Critical care of the bariatric patient

Association between obstructive sleep apnea and multiple adverse clinical outcomes: evidence from an umbrella review

Background and objective

In recent years, there has been a notable rise in awareness regarding obstructive sleep apnea (OSA), and a significant number of potential OSA cases have been identified. Numerous studies have established associations between OSA and various adverse clinical outcomes. This umbrella review aims to summarize and evaluate the available evidence on the relationship between OSA and multiple adverse clinical outcomes.

Methods

PubMed, Embase, and Web of Science databases were systematically searched from inception to September 2023. The AMSTAR and GRADE were used to evaluate the quality of meta-analysis literature and classify the quality of literature evidence. Furthermore, the size of the effect size of the association between OSA and adverse clinical outcomes were assessed by using either a random or fixed-effect model and 95% confidence interval (CI).

Results

A total of 27 meta-analyses were enrolled with 43 adverse clinical outcomes. The umbrella review primarily reported the associations between sleep apnea syndrome and thyroid cancer (HR = 2.32,95%CI:1.35-3.98), kidney cancer (RR = 1.81, 95% CI: 1.20-2.74), liver cancer (RR = 1.19, 95% CI: 1.10-1.29), GERD (Gastroesophageal reflux disease)(OR = 1.53, 95% CI: 1.23-1.91), Atrial fibrillation (AF) (OR = 2.54, 95% CI: 2.20-2.92), osteoporosis (OR = 2.03, 95% CI: 1.26-3.27), and diabetes (OR = 1.40, 95% CI: 1.32-1.48). Overall, the AMSTAR rating scale and GRADE quality assessment included in the meta-analysis were generally low.

Conclusion

Our study shows that OSA is significantly associated with a variety of adverse clinical outcomes, especially an increased risk of certain malignancies, and some adverse clinical outcomes are closely related to OSA severity.

Mobility and self-care outcomes in patients with a bariatric comorbidity during inpatient rehabilitation

OBJECTIVE

First, we describe the characteristics and functional outcomes of obese and bariatric patients in an inpatient rehabilitation facility (IRF). Second, we assessed differences in functional outcomes for bariatric, obese, and standard weight body mass index (BMI) groups. Third, we explored whether these characteristics differ between time periods and diagnostic groups.

DESIGN

A retrospective study comparing electronic medical record data collected in 2016 and 2018, using a repeated cross-sectional cohort design.

SETTING

IRF.

PARTICIPANTS

Individuals ≥18 years of age diagnosed with brain injury, medical complexity, general neurology, orthopedic, spinal cord injury (SCI), and stroke. Participants grouped as standard (BMI <30 kg/m2), obese (BMI 30-39 kg/m2), and bariatric (BMI ≥40 kg/m2) weights. (N = 2015 in 2016, N = 2768 in 2018.) INTERVENTIONS: Patients received standard inpatient rehabilitation. In 2018, clinicians had access to new weight-appropriate equipment.

MAIN OUTCOME MEASURES

Discharge destination; length of stay (LOS) by BMI group and medical diagnoses; item-specific functional independence measure (FIM) change scores.

RESULTS

Sixty-four percent to 67% of all BMI groups achieved a home discharge. The bariatric BMI group had a longer LOS (21 days) than the standard or obese groups. There was a significant interaction in a linear regression analysis between diagnosis and LOS, where LOS was longer in medically complex patients with bariatric BMI (19.3 days compared to 16.1 days) but shorter in bariatric patients with SCI (20.6 days) compared to standard weight patients (26.2 days). In 2018, the bariatric BMI group had greater average FIM change scores for bathing, lower body dressing, toilet transfers, and bed transfers.

CONCLUSIONS

Patient BMI is associated with LOS in the IRF, although affected by diagnosis. Patients with higher BMIs can make changes in specific individual motor FIM items. For patients with bariatric BMIs, FIM change scores were higher in 2018, possibly due to the use of equipment and facilities designed for higher weight capacities.

