Anaesthetic nurse specialist role in perioperative anaesthetic management of patients who are morbidly obese

Surgery in patients who have morbid obesity is considered high risk and concerns have been raised among patients and surgeons regarding the outcomes and complications of orthopaedic procedures, such as joint replacements, in this patient population in the UK. To reduce the risk necessitates careful planning, pre-operative risk assessment, adequate anaesthetic management, strict thrombolytic event prevention, and effective postoperative pain control (Nightingale et al, 2015). Wang et al (2017) highlighted that special training is necessary when providing care to a patient who is morbidly obese. Failure by nursing staff to recognise complications can lead to a delay in appropriate and timely management, and even lead to death. Public Health England (2017) and National Institute for Health and Care Excellence (NICE) (2022) have highlighted that special equipment is required for this patient group to ensure safe working practices and reduce risks to staff. Patients who are morbidly obese require individual ‘tailored’ plans (Lotia and Bellamy, 2008). A detailed anaesthetic assessment may be performed for an elective procedure, emergency surgery, or obstetric anaesthesia or analgesia.

Morbid obesity has become an increasing problem worldwide. It is a significant contributor to metabolic dysfunction of lipids, glucose and other factors involved in insulin resistance, such as high blood sugar, causing type 2 diabetes (Wynn-Hebden and Bouch, 2020). On a broader scale, it triggers organ dysfunction involving the cardiac, liver, intestinal, pulmonary, endocrine and reproductive functions, and some cancers (NHS Digital, 2019). Hence, peri-operative teams will be caring for an increasing number of patients with obesity in the foreseeable future and should be prepared to provide optimal management for these individuals.

Body mass index (BMI) is usually used to classify obesity. A BMI of >35 with associated comorbidity, or a BMI>40 without significant comorbidity, is defined as morbidly obese by the World Health Organization (WHO); BMI>55 is defined as super-morbidly obese (WHO, 2022). However, morbidity and mortality increase when BMI is>30, particularly in smokers (NICE, 2015). Obesity is a global issue and expected to increase by 130% in the adult population of the UK by 2030 (NHS Digital, 2019). Men are more likely to be obese or overweight and at high risk (65%) of cardiovascular complications than women (57%) (NICE, 2022).

To explore peri-operative anaesthetic nursing management associated with elective orthopaedic surgery in patients aged 18–65 years with morbid obesity (BMI>35), the authors undertook an integrative review.

Aim

This integrative review aimed to highlight the importance of the role of anaesthetic nurse specialists (ANS) in recognition that patients who are morbidly obese present different challenges and have specific peri-operative care needs. The objectives were to:

• Critically appraise the challenges presented by patients who are morbidly obese and require elective orthopaedic surgery
• Significantly evaluate the resource needs of this patient population who require peri-operative care.

Design

An integrative review was chosen to identify, appraise and synthesise published studies to understand the topic and provide a rationale for further research.

Step 1. Problem identification

The question guiding the authors was: ‘In patients who are morbidly obese, compared to non-obese, what are the challenges and resource requirements for orthopaedic peri-operative care?’

The formulation of the morbid obesity research problem was prompted by discussions in the workplace with medical, surgical and nursing colleagues, which highlighted a need to examine the challenges and resource requirements of orthopaedic peri-operative management. Care for patients with morbid obesity is complex, and the literature strongly indicates a focus on the available peri-operative reports/guidelines/information on safe anaesthesia in morbidly obese patients (Box 1).

Box 1.Resources

• Association of Anaesthetists of Great Britian and Ireland: Nightingale CE, Margarson MP, Shearer E et al. Peri-operative management of the obese surgical patient 2015. Anaesthesia 2015;70(7): 859-876. 10.1111/anae.13101
• Department of Health. Whole systems approach to obesity. A guide to support local approaches to promoting a healthy weight. July 2019. https://tinyurl.com/yc7bmsek (accessed 19 June 2023)
• National Institute for Health and Care Excellence. Obesity: identification, assessment and management. Clinical guideline [CG189]. 2022. https://tinyurl.com/36pfb2t8 (accessed 22 June 2023)
• National Obesity Observatory: Rutter H. Overweight and obesity: where are we and where are we heading? (Slide presentation). 2012. https://tinyurl.com/mwvsfdbm (accessed 22 June 2023)
• Society for Obesity and Bariatric Anaesthesia: Anaesthesia consent for obesity. 2021. https://tinyurl.com/3dn377py (accessed 22 June 2023)

