OBESITY AND ICU HAMIDREZA JAMAATI MD, FCCP, FCCM.

OBESITY OBESITY AND ICUAND ICU

HAMIDREZA HAMIDREZA JAMAATI MD, FCCP, JAMAATI MD, FCCP, FCCMFCCM

CARDIOVASCULAR CARDIOVASCULAR PHYSIOLOGY IN OBESITYPHYSIOLOGY IN OBESITY

PULMONARY PHYSIOLOGY IN PULMONARY PHYSIOLOGY IN OBESITYOBESITY

IMMUNOLOGIC CHANGES IN IMMUNOLOGIC CHANGES IN OBESITYOBESITY


Adipocytes are now known to produce Adipocytes are now known to produce signaling molecules, called adipokines, that signaling molecules, called adipokines, that can significantly alter inflammatory cell and can significantly alter inflammatory cell and immuneimmune

function. function. (Honiden & McArdle Clin Chest Med 2009)(Honiden & McArdle Clin Chest Med 2009)

The percentage of macrophages is The percentage of macrophages is substantially higher in obese personssubstantially higher in obese persons. . (Dixit VD. J (Dixit VD. J Leukoc Biol 2008)Leukoc Biol 2008)

Pre-adipocytes produce macrophage colony Pre-adipocytes produce macrophage colony stimulating factor (M-CSF) and peroxisome stimulating factor (M-CSF) and peroxisome proliferation activated receptor gamma proliferation activated receptor gamma (PPARg), both of which promote macrophage (PPARg), both of which promote macrophage activation. activation. (Karagiannides. Curr Opin Gastroenterol 2007)(Karagiannides. Curr Opin Gastroenterol 2007)


Increased monocyte and Increased monocyte and granulocyte oxidative burst, have granulocyte oxidative burst, have been found in obese subjectsbeen found in obese subjects. . (Lamas O, Eur J Clin Nutr 2002)(Lamas O, Eur J Clin Nutr 2002)

One such adipokine is leptin, One such adipokine is leptin, which acts to decrease food which acts to decrease food intake and increase energy intake and increase energy consumption by promoting consumption by promoting production of anorexigenic production of anorexigenic factors. factors. (Marti A,Obes Rev2001)(Marti A,Obes Rev2001)

Leptin involvement in Leptin involvement in immunoregulationimmunoregulation

COMMON DISORDERS IN COMMON DISORDERS IN CRITICALL ILL OBESE CRITICALL ILL OBESE PATIENTSPATIENTS

Thromboembolic DiseaseThromboembolic Disease AspirationAspiration Abdominal Compartment SyndromeAbdominal Compartment Syndrome

CHALLENGES IN THE CARE OF CRITICALLY ILL CHALLENGES IN THE CARE OF CRITICALLY ILL OBESE PATIENTSOBESE PATIENTS

Airway ManagementAirway Management Central Venous AccessCentral Venous Access Surgical AirwaysSurgical Airways Hemodynamic MonitoringHemodynamic Monitoring Imaging and TestsImaging and Tests Nutritional SupportNutritional Support

DRUG DOSINGDRUG DOSING NURSING CARENURSING CARE

Thromboembolic DiseaseThromboembolic Disease The incidence of thromboembolic disease (TED) The incidence of thromboembolic disease (TED)

varies:10% to 20% in general ward to 40% in pts varies:10% to 20% in general ward to 40% in pts with major trauma and as high as 80% in critical with major trauma and as high as 80% in critical

care patients.care patients. (Geerts WH. Chest 2004)(Geerts WH. Chest 2004)

Stein and colleagues found an increased risk for Stein and colleagues found an increased risk for VTE in obese men and women compared with VTE in obese men and women compared with nonobese patients. nonobese patients. (Stein PD. Am J Med 2005)(Stein PD. Am J Med 2005)

Alterations in PAI-1 and fibrinolytic activity in Alterations in PAI-1 and fibrinolytic activity in obese patients may contribute to their increased obese patients may contribute to their increased risk for VTE. risk for VTE. (Loskutoff DJ.Thromb Vasc Biol 1998)(Loskutoff DJ.Thromb Vasc Biol 1998)

Abdominal obesity may predispose obese Abdominal obesity may predispose obese patients to atelectasis and arterial patients to atelectasis and arterial hypoxemia,particularly when immobile and in the hypoxemia,particularly when immobile and in the supine position. PE may be a concern in these supine position. PE may be a concern in these situations,but diagnosis of PE is a challenge in situations,but diagnosis of PE is a challenge in patients with morbid obesity.patients with morbid obesity.

