New Strategy for Management of Morbid Obese Patients in Intensive Care Unit
Tamer Adel Gomaa;
Abstract
Obesity is intimately related to body mass index (BMI) (which is the weight in kilograms divided by the square of height in meters) which is used to distinguish between obese, non obese from 18 to 56 years old. Obesity is classified according to BMI into three classes, class I (BMI from 30-34.9 kg/m2), class II (BMI from 45-39.9 kg/m2) and class III (BMI equal or more than 40 kg/m2).
No one can deny that obesity is a major health problem worldwide, and it has become an epidemic disease globally, so that an increasing number of morbidly obese patients are being admitted to intensive care unit in which the management of these patients is always challenging.
Any patient can have a difficult airway, but obese patients have anatomic and physiologic features that can make airway management particularly challenging either by endotracheal tubes or tracheostomy. Newly developed laryngeoscopes: airtraq, fastrach, and glidescope have facilitated intubation and decreased time required for intubation. The ramped position has been proposed to improve oxygenation and the ability of the clinician to visualize the glottis. Also, preoperative preparation is challenging due to increased risk of aspiration. Reverse trendelenburg helps to alleviate intra-abdominal pressure (IAP) and prevents GERD.
It is clear to get benefit from traceostomy for morbid obese patients with obstructive sleep apnea (OSA) and ventilator dependent respiratory failure (VDRF). The difficulty of the surgical procedure and size discrepancy of the tracheostomy tubes is recently solved by modified tracheotomy technique that includes the removal of cervical fat, and use of custom-fit tracheostomy tubes provide a good solve to these problems.
There are several challenges in the management of respiratory failure in the obese population. Pulmonary physiology is significantly altered leading to reduced lung volumes, decreased compliance, abnormal ventilation and perfusion relationships, respiratory muscle insufficiency, and limited movement of diaphragm, resulting in rapid shallow breathing and hypoxemia. These complications lead to a prolonged requirement for mechanical ventilation and increased intensive care unit (ICU) length of stay. A recent strategy is to limit trans-pulmonary pressure to about 35 cm H2O and to add positive end-expiratory pressure (PEEP). The use of bi-level positive airway pressure at a level of 12/4 post-extubation improves oxygenation post-operative. Reverse Trendelenburg position at 45 degrees in morbid obese patients results in a larger tidal volume and lower respiratory rate.
Atelectasis especially post-operative is another challenge but can be faced by the recently developed nasal high flow therapy deliverd by Optiflow system that supplies heated and humidified oxygen gas at >30 L/min which increases mucociliary movement and guard against atelectasis.
Morbid obesity increases of hypertension, coronary artery diseases due to hyperlipidemia, congestive heart failure due to increased blood volume, elevated cardiac output, and left ventricular diastolic dysfunction, and arrhythemia (the most common is atrial fibrillation) due to increased level of catecholamines in obese patients. These complications are attributed to the increased in the level of various inflammatory markers (adipokines) which have a pro-inflammatory and pro-thrombotic state. Evaluation of these diseases by ECG, echocardiography and coronary angiography is important. ECG may show left ventricular hypertrophy or left axis deviation. Echocardiography may reveal left ventricular dysfunction. Exercise and tight observation of intravascular volume is of great value to decrease cardiac dysfunction.
Venous thrombo-embolic disease continues to be a major source of morbidity and mortality, with obese patients who are critically ill presenting one of the most risky patients. Primary prevention with low dose unfractionated heparin with or without sequential compression device is the key to reduce morbidity and mortality. Low molecular weight heparin is also used in such prevention. Current recommendations are to continue prophyaxis for up to 30 days after hospitalization. The recently developed oral anticoagulation activated factor X inhibitors apixapan and rivaroxaban provide a good prophylaxis against veous thrombo-embolism during hospitalization.
Morbid obesity results in different gastro-intestinal tract diseases like gastro-oesophageal reflux disease, intra-abdominal hypertension (intra-abdominal pressure more than 10 mmHg) which results in deterioration or even failure in one or more organ function, the most common is acute renal failure. Obesity also causes steasosis and steato-hepatitis.
Morbid obese patients with acute compartement syndrome (ACS) due to increased intra-abdominal pressure (IAP) should have frequent determinations of IAP indirectly by measurement of urinary bladder pressure (UBP). Ttreatment of ACS mandates a reduction of IAP with abdominal decompression even if hemodynamics are acceptable. Preparation for decompression should entail reversal of clotting deficiency, rewarming, reversal of acidosis, and aggressive volume loading. Abdominal decompression is the key to reverse organ deterioration. Normalization of preload, pulmonary function, splanchnic circulation, and diuresis in abdominal compartement syndrome (ACS) is observed after abdominal decompression. Recent researches confirm the role of nitric oxide in management of ACS, and the role of mannitol in decreasing tissue edema.
Abdominal wound dehiscence is usually ascribed to increased tension on the fascial edges at time of closure. Recently, the vacuum assisted closure system is used in morbid obese patients with postoperative abdominal wound dehiscences that could not be closed. It is maintained on a continuous mode with a negative pressure of −75 to −125 mm Hg.
Intensive care unit (ICU) team faces several difficulties in doing different procedures for morbid obese patients like radiologic procedures (ultrasonography is an example because of image noise but can be overcome by using low frequency, high-energy probes and deep tissue interrogation, such as duplex).
