Morbid obesity is an independent
determinant of death among
surgical critically ill patients
From: Crit Care Med 2006 Vol....
Introduction
National Health and Nutrition
Examination Survey conducted in
1999–2002 65.7% of adult is
overweight ([BMI]>...
obesity to be an independent predictor of
death in critically ill patients…….. Bercault N,
Boulain T, Kuteifan K, et al: O...
Methods
Study PopulationJanuary 1998 to March
2001 in the Tufts-New England Medical
Center SICU1471 patients but exclude...
Severity of illness the Simplified Acute
Physiology Score II as assigned at the time of
SICU admission and Mortality Pred...
Prolonged critical illness was defined as an
ICU length of stay (LOS) 4 days406 critically
ill surgical patients
Statisti...
Multivariable models of ICU using a stepwise
selection process, with p values for entry and
retention in the model of .15 ...
univariate relationships of characteristics with
the ICU mortality using logistic regression
nonparametric smoothing splin...
Results
( general : prolonged stay)  neurosurgery
(25%, 17%), general surgery (21%, 29%),
cardiothoracic surgery (18%, 19...
mortality was seen with  BMI, also
related to mortality, including age,
gender, and MPM-24.
Morbidly obese critically il...
Discussions
26.7% of all SICU
admissions were obese
or extremely
obese(6.8%)
Extreme obesity was an
independent risk facto...
Galanos and associates concluded that high
BMI was not significantly related to risk of
death in seriously ill hospitalize...
Obese trauma patients have an 8-fold greater
mortality rate than non-obese , the most
severely overweight are most likely ...
Relationship between BMI and outcome
in 41,011 critically ill patients using the
Project Impact ICU database. High BMI
was...
(N= 2148 in MICU )…no differences observed
in severity of illness, mortality, length of
mechanical ventilation, ICU LOS, o...
2 groups each of 170 patients (89% admitted
to ICU with medical pathology) with MV for
48 hrs --- Obesity doubled odds of ...
In the present studyextreme obesity in
a critically ill surgical population was
independently associated with an
increase...
Complications of obesity  ventilatory and
cardiac failure, increased challenges in safely
obtaining vascular access, and ...
Respiratory disorders --- obesity
hypoventilation syndrome and pulmonary
emboli are a frequent cause of sudden death
….mea...
Appropriate weight-related dosage
adjustment in obese patients ---ESP.
antibiotics generally tend to be significantly
unde...
Clinicians and hospitals generally
underestimate the practical difficulties
imposed in caring for increasing numbers of
ob...
Thank you for your attention
Morbid obesity is an independent determinant of death among
Morbid obesity is an independent determinant of death among
Morbid obesity is an independent determinant of death among
Morbid obesity is an independent determinant of death among
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Morbid obesity is an independent determinant of death among

  1. 1. Morbid obesity is an independent determinant of death among surgical critically ill patients From: Crit Care Med 2006 Vol. 34, No. 4 By: Stanley A. Nasraway Jr, MD, FCCM 本檔僅供內部教學使用 檔案內所使用之照片之版權仍屬於原期刊 公開使用時 , 須獲得原期刊之同意授權
  2. 2. Introduction National Health and Nutrition Examination Survey conducted in 1999–2002 65.7% of adult is overweight ([BMI]> 25 kg/m2); obesity (BMI 30 kg/m2) in 2000 ---30.6% extreme obesity (BMI 40 kg/m2) morbid or class III obesity  5.1% in USA, an increase of 570% over the last 4 decades
  3. 3. obesity to be an independent predictor of death in critically ill patients…….. Bercault N, Boulain T, Kuteifan K, et al: Obesity-related excess mortality rate in an adult intensive care unit: A risk-adjusted matched cohort study. Crit Care Med 2004; 32:998–1003 Hypothesized that morbid obesity is an independent determinant of death among critically ill surgical patients, as it is in the general population
  4. 4. Methods Study PopulationJanuary 1998 to March 2001 in the Tufts-New England Medical Center SICU1471 patients but exclude 98( no height and weight data)1,373 patients for final analysis Study Design  Sociodemographic data were entered into the database on admission including age, gender, and coexisting diseases.
  5. 5. Severity of illness the Simplified Acute Physiology Score II as assigned at the time of SICU admission and Mortality Prediction Model (MPM)-24 as determined 24 hrs after SICU admission National Institutes of Health and World Health Organization criteria for BMI  Underweight-- BMI 18.5 kg/m2; normals ---18.5–24.9 kg/m2; overweight --- 25–29.9 kg/m2; obese -- 30– 39.9 kg/m2; extreme or morbid obesity – 40 kg/m2.
  6. 6. Prolonged critical illness was defined as an ICU length of stay (LOS) 4 days406 critically ill surgical patients Statistical Analysis  Demographic characteristics, severity of illness, and outcomes were compared among 5 BMI groups, Statistical comparisons were done between the extremely obese (BMI 40) patients and patients with BMI < 40 using the Student’s t-test (age), Kruskal- Wallis test (Simplified Acute Physiology Score II, MPM- 24), or Fisher’s exact and chi-square tests
  7. 7. Multivariable models of ICU using a stepwise selection process, with p values for entry and retention in the model of .15 and .10 to pick among all potential determinants of ICU death (other than BMI). BMI was then added to this covariate model of mortality to estimate the relationship of extreme obesity (BMI> 40) and ICU mortality after adjusting for the final subset of covariates also related to mortality.
