Intraoperative nursing in bariatric surgery: integrative review

Abstracts

Estudo de revisão integrativa da literatura científica com a finalidade de identificar e analisar a produção de conhecimento sobre avanços clínicos em necessidades de segurança de pacientes no período transoperatório de cirurgia bariátrica, baseada em 12 estudos selecionados em bases eletrônicas, a partir de descritores previamente definidos. Com exceção de dois estudos, o conteúdo específico dessa produção compunha o contexto geral da assistência perioperatória. A análise dos estudos possibilitou evidenciar o estado da arte da atuação da enfermagem sobre essas necessidades, as quais já estão bem estabelecidas, inclusive por vários guias de recomendações, contudo, fundamentalmente baseadas na ciência da prática clínica tradicional, por meio da elaboração de juízos racionais teóricos de especialistas. Conclui-se pela pertinência de realização de estudos primários para avaliar, principalmente, impacto e resolutividade dos recursos identificados para atendimento dessas necessidades, assim como melhoria ou geração de outros recursos inovadores e identificação de novas necessidades.

Cirurgia bariátrica; Cuidados intraoperatórios; Enfermagem perioperatória; Revisão

CRITICAL REVIEW

Intraoperative nursing in bariatric surgery: integrative review

Enfermería intraoperatoria en cirugía bariátrica: revisión integradora de la literatura

Renata Tavares Franco Rodrigues^I; Rúbia Aparecida Lacerda^II; Rita Burgos Leite^III; Kazuko Uchikawa Graziano^IV; Katia Grillo Padilha^V

^IRN. Master student of the Graduate Program in Adulty Health, University of São Paulo School of Nursing. São Paulo, SP, Brazil. [e-mail]

^IIRN. Asociate Profesor of the Medical-Surgial Nursing Department, University of São Paulo School of Nursing. São Paulo, SP, Brazil. [e-mail]

^IIIRN. Ph.D., Professor of the Medical-Surgial Nursing Department, University of São Paulo School of Nursing. São Paulo, SP, Brazil. [e-mail]

^IVRN. Full Professor of the Medical-Surgial Nursing Department, University of São Paulo School of Nursing. São Paulo, SP, Brazil. [e-mail]

^VRN. Full Professor of the Medical-Surgial Nursing Department, University of São Paulo School of Nursing. São Paulo, SP, Brazil. [e-mail]

Correspondence to

ABSTRACT

Integrative review of scientific literature study to identify and analyze the production of knowledge about clinical advances in security needs of patients during the intraoperative period of bariatric surgery. It was based on 12 selected studies in electronic databases, with descriptors previously defined. Except for two studies, the specific content of this production was composed of the general context of perioperative care. The studies highlight the possible state of the art of nursing activities on these needs, which are well established, including recommendations by several guidelines. However, they are fundamentally based on the science of traditional clinical practice through the development of rational judgments issued by experts. It concludes for the relevance of primary studies to evaluate the impact and resolution of the identified resources to answer those needs, as well as improving or generating other innovative features and identification of new needs.

Descriptors: Bariatric surgery; Intraoperative care; Periperative nursing; Review

RESUMEN

Investigación de revisión integradora de la literatura con el fin de identificar y analizar la producción del conocimiento sobre los avances clínicos en las necesidades de seguridad de los pacientes durante el período transoperatorio de la cirugía bariátrica. Está basado en 12 estudios seleccionados en bases de datos electrónicas, con descriptores definidos. A excepción de dos estudios, el contenido de esta producción se compuso por el contexto general de los cuidados perioperatorios. El análisis de los estudios ha puesto en evidencia el estado del arte de la actuación de enfermería sobre esas necesidades, que ya están bien establecidas. Sin embargo, este análisis está basado principalmente en la ciencia de la práctica clínica tradicional a través de la elaboración de juicios teóricos de expertos. Se concluye que estudios primarios son necesarios para evaluar el impacto y la resolución de los recursos identificados para satisfacer las necesidades de seguridad de estos pacientes.