No one can deny that obesity is a major health problem worldwide, and it has become an epidemic disease globally, so that an increasing number of morbidly obese patients are being admitted to intensive care unit in which the management of these patients is always challenging.
Any patient can have a difficult airway, but obese patients have anatomic and physiologic features that can make airway management particularly challenging either by endotracheal tubes or tracheostomy. Newly developed laryngeoscopes: airtraq, fastrach, and glidescope have facilitated intubation and decreased time required for intubation. The ramped position has been proposed to improve oxygenation and the ability of the clinician to visualize the glottis. Also, preoperative preparation is challenging due to increased risk of aspiration. Reverse trendelenburg helps to alleviate intra-abdominal pressure (IAP) and prevents GERD.
It is clear to get benefit from traceostomy for morbid obese patients with obstructive sleep apnea (OSA) and ventilator dependent respiratory failure (VDRF). The difficulty of the surgical procedure and size discrepancy of the tracheostomy tubes is recently solved by modified tracheotomy technique that includes the removal of cervical fat, and use of custom-fit tracheostomy tubes provide a good solve to these problems.
There are several challenges in the management of respiratory failure in the obese population. Pulmonary physiology is significantly altered leading to reduced lung volumes, decreased compliance, abnormal ventilation and perfusion relationships, respiratory muscle insufficiency, and limited movement of diaphragm, resulting in rapid shallow breathing and hypoxemia. These complications lead to a prolonged requirement for mechanical ventilation and increased intensive care unit (ICU) length of stay. A recent strategy is to limit trans-pulmonary pressure to about 35 cm H2O and to add positive end-expiratory pressure (PEEP). The use of bi-level positive airway pressure at a level of 12/4 post-extubation improves oxygenation post-operative. Reverse Trendelenburg position at 45 degrees in morbid obese patients results in a larger tidal volume and lower respiratory rate.
Atelectasis especially post-operative is another challenge but can be faced by the recently developed nasal high flow therapy deliverd by Optiflow system that supplies heated and humidified oxygen gas at >30 L/min which increases mucociliary movement and guard against atelectasis.
Morbid obesity increases of hypertension, coronary artery diseases due to hyperlipidemia, congestive heart failure due to increased blood volume, elevated cardiac output, and left ventricular diastolic dysfunction, and arrhythemia (the most common is atrial fibrillation) due to increased level of catecholamines in obese patients. These complications are attributed to the increased in the level of various inflammatory markers (adipokines) which have a pro-inflammatory and pro-thrombotic state. Evaluation of these diseases by ECG, echocardiography and coronary angiography is important. ECG may show left ventricular hypertrophy or left axis deviation. Echocardiography may reveal left ventricular dysfunction. Exercise and tight observation of intravascular volume is of great value to decrease cardiac dysfunction.
Venous thrombo-embolic disease continues to be a major source of morbidity and mortality, with obese patients who are critically ill presenting one of the most risky patients. Primary prevention with low dose unfractionated heparin with or without sequential compression device is the key to reduce morbidity and mortality. Low molecular weight heparin is also used in such prevention. Current recommendations are to continue prophyaxis for up to 30 days after hospitalization. The recently developed oral anticoagulation activated factor X inhibitors apixapan and rivaroxaban provide a good prophylaxis against veous thrombo-embolism during hospitalization.
Morbid obesity results in different gastro-intestinal tract diseases like gastro-oesophageal reflux disease, intra-abdominal hypertension (intra-abdominal pressure more than 10 mmHg) which results in deterioration or even failure in one or more organ function, the most common is acute renal failure. Obesity also causes steasosis and steato-hepatitis.
Morbid obese patients with acute compartement syndrome (ACS) due to increased intra-abdominal pressure (IAP) should have frequent determinations of IAP indirectly by measurement of urinary bladder pressure (UBP). Ttreatment of ACS mandates a reduction of IAP with abdominal decompression even if hemodynamics are acceptable. Preparation for decompression should entail reversal of clotting deficiency, rewarming, reversal of acidosis, and aggressive volume loading. Abdominal decompression is the key to reverse organ deterioration. Normalization of preload, pulmonary function, splanchnic circulation, and diuresis in abdominal compartement syndrome (ACS) is observed after abdominal decompression. Recent researches confirm the role of nitric oxide in management of ACS, and the role of mannitol in decreasing tissue edema.
Abdominal wound dehiscence is usually ascribed to increased tension on the fascial edges at time of closure. Recently, the vacuum assisted closure system is used in morbid obese patients with postoperative abdominal wound dehiscences that could not be closed. It is maintained on a continuous mode with a negative pressure of −75 to −125 mm Hg.
Intensive care unit (ICU) team faces several difficulties in doing different procedures for morbid obese patients like radiologic procedures (ultrasonography is an example because of image noise but can be overcome by using low frequency, high-energy probes and deep tissue interrogation, such as duplex).
Other data
| Title | New Strategy for Management of Morbid Obese Patients in Intensive Care Unit | Other Titles | إستراتيجية جديدة لعلاج المرضى ذوى السمنة المفرطة داخل وحدة الرعاية المركزة | Authors | Tamer Adel Gomaa | Issue Date | 2014 |
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