Step 2. Literature search method

The following databases were searched for articles published between January 2007 and June 2017: CINAHL, Medline, Web of Science, EBSCO and the British Nursing Index. In addition, one of the authors (NJ) reviewed relevant studies published in high-impact journals and the reference lists of pertinent research studies to identify further significant studies. The relevant literature was sourced via the Cochrane Library, the Association of Anaesthetists of Great Britain and Ireland (AAGBI), WHO, NICE and the Department of Health and Social Care. Appropriate and targeted key words were essential to undertake an effective literature search.

Step 3. Selection criteria

Studies were eligible for review if they met the following criteria:

• Inclusion criteria: adults aged 18–65 years who were morbidly obese (BMI>35 with associated comorbidity, or BMI>40 without significant comorbidity); required peri-operative care following orthopaedic surgery
• Exclusion criteria: studies published in languages other than English; those that included children or older adults; information from posters or conferences; commentaries and editorials (to reduce potential for author bias).

Type of studies

The review included studies from the USA, where morbid obesity has been a longstanding issue; this research was found to have appropriate themes. Although UK research is limited, priority was given to UK-based studies to maintain relevance to the healthcare system. It is consequently essential to address the gap in the literature to ensure that orthopaedic operations are safe for patients who are morbidly obese.

Step 4. Synthesis

No literature reviews were included in this research. The Polit and Beck (2013) evidence hierarchy was used to rank articles according to level of evidence. The higher the scale, the better the reliability and clinical acceptance of the work. The integrative review included two level I evidence articles, three level II, four level III, and three level IV articles. The hierarchical rank of the evidence signifies probability of bias, with meta-analysis ranking the highest. Case reports are lowest but offer important information regarding rare events and may be considered anecdotal evidence. Case reports may stimulate the generation of new hypotheses and thus may support the emergence of further research. Level V recommendations (guidelines) were selected only when higher levels of evidence were unavailable.

The studies were designed to address the key learning outcomes of efficacy and acceptability of the ANS role in the context of:

• Current practice in the peri-operative management of patients who are morbidly obese
• Peri-operative management for morbidly obese patients who require orthopaedic surgery
• Morbid obesity and nursing challenges
• Morbid obesity and guidelines for peri-operative management
• Anaesthesia and morbid obesity
• Individualised patient care
• Promoting better outcomes.

Step 5. Results

Initial searches produced 247 abstracts, with 11 meeting the aims of the review. All 11 studies used a quantitative methodology. They were reviewed, and data extracted and summarised in tabular form with the aims of the review process (Table 1).

Data analysis and synthesis

The authors used thematic analysis to identify, analyse and report patterns within the data, identifying two core themes:

• Morbid obesity and resource requirements
• Morbid obesity and its clinical challenges in peri-operative management.

Findings

This integrative review shows the importance of recognising clinical challenges and resource requirements in the peri-operative management of patients who are morbidly obese, including airway and breathing, circulation problems, intravenous access, risk of pressure ulcers, differences in drug calculations and metabolism, and limitations in equipment, diet and nutritional recommendations. Lack of knowledge regarding the peri-operative nursing care of patients who are morbidly obese may lead to surgical anaesthetic risks. ANSs have a crucial role in managing and preventing obesity, yet they are not immune to prejudice in obesity care (fat shaming) that is prevalent in society and across social media.

This integrative review identified factors that increase the risk of such attitudes and ways to improve, to ensure ANSs are better equipped to provide patient-centred and non-judgemental care.

Theme 1. Morbid obesity and resource requirements

A comprehensive pre-operative assessment and preparation service is fundamental to high-quality, safe practice for this patient population. Such a service aims to identify the presence of morbid obesity-related comorbidities and the risks of post-operative complications for these patients. It is vital that ANSs accurately assess patients with morbid obesity undergoing orthopaedic surgery to provide safe peri-operative nursing interventions (Fencl et al, 2015). Moreover, individualised surgical preparation for these patients is recommended by the AAGBI (Nightingale et al, 2015).

