Obesity Epidemic

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Obesity Epidemic

• Nazir J. Habib
• ICU, Kaiser
• Vallejo

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• Cases

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Definition

• BMI most common but controversy Weight in
  kg/(height in meters) square
• BMI lt25 normal
• BMI 25-30 overweight
• BMI 30-40 obese (25 pop)
• BMI gt40 morbid obesity (5-7 pop.)
• BMI gt50 super obese (1-2 pop)
• Does not account for muscle mass
• Visceral fat is endocrine organ
• Waist circumference best correlates with visceral
  fat
• Asians and Hispanics have more visceral fat..
• WaistHip ratio important predictor (.80 female
  and .90 in male)

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CDC Obesity trends since 1993
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Obesity Epidemic
2005 Data 1.Mississipi 29 2.Alabama
29 3.W.Virginia 4.Louisiana 5.Tenessee 6.Texas 7.
Michigan 8. Kentucky 9..Indiana 10.S.Carolina
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Impact Obesity Annals IM 2005142525

• 300,000pts die /year from complications of
  obesity
• Almost 10 US healthcare expenses
• 100 Billion dollars per year
• 50 increase in expenditure in last decade
• Hospitalization rate is 2-4x higher
• Mortality increases 40 if BMI gt25 esp if age
  gt50yrs. Mortality 2-3 times if BMIgt30
• NEJM Adams 2006 august 24 2 studies confirm

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Obesity and Health Risk Arch.Int,Med 2000
160898-904
Stroke
Resp.Failure/OSA
CAD
DJD,Cancers, NAFL/ GBD, wound infections
Heart Failure/HPN
DVT/PE high risk , Increase fibrinogen factor
V, PAI 1,
DM/Renal Failure
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Case 1

• 54 yr hispanic female BMI 42. PMH lipids,
  smoker ½ PPD. No PCP . No meds
• Seen in ER with dyspnea for 5 days. No CP
• Exam RR 28, temp. 98.8, BP 170/100, HR 160
• Lab Hg 16, HCT 50, WBC 13k, platelet 400k
• RBS 220 Lytes/creatNormal
• Troponin 0.4
• ABG 7.34, CO2 50, O2 55 on 6l n.c
• CXR and EKG shown

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CXR shown
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EKG case 5
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Further management..?

• Patient intubated, Lovenox, ASA, b blocker
• ?Evaluation
• Persantine Thallium/TMT prior discharge
• Coronary angiogram
• No further workup send patient home on ASA,
  lopressor, diet, statins, quit smoking
• Risk stratification of CAD in this group?
• Interheart study Lancet 2004364937 52
  countries30,000 patients evaluated after AMI and
  assoc. risk factors including smoking, DM, HPN,
  lipids and diet and activity

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INTERHEARTRisk of AMI with Multiple Risk
Factors lancet 2004 364 937 Yusuf. S
Smk
DM
HTN
APoB/A
123
all4
O
PS
All RFs
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Metabolic Syndrome Criteria IDF

• Screen Waist 38 in. male/32 inch female
• Plus any 2 of the following
• F. Blood sugar gt100
• TGgt150
• BP gt130s or gt85d
• HDL lt40 male(lt50 in females)
• (ATP guidelines 40 inch /34 in. waist)
• Risk of CAD and CVA is increased 3 fold and
  mortality 2 fold
• Risk of diabetes 5 fold

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Nurses Health study

• 1976 Nearly 120,000 nurses followed for 16 yrs
• BMI and risk of death adjusted for other factors
• MOST important risk factor for Diabetes is BMI
• BMI 23-25 risk ratio is 2.67
• BMI 30-35 risk ratio is 20.1
• BMI gt35 risk ratio 38.8
• Good correlation to waist circumference
• Lowest risk death High fiber diet, exercise,
  non-smoker and moderate alcohol Hu F,
  NEJM200034316-22 and 2001345790

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Risk of DM, HPN and CAD
Female
Male
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Case 2 CHF

