Obesity, defined as BMI>30kg/M², is a growing problem in the US and worldwide. Multiple studies linked obesity to increased morbidity and mortality. Extremely obese patients present unique challenges to the inpatient physician.

It is reasonable to assume that obese patients do worse in the Intensive Care Unit as well. Yet, the clinical evidence on this issue is quite contradictory. Some studies showed a higher risk of death, while others revealed no difference in mortality or even showed a protective effect of obesity on ICU mortality. So, do chubby people do better in the ICU?

This would contradict common sense. It has been shown that obesity adversely affects metabolic, immune and microcirculatory functions leading to a higher incidence of hypertension, diabetes, dyslipidemia and infection.

Researchers from France (obesity study in France, really?) suggested that it is not the BMI, but the fat distribution that affects ICU morbidity and mortality. Specifically, it is abdominal obesity or belly fat that increases the risk of dying. It is not the weight but the shape that is important.

The study was published in the May issue of the Critical Care Medicine Journal. This elegantly conducted study showed that patients with predominantly abdominal obesity had a higher rate of death in the ICU independent of other predictors of mortality. BMI>30kg/m², by itself, did not affect mortality. I guess, some chubbiness could, actually, be protective in critical illness.

The researchers from France also found that the patient with predominantly abdominal obesity required renal replacement therapy (dialysis) and developed abdominal compartment syndrome more often than the control group. The higher risk of abdominal compartment syndrome is not a surprise – the sheer pressure of the fat on the abdomen can cause abdominal hypertension. I am still trying to wrap my mind around the fact that there was a higher incidence of renal failure.

In conclusion, not all fat is bad fat. Some chubbiness could, actually, be good for ICU patients. It’s the belly fat that could kill you or, at least, land you on a dialysis machine.

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?”