  8. 8. univariate relationships of characteristics with the ICU mortality using logistic regression nonparametric smoothing spline plot based on a generalized additive model, where the value of the smoothing parameter was selected by generalized cross- validationshow nonlinear relationship between BMI as a continuous variable and the probability of death in the ICU SAS system for Windows, version 8.0 (SAS Institute, Cary, NC)
  9. 9. Results ( general : prolonged stay)  neurosurgery (25%, 17%), general surgery (21%, 29%), cardiothoracic surgery (18%, 19%), vascular surgery (13%, 12%), transplantation (12%, 15%), and all others combined (12%, 7%) Patients with extreme obesity were younger, female and diabetic, and higher severity of illness median ICU LOS was short, between 2.0 and 2.2 days, and there were no differences in ICU or hospital mortality compared with all other patients
  10. 10. mortality was seen with  BMI, also related to mortality, including age, gender, and MPM-24. Morbidly obese critically ill surgical patients had a greater than 7-fold likelihood of death over nonmorbidly obese critically ill patients.
  11. 11. Discussions 26.7% of all SICU admissions were obese or extremely obese(6.8%) Extreme obesity was an independent risk factor for death in critically ill patients who sustained a protracted stay, increasing the odds of death 700%
  12. 12. Galanos and associates concluded that high BMI was not significantly related to risk of death in seriously ill hospitalized patients------- Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. Crit Care Med 1997; 25: 1962–1968 Obese patients undergoing surgery are more susceptible to postoperative complications, including wound dehiscence and infection, CHF, and pulmonary failure-------Pasulka PS, Bistrian BR, Benotti PN: The risks of surgery in obese patients. Ann Intern Med 1986; 104:540–46
  13. 13. Obese trauma patients have an 8-fold greater mortality rate than non-obese , the most severely overweight are most likely to sustain irreversible deterioration Sawyer and colleaguesintra-operative transfusion requirements, wound infections, and early death from multiple organ failure were more common in morbidly obese (defined in that study as BMI 35 kg/m2) in liver transplant recipients
  14. 14. Relationship between BMI and outcome in 41,011 critically ill patients using the Project Impact ICU database. High BMI was not associated with an increased risk of death; however, the median ICU LOS in this study was very short, 2.0 days----Tremblay A, Bandi V: Impact of body mass index on outcomes following critical care. Crit Care Med 2003; 1202–1207
  15. 15. (N= 2148 in MICU )…no differences observed in severity of illness, mortality, length of mechanical ventilation, ICU LOS, or ICU- related complications among groups stratified by BMI. The investigators concluded BMI has little effect on overall ICU outcome---Ray DE, Matchett SC, Baker K, et al: The effect of body mass index on patient outcomes in a medical ICU. Chest 2005; 127: 2125–2131……… mean ICU LOS in these patients was 5 days, maybe not sick enough
  16. 16. 2 groups each of 170 patients (89% admitted to ICU with medical pathology) with MV for 48 hrs --- Obesity doubled odds of death (odds ratio, 2.1; 95% confidence interval, 1.6 –3.6)--- 4-fold increase in likelihood of nosocomial infections and other ICU-related complications, likely explaining increased death rate in the obese----Bercault et al: Obesity-related excess mortality rate in an adult intensive care unit: A risk-adjusted matched cohort study. Crit Care Med 2004; 32:998–1003
  17. 17. In the present studyextreme obesity in a critically ill surgical population was independently associated with an increased risk of death esp. in prolonged critical illness
  18. 18. Complications of obesity  ventilatory and cardiac failure, increased challenges in safely obtaining vascular access, and wound infection and dehiscence. increased insulin resistance and hyperglycemia( may  risk of death by severe sepsis) Extreme obesity is frequently associated with LV hypertrophy with resultant systolic and diastolic dysfunction and sudden death
  19. 19. Respiratory disorders --- obesity hypoventilation syndrome and pulmonary emboli are a frequent cause of sudden death ….mean BMI 50 kg/m2 1/3 were classified as having severe sleep apnea(41% with arrhythmia), lung volumes ,  work of breathing is increased, and difficult weaning ,  aspiration pneumonia (greater gastric volume of acidic juices and an increased incidence of GERD)
  20. 20. Appropriate weight-related dosage adjustment in obese patients ---ESP. antibiotics generally tend to be significantly under-dosed, inaccurate CCr Simple tasks of daily nursing care require more manpower and resources----nosocomial pneumonia, venous thromboembolism, and pressure sores, difficult venous access and its complications Difficult imaging studies
  21. 21. Clinicians and hospitals generally underestimate the practical difficulties imposed in caring for increasing numbers of obese patients and can misjudge the necessary infrastructural resources required to support these demanding patients----need to redesign hospital systems, devote more resources, and put into place infrastructure more tailored to the demands of the morbidly obese, acutely ill patient
  22. 22. Thank you for your attention

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