• 54 yr male 57, 300 lbs. BMI 47, not seen PCP
  for 4 years
• C/o SOB , tired for 4 weeks and ankle edema
• Admitted for cellulitis of left leg. Staph.
  aureus
• Exam T 100,RR 28, BP160/100,HR100 Rales
  at bases, pitting edema
• LAB
• RBS 160, Hg 16 /HCT 48. Troponin Nl
• ABG pH 7.28, pCO2 58, pO2 65 CXR
  cardiomegaly and chf
• BNP 1500-2300
• EKG ST, No acute changes.Troponin Nl.
• Echo EF 25, TR 3.1 m/sec c/w PA hypertension

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Management Patient needs

• Spiral CT to R/o PE
• Check lipid panel
• Start NIV (BiPAP)
• Intubate and start MV
• Phlebotomy one unit
• Nocturnal pulse oximetry on room air
• Sleep disorder study(PSG)
• Cardiac cath. immediately

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FirstNon Invasive ventilation

• Indication for NIV
• pH lt7.35 secondary to hypercapnia associated with
  any of the following -WOB increased - -RR
  gt25/min
• -Accessory muscle -Abdo. Paradox resp .
• Most useful in COPD and obesity hypoventilation
  syndrome.
• Avoid complications of mechanical ventilation
• 53 patients obese patients treated with NIV for
  hypercapnic resp. failure and followed for one
  year
• CHEST Cuvelier August 2005
  483 De Llano 587

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Obstructive Sleep
Apnea/SRBD Caples Ann.Int Med. 2005
feb187-197

• Epidemiology gt5-15 adults. Male gtFemale.
• Definition AHI
• Apnea no flow for gt10 secs.
• Hypopnea gt30 decrease flow with decrease in
  oxygen saturation 4 or greater
• Apnea-hypopnea index AHI/hr How useful in
  diagnosis?
• lt10 is mild OSA or normal
• 10-20 is moderate OSA grey Zone
• gt30 is probably severe OSA
• Decrease in oxygen saturations by gt4
• Total arousals /night
• Correlate with BMI, exam and symptoms 80
  undiagnosed!!!
• (SLEEP200528499AASM parameters
  review)

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Obstructive Sleep Apnea

• Anatomy micrognathia, macroglosssia, neck
  circum.gt17 inches, obesity.
• Posterior movement of tongue and palate obstructs
  airway, brief asphyxia
• Disturbed sleep
• Daytime Somnolence 40 pts
• Forgetfulness, personality changes
• Auto accidents risk

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Risk Factors for OSA

• Obesity is strongest predictor
• BMI gt 30 increases risk 4 fold and 10 increase
  in weight increase risk 6 fold
• Male 31
• Age older 60-70 25 incidence
• Data from pooled studies
• JAMA20042013.Young T

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Screening Pulse oximetry

• HR 43-175, O2 sat 75-98, mean 90
• 38 time spO2 lt90
• 30 min. episode with sat lt88
• Refer to PSG study ASAP

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Diagnosis

• Polysomnogram (PSG) monitors EEG/EMG, O2 sats,
  airflow,chest movement, ekg
• Pulse oximetry
• Kaiser Vallejo data 452 patients in
  lab 85 OSA
• Ave. CPAP 9 cm
• RDI ave. 29
• Ave. BMI 35
• MF 4.43
• Compliance rate 80

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Obstructive Sleep Apnea ( Annal IM 2005 Caples)
arousal
Sympathetic drive
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PSG Central (a) and Obstructive (b)
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Manifestations(BradleyCirculation 20031671-78)

• Hypertension 70- 80 pts. With resistant HPN have
  OSA . Most important?
• Diabetes 30
• CAD, CHF 50 pts.
• Arrhythmias (AF, pvcs)
• Pulmonary Decrease FRC and VC, decrease chest
  compliance and increase WOB. PA hypertension
• CO2 retention in 10 pts and 25 if BMI gt40 in
  2200 pts. with OSA. (Pickwickian)
• Increase mortality rate 40 at 8yr Chest
  Labaan March 2005127710-715
• Patients with OSA decrease in utilization of
  medical services by 50 after diagnosis and
  treatment (Sleep 1999 225-9)

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Does obesity cause CHF..?