Thromboembolic DiseaseThromboembolic Disease

Compression ultrasonography with Compression ultrasonography with venous imaging is not as sensitive in venous imaging is not as sensitive in patients with severe obesity and/or patients with severe obesity and/or significant leg edema.significant leg edema.

Morbid obesity may limit CT Morbid obesity may limit CT angiography.angiography.

Ventilation-perfusion scanning or Ventilation-perfusion scanning or perfusion scanning alone is a potential perfusion scanning alone is a potential alternative, but neither modality can alternative, but neither modality can give a definitive diagnosis. give a definitive diagnosis. (Tapson VF. Am J (Tapson VF. Am J Respir Crit Care Med 1999)Respir Crit Care Med 1999)

AspirationAspiration

Obesity, especially central adiposity, Obesity, especially central adiposity, is a significant risk factor for is a significant risk factor for gastroesophageal reflux disease gastroesophageal reflux disease (GERD). (GERD). (Corley DA.Gut 2007)(Corley DA.Gut 2007)

Proposed mechanisms include Proposed mechanisms include increased intra-abdominal pressure, increased intra-abdominal pressure, decreased lower esophageal decreased lower esophageal sphincter pressure,increased sphincter pressure,increased frequency of hiatal hernia, and frequency of hiatal hernia, and perhaps alterations in esophageal perhaps alterations in esophageal motility and gastric emptying in the motility and gastric emptying in the obeseobese. . (Friedenberg FK. Am J Gastroenterol 2008)(Friedenberg FK. Am J Gastroenterol 2008)

AspirationAspiration

Histamine H2 antagonists and proton Histamine H2 antagonists and proton pump inhibitors might minimize the pump inhibitors might minimize the deleterious effects of gastric acid deleterious effects of gastric acid aspiration on the lung, but the loss of the aspiration on the lung, but the loss of the antimicrobial effects of gastric acid has antimicrobial effects of gastric acid has been suggested as a potential risk factor been suggested as a potential risk factor for pneumonia. for pneumonia. (Nishina K. Anesth Analg 1996)(Nishina K. Anesth Analg 1996)

Elevation of the patient’s head and the use Elevation of the patient’s head and the use of special endotracheal tubes that allow of special endotracheal tubes that allow for continuous suctioning of subglottic for continuous suctioning of subglottic secretions may also decrease the risk for secretions may also decrease the risk for aspiration and VAP , although the use of aspiration and VAP , although the use of these devices has not been studied in these devices has not been studied in obese patientsobese patients. (. (Valles J. Ann Intern Med 1995)Valles J. Ann Intern Med 1995)

Abdominal Compartment SyndromeAbdominal Compartment Syndrome

Obese patients have higher IAP than nonobese Obese patients have higher IAP than nonobese control subjects.control subjects.

The incidence of clinically significant abdominal The incidence of clinically significant abdominal compartment syndrome in critically ill obese compartment syndrome in critically ill obese patients is unknown.patients is unknown.

The abdominal compartment syndrome should The abdominal compartment syndrome should be suspected in the setting of increased IAP be suspected in the setting of increased IAP with attendant poor urine output, respiratory with attendant poor urine output, respiratory acidosis, or metabolic acidosis.acidosis, or metabolic acidosis.

In these settings, abdominal decompression In these settings, abdominal decompression should be considered, with treatment of ileus, should be considered, with treatment of ileus, large volume paracentesis, or laparotomylarge volume paracentesis, or laparotomy..

CHALLENGESCHALLENGESIN THE CAREIN THE CAREOF OF CRITICALLYCRITICALLY ILL ILL OBESE OBESE PATIENTSPATIENTS

Airway ManagementAirway Management

Morbidly obese patients often have Morbidly obese patients often have anatomic changes that make intubation anatomic changes that make intubation difficult, such as a short and thick neck, difficult, such as a short and thick neck, redundant soft tissue in the oropharynx, redundant soft tissue in the oropharynx, and limited mouth opening, and the and limited mouth opening, and the availability of two experienced intubators availability of two experienced intubators is preferable.is preferable.