Descriptores: Cirugía bariátrica; Cuidados intraoperatorios; Enfermería perioperatoria; Revisión

INTRODUCTION

As a chronic disease, obesity has lately been labeled as a relevant global phenomenon in the public health area. The prevalence of the disease doubled over the last 30 years and it is now being considered as the 21^st century epidemics⁽¹⁾. In 2008, the WHO estimated that nearly 2.3 billion adults were overweight, and over 700 million people could be considered as obese in the world⁽²⁾. The enhancement of such phenomenon is also observed in Brazil. In the last 30 years, the country left historical rates of malnutrition behind in order to play a prominent role in the world obesity ranking. Recent information disclosed by the Ministry of Health points out that overweight problems affect more than 50% of the Brazilian population⁽³⁾.

In face of such global epidemics, the resulting impacts are not only bound to the health risks experienced by those who suffer from the disease, but also to the costs related to the direct (prevention actions, diagnosis and treatment) and indirect (morbidities, mortality, reduced productivity due to activity restrictions, absenteeism and loss of future income as a result of premature deaths) care.

In addition to genetic or hereditary causes, no one can deny the social determination involved in the occurrence of the disease. Allied to the current sedentarism, the contemporary society's lifestyle has settled unfavorable dietary standards to the health of populations at large⁽⁴⁾. Add to that equation the advancement of anxiety and depression originated from a distressed and stressing daily life, the demands for higher and higher performance, competition, especially in the field of productive activities, and also the permissive stimulus toward an unrestrained consumerism, which has in edible products one of its highlights.

Obesity is now included in the agendas of governmental healthcare policies. In 2006, the Brazilian Ministry of Health published the 12^th edition of the Primary Health Care Handbook, speficically addressing such issue⁽⁴⁾. Nonetheless, preventive measures are still far from presenting positive results, especially in populations that have reached severe obesity levels. One of the most employed resources, the weight loss surgery, technically named gastroplasty or bariatric surgery, has exponentially grown in the country. Between 2001 and 2010, the figures of this surgery observed only in hospitals accredited by the Brazilian Unified Health System (Sistema Único de Saúde - SUS) increased nearly 800%. In the same period, private institutions recorded lower figures - around 300%; however, their absolute numbers outdo in 13 times the numbers seen in the SUS. These figures caused Brazil to carry out 64.4 thousand surgeries in 2010, leaving only the US ahead, where 300 thousand surgical interventions of such type are performed annually⁽³⁾.

Despite the relevance of the bariatric surgery in the improvement of the life conditions of needy populations, it is not at all a risk-free medical intervention. Obesity, as well as its consequent comorbidities, is constituted by a group of patients that presents special needs regarding any other type of surgery besides the bariatric procedure. Such conditions require specific safety actions to be taken toward a secure proceeding, beginning with the definition of criteria and finishing with the provision of adequate human and material resources throughout the perioperative period⁽⁵⁾.

Led by the WHO, a world movement in search of health care safety measures - named Global Challenges - has been seen in recent years. The challenge in 2007-2008 was related to the Safe Surgery Saves Lives⁽⁶⁾ initiative. Although this action has already been implemented in hospitals all around the world, it is aimed at surgeries at large. The empirical practice still lacks human and material resources that are able to both identify and assist specific special needs, among them the weight loss surgeries.

In spite of the relevance of the nursing performance toward the safety of patients in the perioperative period, it is not yet widely recognized whether and in what ways the practice has been gathering knowledge aimed to favor bariatric surgery patients. The objective of this present study was to identify and analyze the production of knowledge on the clinical advancements regarding a nursing care pattern that can meet the needs of obese bariatric surgery patients in their intraoperative period. The intraoperative period starts counting from the time the patient is admitted into the surgical unit, includes his length of stay in and discharge from the surgery room, and is finalized after his transference to the anaesthetic recovery center⁽⁷⁾.

