Abstract
Every year the number of patients with morbid obesity entering the intensive care unit increases. Due to the comorbidities that are often present, the medical complications and increased mortality rates faced by this patient population are staggering. As a patient becomes more clinically unstable, mobility and nutritional status deteriorate, and the interventions that are intended to help can lead to further complications. Meeting the challenges of providing safe and highly effective care to this population must become a focus for nursing and hospital administrations.
Introduction
The primary objectives of critical care medicine are to halt the underlying critical health event, limit its permanent damage, restore well-being, and preserve quality of life. Much research has been conducted over the last 20 years to develop standards of care to achieve these goals. Three of these standards of care are significantly hindered in the morbidly obese patients, specifically: ensuring proper and adequate nutrition, early and frequent mobility, and achieving unassisted respiratory status. 6 This case study will examine each of these three challenges, as well as their impact on the hospital staff.
Critical Illness and the Morbidly Obese Patient
Critical care medicine involves the care of patients who are experiencing a complex medical, surgical, or traumatic event that requires a heightened level of oversight by a multidisciplinary medical team. While the likelihood of an individual requiring intensive medical treatment is somewhat independent of his/her BMI, once admitted to a critical unit, the achievement of several key patient care goals becomes significantly more challenging as a patient's BMI increases.4,7
Ensuring proper and adequate nutrition in the critical care patient has been well documented as a key element to achieving a successful patient outcome. 8 Malnutrition is prevalent in as many as 40% of intensive care unit (ICU) patients and is associated with increased morbidity and mortality, such as further complications from infection or increased time requirements for mechanical ventilation. 8 Nutrition in the morbidly obese is often overlooked or not considered a priority for the patient simply due to their size. However, many morbidly obese patients are malnourished prior to hospitalization. This malnutrition often stems from a lack of nutrient intake that is replaced with empty calories, poor food choices, and overconsumption of unhealthy foods. Nutritional status is likely to worsen due to critical illness, 9 as severe illness and multiple complications only cause this issue to become more complex, and metabolic abnormalities may be persistent. 7 As with all critical care patients, nutrition for the obese patient must be addressed on admission in order to provide the best possible outcomes in healing and infection prevention.
In addition to nutrition, early mobility has been identified as crucial to the recovery of the ICU patient. 10 Mobility can be directly attributed to early discontinuation of mechanical ventilation, decreased incidence of pressure ulcer development, and venous thromboembolism (VTE) prevention. 10 Decreased lengths of stay and fewer complications are seen in patients who are able to avoid major muscle deconditioning. The patient with obesity presents many mobility issues for the ICU staff. Oftentimes, muscle tone and mobility issues existed prior to acute or critical illness. Therefore, in order to plan realistically for the patient's mobilization, a baseline assessment of mobility should occur at the time of admission. VTE prophylaxis must be initiated at the earliest possible moment in the obese patient. As mobility decreases, the opportunity for VTE development increases in all patient populations. Patients suffering with obesity are oftentimes at risk prior to the onset of illness due to impaired mobility and activity intolerance.
Patients admitted to an ICU may also be at increased risk for developing hospital-acquired pneumonia and respiratory distress or failure due to increased levels of illness-related stress and potentially compromised immune systems. This means that whether the patient is receiving ventilatory support or not, initiation of interventions to prevent pulmonary complications are essential during acute illness. Once on ventilator support, aggressive weaning protocols from mechanical ventilation have been shown to provide several key benefits to the patient. These protocols have been associated with decreases in infections such as ventilator-associated pneumonia, decreased damage to alveoli, and decreased mortality and length of stay. 11 Strategies such as head-of-bed elevations and gradual discontinuation of mechanical ventilation should be employed as soon as possible to help ensure the best outcomes, but these strategies are sometimes more difficult to implement in the patient with morbid obesity.