Several studies have established an Several studies have established an association between increasing BMI and association between increasing BMI and difficulties with intubationdifficulties with intubation. . (Grant P. Emerg Med (Grant P. Emerg Med

Australas 2004)Australas 2004) Proper positioning,with the head elevated Proper positioning,with the head elevated

above the shoulders in the ‘‘sniffing above the shoulders in the ‘‘sniffing position,’’ is important. position,’’ is important. ((Rao SL. Anesth Analg 2008)Rao SL. Anesth Analg 2008)

Airway ManagementAirway Management

Bilevel positive airway pressure (BiPAP) has Bilevel positive airway pressure (BiPAP) has been used to oxygenate patients before rapid been used to oxygenate patients before rapid sequence intubation when conventional sequence intubation when conventional methods of preoxygenation have failed to bring methods of preoxygenation have failed to bring the saturation above 90%.the saturation above 90%. (El-Khatib MF.Can Anesth 2007)(El-Khatib MF.Can Anesth 2007)

Ultimately,when other advanced airway Ultimately,when other advanced airway techniques fail,skilled operators may need to techniques fail,skilled operators may need to intubate under fiber-optic guidance or with the intubate under fiber-optic guidance or with the aid of newer devices (for example, LMA CTrach, aid of newer devices (for example, LMA CTrach, Airtraq, Glidescope) that allow for video-Airtraq, Glidescope) that allow for video-assisted intubation without the need to align assisted intubation without the need to align the oral and pharyngeal axesthe oral and pharyngeal axes..

If such methods are not successful, an If such methods are not successful, an emergent tracheostomy should be considered. emergent tracheostomy should be considered. (Dhonneur G. Obes Surg 2008)(Dhonneur G. Obes Surg 2008)

Central Venous AccessCentral Venous Access Because of the distortion of normal anatomic landmarks Because of the distortion of normal anatomic landmarks

in obese patients, establishing central venous access in obese patients, establishing central venous access can be time-consuming and challenging.can be time-consuming and challenging.

In a randomized, crossover study in obese or In a randomized, crossover study in obese or anticoagulated patients, real-time ultrasound guidance anticoagulated patients, real-time ultrasound guidance improved success rates at cannulation and led to fewer improved success rates at cannulation and led to fewer complications. complications. (Gilbert TB. Crit Care Med 1995)(Gilbert TB. Crit Care Med 1995)

Central Venous AccessCentral Venous Access Longer needles (for example, spinal needles) may be Longer needles (for example, spinal needles) may be

required in obese patients because standard needles required in obese patients because standard needles may be too short to clear excessive soft tissue.may be too short to clear excessive soft tissue.

Vigilance for infection and catheter-related phlebitis and Vigilance for infection and catheter-related phlebitis and thrombosis is important as well because intertriginous thrombosis is important as well because intertriginous folds predispose these patients to local skin infections.folds predispose these patients to local skin infections.

Surgical AirwaysSurgical Airways Longer tubes with sharper angles may be required for Longer tubes with sharper angles may be required for

tracheostomy in obese patients because of their tracheostomy in obese patients because of their increased soft tissue, but such tubes carry a higher risk increased soft tissue, but such tubes carry a higher risk of becoming dislodged or occluded.of becoming dislodged or occluded.

Higher complication rates have also been reported with Higher complication rates have also been reported with tube placement itself (whether via a surgical77 or tube placement itself (whether via a surgical77 or percutaneous route), although the magnitude of excess percutaneous route), although the magnitude of excess risk in experienced hands is not clear. risk in experienced hands is not clear. (Byhahn C. (Byhahn C.

Anaesthesia 2005)Anaesthesia 2005)

Hemodynamic Hemodynamic MonitoringMonitoring

Noninvasive blood pressure Noninvasive blood pressure monitoring by cuff monitoring by cuff sphygmomanometer has sphygmomanometer has unpredictable accuracy because of unpredictable accuracy because of difficulties with cuff size selection. difficulties with cuff size selection. Inaccuracies may persist, even Inaccuracies may persist, even when an appropriately sized cuff is when an appropriately sized cuff is available. available. (Maxwell MHf.Lancet 1982)(Maxwell MHf.Lancet 1982)

Hemodynamic parameters are often Hemodynamic parameters are often adjusted according to body surface adjusted according to body surface area. area.

Hemodynamic Hemodynamic MonitoringMonitoring

Beutler and colleagues highlight the potential Beutler and colleagues highlight the potential variations in calculated indexed values variations in calculated indexed values depending on weight chosen (actual, depending on weight chosen (actual, adjusted, or ideal), which could lead to adjusted, or ideal), which could lead to different conclusions regarding a patient’s different conclusions regarding a patient’s status, and, ultimately, treatment.status, and, ultimately, treatment.

Ideal body weight is not optimal because Ideal body weight is not optimal because oxygen demand and cardiac output are higher oxygen demand and cardiac output are higher in obese patients than in nonobese patients.in obese patients than in nonobese patients.

As a compromise, a 40% adjustment for As a compromise, a 40% adjustment for weight above ideal body weight is commonly weight above ideal body weight is commonly used as in drug dosing, but no study has used as in drug dosing, but no study has rigorously validated this adjustment.rigorously validated this adjustment.