METHOD

This study is an Integrative Review of scientific literature. The applied methodology presents a broad scope of purposes^(8-14). Among them, predominantly aimed to the goals of the research, we seek to draw synthetic evidences that can intervene or improve care pratices, as well as identify knowledge gaps that indicate the need of further investigations and build an agenda of research priorities.

Due to its wide array of purposes, the publications to be inserted here can eventually embody other types of studies, including theoretical and empirical ones, in addition to primary research. In the integrative review, whenever a broader comprehension of any given phenomenon is sought, pertaining issues do not elicit quantitative responses, as opposed to the systematic review. Notwithstanding, in accordance with Ganong⁽⁹⁾, the establishment of a rigourous analysis requires indispensable stages to be met toward the development of such type of review. The stages of this present review were backed-up by the following question, Are there any evidences of clinical advancements in the nursing production toward the safety needs of bariatric surgery patients in the intraoperative period?

In order to determine the studies to be analyzed, inclusion criteria corresponded to those of scientific publications available in electronic databases of health literature on bariatric surgery in adults, in any language and period, related to the nursing safety aspects in the intraoperative period, comprised of primary studies, recommendations, experience reports and critical reflections on the issue.

Exclusion criteria refer to unrecorded situations, repeated publications and other types of unavailable publication in those electronic sources. We see a restriction here. It is highly probable that the specific knowledge one may be searching for about bariatric surgery can be located in books, book chapters, theses and ongoing or concluded dissertations, studies published in the annals of scientific events and other types of publications related to surgery at large; however, it is definitely not easily identifiable, both nationally and internationally.

The following sources were employed in this research: electronic databases massively used in review studies (PubMed/ MEDLINE, CINAHL); the Latinamerican database (LILACS); the Brazilian database (SciELO); and three databases that publish review-related finished studies - one general database (the Cochrane Library) and two databases that gather nursing-based reviews (Moby's Nursing Consult and The Joanna Briggs Institute). Another applied source was comprised of other bibliographic references inserted into the searched publications that could somehow be connected to the issue of this present research.

The search was carried out between January and April 2012. The used indexed and non-indexed descriptors concerning the issue were: bariatric surgery, gastroplasty, weight loss surgery, and gastric reduction surgery. The used indexed and non-indexed descriptors concerning the nursing interventions were: nursing, nursing care, perioperative nursing, and intraoperative care. Control group and outcome-related descriptors were not used. Comparative and non-comparative primary studies, as well as theoretical studies, were taken into account, as the research aimed to reach not only the results of the interventions, but also the produced knowledge.

Chart 1 presents the search strategy.

The selection process of the publications dealt with in the search went through three steps, namely: 1) repeated publications in the database were excluded; 2) the title and the abstract of remaining publications were read - those texts that clearly did not meet the demand of the review were excluded; and 3) each pertaining full-length publication was exhaustively read and included as part of the research - those who ultimately did not meet the demand of the review were excluded. Steps 2 and 3 were simultaneously carried out by two researchers.

Data were displayed in two stages: 1) selection of publications in their specific databases; and 2) analysis of included studies related to their data, type of publication, methodological aspects, scopes, content extraction of the nursing practice in the intraoperative period, and assessment of the level of evidence. Aiming to support this assessment, we decided to employ the Melnyk, Fineout-Overholt evidence-based diagram⁽¹⁵⁾ aimed to address nursing-related and other general health issues. The data analysis process led to a discussion about the existence of types and conditions for the nursing performance in the intraoperative period following a bariatric surgery, as well as whether they were sufficient or lacked evidences, left questionable gaps or were in need of a new investigative agenda.

The publications included in the analysis were given alphanumeric codes: letter S (from Study) and numbers from 1 through 12 (the sequence in which they were read, selected and finally included in the research).