The Society for Obesity and Bariatric Anaesthesia (SOBA) (2022) recommended that patients with morbid obesity should be assessed in a multidisciplinary clinic, where there is ready access to imaging, laboratories and specialist services such as cardiology (including echocardiography and stress-testing) and respiratory medicine (including spirometry and arterial blood gas analysis). In addition, this patient group should be preassessed by a senior consultant anaesthetist for associated risks (Royal College of Anaesthetists (RCoA), 2016), working closely with an ANS. Patients suspected of having obstructive sleep apnoea should undergo special investigations and receive treatment throughout the peri-operative period. Pulmonary function must be evaluated to anticipate the need for postoperative controlled ventilation (Hodgson et al, 2015).

As part of pre-operative assessment, when managing patients with morbid obesity, the ANS will apply specialist assessment and management strategies to prevent adverse patient outcomes. The ANS will record the patient's height and weight, and calculate BMI. This information will be placed on the active list to inform the multidisciplinary team (MDT) that additional time, staff, equipment and preparation will be required. Early communication between those caring for the patient is essential to manage the additional time, resources and personnel required efficiently during surgery.

The ANS's pre-operative assessment may include optimisation of nutritional status and safe weight loss strategies before the surgery, including exercise training (an average of 60 minutes of physical activity a day) (Lotia and Bellamy, 2008). Patients who are morbidly obese must understand how elective orthopaedic surgery is helpful, the pre-operative and postoperative risks, and the increased risks related to the anaesthesia due to their weight.

Studies (Sadati et al, 2013; Ortiz and Kwo, 2015; Solsky et al, 2016) have shown that there is a benefit to the ANS visiting patients with morbid obesity in the admission ward pre-operatively, in that this can reduce anxiety, aid recovery, and offers the individual an opportunity to express concerns about the procedure. The visit enables the ANS to assess the patient, establish a rapport and develop a care plan before the patient arrives in the theatres department. Pre-operative visiting, however, has met with resistance from staff due to limited staffing, visit timing and patient availability (Mitchell, 2012; Ortiz and Kwo, 2015).

This integrative review has highlighted the importance of providing patients with morbid obesity dignified care, delivered with compassion and respect at all times (Drake et al, 2008; Ortiz and Wiener-Kronish, 2016). However, health professionals often hold negative attitudes toward patients who are morbidly obese (Couch et al, 2015), which may contribute to decreased healthcare quality. Developing a bariatric team of experts to consult on mobility and care issues for these individuals is paramount for promoting patient and staff safety and dignity (Thomas and Lee-Fong, 2011; Severson et al, 2012). It is important that health professionals reflect on prejudice against this patient group and the negative effect this can have on outcomes (Nightingale et al, 2015). The ANS can contribute by facilitating reflections and fostering respectful communication using supportive language, and ensuring the availability of size-appropriate equipment, supplies (such as operating-room gown, disposable underwear) and instruments (such the appropriate blood pressure cuff) – and that the right equipment is in place at the right place and at the right time.

Drake et al (2008) and Solsky et al (2016) demonstrated that ANS skills, interventions, attitudes, communication and continuity of care are essential components in the orthopaedic nursing care of patients who are morbidly obese. Patient education for this population is critical in orthopaedic peri-operative management, and most mortality and catastrophic outcomes following orthopaedic surgery in these individuals are preventable (Hodgson et al, 2015). Moreover, it is vital to provide patients with comprehensive information to ensure they understand the risks of operative and postoperative complexities. Awareness of possible emergencies and their effective management is the best practice for good outcomes.