In obese patients, size is often a limiting factor in the effectiveness of these strategies. The impact of head-of-bed elevations may be limited when the abdominal adipose tissue crowds the diaphragm, effectively reducing the intrathoracic space. Additionally, obesity may present challenges to the gradual discontinuation of mechanical ventilation. This is most often due to the weight of adipose tissue limiting chest wall expansion and decreased muscle tone in the chest cavity limiting the patient's ability to inhale adequate tidal volumes. 12
In addition to the increased challenges faced by the critically ill morbidly obese patient, the critical care staff caring for the patient is also faced with challenges. Hospitals around the United States are reporting increasing numbers of employees experiencing injuries while lifting and moving patients. 13 Occupational Safety and Health Administration (OSHA) and The Joint Commission (TJC) have set forth guidelines for the purpose of addressing both patient and employee safety issues. 13 There is significant risk of injury to the patient and staff when moving obese patients due to weight and impaired mobility. Adequate equipment and staffing must be available, and all staff must be trained to use equipment safely. It is imperative to provide workplace safety initiatives for staff caring for patients with obesity. 14
Despite the focused attention on obesity, the American population of adults, adolescents, and children continues to grow in size. Hospitals are now caring for more young adults with morbid obesity in ICUs. 15 Obesity is not new to these patients, but rather it is a disease they have had since childhood. Recently, a patient admitted to the ICU of an urban, academic medical center provided staff with a firsthand experience of the challenges that a morbidly obese patient presents in achieving positive patient outcomes. The Institutional Review Board (IRB) reviewed this case study and determined that IRB approval was not required. This case is presented here for your consideration.
Case Study for 23-Year-Old Male Patient
Mr. M, a 23-year-old male, was transferred to the ICU of an academic medical center from the emergency department at his local community hospital. Mr. M weighed 227 kg and had a BMI of 69. Recent patient history obtained from his family and referring medical team included a 2-week history of back pain, fever, and progressively worsening weakness and tenderness in his legs and pelvis region. Mr. M's family also reported that he had experienced a 2-day history of incontinence and a fall with no loss of consciousness. At the time of admission to the ICU, Mr. M was diagnosed with septic shock, mild anemia, and hypoxic respiratory failure. He was immediately intubated, placed on mechanical ventilation, and a heparin infusion was initiated for suspicion of a pulmonary embolus.
In the first 24 hours, the patient's treatment included aggressive fluid resuscitation, antibiotic therapy, and administration of vasopressors in order to maintain hemodynamic stability. A computed tomography angiogram (CTA) of the chest and abdomen was ordered, but completion of the test was delayed because the medical staff struggled with how to transport Mr. M safely. In addition, his body habitus presented challenges due to the size limitations of the CT scanner. Ultimately, abdominal binders were used to assist with positioning, and the test was completed. An epidural abscess with spinal cord compression was diagnosed, the neurosurgery team was immediately consulted, and the patient underwent an emergency laminectomy, as well as removal and drainage of the associated abscess. Cultures from the abscess fluid were positive for Methicillin-resistant Staphylococcus aureus (MRSA).
Mr. M's size presented many challenges to the medical and nursing staff caring for him. The team was unable to avoid delays in vital diagnostics, as transporting Mr. M to and from procedural areas and the operating room required a team of clinicians. During transport, concerns for the safety of both the patient and staff needed to be addressed. In addition to transport, further concern was raised about the amount of time Mr. M had spent supine in bed without adequate repositioning due to his habitus and clinical condition.
During the next 2 weeks, Mr. M remained febrile and intermittently required vasopressors for blood pressure control. The medical team realized from the time of admission that treatment for Mr. M was going to be complicated due to the nature of his illness and his comorbidities. A decision was made to perform a tracheostomy early during his time on ventilatory support with the hope that it would allow for aggressive weaning from mechanical ventilation. A percutaneous endoscopic gastrostomy (PEG) tube was also placed in order to provide enteral feeding for nutritional support.