• Extreme obesity itself is a risk factor for heart
  failure 30 patients with obesity had
  impaired LV function Obesity cardiomyopathy
  (Am.J.Card.20051521)
• Increase in the risk of heart failure with
  increases in BMI Framingham 5881 pts over 14
  yrs follow.
• Increase in risk of 5 percent for men and 7
  percent for women for each increment of 1 in BMI
• Obesity accounts for about 11 percent of heart
  failure among men and 14 percent among women in
  the Framingham population
• Increase risk of heart failure also due to
  hypertension, diabetes, and hyperlipidemia
• NEJM S. Kenchariah2002 347305

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Risk of Heart Failure in Obese Subjects,
According Body-Mass Index
women
men
Kenchaiah, S. et al. N Engl J Med 2002347305-313
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Treatments

• Weight loss multiple approach, goal is 10
  loss. Large studies Most patients unable to
  lose weight
• Surgery ill-defined criteria UPPP-no data
• Nasal CPAP night improves symptoms
• Decrease Leptin levels and insulin resistance
• Weight loss and reduce body fat
• Reduce BP/vasodilate
• Control CHF, improve St depression
• Improved mortality in OSA secondary to cardiac
  fatal events over 10 years with CPAP. Untreated
  patients had 3 fold mortality
• Marin lancet march 20053651046.
• Is patient a candidate for bar iatric surgery??
  VerseChest 2005485-7.OSA patients cannot lose
  weight.lt5 chance
• Evaluate criteria

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Change in body fat with CPAP
CHINCirculation1999100706
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Case 3 Surgical Patient Pre-op

• 57 year WF , weight 165 kg, BMI 44, is admitted
  for hemi-colectomy for colon cancer. Has dyspnea
  on exertion
• PMH DM, HPN and hyperlipidemia. Meds. none
• Exam BP 160/90. HR 90, Otherwise WNL.
• EKG low voltage, BNP 300, CXR Cardiomegaly, CBC,
  Lipids, SpO2 95
• Risks..? Post-op care and complications
• Review CCM June 2006 1796 Pieracci

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Airway

• Most difficult intubations (15-20 chance) in
  large Australian study, difficult laryngoscopy in
  20.
• No Nasal intubations.
• Assess Mallampati Score neck size gt17in, tongue,
  chin, and opening . Assess for OSA/OHS risk,
  spO2, pCO2
• Discuss risks/consent
• Awake intubation with FOB
• Consider LMA
• Absolutely AVOID supine position!!

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Ventilator /Pulmonary Management

• Post-operative respiratory events TWICE as likely
  in obese( low pO2, aspiration, ARF , PE, etc)
• Consider NIV early
• Higher ICU LOS and Ventilator LOS
• Maintain always in reverse Trendelenberg 45
  degree position in OR and ICU
• PEEP minimum 10cm until extubation
• TV 10 cc /kg IBW (unless ARDS 6cc/kg)
• Elevate HOB 30-45 to prevent VAP

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Drug Pharmacokinetics

• Based on normal renal/hepatic function
• T 1/2 life of drug metabolism
• Distribution of drug in body compartments/ fat
• Studies in human subjects limited
• Dosage recommended by
• Ideal body weight
• Adjusted body weightIBW 0.4(TBW-IBW)
• Total body weight

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Drug Dosages

• Opiods give judiciously
• resp. depression and arrest. Titrate every 15
  min. to goal
• Sedation
• Versed stores in adipose tissue. ½ life increases
  to 6 hrs vs. 2 hrs. Avoid infusion.
• Propofol may increase TG levels
• NMB
• Use IBW and titrate to effect with monitor TOF.
  Avoid infusion
• Wake up/wean ASAP daily
• Vasopressors use TBW

