Gastric Sleeve or Bypass Protocol

Guideline · Aug 2019 · 1 min read

In brief

Clinical protocol for perioperative management of patients undergoing sleeve gastrectomy or gastric bypass procedures, likely covering preoperative preparation, surgical technique standards, and postoperative care pathways.

Written by the GCMD Library team from the guideline.

Pre-Operative Management

Standard pre-operative preparation includes compression stockings, sequential compression devices, type and screen, single dose Lovenox 40mg subcutaneously, pre-incision Cefoxitin, and scopolamine patch. For Type II diabetes patients, endocrine pre-operative consultation recommendations should be followed.

Post-Operative Day 0 (Surgery Day)

Immediate post-operative care includes continuous pulse oximetry, bariatric stage I diet (sugar-free clear liquids), ambulation three times daily, and incentive spirometry 10 times per hour. Patients receive D5 ½ NS with 20 mEq KCL at 75 cc/hr, continue compression devices, receive three doses of Cefoxitin, and standing Zofran every 8 hours.

Post-Operative Day 1

CBC is checked and Lovenox 40mg daily is initiated if results are acceptable. Nutritional supplementation begins with daily multivitamin (2 chewable tablets) and thiamine, while continuing stage I diet, ambulation, incentive spirometry, IV fluids, compression devices, and antiemetics. Type II diabetes patients receive endocrine consultation.

Post-Operative Day 2 and Discharge

IV fluids are discontinued while continuing bariatric stage I diet, ambulation, incentive spirometry, compression devices, and antiemetics. Standard patients may be discharged if oral intake is adequate with Lovenox discontinued at discharge. Type II diabetes patients advance to stage II diet with blood glucose monitoring per endocrine recommendations and typically discharge on POD 3 with adequate oral intake and glycemic control.

Statements in this guideline

Administer Lovenox 40 mg subcutaneously as a single dose pre-operatively.
RecommendationPre-Operatively
Administer Cefoxitin prior to incision.
RecommendationPre-Operatively
Apply compression stockings and sequential compression devices pre-operatively.
RecommendationPre-Operatively
Maintain continuous pulse oximetry on postoperative day 0.
RecommendationPOD 0
Start bariatric stage I diet (sugar free clear liquids) on postoperative day 0.
RecommendationPOD 0
Ambulate three times daily starting postoperative day 0.
RecommendationPOD 0
Perform incentive spirometry 10 times per hour starting postoperative day 0.
RecommendationPOD 0
Infuse D5 ½ NS with 20 meq KCL at 75 cc/hr starting postoperative day 0.
RecommendationPOD 0
Administer Cefoxitin for 3 doses postoperatively.
RecommendationPOD 0
Administer Zofran every 8 hours as a standing order starting postoperative day 0.
RecommendationPOD 0
Check CBC on postoperative day 1.
RecommendationPOD 1
Start Lovenox 40 mg every 24 hours on postoperative day 1 if CBC is okay.
RecommendationPOD 1
Administer multivitamin daily (2 chewable tablets) starting postoperative day 1.
RecommendationPOD 1
Administer thiamine every 24 hours starting postoperative day 1.
RecommendationPOD 1
Stop intravenous fluids on postoperative day 2.
RecommendationPOD 2
Discharge home if adequate oral intake is achieved, and stop Lovenox on discharge.
RecommendationPOD 2
For patients with type II diabetes, follow endocrine recommendations from pre-operative consult.
RecommendationPre-Operatively
For patients with type II diabetes, obtain endocrine consult on postoperative day 0.
RecommendationPOD 0
For patients with type II diabetes, begin bariatric stage II diet on postoperative day 2.
RecommendationPOD 2
For patients with type II diabetes, monitor blood glucose per endocrine recommendations.
RecommendationPOD 2
For patients with type II diabetes, discharge home on postoperative day 3 if adequate oral intake and adequate blood glucose control are achieved, and stop Lovenox on discharge.
RecommendationPOD 2

Full text

Pathway for Gastric Sleeve or Bypass (see gastric bypass orderset) •Compression Stockings•SCDs•Type and Screen•Lovenox40 mg subqx 1 dose•Cefoxitin prior to incision•Scopolamine patch •Continuous pulse oximetry•Bariatric stage I diet (sugar free clear liquids)•Ambulate TID•Incentive spirometry 10x/hour•D5 ½ NS + 20 meqKCL @ 75 cc/hr•Compression Stockings•SCDs•Scopolamine patch •Cefoxitin x 3 doses•Zofran Q8H standing Initiate POD1•Check CBC•Start lovenox40 mg Q24H if CBC okay•Multivitamin Qday(2 chewable tablets)•Thiamine Q24HContinue from POD0•Bariatric stage I diet •Ambulate TID•Incentive spirometry 10x/hour•D5 ½ NS + 20 meqKCL @ 75 cc/hr•Compression Stockings•SCDs•Scopolamine patch •Zofran Q8H standing Initiate POD2•Stop IVFContinue from POD0/1•Bariatric stage I diet •Ambulate TID•Incentive spirometry 10x/hour•Compression Stockings•SCDs•Scopolamine patch •Zofran Q8H standingDischarge home if adequate PO (stop lovenoxon DC) Pre-OperativelyPOD 0 POD 1POD 2 Updated 1/2019

Pathway for Gastric Sleeve or Bypass (see gastric bypass orderset)Type II Diabetes (differences in protocol for type II DM noted in red) •Compression Stockings•SCDs•Type and Screen•Lovenox40 mg subqx 1 dose•Cefoxitin prior to incision•Scopolamine patch •Follow endocrine recommendations from pre-operative consult •Continuous pulse oximetry•Bariatric stage I diet (sugar free clear liquids)•Ambulate TID•Incentive spirometry 10x/hour•D5 ½ NS + 20 meqKCL @ 75 cc/hr•Compression Stockings•SCDs•Scopolamine patch •Cefoxitin x 3 doses•Zofran Q8H standing•Endocrine consult Initiate POD1•Check CBC•Start lovenox40 mg Q24H if CBC okay•Multivitamin Qday(2 chewable tablets)•Thiamine Q24HContinue from POD0•Bariatric stage I diet •Ambulate TID•Incentive spirometry 10x/hour•D5 ½ NS + 20 meqKCL @ 75 cc/hr•Compression Stockings•SCDs•Scopolamine patch •Zofran Q8H standing Initiate POD2•Stop IVFContinue from POD0/1•Begin bariatric stage II diet •Monitor blood glucose per endocrine•Ambulate TID•Incentive spirometry 10x/hour•Compression Stockings•SCDs•Scopolamine patch •Zofran Q8H standingDischarge home on POD 3 if adequate PO and adequate blood glucose control(stop lovenoxon DC) Pre-OperativelyPOD 0 POD 1POD 2 Updated 1/2019

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