Imaging and TestsImaging and Tests Variable lead positioning owing to indistinct landmarks Variable lead positioning owing to indistinct landmarks

and excessive soft tissue can lead to low voltages and and excessive soft tissue can lead to low voltages and make accurate interpretation of electrocardiograms make accurate interpretation of electrocardiograms (ECG) difficult. (ECG) difficult.

Specifically,application of ECG-based criteria for the Specifically,application of ECG-based criteria for the assessment of left ventricular hypertrophy and chamber assessment of left ventricular hypertrophy and chamber enlargements is limited.enlargements is limited.

Similarly, image acquisition using an echocardiogram is Similarly, image acquisition using an echocardiogram is poor.poor.

Inadequate soft tissue penetration makes interpretation Inadequate soft tissue penetration makes interpretation of portable radiographs difficult.of portable radiographs difficult.

Imaging and TestsImaging and Tests Confluence of shadows from overlyingConfluence of shadows from overlying soft tissue can mimic abnormalitiessoft tissue can mimic abnormalities such as pleural thickening.such as pleural thickening. Distinguishing the nature of parenchymal Distinguishing the nature of parenchymal opacities (infiltrate versus edema,opacities (infiltrate versus edema, for example)for example) can be difficult.can be difficult. Computed tomography (CT) is limitedComputed tomography (CT) is limited by load limits of the scanning tables as well as theby load limits of the scanning tables as well as the diameter of the aperture. diameter of the aperture. Some veterinary hospitals haveSome veterinary hospitals have specialized CT equipment tospecialized CT equipment to accommodate large animalsaccommodate large animals may be willing to perform scans in morbidly may be willing to perform scans in morbidly obese patients who cannot fit into obese patients who cannot fit into conventional human scanners.conventional human scanners.

Nutritional SupportNutritional Support

Obesity and malnutrition can coexist, Obesity and malnutrition can coexist, particularly in the setting of critical particularly in the setting of critical illness, and appropriate nutritional illness, and appropriate nutritional support of obese patients is essential.support of obese patients is essential.

Accelerated protein breakdown can lead Accelerated protein breakdown can lead to a rapid reduction in lean body mass. to a rapid reduction in lean body mass.

Hypocaloric,high-protein feeding Hypocaloric,high-protein feeding theoretically prevents overfeeding (and theoretically prevents overfeeding (and its consequences, such as its consequences, such as hyperglycemia) and allows for net hyperglycemia) and allows for net protein anabolism and secondary fat protein anabolism and secondary fat weight loss. weight loss. (Malone AM. Curr Gastroenterol Rep 2007)(Malone AM. Curr Gastroenterol Rep 2007)

Nutritional SupportNutritional Support

Although small studies have suggested Although small studies have suggested improved morbidity end points with this improved morbidity end points with this approach, including shorter ICU stay and approach, including shorter ICU stay and ventilator days, it remains controversial.ventilator days, it remains controversial.

Estimation of the metabolic need of the Estimation of the metabolic need of the critically ill obese patient is difficult.critically ill obese patient is difficult.

Some investigators have advocated the Some investigators have advocated the use of an obesity-adjusted weight with a use of an obesity-adjusted weight with a 25% correction for excess weight above 25% correction for excess weight above ideal body weight as follows: adjusted ideal body weight as follows: adjusted body weight =(actual weight- IBW) 0.25 body weight =(actual weight- IBW) 0.25 + IBW+ IBW

This approach has not been validated for This approach has not been validated for standard practice.standard practice.

DRUG DOSINGDRUG DOSING

The physiologic changes in obesity markedly The physiologic changes in obesity markedly affect distribution, binding, and elimination of affect distribution, binding, and elimination of medications commonly prescribed in the ICU.medications commonly prescribed in the ICU.

Although systemic absorption of oral drugs is not Although systemic absorption of oral drugs is not significantly altered in obese patients, the significantly altered in obese patients, the increase in fat body mass and relative decrease increase in fat body mass and relative decrease in percentage contribution of lean mass and in percentage contribution of lean mass and water can cause dramatic changes in the volume water can cause dramatic changes in the volume of distribution. of distribution.

Other important changes include increases in Other important changes include increases in total blood volume and cardiac output, total blood volume and cardiac output, alterations in plasma protein binding, and alterations in plasma protein binding, and obesity-induced changes in liver and kidney obesity-induced changes in liver and kidney function that may affect drug eliminationfunction that may affect drug elimination. . (Casati A. J (Casati A. J Clin Anesth 2005)Clin Anesth 2005)

DRUG DOSINGDRUG DOSING For many lipophilic medications, such as For many lipophilic medications, such as

aminoglycosides, with a large volume of distribution, aminoglycosides, with a large volume of distribution, the use of adjusted body weight is recommended.the use of adjusted body weight is recommended.