RESULTS

In the first stage, 589 publications were found - 369 in the CINAHL database (62.64%) and 154 in the PubMed database (26.14%), followed by MEDLINE with 36 (6.11%), Cochrane with 22 (3.7%), LILACS with five (0.8%) and SciELO with three (0.5%). No publication was found in the Nursing Consult and Joanna Briggs databases.

In the second phase, following the exclusion of repeated publications, the number of publications was reduced to 130 out of the total achieved amount (589). In the reading process of titles and abstracts, the amount dropped to 31. On this stage, texts that only addressed the surgical technique or the postoperative period, or that lacked specific nursing production on the issue, were excluded.

In the third stage, following the full-length reading of the studies, only 12 publications were definitely included in the research. These studies were codified from S1 through S12, as they approached contents pertaining to the intra-operative period. From this universe, 11 (91.6%) studies were found in American electronic databases published in the English language from 2003 onwards, and one (8.3%) was produced in Brazil, in the Portuguese language (Chart 2).

The majority of these studies (seven, or 56.6%) is comprised of opinions, reflections and/or information (S2, S5, S7, S9, S10, S11, S12), followed by four (33.3%) researches (S3, S4, S6, S8), and four (33.3%) recommendation guidelines or recommendation updates (S1, S4, S6, S8). Composed of guidelines and recommendation updates, studies S3, S4 and S8 were also considered as researches due to the systematic search methodology employed by the researchers, and finally ranked in levels of evidence. Although Study S11 also carried out a literature review, it did not disclose the employed methodology; therefore, it was included as a simple knowledge update review. Study S3, on its turn, was found to be a primary research addressed by a descriptive exploratory outline. Chart 3 briefly shows the contents of those publications regarding their scopes, types of approach and conclusions.

Besides elaborating on the epidemiologic aspects of obesity and comorbidities, weight loss surgery and the criteria for the recommendation of the surgery, this brief presentation of the contents of the studies included in this present research shows that the vast majority of the papers also seeks to identify risks and recommend specific nursing care directed to the whole perioperative period encompassed between precocious preoperative and late postoperative times. In this way, except for two studies (S3 and S12), the theme of this present review is not addressed in isolation, but within the general context of the obesity issue and the perioperative care to bariatric surgery patients. Even systematic review-based researches seek evidences within this context. One of the two studies specifically dealing with the intraoperative period (S12) addresses only the anaesthetic procedure.

The specific contents related to nursing safety measures in the intraoperative period were extracted after the full-length reading of the publications, and were classified as follows: 1) environment/physical space; 2) furniture; 3) health care equipment; 4) patient positioning; 5) performance of the nursing team (training and conduct); and 6) emotional support. (Chart 4).

In Chart 4, the studies that most elaborated on contents related to the patient's safety needs in the intraoperative period were S1 (20 items) and S3 (14 items). On the other hand, those that less presented contents related to this same area were S10, S11 and S12 (2 and 3 items each, respectively), followed by S7 (1 item). Taking into account the classification of the levels of evidence displayed in an analyzed study⁽¹⁴⁾ (I through VII), the studies included in this review are located at the weakest levels: VI (S3) and VII (all others).

DISCUSSION

Throughout the literature search for this present review, we realized how extensive the production of knowledge on general obesity is, as well as its related epidemiologic aspects, such as incidence rates and prevalence, comorbidities and social-economic issues, risks and benefits of the bariatric surgery. Several recommendation guidelines and updates have already been produced regarding the perioperative period that starts with the precocious preoperative and ends with the late postoperative moment, mainly defined by expert societies composed of doctors, nurses and multiprofessionals^(16-19). It has been nearly 20 years now since the inception of the bariatric surgery⁽⁵⁾; however, all studies included in this research and virtually the whole amount of articles found in our search have been published on the last decade, thus confirming that the knowledge production in this area is a relatively recent practice.

