What are the preoperative concerns for a 35-year-old white male with a past medical history (PMH) of alcoholism, Gastroesophageal Reflux Disease (GERD), Obstructive Sleep Apnea (OSA), and bipolar disorder, who is on Bilevel Positive Airway Pressure (BiPAP) therapy, taking Nexium (esomeprazole), Disulfiram (generic), and Propranolol (as needed), with a history of medical recommendations for bariatric surgery?

From the Guidelines

This 35-year-old white male with a history of alcoholism, GERD, obstructive sleep apnea, and bipolar disorder should continue his BiPAP therapy for OSA through the perioperative period, including bringing his device to the hospital for use immediately after extubation, as recommended by the ERAS society guidelines 1. His MICA score of 0.0% indicates very low risk for major adverse cardiac events, and his DASI score of 9.89 METs demonstrates adequate functional capacity for surgery.

• Key considerations for his perioperative care include:
  • Continuing Nexium (esomeprazole) through the morning of surgery to reduce aspiration risk
  • Continuing Disulfiram to support alcohol abstinence, which is critical for surgical safety and recovery
  • Holding Propranolol on the day of surgery to avoid potential hypotension during anesthesia, but informing the anesthesiologist of its use
  • Maintaining strict alcohol abstinence for at least 4-6 weeks before surgery to minimize surgical complications and optimize liver function
  • Confirming psychiatric stability before proceeding with surgery, with continuation of any psychiatric medications not mentioned here
• Postoperative care should focus on preventing respiratory complications, with strategies such as:
  • Using supplemental oxygen with caution, as it may increase the duration and time to detection of apnoea/hypopnoea as well as carbon dioxide retention 1
  • Utilizing positive airway pressure treatment, such as CPAP or BiPAP, to prevent hypoxic events in the postoperative phase 1
  • Positioning the patient in a head-elevated, semi-seated position to prevent further development of atelectasis and improve oxygenation 1
• The patient's medication regimen may need to be adjusted postoperatively due to altered medication absorption resulting from the anatomical changes of bariatric surgery.

From the Research

Patient Profile

• 35-year-old white male with a history of alcoholism, GERD, OSA, and bipolar disorder
• Preoperative patient with a MICA of 0.0% and DASI 9.89 mets
• Currently on BiPAP, nexium, disulfiram, and propranolol PRN
• Medical records indicate previous recommendations for bariatric surgery

Bariatric Surgery Considerations

• According to 2, bariatric surgery is recommended for patients with a body mass index (BMI) of 40 or higher or 35 or higher with serious obesity-related comorbidities
• The patient's history of GERD is a significant consideration, as bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD 3
• Laparoscopic sleeve gastrectomy (LSG) has been linked with worsening GERD, while Roux-en-Y gastric bypass may be a better option for patients with GERD and esophageal dysmotility 3

GERD Management

• GERD is a common comorbidity in bariatric patients, and patient selection is important to ensure avoiding postoperative development or worsening of GERD 4
• A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed, with consideration for formal testing with high-resolution manometry and pH testing 3
• Management options for GERD in the obese population include fundoplication and gastric bypass, with expert recommendations based on current available data 5

Comprehensive Patient History

• Taking a comprehensive patient history is fundamental for accurate diagnosis and effective management of health conditions 6
• Important communication skills for healthcare professionals include active listening, empathetic communication, and cultural sensitivity 6