The distribution is presumed to be approximately 20% The distribution is presumed to be approximately 20% to 50% of the weight above ideal body weight. A typical to 50% of the weight above ideal body weight. A typical calculation using 40% of excess weight is as follows: calculation using 40% of excess weight is as follows: adjusted body weight = (Actual body-weight IBW) adjusted body weight = (Actual body-weight IBW) 0.41+ IBW 0.41+ IBW

However in the ICU,measurement of weight itself can be However in the ICU,measurement of weight itself can be affected by temporary changes in body water from third affected by temporary changes in body water from third spacing, which may or may not influence the spacing, which may or may not influence the distribution of medications.distribution of medications.

Dr. Who’sDr. Who’s Adipose monsters

Shyoko Hoinden.Clin Chest Med Shyoko Hoinden.Clin Chest Med 20092009

Nursing CareNursing Care All staff caring for the obese ICU patient should be All staff caring for the obese ICU patient should be

aware of the potential effect of personal prejudices aware of the potential effect of personal prejudices toward the obese, who may have insecurities about toward the obese, who may have insecurities about body image. body image. (Charlebois D.Crit Care Nurse 2004)(Charlebois D.Crit Care Nurse 2004)

Skin integrity can be particularly problematic in obese Skin integrity can be particularly problematic in obese patients. patients. (Winkelman C. Clin Nurs Res 2005)(Winkelman C. Clin Nurs Res 2005)

Multiple skinfolds can lead to the buildup of moisture, Multiple skinfolds can lead to the buildup of moisture, posing a threat to skin integrity. Limited mobility, posing a threat to skin integrity. Limited mobility, difficulty in nurse-assisted turning, decreased difficulty in nurse-assisted turning, decreased vascularity within adipose tissue, and excessive weight vascularity within adipose tissue, and excessive weight all contribute to pressure ulcer risk. all contribute to pressure ulcer risk. (El-Solh AA.Am J Respir Crit (El-Solh AA.Am J Respir Crit Care Med 2004)Care Med 2004)

Nursing CareNursing Care Pressure ulcers that begin in skin folds may go Pressure ulcers that begin in skin folds may go

undetected during their early stages unless all such undetected during their early stages unless all such regions are examined carefully during routine turning.regions are examined carefully during routine turning.

Patients with a BMI greater than Patients with a BMI greater than

40 generally require at least four staff 40 generally require at least four staff

members to assist with members to assist with

repositioning.repositioning. (Hurst S. Dimens Crit Care Nurs 2004)(Hurst S. Dimens Crit Care Nurs 2004)

Mobilization and rehabilitation inMobilization and rehabilitation in

obese patients may require increasedobese patients may require increased

personnel andequipment.personnel andequipment.

SUMMARYSUMMARY Obesity poses unique challenges for the ICU team.Obesity poses unique challenges for the ICU team. Important changes in cardiovascular, pulmonary, and Important changes in cardiovascular, pulmonary, and

immunologic physiology predispose such patients to immunologic physiology predispose such patients to respiratory failure, thromboembolic disease, abdominal respiratory failure, thromboembolic disease, abdominal compartment syndrome, and aspiration. compartment syndrome, and aspiration.

Special attention is required when performing routine ICU Special attention is required when performing routine ICU procedures, such as intubation and insertion of central procedures, such as intubation and insertion of central venous catheters, and limitations in testing capabilities venous catheters, and limitations in testing capabilities may lead the astute ICU clinician to rely solely on clinical may lead the astute ICU clinician to rely solely on clinical suspicion when making therapeutic decisions.suspicion when making therapeutic decisions.

Daily management can be further hampered by Daily management can be further hampered by uncertainties regarding drug metabolism and uncertainties regarding drug metabolism and pharmacokinetics, nutritional needs, and challenges in pharmacokinetics, nutritional needs, and challenges in bedside nursing care. bedside nursing care.

Dedicated research is much needed in obese patients to Dedicated research is much needed in obese patients to allow for formulation of evidence-based guidelines that allow for formulation of evidence-based guidelines that would further enhance delivery of ICU care for this would further enhance delivery of ICU care for this challenging population.challenging population.

Thank youThank you

OBESITY AND ICU HAMIDREZA JAMAATI MD, FCCP, FCCM.

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