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Spotlight Case March 2005

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Commentary by: Douglas D. Brunette, MD, Hennepin County Medical Center ... Brunette DD. Am J Emerg Med. 2004;22:40-7. 21. Case (cont.): The Hidden Mystery ... – PowerPoint PPT presentation

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Title: Spotlight Case March 2005


1
Spotlight Case March 2005
  • The Hidden Mystery

2
Source and Credits
  • This presentation is based on the March 2005
    AHRQ WebMM Spotlight Case in Hospital Medicine
  • See the full article at http//webmm.ahrq.gov
  • CME credit is available through the Web site
  • Commentary by Douglas D. Brunette, MD, Hennepin
    County Medical Center
  • Editor, AHRQ WebMM Robert Wachter, MD
  • Spotlight Editor Tracy Minichiello, MD
  • Managing Editor Erin Hartman, MS

3
Objectives
  • At the conclusion of this educational activity,
    participants should be able to
  • Appreciate the challenges of caring for morbidly
    obese patients
  • List specific interventions that can be
    implemented when caring for obese patients
  • Develop a rational approach to medication dosing
    in obese patients

4
Case The Hidden Mystery
  • A 45-year-old morbidly obese woman with diabetes
    mellitus was transferred to a tertiary care
    center for management of abdominal pain,
    vomiting, and subjective fevers. Upon transfer,
    the patient complained of diffuse abdominal pain.
    She was febrile with stable vital signs. Exam
    revealed a diffusely tender abdomen with chronic
    erythematous changes extending over her pannus.

5
Case (cont.) The Hidden Mystery
  • Empiric broad-spectrum antibiotics were started.
    The consulting surgeon recommended abdominal
    imaging, but the patient was unable to fit in the
    CT scanner or MRI due to her obesity. She was
    observed, and her abdominal pain was treated with
    narcotics.

6
Obesity in the United States
  • Is defined as having a very high amount of body
    fat in relation to lean body mass
  • Is a major health care problem in the U.S.
  • Has increased dramatically in recent years
  • Contributes to numerous negative health
    consequences

Source CDC web site. Flegal KM, et al. Int J
Obes Relat Metab Disord. 19982239-47. NIH. Obes
Res. 19986 Suppl 251S-209S
7
Body Mass Index
  • Body Mass Index (BMI) calculator
  • A measure of an adults weight in relation to
    height specifically weight in kilograms divided
    by the square of height in meters
  • Overweight BMI 25 kg/m2
  • Obese BMI 30 kg/m2
  • Morbidly obese BMI 40 kg/m2

8
Obesity Trends Among U.S. Adults
(BMI ? 30)
Source Behavioral Risk Factor Surveillance
System, CDC.
9
Leading Causes of Death the U.S. 2000
Source Mokdad AH, et al. JAMA. 20042911238-45.
10
Challenges in Caring for Obese Patients
  • Transportation
  • Physical exam
  • Diagnostic imaging
  • Nursing care
  • Airway management
  • Venous access
  • Medication dosing

11
Transportation Challenges
  • Need to recruit more personnel
  • Need multiple slide boards
  • Requires use of specially designed soft
    stretchers, operating room tables, hospital beds
  • Must provide special commodes, mechanical lifts,
    and larger wheel chairs

12
Physical Exam Challenges
  • Pannus and increased thickness of subcutaneous
    fat interferes with auscultation, palpation, and
    inspection
  • Positioning the patient is difficult due to
    decreased mobility
  • Blood pressure readings may be inaccurate when
    wrong size cuff used
  • Pain threshold in obese patients may be higher,
    further diminishing accuracy of exam

13
Imaging Challenges
  • Standard radiographsoften cannot fit entire
    field of image into single film
  • CT and MRI hindered by weight and circumference
    restrictions of typically 300-350 lbs
  • Ultrasound imaging technically difficult

Source Varon J, Marik P. Crit Care Clin.
200117187-200 Boulanger BR, et al. J
Trauma.19884552-56 Melanson SW, Heller M.
Emerg Med Clin North Am. 199816165-89 McKenney
KL. Radiologic Clin North Am. 199937879-93.
14
Nursing Care Challenges
  • Cardiac and pulse ox monitoring less reliable
  • Wound care technically difficult
  • Blood draws and IV access hard to establish
  • Skin care and pressure sore prevention
    challenging due to need to move patient often