A carefull analysis of the studies included in this research shows that, except for two studies (S3 and S12), the envisaged objective of assessing the clinical advancements of the nursing care in the intraoperative period is not found in isolation, either in the nursing^(15,17-18) or in the multiprofessional⁽¹⁶⁾ practice, but is inserted within the perioperative context of the bariatric surgery. If, on the one hand, a positive aspect is deemed to favor an integral, non-fragmented view of the care, on the other hand such specific content is poorly represented and under-developed.

Nonetheless, nursing studies on the specific aspects of the perioperative care practice regarding the postoperative period⁽²⁰⁾ have already been produced. This finding prompted our interest in searching for all knowledge produced on the intraoperative period as a constituent, fundamental step in the whole perioperative context.

The specific content used in this review, therefore, was extracted from this perioperative context and arbitrarily classified in the following special needs: environment/physical space; furniture; health care equipments; patient positioning on the operating table; performance of the nursing team (training and conduct); and emotional support. Several of these contents emerge in all studies; however, the appearance of individual aspects is more observed in S1⁽²⁰⁾ and S3⁽¹⁴⁾. Despite the identification of several different resources, the research did not find any divergence regarding common needs presented in different studies. The majority of identified needs are repeatedly brought up, for instance: use of elastic stockings, pneumatic compression toward preventing thrombosis, and types of accessories to raise the patient's head.

Special needs concerning furniture and health care equipments were also repeatedly brought up, pointing out a greater concern at material resources. Such fact is quite relevant, as the technology employed in the intraoperative period is highly essential for the physical safety of the patient and the success of the surgery. Despite being insufficient to provide an integral and globalized care process, this fact positively echoes in the emotional aspect, once the patient recognizes that his special needs are met.

Another highlight is the generic recognition or the under-exposition of needs and resources in the corpus of the texts. For instance: the necessary materials for the anaesthesia, equipments to strengthen the operating table, special vesical catheterization technique, emotional support, etc. It can be clearly observed that the theoretical production is not sufficient to uphold the pratice, as it does not provide information or proof on the existing types of special resources. Specifications are displayed only in a few studies. For example: hydraulic operation operating table that favors patient transference and positioning and prevents ergonomic risks to the professionals (S1, S3, S4, S5). However, ways to compare available resources, orientations on how to operate the equipments, and difficult and easy experiences found out in the process, among others, are absent. Thus, if on the one hand, indications help identify special needs, on the other, they do not favor the recognition and comparison of the pratical impact of their application.

In spite of the presence of these aspects, the way the included studies were built does not reach a status of strong evidence. Hence, their classification was predominantly directed to the nursing area, presenting the following levels: I (Strong) - systematic review or meta-analysis of all controlled randomized clinical essays; II (Strong) - clearly outlined controlled randomized clinical essays; III (Moderate) - controlled clinical essays without randomization; IV - (Moderate) - clearly outlined case-control and cohort studies; V (Weak) - systematic review of qualitative and descriptive studies; VI (Weak) - one and only descriptive or qualitative study; VII (Weak) - opinion of authorities and/or reports from expert committees⁽¹⁵⁾.

Although one of the studies is labeled as a systematic review (S6) and two as systematic search (S4 and S8), the major part of the literature used to ground recommendations in the other studies is not deemed to be researches, but expert opinions and consensuses. Consequently, they are placed at the last level (VII) of a weak evidence. Moreover, in spite of employing the classification per level of evidence, none of the studies achieved high levels of evidence. Only one recommendation adopted by S4 achieved a level B (employment of an ergonomics program, including a special device aimed to tranfer the patient); all other recommendations in these studies displayed levels C and mainly D. S6, by the way, recognizes the limits of its review and suggests the implementation of future research.

As S11 does not adopt methodological criteria toward searching and analyzing obtained results, it is dealt with as a simple review. Together with the other studies comprised of opinions, reflections or updates, S11 is not included in the adopted diagram; therefore, all studies are not liable for classifications per level of evidence. Despite pointing out that its guideline is based on current research and opinions of experts, S1 does not indicate the research references that grounded the recommendations; therefore, it does not allow for the comprehension of what is identified as research result and what corresponds to an opinion. On its turn, S3 was the only primary study obtained by the research; it is listed at level VI of evidence, as it deals with a descriptive methodological outline.