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Antibiotics

• Cephalosporins
• Higher doses. Esp. in serious infections. Pre-op
  cefazolin 2 Gm. Results in fewer wound
  infections
• Quinolones
• Cipro 600mg IV q.12h
• Aminoglycosides avoid if possible
• Vancomycin
• 30 mg/kg TBW daily in 3 doses cleared
  faster(3.3 hour T 1/2)
• Carbepanems No change in dose

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Anticoagulants

• IV heparin use adjusted body weight and monitor
  PTT to goal. Need high doses.
• LMW heparin Poor data 1 mg/kg IBW every12 hrs
  for Rx. DVT or ACS if gt120 kg and lt50 yrs age or
  gt90kg and gt50yr age 96 pts. Monitored Xa
  activity and bruising
• (J. Clinical Pharm200356 96-103)
• Activated protein C use TBW
• Thrombolytics. Limited data. Use maximum
• dosages
• DVT prophylaxis lovenox 40 mg Q 12h if BMI gt40.

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Hospital Outcomes

• Increase number of hospital/ICU admissions esp.
  younger patients.
• Morbid obesity shortens life span 8-13 yrs
• Weaning more difficult
• Hypoxia, 5 fold increase WOB, atelectasis
• High aspiration risk, PE risk increase 2-3
  times
• Increase risk sepsis and ARDS 30
• Outcomes are mixed
• BMI gt30 not associated with poorer outcomes in
  short term stay (Tremblay Chest20031231202)
  database of 41000 pts.
• MICU/vent. LOS same (RayChest June
  20051272125)
• BMI gt27 higher mortality (GoulenokChest
  20041251441)
• Increased infections esp. wound infections

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ICU Mortality

• 406 Surgical patients in ICU in Boston for gt4
  days
• 26 obese
• 6.8 with BMI gt40
• Mortality was 33 vs 13
• Odds of death were 7.4 times higher
• S. NasrawayCCM april 2006

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Nursing Care of Patients

• Maintain in reverse Trendelenberg
• Skin /wound care
• Special beds/kinetic
• Transport patient
• Imaging
• DVT prophylaxis
• PT involved early
• Central line care
• Avoid sedation esp. non intubated

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Management Multiple Approach

• Diet Mediterranean
• Exercise 150 minutes /week
• Medication for diabetes, lipids, HPN
• Screening at PE BS, lipids, BP, HCT,bicarb.
• Evaluate symptoms
• PSGCPAP for OSA
• Gastric Bypass surgery
• Ave. wt. loss 20kg
• 30 day mortality is 1-2
• Hospital admissions 10 first year.

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Bariatric Surgery

• BMI gt50 , no conditions needed
• BMI 40-50 One category 1 or 2 category 2
  conditions
• Category 1AHI gt20, DM uncontrolled on one med,
  severe DJD hip/knees or GERD
• Category 2OSA with AHIgt5, DM with FBSgt126, DJD,
  chf, ventral hernia, hyperlipidemia, GERD
  persistent need H2 blockers, HPN on meds
• BMI 35-40 NO unless under special
  circumstances only

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Summary

• Potential decline in life expectancy in USA as
  obesity increases
• Optimum BMI is 21-23 for males, 22-24 females
• BMI gt40 increases mortality 4 fold esp. after
  age gt50yrs
• Average life span reduced by 5-15 years if BMI is
  gt40
• Increase in obesity may continue unabated and
  increase healthcare costs NEJM K . Adams
  2006 august 763 NEJM 2005 352 1138
  Olshansky

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References

• Anesthesiology clinics N.Am 2005 Sept.
  Excellent review
• Intensive care medicine 2004 Dosing medications
  in obese patients Erstad 3018-32
• Prog.cardiovasc.nursing 200419155-161
  K.Garrett. Effect of obesity on critical care
  nursing
• Am.J. Resp. and crit. Care med Ali El-solh
  Clinical approach to critically ill morbidly
  obese 2004169557
• Chest Obesity hypoventilation syndrome
  revisited2001 120369 R.Kessler
• Obesity guidelines from ACP Ann. IM.
  2005142525
• Sleep apnea and heart failure circulation2003
  1671