Hilab System Device in an Oncological Hospital: A New Clinical Approach for Point of Care CBC Test, Supported by the Internet of Things and Machine Learning

The complete blood count (CBC) is a highly requested test that is generally restricted to centralized laboratories, which are limited by high cost, being maintenance-demanding, and requiring costly equipment. The Hilab System (HS) is a small, handheld hematological platform that uses microscopy and chromatography techniques, combined with machine learning (ML) and artificial intelligence (AI), to perform a CBC test. This platform uses ML and AI techniques to add higher accuracy and reliability to the results besides allowing for faster reporting. For clinical and flagging capability evaluation of the handheld device, the study analyzed 550 blood samples of patients from a reference institution for oncological diseases. The clinical analysis encompassed the data comparison between the Hilab System and a conventional hematological analyzer (Sysmex XE-2100) for all CBC analytes. The flagging capability study compared the microscopic findings from the Hilab System and the standard blood smear evaluation method. The study also assessed the sample collection source (venous or capillary) influences. The Pearson correlation, Student t-test, Bland-Altman, and Passing-Bablok plot of analytes were calculated and are shown. Data from both methodologies were similar (p > 0.05; r ≥ 0.9 for most parameters) for all CBC analytes and flagging parameters. Venous and capillary samples did not differ statistically (p > 0.05). The study indicates that the Hilab System provides humanized blood collection associated with fast and accurate data, essential features for patient wellbeing and quick physician decision making.

Impact of Obesity on Early In-Hospital Outcomes after Coronary Artery Bypass Grafting Surgery in Acute Coronary Syndrome: A Propensity Score Matching Analysis

Recent advances in perioperative care have considerably improved outcomes after coronary artery bypass graft (CABG) surgery. However, obesity can increase postoperative complication rates and can lead to increased morbidity and mortality. Between June 2011 and October 2019, a total of 1375 patients with acute coronary syndrome (ACS) underwent cardiac surgery and were retrospectively analyzed. Patients were divided into 2 groups: non-obese (body mass index (BMI) < 30 kg/m2, n = 967) and obese (BMI ≥ 30 kg/m2, n = 379). Underweight patients (n = 29) were excluded from the analysis. To compare the unequal patient groups, a propensity score-based matching (PSM) was applied (non-obese group (n = 372) vs. obese group (n = 372)). The mean age of the mentioned groups was 67 ± 10 (non-obese group) vs. 66 ± 10 (obese group) years, p = 0.724. All-cause in-hospital mortality did not significantly differ between the groups before PSM (p = 0.566) and after PSM (p = 0.780). The median length of ICU (p = 0.306 before PSM and p = 0.538 after PSM) and hospital stay (p = 0.795 before PSM and p = 0.131 after PSM) was not significantly higher in the obese group compared with the non-obese group. No significant differences regarding further postoperative parameters were observed between the unadjusted and the adjusted group. Obesity does not predict increased all-cause in-hospital mortality in patients undergoing CABG procedure. Therefore, CABG is a safe procedure for overweight patients.

Evaluating the Effectiveness of a Clinical Practice Intervention in Increasing Obesity Data Recording at a Western Australian Country Health Service Hospital: A Quasi-Experimental Controlled Trial

Purpose

Identification and mitigation of obesity-related risks to staff and healthcare organisations can occur using patient obesity data; however, a 2017/18 audit of obesity data accuracy was assessed to be poor. This study investigates the results of an intervention to improve obesity data recording and coding accuracy at an Australian hospital.

Background

Increasing population obesity rates result in increased organisational and financial risks to hospitals. Australian obesity prevalence has steadily increased since 1995, and 42% of the Australian population is predicted to be obese in 2035. To reduce risks to healthcare staff who care for obese patients, complete and accurate obesity recording is required.

Methods

Following a previous audit of obesity recording and coding accuracy of patients admitted to hospital with Type II diabetes, a 12-month intervention was undertaken, comprising staff education, introduction of tape measures and obesity decision-making tools, recording of patient volunteered height, regular reinforcement of obesity recording requirements and enhanced clinical coding of obesity. A re-audit was subsequently conducted to determine if the intervention impacted obesity recording and coding at the previously audited site.

Results

Improved recording of obesity-related measures and obesity data accuracy were observed, including increased patient BMI, impacted by increased patient height measurements and increased patient weight measurements. Obesity recording accuracy increased due to the intervention, including increased sensitivity, increased negative predictive values and reduced false negatives.

Conclusion

The obesity recording intervention was successful; however, as hospitals increasingly use electronic health records, improvement opportunities should be considered such as compulsory recording of patient weight and height, embedded BMI calculators and “check boxes” for recording impacts of obesity conditions on treatment. Immediate improvement of obesity recording in manual patient files can be achieved in the meantime by implementing targets of 100% weight, height and BMI recording, introducing education programs and auditing compliance.

Estimated Financial Impacts of Inaccurate Obese Patient Data Recorded by the Western Australian Country Health Service

Purpose

Pressure on Australia’s healthcare system is increasing annually due to corresponding increases in chronic diseases such as obesity and rapidly ageing population growth across Australia, resulting in requirements for increased funding. This study investigates the financial impact to hospitals due to inaccurate obese patient recording and coding.