A number of authors (Severson et al, 2012; Solsky et al, 2016; Gholson et al, 2017; Obias et al, 2017) suggested that appropriate risk reduction strategies take the form of guidelines or checklists of critical points, which are considered at each stage of the patient's journey (surgical outpatients, morbid obesity pre-assessment clinic, inpatient admission, theatres, recovery/high dependency, ward/discharge suite). All anaesthetists and theatre staff will deal with patients who are morbidly obese in an orthopaedic operating environment. Therefore, ANSs should be mindful of any departmental guidelines based on national guidelines, and be aware of locally produced instructions or checklists (Nightingale et al, 2015; RCoA, 2016). According to Hanly et al (2016) and SOBA (2015), an ‘obesity pack’ requires specific equipment, protocol guidelines and contact numbers. The AAGBI (Nightingale et al, 2015) has developed a policy for patients with a BMI>35, or those who are morbidly obese, which can be used as a rational approach to best-practice orthopaedic anaesthetic services.

Nightingale et al (2015) and Cook et al (2011) recommended that each hospital has a designated consultant anaesthetist and an ANS with responsibility for ensuring that the operating suite is adequately resourced to safely manage patients with morbid obesity. Yet the main challenges are inconsistent primary care team integration, poor staffing levels and the lack of forward planning due to inadequate knowledge about treating and managing this patient population through the surgical journey. Notably, the safe and successful treatment of patients requires organisational commitment, protocols, expertise and staff training. In reality, not all training hospitals where such patients undergo orthopaedic surgical procedures, elective or private, will have staff training in place. Hence, the ANS should continue to identify learning needs in the operating department and act as a role model to educate staff and support in-service training to address morbid obesity as a chronic condition and emphasise the importance of person-centred peri-operative management.

This integrative review suggests that, when going through the surgical checklist, the pre-operative team brief should cover the specific peri-operative requirements of the patient to ensure the availability of appropriate equipment, including suitable operating tables, beds and trolleys. It should be noted that tourniquet time and anaesthesia duration are longer in total-knee arthroplasty for patients with a high BMI than for lean patients (Severson et al, 2012). Consequently, extra time is needed to position patients and induce anaesthesia using HELP (head elevation laryngoscopy pillow), and adequate personnel and equipment required to safely transfer the patient to the operating room table and position them. The ANS should recognise when additional staff (trained anaesthetists or senior nurses) are required.

The positioning and mobilisation of patients who are morbidly obese can pose an increased risk of musculoskeletal disorders to healthcare workers (Yasobant and Rajkumar, 2014). A Health and Safety Executive report identified that 40-70% of NHS trusts in England did not have a bariatric moving and handling policy for morbidly obese patients (Hignett et al, 2007). Up to 40% do not provide training additional to general moving and handling (Hignett et al, 2007). Nonetheless, the safe moving and handling of surgical patients who are morbidly obese is the responsibility of all team members. Hence, training resources may include online guidance from equipment manufacturers and a moving and handling link nurse should be identified.

In summary, equipment availability is vital prior to a patient's arrival, and unique positioning and padding pressure points are needed throughout the peri-operative journey to prevent body shifts.

Theme 2. Morbid obesity and its clinical challenges in peri-operative management

Secure positioning of the patient who is morbidly obese may require a specially designed operating table. Standard-size operating tables have a maximum weight limit of about 200 kg, but tables are available that can take a weight maximum of 455 kg. Pressure ulcers and neural injuries are common in this patient population, especially in individuals with diabetes (Kadry et al, 2014). Liu et al (2015) argued that positioning these patients in the supine position for prolonged orthopaedic surgery (>1 hour) may exacerbate these complications. However, Kitahara et al (2014) noted that a 30° tilt position with a pressure support pillow at the back helps maintain perfusion over weight-bearing areas.

