwanted invaders, such as viruses and bacteri + Therefore, immune system may attempt to attack and destroy the new liver. This is called rejection episode +Antirejection medications are given to ward off the immuneattack b. Infection + Because antirejection drugs that suppress immune system are needed to prevent the liver from being rejected, it places patient at increased risk for infections Liver Transplant Guidelines: 1. Monitor prothrombin time, partial thromboplastin time, fibrinogen, and factor V levels as ordered. Monitor blood pressure: hypertension is common. GI assessment: Monitor for ascites, bowel sounds, tenderness, nausea, vomiting and distention. Do not reposition or irrigate the nasogastric tube without orders, Measure abdominal girth every 12 hours Monitor for biliary leak: Fever, jaundice, shoulder, sepsis. Monitor for biliary stricture: Jaundice, itching, abnormal bilirubin/ alkaline phosphatase. x » NOE6, BARIATRIC SURGERY + Gastric bypass and other weight-loss surgeries—known collectively as bariatric surgery—involves making changes to the digestive system to help lose weight. = Done when diet and exercise haven't worked or when you have serious health problems because of your weight ‘Types: a. Biliopancreatic diversion with duodenal switch b. Roux-en Y Gastric bypass c. Sleeve gastrectomy.Indications: + Done to help lose excess weight and reduce risk of potentially life-threatening weight-related health problems, including: + Heart disease and stroke + High blood pressure + Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) + Sleep apnea + Type 2 diabetes + In general, bariatric surgery could be an option if: © Body mass index (BMI) is 40 or higher (extreme obesity) © BMI is 35-39.9 (obesity), and patients who have serious weight-related health problems BMI CLASSIFICATION HEALTH RISK <18.5 Underweight Minimal 18.5-24.9 Normal Minimal 25-29.9 Overweight Increased 30-34.9 Obese High 35-39.9 Severely obese Very high >40 Morbidly obese Extremely highPost op: + Careful respiratory monitoring for 24-48 hours post-op + Assess and educate patients of anastomotic leaks(leakage ofgastriccontents atthesiteofanastomosisisa potentiallylife-threatening complication which would lead to sepsis if leftuntreated) + NPO for at least 1-2 days + Diet: Liquids -> pureed, very soft foods > regular foods + Frequent medical checkups to monitor health in first several months after surgery 7. REVERSE HYDRATION - drinking plenty of fluids, such as water, diluted squash or diluted fruit juice 8. REVERSE KETOACIDOSIS - Insulin reverses diabetic ketoacidosis 9. ELECTROLYTE REPLACEMENT 10. RAPID HYDRATION