Background

Australian healthcare organisations receive Activity-Based Funding (ABF) which provides reimbursement of costs relating to the type of patient care delivered and the resources required for the patient treatment. Accurate healthcare data are essential to ensure accuracy of ABF and appropriate reimbursement of costs incurred by hospitals that manage obese patients. Managing obese patients results in operational funding requirements such as increased staffing and purchasing of equipment such as hoists, bariatric wheelchairs and bariatric beds, and hospitals must ensure that these clinical requirements are documented accurately in order to be reimbursed of these costs by way of ABF.

Methods

This study identifies the financial implications of inaccurate obesity data within the Western Australian Country Health Service (WACHS) and examines factors that may affect obesity data recording accuracy. The study involves 85 cases of identified obesity data recording inaccuracy that were adjusted by entering corrected obesity codes, which then adjusted Diagnosis-related Groups, National Weighted Activity Units and Activity-Based Funding results.

Results

The study demonstrated estimated annual lost funding opportunities of $2.23 million due to obesity coding inaccuracy. An annual average of 616 cases of obesity data inaccuracy was calculated with an average lost funding opportunity of $3625 per case.

Conclusion

Improvements are required in the clinical recording and coding of patient obesity, such as mandatory recording of patient weight and height data and automated BMI calculations within electronic patient records. Enhanced obesity recording and coding accuracy will result in increased funding opportunities and reduced cost burdens that hospitals currently experience when required to fund obesity-related clinical and safety requirements within operational budgets.

Risks to Healthcare Organizations and Staff Who Manage Obese (Bariatric) Patients and Use of Obesity Data to Mitigate Risks: A Literature Review

This literature review explores obesity risks to healthcare staff and organizations that manage and caring for obese (bariatric) patients. These risks are anticipated to increase due to Australian population obesity rate projections increasing from 31% in 2018 to 42% by the year 2035, which will result in increased hospital admissions of patients with obesity. Literature searches were conducted through the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Scopus, and Web of Science. Thirty studies met the inclusion criteria and were tabulated and critiqued using appropriate appraisal techniques. High risk of injury to healthcare staff was identified relating to bariatric patient handling tasks. High liability and financial risks of organizations were also identified relating to workers' compensation and common law claims by injured staff and medical negligence claims by patients with obesity. Availability of obesity data was identified within clinically captured information, which could be utilized to inform obesity risk management programs. Future research should focus on improving the use and quality of obesity data to better understand obesity risks to healthcare organizations and staff, including accurate identification of obese patient admissions, enhanced ability to measure bariatric patient handling hazards and related staff injuries and improved assessment of bariatric intervention effectiveness.

Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit

BACKGROUND

Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort.

METHODS

We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery.

RESULTS

Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3.

CONCLUSIONS

The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.

Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection

BACKGROUND

Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI.

METHODS

Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI.

RESULTS

Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64).

CONCLUSIONS

Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.

Obesity Prevalence and Associated Outcomes in Cardiothoracic Patients: A Single-Centre Experience

The objective of this study was to investigate the prevalence of obesity and its relationship with adverse outcomes in ICU cardiothoracic patients. We performed a retrospective analysis of cardiothoracic patients admitted to The Royal Melbourne Hospital ICU between 2002 and 2014. Eight thousand and sixty-four patients who underwent coronary artery bypass, valve replacement/repair, or both, were divided into six categories of body mass index using World Health Organization criteria. Prevalence of obesity over time in the ICU was measured and compared to prevalence of obesity in the adult Australian population. The association between obesity and adverse postoperative outcomes was then analysed. Obesity is currently 1.2 times more prevalent in the Royal Melbourne Hospital ICU cardiothoracic patients than in the adult Australian population, with 33.5% of patients having a body mass index ≥30 kg/m2. Over time, this was relatively constant, but an increasing proportion were morbidly obese. Obesity, but not morbid obesity, was associated with reduced 30-day mortality (odds ratio [OR] 0.41). Both obese and morbidly obese patients had reduced odds of return to theatre for bleeding (OR 0.49 and OR 0.19, respectively), but increased odds of new-onset renal failure (OR 1.62 and OR 3.17, respectively). Morbidly obese patients had double the odds of an ICU stay longer than 14 days (OR 2.05). In summary, a growing proportion of our obese ICU patients are morbidly obese, with a dramatically increased length of ICU stay. This has major implications for resource allocation in the ICU, and may inform modelling of future bed utilisation. Obesity, but not morbid obesity, conferred a mortality benefit.

