Sleeve Gastrectomy

• Drug dose adjustment for Bariatric Patients SOBA Calculator
• Obesity Surgery Mortality Risk Score MDCalc
• STOP-Bang MDCalc
• Involves MDT management with optimisation of comorbidities

Pre-Induction

• aprepitant ( 80mg )
• Consider high-flow nasal cannulae during pre-oxygenation
• Pre-oxygenation in ramped position
• BIS monitoring

Drugs (TCI)

• remifentanil ( TCI )
• propofol ( TCI )
• rocuronium ( 0.6mg/kg )

Intubation

• Videolaryngoscopy
• Airway
  ETT

Post-Induction

• Procedure Orogastric Tube Insertion - 36Fr
• Position OG tube within oesophagus

Maintenance

• propofol ( TCI )
• remifentanil ( TCI )

Analgesia

• morphine ( 0.1mg/kg ) or fentanyl ( 2-3mcg/kg )
• magnesium sulphate ( 2.5g )
• paracetamol ( 1g )
• diclofenac ( 75mg ) or parecoxib ( 40mg )
• Local anaesthetic infiltration by surgical team (Subcostal block)

Anti-emetics

• ondansetron ( 4mg )
• dexamethasone ( 6.6mg )

Other

• Antibiotics as per local protocol

Gastric decompression

• Reduces stomach volume, improves exposure, lowers aspiration risk

Guidance for stapling (sizing the sleeve)

• Pass OG tube along lesser curvature, advanced under direct communication with surgeon
• Acts as stapling guide to ensure uniform gastric sleeve + patency of GI passage

Leak testing

• Abdominal cavity filled with saline solution
• At surgeon's request, oxygen insufflated at 2l/min into gastric pouch, then released
• Surgeon watches laparoscopically for bubbles

Recovery Use

• fentanyl ( IV, 10-20mcg, PRN )
• morphine ( IV, 1-2mg, PRN )

Analgesia

• tramadol ( PO/IV, 50-100mg, QDS PRN )
• morphine ( PO, 5-10mg, QDS PRN )
• morphine ( SC, 5-10mg, QDS PRN )
• Paracetamol ( 1g QDS )

Anti-emetics

• ondansetron ( 4mg, TDS )
• ondansetron ( 4mg, TDS PRN )
• cyclizine ( 50mg, TDS PRN )
• aprepitant ( 80mg, 48 hourly )

Anti-hypertensives

• nifedipine ( Sublingual, 10mg, PRN )
• amlodipine ( PO, 10mg, PRN )
• glyceryl trinitrate ( Transdermal, 1 Patch, PRN )

Other

• salbutamol ( Nebulised, 2.5mg, 4 hourly PRN )
• methylene blue ( PO, 3 drops in 60ml water, Blue dye leak test )
• simeticone ( PO, 5ml, TDS )
• pantoprazole ( IV, 40mg, Once Only )
• lansoprazole ( PO, 30mg OD )

VTE Prophylaxis

• enoxaparin ( SC, 40mg OD, <160kg ) or enoxaparin ( SC, 40mg BD, >160kg )

Fluids

• Plasma-Lyte 148 ( 1,000ml IV over 8 hours ) x 3