Morbid obesity and surgery don't mix

67% of Australian adults are overweight and one in four adults in Australia are obese. 

This story tells the impact that obesity can have on surgical outcomes. And why stricter guidelines on who can have elective surgery might save lives.

An morbidly obese woman in her seventies called ‘Maria’ had difficulty walking. She had been diagnosed with advanced arthritis in both her knees, was told she needed joint replacements.

She was assessed as a suitable candidate for bilateral knee replacements. Maria was on the hospital waiting list for eighteen months.

While vague references were made to her weight by the surgical team who assessed her, she was never told directly that she must lose weight. No referral was made to a dietitian.

No clear advice was given that obesity would have a direct impact on her ability to recover from surgery. There was no surgical checklist done of pre surgical patients, grading them into a high risk or a low risk category. In turn,

Maria asked no questions of her doctors. She passively accepted what she was told and waited for surgery.

Post surgical complications pile up

The consequences of obesity and surgery can occur weeks after the actual procedure.

The surgical team decided to do both knee replacements at the same time.

After surgery Maria’s wounds recovery was slow. She had extreme difficulty getting out of bed, due to her obesity and bilateral knee surgery. Subsequently she was not able to do deep breathing and coughing, to clear her lungs.

Ward staff found it difficult to coordinate the nurses, physiotherapists and attendants needed to help mobilise her.

So she stayed in bed, day after day.

At the same time, her wounds were very slow to heal. They oozed slowly but continuously.

At this stage Maria was not assessed as having a poor recovery from surgery. No special measures were taken to quickly improve her general health.

Maria remained unwell for several weeks, with constant pain and a low grade temperature. A special hoist was finally sourced from another ward, and staff began to lift her out of bed for one hour every day.

Her blood pressure remained low. She didn’t feel like eating. Maria just lay in the bed, listless and unhappy, with both knee wounds slowly oozing.

She complained all the time. Staff began to get sick of the effort involved in mobilising her.

After a week her dressings came down and the surgical team was not happy. The wound was still wet, with watery, bloody ooze.

Both surgical sites were swabbed. When the results came back that she had an infection, oral antibiotics were started.

While her dressings were constantly changed, there was no systematic approach to keep her wound management appropriate.

Her surgical wounds were not photographed, monitored or measured.

Ward staff realised that Maria was going to be with them for some time. They ordered an air bed to make sure she didn’t get a pressure ulcer.

However there was no checklist to assess her obvious post surgical risk factors, being overweight, having infected surgical wounds, being very slow to recover, having a low blood pressure and constant low grade temperature.

Four weeks after the surgery Maria went into cardiac arrest on the ward.

Staff flew into a panic. They had tried to get her out of bed, and she slipped down off the chair, and on to the floor. She was revived, fluids and intravenous antibiotics were started and a large team of people eventually got her back on to the bed.

She was taken to Intensive Care, assessed as being dry from lack of oral fluids and overwhelmed with an infection. The wound was re swabbed and new antibiotics were started. Maria was sent back to the ward the next day.

Staff vowed never to get her out of bed again. So she lay on her back, moaning about the pain, not eating or drinking. Her knee wounds continued to slowly ooze.

Six weeks after surgery Maria went into cardiac arrest again.

She was taken back to Intensive Care were she stayed for a week. When she was discharged she went into a general medical ward.

The orthopaedic ward needed it’s beds for new surgical patients, and Maria was now a complex medical case.

Her surgical team did not see her, as they only did rounds on the orthopaedic ward. The medical ward did not have a physiotherapy team and Maria was not made to sit out of bed every day. She continued to slowly deteriorate.

The final conclusion

Eight weeks after the surgery, Maria arrested again.

She was taken back to Intensive Care, and assessed as having septic shock. 

She failed to recover.

Twelve weeks after doing an elective, bilateral knee replacement on an elderly, morbidly obese woman, Maria died in hospital.

There was no enquiry. The hospital did not review it’s practices. No changes were implemented to improve the management of high risk surgical patients.

Wikihospitals 2014

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