Cefoxitin Plasma and Subcutaneous Adipose Tissue Concentration in Patients Undergoing Sleeve Gastrectomy

PURPOSE

Antibiotic dosing in obese surgical patients has not been adequately evaluated. The objective of this study was to identify whether currently prescribed doses of cefoxitin achieve adequate and sustained plasma and tissue concentrations in obese patients undergoing sleeve gastrectomy.

METHODS

A prospective evaluation of plasma and tissue cefoxitin concentrations in patients undergoing sleeve gastrectomy was performed. On the day of the surgical procedure, venous blood samples (5 mL) were collected just before cefoxitin administration and then at 5, 30, 60, 120, and 240 minutes after dose administration. In addition, subcutaneous adipose tissue was collected from the surgical site at the time of surgical incision and at closure. Cefoxitin concentrations in the collected samples were quantified by using an HPLC-ultraviolet method. A standard noncompartmental analysis was performed for each individual cefoxitin plasma concentration-time profile. In addition, the ratio of tissue to plasma concentration was calculated for all patients.

FINDINGS

Plasma and tissue pharmacokinetics of cefoxitin were evaluated in 6 patients undergoing sleeve gastrectomy. The mean age and BMI were 48.7 (6.2) years and 42.8 (7.1) kg/m(2), respectively. At the time of surgical closure, subcutaneous adipose tissue concentrations of cefoxitin were subtherapeutic (<8 µg/mL) in all evaluated patients.

IMPLICATIONS

Current dosing strategies for cefoxitin in obese surgical patients may be inadequate, and there is an urgent need to define the appropriate dosage.

Vitamin D status following bariatric surgery: implications and recommendations

Individuals with extreme obesity who qualify for bariatric surgery are frequently vitamin D deficient before and after surgery. The anatomical changes that occur during some bariatric procedures may lead to decreased absorption of vitamin D, although vitamin D absorption and metabolism has not been quantified or compared across surgeries, and multiple other factors could influence vitamin D status in these individuals. Vitamin D treatment and dosing studies show that there is variability in how individuals respond to supplementation regimens regardless of the bariatric procedure. It is unknown if improving vitamin D status before and/or after bariatric surgery can affect health-related outcomes in this population beyond the traditional roles of vitamin D. Vitamin D has been purported to positively influence a variety of obesity-related comorbidities. Furthermore, in light of the potential role of vitamin D in immunity and inflammation, it seems important to consider the ramifications of vitamin D deficiency in the postbariatric individual in the critical care setting and particularly in the context of aging. Additional research is needed to develop evidence-based guidelines for optimal treatment of vitamin D deficiency in individuals before and after bariatric surgery and to determine the impact of vitamin D repletion on non-bone health-related outcomes in these individuals.

Obesity does not increase morbidity of laparoscopic cholecystectomy

BACKGROUND

Obesity has historically been a positive predictor of surgical morbidity, especially in the morbidly obese. The purpose of our study was to compare outcomes of obese patients undergoing laparoscopic cholecystectomy (LC).

METHODS

We reviewed 1382 consecutive patients retrospectively who underwent LC for various pathologies from January 2008 to August 2011. Patients were stratified based on the World Health Organization definitions of obesity: nonobese (body mass index [BMI] < 30 kg/m(2)), obesity class I (BMI 30-34.9 kg/m(2)), obesity class II (BMI 35-39.9 kg/m(2)), and obesity class III (BMI ≥ 40 kg/m(2)). The primary end points were conversion rates and surgical morbidity. The secondary end point was length of stay.

RESULTS

There were significantly more females in the obesity II and III groups (P = 0.0002). American Society of Anesthesiologists scores were significantly higher in the obesity I, II, and III groups compared with the nonobese (P < 0.05; P < 0.01; and P < 0.0001, respectively). Independent predictors of conversion on multivariate analysis (MVA) included age (P = 0.01), acute cholecystitis (P = 0.03), operative time (P < 0.0001), blood loss (P < 0.0001), and fellowship-trained surgeons (P < 0.0001). Independent predictors of intraoperative complications on MVA included age (P = 0.009), white patients (P = 0.009), previous surgery (P = 0.001), operative time (P < 0.0001), and blood loss (P = 0.01). Independent predictors of postoperative complications on MVA included American Society of Anesthesiologists score (P < 0.0001), acute cholecystitis (P < 0.0001), and a postoperative complication (P < 0.0001). BMI was not a predictor of conversions or surgical morbidity. Length of stay was not significantly different between the four groups.