As the vast majority of these incldued studies deals with the perioperative context at large, the weak evidences achieved are not only bound to the intraoperative period, but refers to the whole context. In other words, the production of knowledge by nursing toward assisting patients in the perioperative period of bariatric surgeries still does not derive from research-based evidences; on the contrary, it is almost exclusively grounded on theoretical rational elaborations originated in traditional clinical rationale issued by the opinions and consensuses of experts.

Notwithstanding, since obesity is recognized as the epidemics of the 21^st century, such as any other emerging epidemics, the initial foundations that aimed to control, prevent and treat the disease necessarily go down to theoretical elaborations; just later, following a collection of empirical data, primary studies were triggered, aiming at generating evidences that could ground the practical science (Practice-Based Evidence - PBE). In other words, the currently available actions are still based upon traditional clinical practices grounded on the knowledge of signs and symptoms related to the so-called basic sciences, such as anatomy, physiology, etc.

Again, the final objective of this present review was to search for synthetic evidences aimed to intervene or improve the care practice, or identify knowledge gaps on the nursing safety needs in the intraoperative period of bariatric surgery patients. If, on the one hand, the achievement of results was not possible due to the current PBE science, on the other hand, this study found an extensive production of knowledge grounded on the traditional clinical practice. In order to fill the gaps, a series of knowledge productions grounded on strong foundations and aimed to provide the PBE with support have already been triggered and elaborated, thus transforming this field into a broad, fruitful research area.

The reality of the elaboration of primary research specifically dealing with the advantages and disadvantages of the special material resources described in the included studies is a possibility. If affirmative, the results of those studies have not yet been inserted into the accessed electronic databases. Throughout our search for this paper, such documents have been neither found nor quoted in the studies included in this review. Although S3 was classified as a weak evidence, it was the one and only primary study to question the aspects related to the physical space, materials and equipments in its search for the identification of the difficulties faced by nurses in the intraoperative care to bariatric surgery patients; the study finally recognizes the need of professional training toward this specific knowledge, so that patients are provided with comfort, physical and emotional security.

As several special needs aimed to assist bariatric surgery patients have been identified by the review, future research must be produced in order to assess and ratify their sufficiency. S6 clearly shows this perspective: attitude of nurses toward severe obese patients; impacts of their attitudes and biases in the results of patients; identification of technical knowledge that prompts patients to the surgery, improvement of results and safety of patients; occupational risks; identification of best practices toward improving safety of the professional team and preventing occupational risks; and identification of best practices toward managing pain reduction levels.

Other future researches could include, for instance, cohort or case-control studies on the assessments of recommendation guidelines regarding the lack of adverse events, development of innovative techniques for female vesical probing, patient positioning on the table for anaesthesia and surgery, physiologic responses of obese patients to the pneumoperitoneum, anaesthesia, among other events. The problems generated by this integrative review also lead to the elaboration of other studies dealing with the impact, sufficiency and adequacy of the resources provided by the industry of materials and specific equipments.

CONCLUSION

This integrative review clearly shows the state-of-the-art nursing performance toward the safety needs of patients in the intraoperative period of weight loss surgeries. Such well established needs can also be seen in several recommendation guidelines. However, these recommendations are fundamentally based on the traditional clinical science practice set out by the elaboration of theoretical rational judgments of experts. This present research recommends that primary studies be carried out in order to assess the impact and the solvability of the identified resources toward fulfilling these needs, as well as to generate other innovative resources and identify new needs.

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Endereço para correspondência:

Rúbia Aparecida Lacerda

Av. Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira Cesar

CEP 05403-000 São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  12 Dec 2012
• Date of issue
  Oct 2012

History

• Received
  10 Apr 2012
• Accepted
  30 May 2012