This review has identified that the use of spinal anaesthesia in patients who are morbidly obese undergoing orthopaedic procedures has advantages (Watters, 2012; Napier et al, 2014). The main recommendation made by Watters (2012) and Napier et al (2014) concerns the use of isobaric spinal anaesthesia for orthopaedic surgeries, which reduces the risk of haemodynamic instability (especially in patients with comorbidities), and is beneficial when there are limitations in patient positioning. Compared with general anaesthesia, the advantages include decreased cost, fewer complications and infections, and improved pain control. Studies (Napier et al, 2014; Gholson et al, 2017) have demonstrated that skilful peri-operative management by the MDT, administering spinal anaesthesia combined with peripheral nerve block for orthopaedic surgeries may be an option to avoid respiratory problems, wound infection, thromboembolism complications and cardiac arrest post-operatively. However, Nightingale et al (2015) argued that spinal anaesthesia is technically more challenging due to the complicated placement of spinal needles, failure to establish, aortocaval compression, insufficient duration of regional anaesthesia and longer intra-operative time in orthopaedic surgeries. Morbid obesity is associated with higher peripheral block failure (mainly supraclavicular and axillary brachial plexus). Cook et al (2011) highlighted that failure of regional anaesthesia may necessitate general anaesthesia. Therefore, patients undergoing regional anaesthesia still require a strategy for airway management. The ANS's role is paramount as patient advocate in ensuring that local, regional or general anaesthesia is administered safely.

Patients with morbid obesity are particularly at risk of complications in airway management at the time of induction of anaesthesia (Nightingale et al, 2015). Interestingly, Solsky et al (2016) postulated that a thorough airway examination should be completed to identify the possibility of a difficult airway before performing the procedure. Since appropriate bag-and-mask ventilation necessitates a patent airway, good head and neck positioning becomes especially important to establish this. Frerk et al (2015) and Cattaneo et al (2010) demonstrated that creating a head-elevated laryngoscopy position (HELP) or reconfiguring the operating table to a 30° back-up position provides optimal conditions for successful intubation. Frerk et al (2015) also showed that pre-oxygenation was more effective in the 30° head up position. Herman and Mahla (2016) highlighted the need for an intubating laryngeal mask as part of airway adjuncts for patients who are morbidly obese who require general anaesthesia; this is especially needed for patients with an unstable spine and minimal range of movement. In addition, Herman and Mahla (2016) debated the importance of using video laryngoscopes and awake fibre-optic intubation to maintain a patent airway.

The RCoA (2023) guidelines recommend the use of awake intubation in this patient population for whom it would be challenging to establish rescue oxygenation or an emergency surgical airway. ANSs must anticipate and assist the anaesthetist in clinical decision-making and difficult airway management situations (RCoA, 2023).

Rapid-sequence induction with cricoid pressure is essential to avoid gastric aspiration in morbidly obese patients with symptomatic gastroesophageal reflux or if they have predisposing conditions such as diabetes mellitus and gastrointestinal disorders. A practical approach to a known or highly suspected difficult airway would be awake fibreoptic intubation. SOBA (2022) highlighted that, if tracheal intubation with direct laryngoscopy is planned, appropriate positioning, pre-oxygenation and preparation of adequate and emergency airway equipment are essential, and traditional teaching has emphasised that the supine sniffing position aids in airway instrumentation.

Moreover, the ANS will anticipate that a difficult airway trolley may be necessary for this patient group (Cook et al, 2011). The trolley should contain essential items for all situations, regardless of the individual facility (Wadlund and Seifert, 2015). Therefore, peri-operative team members need to familiarise themselves with the difficult airway trolley and the availability of additional resources that are necessary to provide a surgical airway. Cook et al (2011) and the Difficult Airway Society (DAS) (2015) highlighted that inadequate skill, poor judgement in airway management, and lack of education and training are leading causes of significant airway complications in patients with morbid obesity. The UK-based DAS (2015) recommends regularly rehearsing simulations of airway management for difficult airway situations.

Hodgson et al (2015) pointed out that respiratory management of the patient with morbid obesity for orthopaedic surgery provides several peri-operative challenges. These patients are more likely to develop postoperative acute respiratory failure and have higher rates of pneumonia, prolonged mechanical ventilation and difficulty in extubation. In addition, changes in respiratory system compliance and lung volumes can adversely affect pulmonary gas exchange, combined with upper airway obstruction and sleep-disordered breathing, which require consideration in the peri-operative period. A careful pre-operative assessment, patient positioning at induction, anaesthesia, extubation and the immediate postoperative period can overcome these challenges. It is important to remember that postoperative extubation should be performed in the reverse Trendelenburg or ramped-up position on the operating table and should be used only when the patient is fully awake and has recovered from muscle relaxation (Cook et al, 2011; Smedley, 2015). Corroborating these positions helps improve oxygenation and decrease intra-abdominal pressure (Hodgson et al, 2015).