CONCLUSIONS

This study demonstrates that overall conversion rates and surgical morbidity are relatively low following LC, even in obese and morbidly obese patients.

The effect of obesity on outcomes in mechanically ventilated patients in a medical intensive care unit

BACKGROUND

The effect of obesity on outcomes in critically ill patients requiring invasive mechanical ventilation in a medical intensive care unit (ICU) is uncertain.

OBJECTIVES

This study was intended to further explore the relationship between outcomes and obesity in patients admitted to a medical ICU who required invasive mechanical ventilation.

METHODS

All adult patients admitted to the medical ICU at Washington Hospital Center requiring intubation and invasive mechanical ventilation for at least 24 h between January 1 and December 31, 2009, were retrospectively studied. Patients were categorized as nonobese (BMI <30) and obese (BMI ≥30). The primary outcome measure was 30-day mortality following intubation. Secondary outcomes included ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation.

RESULTS

There were 504 eligible patients: 306 nonobese and 198 (39%) obese. Obese patients had significantly higher rates of diabetes (43 vs. 30%, p = 0.004), hyperlipidemia (32 vs. 24%, p = 0.04), asthma (16 vs. 8%, p = 0.004) and obstructive sleep apnea requiring continuous positive airway pressure treatment (12 vs. 1%, p < 0.001). Nonobese patients had a significantly higher rate of HIV infection (10 vs. 5%, p = 0.05) and malignancy (21 vs. 13%, p = 0.03). There were no significant differences in mortality up to 30 days following intubation and secondary outcomes between obese and nonobese patients. Multivariate analysis using logistic regression showed no significant relationship between mortality rate at 30 days following intubation and obesity. Outcomes were similar for the black obese (n = 153) and nonobese (n = 228) patients and the obese (n = 85) and very obese (n = 113) patients.

CONCLUSIONS

Obesity did not influence outcomes in critically ill patients requiring invasive mechanical ventilation in a medical ICU. Black obese patients had similar outcomes to black nonobese patients, and very obese patients also had similar outcomes to obese patients.

Complex Interaction between Obesity and Trauma

Trauma and obesity are large-scale epidemics that can be associated with significant morbidity and mortality. In few studies, it has noted that there is the ‘obesity paradox’ (obesity has been found to be protective against mortality) due to certain causes, i.e. heart failure or cardiovascular disease. Subcutaneous fat can show great variability between individuals and increased subcutaneous fat may be protective against injuries by cushioning the internal abdominal organs against injurious forces in road traffic accidents. Many factors including the body fat distribution, body shape, and center of gravity may play an important role in the different injury patterns and severity of injury between men and women. A better understanding of how obesity influences trauma related injuries not only will help to improve the outcome but also foster the development of interventions to address the most salient and modifiable risk factors to reduce obesity related morbidity and mortality. In present article, we review the relevant literature with special considerations to understand the interactions of obesity and trauma with their impact on patient management and outcomes.

How to cite this article

Agrawal A. Complex Interaction between Obesity and Trauma. Panam J Trauma Crit Care Emerg Surg 2014;3(3):109-113.

A growing problem: implications of obesity on the provision of trauma care

The incidences of both trauma and obesity are rapidly on the rise. Whilst dedicated trauma centres exist, these may not be equipped to manage obese and super-obese patients' unique medical and surgical demands. This review assesses the impact of trauma on the obese patient and the specialist considerations required in their management throughout pre-hospital, acute and inpatient phases of trauma care. Specific recommendations for the necessary infrastructure and equipment are made to ensure optimal care of the obese trauma patient. We also review evidence-based best practice in the assessment, diagnosis and treatment of this patient group. Only by addressing the unique needs of obese trauma patients with specialist education, equipment and infrastructure can optimal patient outcomes be assured.

Bariatric surgery: severity, level of control, and time required for preoperative asthma control

BACKGROUND

There is an increased prevalence of asthmatic, obese patients undergoing bariatric surgery. The objective of our study is to evaluate the severity, level of control, respiratory medication use, and time required for prebariatric surgery asthma control.

METHODS

This is a prospective study in which 88 obese asthmatics were evaluated by a pulmonologist in two steps, prebariatric surgery. In the first step, patients were evaluated for severity, level of control, and respiratory medication in use, categorized as bronchodilators and corticosteroids. In the second step, the time required for asthma control between steps and appropriate respiratory medication was determined.