Over the course of several weeks, Mr. M experienced recurring sepsis and multiorgan failure, including renal failure requiring hemodialysis (HD) and continuous renal replacement therapy (CRRT), but there were intermittent periods when he seemed to be improving. He was requiring less sedation and lower ventilator settings, the use of vasopressors had been discontinued, and he was tolerating enteral nutritional support. Mr. M was also showing improvement in his neurological status, and he was awake and able to follow commands. Due to the abscess, however, he never did regain movement in his lower extremities. Fortunately, the availability of lift equipment was helpful, as it assisted staff in transferring Mr. M from the bed to a bariatric chair. The team remained aggressive and continued to increase physical activity as Mr. M tolerated.
One remaining obstacle for Mr. M was the inability to wean mechanical ventilation. Due to the weight of adipose tissue on the chest and the mass of his abdomen, his thoracic space was significantly reduced. Elevating the head of the bed more than 20–30° caused the size of his abdomen to impede thoracic expansion, which further impaired ventilation, and even placing the bed in reverse Trendelenburg had little effect on increasing spontaneous tidal volumes. These challenges are not unique to Mr. M, but are regularly experienced by the morbidly obese patient in the ICU. Over his entire hospital course, it was not possible to wean Mr. M completely from the ventilator, and while all preventative measures possible were employed, he experienced two more episodes of pneumonia during his 3 months in the ICU.
Six weeks into his stay, Mr. M's abdomen became distended, and he developed pain, fever, tachycardia, and hypotension. It was determined that due to the tension his size had placed on the PEG tube, the tube became dislodged and enteral feeds leaked into the abdominal cavity. Mr. M underwent surgery to repair this, but as a result of the surgical treatment, it was no longer safe for him to transfer out of bed to the chair. Lack of mobility further complicated his respiratory disease and further increased his risk of other complications.
Despite being on a specialty bed throughout his hospitalization, Mr. M ultimately developed sacral decubitus pressure ulcers due to the amount of time he was clinically too unstable to move. The wound and ostomy consult team followed Mr. M very closely, but treatment and prevention options were limited due to medical instability and continued mobility hindrances. After three months of treatment in the ICU and continuous multiorgan supportive therapy and immobility, he developed VTEs in all four extremities. At this time, Mr. M. still required hemodialysis. However, it was no longer possible to establish access for dialysis due to the development of VTEs. At this time, it became clear there was little likelihood of achieving a positive outcome for Mr. M. Ultimately, a family meeting was held and a decision was made to cease dialysis and withdraw ventilator support. Mr. M died 4 days later.
Discussion
The case of Mr. M presented the medical staff with many of the problems that are reported when treating the morbidly obese patient. While enteral feeding was initiated early in his admission, his size ultimately led to a complication of PEG dislodgement. This in turn inhibited efforts toward ensuring frequent mobility, which when coupled with the challenges of turning and repositioning, ultimately contributed to pressure ulcer development. Weaning efforts were unsuccessful because of Mr. M's size and deconditioned state, and thus contributed to repeated pneumonias and impaired adequate spontaneous ventilation.
It is important to note that although this case study focuses primarily on the medical effects of obesity, it is equally important to examine the emotional and psychosocial responses to obesity within the healthcare environment. Fifty-five percent of obese patients feel their healthcare providers have biases against them or that they do not receive the same quality of treatment as a patient of normal weight. 15 Obese patients report they do not feel respected by the healthcare providers. Some even report feeling resented.
Studies have shown the tendency to categorize obese people as less educated, less ambitious, less intelligent, and lazy. 15 The negative stereotypes are endless. However, the data on obesity do not support these preconceived notions. 15 Interestingly, while most adults feel negatively about obesity, 65% are overweight.
Patients with morbid obesity need support, compassion, and education. Healthcare providers need to have the proper tools to care safely and effectively for the obese patient. The issues of obesity cannot be addressed and corrected overnight. However, what can be fixed right now is the healthcare provider's approach to the care they provide. Nurses have an obligation to educate patients, families, communities, and ourselves about the issues that are destructive to our health and healthcare systems. Obesity must become a primary focus as we address the needs of our patients and our future generations of patients.
Footnotes
Disclosure Statement
No competing financial interests exist.