Morbid obesity has a significant effect on a patient's cardiopulmonary function. Hence, the ANS must accurately assess and implement interventions during the surgical procedure (Smedley, 2015), particularly monitoring vital signs. Traditional blood pressure cuffs do not fit these patients due to the conical shape of their upper arms. Therefore, an appropriate cuff size will be a bladder that encircles a minimum of 75% of the upper arm circumference, or the entire component should fully encircle the upper arm (Nightingale et al, 2015; Cook et al, 2011). Fencl et al (2015) suggested that invasive arterial monitoring may be considered for patients who have morbid obesity and concomitant cardiopulmonary disease. Additionally, ANSs should be mindful that patients with a history of COVID-19 infection are at increased risk of difficult resuscitation, ventilation and hypoxaemia, especially in the prone position for elective orthopaedic surgery (Leo et al, 2021).

Drake et al (2008) indicated that venous access could be technically challenging for patients who are morbidly obese due to obscure anatomic landmarks and increased insertion depths, with Fencl et al (2015) and Frerke et al (2015) recommending that a central venous catheter be considered. Drake et al (2008) highlighted that patient with morbid obesity have notable changes in their circulatory system, including increased blood volume, blood viscosity, fibrinogen and decreased fibrinolysis. These factors increase the risk of deep-vein thromboses and pulmonary emboli. Standard thromboembolic prophylaxis, such as subcutaneous heparin, combined with sequential compression devices, should always be considered unless contraindicated (Nightingale et al, 2015; NICE, 2015).

Blood loss during orthopaedic procedures can be extensive, and the need for allogeneic blood is a common requirement. The primary therapeutic strategy in treating acute haemorrhage is preventing or correcting hypovolaemic shock. It is essential to restore the circulating blood volume by an infusion of crystalloids/colloids in sufficient amounts to maintain adequate blood flow and pressure, and to ensure tissue oxygenation. In addition, postoperative blood cell-salvaging systems after total knee or hip arthroplasty have been reported to minimise allogeneic blood transfusions significantly (Nightingale et al, 2015).

Patients who are morbidly obese and undergoing orthopaedic surgery may enter the operating room cold. Even if the patient is normothermic, their core temperature will decrease by 0.5-1.5°C in the first 30 minutes after induction of anaesthesia. (Alvarez et al, 2010). Therefore, the ANS should monitor the core temperature of these patients for 20-30 minutes. However, maintaining normothermia can be challenging due to the large volumes of fluid resuscitation and multiple areas of patient exposure (Smith et al, 2016). Continuous monitoring is recommended; 15-minute intervals are acceptable. Hypothermia should be prevented to limit intra-operative bleeding by infusing pre-warming solutions and warming the patient. Forced-air warmers are incredibly efficient in helping to warm the patient, along with blood and intravenous fluid warmers (NICE, 2022). The ANS should be mindful that the following monitors are routine during active rewarming: continuous core temperature and bladder catheterisation to observe urine output.

ANSs must have strong leadership and facilitation skills for good practice in the peri-operative management of patients who are morbidly obese. This integrative review recommends taking a simulated approach to teaching and competency skills development, which will allow staff to explore their feelings and have their ideas respected. Furthermore, other features of competency development may be in morbid obesity risk assessment, care pathways and patient equipment.

Recommendations

This review is a first step in attempting to help ANSs recognise that patients who have morbid obesity present a different set of challenges and require specific peri-operative care. It has highlighted issues that merit further research to improve understanding of peri-operative management of this patient population and thereby improve quality of care. Nurses should stop and reflect on existing mindsets when managing patients with morbid obesity and challenge unfairness in health care.

A problem-based learning approach with standardised patient simulation could be used to deliver education on morbid obesity within nursing programmes. It would enable participants to apply theoretical knowledge to a clinical scenario, enhancing their ability to manage complex clinical situations. In addition, simulation-based learning may help nurses understand the chronic nature of morbid obesity and the physical and psychological challenges faced by patients.

