Obesity is a huge healthcare problem in the United States.
It has reached the proportions of an epidemic and continues to get worse. Multiple medical problems including heart disease, hypertension, diabetes, sleep apnea and cancer are closely associated with obesity. The patients with extreme obesity can reach a body weight of five, six or seven hundred pounds and even higher. Riddled with chronic medical conditions, these patients often end up in the hospital for medical care.
Taking care of the extremely obese patient presents many challenges for the practicing physicians. Below are some practical considerations for how deal with extremely obese patients in the hospital and ICU.
Just moving the patient in bed or even getting the patient out if bed presents a challenge. The ceiling lifts come very handy even to just flip the patient on the side. Even those lifts have a weight limit, so now we are considering getting at least one ceiling lift with a 1000 pounds weight limit for each floor.
Obtaining a radiographical study on an obese patient could be quite difficult. Plain XR of the chest is often unreadable due to its poor quality. Obtaining more involved studies like CT scan or MRI even more challenging. Most radiology equipment has a weight limit and, sometimes, you simply cannot fit the patent into the scan because of the size limits. There were circumstances where we had to perform a diagnostic laparotomy when an acute abdomen was suspected because no useful images could be obtained.
Obese patients often have hypoventilation and sleep apnea, putting them at a higher risk for respiratory failure. Intubating an obese patient could be an absolute nightmare. Using GlideScope or even a bronchoscope might help when dealing with a difficult airway.
Venous access is often problematic as well. The amount of abdominal tissue overlying the groin often precludes the placement of a femoral central venous catheter. Using an ultrasound for the placement of an internal jugular central catheter is helpful if central line is needed. In many cases having a PICC line (percutaneously inserted central catheter) inserted could save you’re a lot of time and effort.
Once the patient is on ventilator, the excessive amount of thoracic adipose (fat) tissue leads to high ventilatory pressures. The shear weight of this tissue compressing the chest precludes the lung from adequate expansion. Thus, higher pressures are required to ventilate the patient, increasing the risk of complications. Tracheostomy often becomes the only option to wean the patient off the ventilator.
DVT (deep venous thrombosis – primarily in lower extremities) prophylaxis is at best uncertain. Many obese patients are bedridden while being in the ICU and are at increased risk for venous blood clots in their legs. The usual method of prophylaxis is the administration of a low dose blood thinner, like Lovenox or Fragmin, under the skin (SQ) of the abdomen. Considering extreme obesity, the absorption of this drug is uncertain.
Wound healing is often impaired in obese patients. This is especially true for abdominal wounds. Many patients end up having a long term VAC dressing (sponge dressing connected to a vacuum device) to keep the wound clean.
Many more practical issues arise when taking care of the extremely obese patients. The problem is not going to go away and will likely to get worse. It’s like the wife of the 700 pound patient had said once I informed her that CT scan was not an option for her husband: “I thought the whole nation is getting fatter. How come you are not prepared for this?”
Ralph Gordon is a critical care physician who blogs at realICU.
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