Source Hahler B. Medsurg Nurs. 20021185-90
Davidson JE, et al. Crit Care Nurs Q.
200326105-18.
15
Airway Management Issues
  • Bag-valve mask ventilation more difficult
  • reduced pulmonary compliance
  • increased chest wall resistance
  • increased airway resistance
  • abnormal diaphragmatic positioning
  • Increased aspiration risk
  • Larger volume of gastric fluid
  • Increased intra-abdominal pressure
  • Higher incidence of reflux

16
Airway Management Issues
  • Obesity limits physicians view of laryngeal
    structures during intubation
  • Australian study of 85 difficult intubations
    obesity, limited neck mobility, or mouth opening
    accounted for two thirds
  • Interventions to consider in morbidly obese
  • Intubate in the semierect position
  • Use the Intubating Laryngeal Mask Airway or
    Combitube

Williamson JA, et al. Anaesth Intensive Care.
199321602-7 Rocke DA, et al. Anesthesiology.
19927767-73.
17
Intubation Laryngeal Mask Airway
18
Venous Access Challenges
  • Greater number of skin punctures during catheter
    placement
  • Delayed catheter changes with increased infection
    and thrombosis
  • Additional personnel needed for positioning and
    pannus retraction

Boulanger BR, et al. Crit Care Clin.
199410613-95.
19
Medication Dosing Issues
  • Marked alteration in pharmacokinetics due to
    altered volume of distribution
  • Volume of distribution is correlated with drug
    lipophilicitydrugs with higher affinity for
    adipose have a larger volume of distribution
  • Ideally base dosing on results of clinical
    research data

20
Medication Dosing Issues
  • When dosing guidelines not provided, base loading
    doses on drugs hydrophilic or lipophilic
    properties, and ideal body weight (IBW) or total
    body weight (TBW)
  • Hydrophilic
  • Dosing Weight IBW 0.3(TBW-IBW)
  • Lipophilic use TBW
  • Maintenance dose should be based on IBW if
    metabolic clearance is not known

Brunette DD. Am J Emerg Med. 20042240-7.
21
Case (cont.) The Hidden Mystery
  • Six days later, the patient developed fevers,
    hypotension, and leukocytosis. Exam showed newly
    identified gangrenous pannus in the deep skin
    folds. She was taken to the OR for presumed
    necrotizing fasciitis. Surgical exploration
    revealed a colocutaneous fistula arising from
    perforated sigmoid diverticula. The patient died
    of multiorgan failure after a complex
    several-month hospital course.

22
Quality of Care for Obese Patients
  • Documented delays in medical care
  • Less likely to receive preventative care
  • Negative physician attitudes and discrimination
  • Reported feeling mistreated and misunderstood by
    medical personnel
  • Surgeons possibly more reluctant to operate

Source Schwilk B. Anasthesiol Intensivmed
Norfallmed Schmerzther. 19953099-107
Heinzelmann M. Am J Surg. 2002183179-90.
23
Obesity and Perioperative Mortality
  • Longer operative times
  • Increased surgical wound infection rate
  • Higher risk of sepsis

Cruse PJ, Foord R. Surg Clin North Am.
19806027-40 Reference 29.
24
Postoperative Complication Rates by Weight
Schwilk B. Anasthesiol Intensivmed Norfallmed
Schmerzther. 19953099-107
25
Obesity and Medical Education
  • Rotations on bariatric surgery service have
    improved students knowledge base
  • Interventions in medical school using video audio
    and written components have lead to improved
    attitudes towards obese patients

Source Nanasiak M, Murr MM. Obes Surg.
200111677-9Wiese HJ, et al. Int J Obes Relat
Metab Disord. 199216859-68.
26
Take-Home Points
  • Obesity is an epidemic in the US and an
    increasing percentage of patients will be
    classified as obese
  • Providing excellent care to this population is
    challenging and requires special attention and
    often the use of customized equipment
  • Airway management is particularly risky and care
    givers should be prepared to use rescue techniques

27
Take-Home Points
  • Medication dosing must often be customized to
    this population
  • Care givers must be mindful of potential biases
    that can influence interactions with patients and
    the quality of care
  • Efforts should be made to increase curriculum at
    the medical school level focusing on the care of
    the obese patient
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