Conclusion

As a specialist qualified nurse, the ANS must anticipate and assist the anaesthetist in clinical decision-making and difficult airway management situations. This integrative review has provided the foundation for developing a single point-of-care resource that focuses on pre-operative assessment for identifying risk factors and the administration of pre-medication. Moreover, it has outlined the care necessary for patients who have morbid obesity and require surgery, such as protecting the airway with pre-oxygenation and tracheal intubation, using rapid sequence induction and a video laryngoscope.

This review has highlighted that the ANS and anaesthetist should accurately assess the morbidly obese patient undergoing orthopaedic surgery to provide safe and appropriate nursing interventions in the peri-operative period. Two studies (Sadati et al, 2013; Ortiz and Wiener-Kronish, 2016) showed that visiting morbid obesity patients in the admission ward pre-operatively can help reduce anxiety, aid recovery and allow patients to express concerns about their orthopaedic procedures. This visit will enable ANSs to assess patients, establish a rapport and develop a care plan before the patient arrives in the theatres department.

This integrative review has explored a range of views and attitudes, what can cause them, why they should be countered and how nurses can be supported to provide non-judgemental care. Hanly et al (2016) and Gholson et al (2017) suggested that ANSs are mindful of resource challenges when caring for patients who are morbidly obese peri-operatively, such as the need to accommodate increased operating time and the impact of increased re-admissions on hospital costs.

There are clear advantages to spinal anaesthesia in the morbidly obese population who are undergoing orthopaedic procedures (Watters, 2012). Isobaric spinal anaesthesia reduces the risk of haemodynamic instability, especially when there are existent comorbidities, and is beneficial when there are limitations to patient positioning. Compared with general anaesthesia, the advantages include decreased costs, fewer complications and infections, and improved pain control. However, Nightingale et al (2015) suggested that isobaric spinal anaesthesia is technically harder with patients who have morbid obesity due to the complicated placement of spinal needles, aortocaval compression, insufficient duration of regional anaesthesia and longer intra-operative time in orthopaedic surgeries. Therefore, regional anaesthesia still requires a strategy for airway management. Hence, the ANS role as patient advocate is paramount – among other things, it enables them to ensure that local, regional or general anaesthesia is administered safely.

In addition, the authors have looked at national and international evidence, highlighting difficulties that the ANS may encounter. There is no doubt that morbid obesity presents a risk in peri-operative management. Patients who have morbid obesity present different challenges and require specific peri-operative care compared with non-obese patients.

Research evidence suggests that individual patients who have morbid obesity presenting for an elective procedure require a ‘tailored’ plan and a detailed anaesthetic assessment. Hence, ANSs must use their skills to assess the patient and work with the interprofessional team to develop a plan of care that will promote safety, dignity, positive outcomes and safety for all in the practice setting. This integrative review has been an essential first step in attempting to help the ANS recognise the importance of peri-operative management of patients who have morbid obesity, and outlined the implications for clinical practice, health education, and future research recommendations.

KEY POINTS

• Importance of recognising clinical challenges and resource requirements in the peri-operative anaesthetics management of patients who are morbidly obese
• Consider airway, breathing, circulation problems, intravenous access, risk of pressure ulcers, and differences in drug calculations and metabolism
• Individual morbid obese patients presenting for an elective orthopaedic surgical procedure require a tailored plan and a detailed anaesthetic assessment
• ANSs must become proactive in educational strategies to enhance skills in infrequently encountered airway management situations and work with the interprofessional team to develop a tailored care plan to promote safety, dignity and positive outcomes for the morbidly obese surgical patient

CPD reflective questions

• Consider the feelings of patients who have morbid obesity and are having elective orthopaedic surgery
• Analyse unfavourable attitudes with regard to morbid obesity that presently exists in healthcare, and ways to challenge this to provide patient-centred, non-judgemental care
• Acknowledge that patient simulation could be used to deliver education/training on morbid obesity in healthcare programmes
• Ruminate on the chronic nature of morbid obesity, and the physical and psychological challenges faced by these patients requiring care