RESULTS

Thirty-eight obese patients (43.2%) had intermittent asthma, 22 had mildly persistent (25.0%), 24 moderately persistent (27.3%), and 4 severely persistent (4.5%). There were 43 patients with controlled asthma (48.9%), 31 partly controlled (35.2%), and 14 uncontrolled (15.9%). The study sample showed a significant increase in bronchodilators in the first step and corticosteroids in the second step (p ≤ 0.0001). Comparisons between steps showed significant differences with a reduction of bronchodilators and increase in corticosteroids in the second step (p ≤ 0.0001). The mean time (days) required for asthma control between steps was 28.98 ± 33.40 days, with significant differences between groups (p ≤ 0.001).

CONCLUSIONS

In prebariatric surgery, there was a higher proportion of intermittent asthma and uncontrolled asthma, with asthma severity influencing the achievement of asthma control and the time required for surgical release.

Disease-specific nutrition therapy: one size does not fit all

INTRODUCTION

The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states.

METHODS

A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients.

RESULTS

Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients.

CONCLUSION

There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.

Effects of CPAP on gastric pouch pressure after bariatric surgery

BACKGROUND

The purpose of this study was to determine if the routine use of postoperative continuous positive airway pressure (CPAP) in patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) is associated with an increase in transmural gastric pouch pressure, which may create the risk for anastomotic leak.

METHODS

Transmural gastric pressures (difference between gastric pouch and bladder pressures) were measured postoperatively [post-anesthesia recovery care unit (PACU) arrival (prior to initiation of CPAP), 5 min, 30 min, and PACU discharge] in 28 patients (19 patients used CPAP, 9 patients did not) following laparoscopic RYGB. Changes in pressure over time were assessed using a generalized estimating equation, taking into account the repeated measurements obtained for each subject. In all cases, two-tailed P values ≤0.05 were considered statistically significant.

RESULTS

Among patients that used CPAP, there were no changes in transmural pouch pressure from baseline at any point in time (P = 0.628). However, in patients that did not use CPAP, there was a trend towards increased transmural gastric/pouch pressure (P = 0.053), which could be attributed to a transient decrease in bladder pressure at the 5-min measurement interval.

CONCLUSIONS

Application of CPAP did not increase transmural gastric pouch pressure in our bariatric patients; therefore, its use in the post-RYGB patients does not pose a risk for pouch distension, which could lead to the disruption of anastomotic integrity.

Complicações e óbitos nas operações para tratar a obesidade mórbida

RACIONAL: A cirurgia bariátrica, apesar de complexa, apresenta baixa morbimortalidade; contudo, quando presente apresenta graves conseqüências. OBJETIVO: Avaliar a presença de complicações e óbitos nos pacientes portadores de obesidade mórbida submetidos a tratamento cirúrgico. MÉTODOS: Análise retrospectiva de 656 pacientes submetidos a procedimento cirúrgico bariátrico. Foram analisados: sexo, idade, peso pré-operatório, índice de massa corporal pré-operatório, procedimento realizado, tempo de internação, complicações pós-operatórias e mortalidade. RESULTADOS: A idade variou entre 16 a 68 anos (média de 36,6 anos). Do total, 80,7% eram do sexo feminino. O índice de massa corporal médio foi de 42,8 kg/m2 (35 e 68 kg/m2) O tempo médio de internação foi de 4,5 dias (1 a 125 dias). O bypass gástrico foi realizado em 370 pacientes (56,40%) e a operação de Capella em 236 casos (35,97%). A principal complicação encontrada foi fístula, em 17 pacientes (2,59%). Houve necessidade de reoperação em 17 pacientes (2,59%). Oito pacientes morreram (1,21%), três foram submetidos à operação de Capella, três à bypass, um à opração de Scopinaro e um à gastrectomia vertical. CONCLUSÃO: A principal complicação foi a fístula digestiva, que ocorreu em 2,59% e a mortalidade foi de 1,21%.

Pain management in critically ill obese patients

Achieving pain control in critically ill patients is a challenging problem for the health care team, which becomes more challenging in morbidly obese patients. Obese patients may experience drug malabsorption and distribution, which may lead to either subtherapeutic or toxic drug levels. To manage pain effectively for the critically ill obese patient, nurses must have an understanding of how obesity alters a patient's physiologic response to injury and illness. In addition, nurses must be knowledgeable about physiologic pain mechanisms, types and manifestations of pain, differing patterns of drug absorption and distribution, pharmacokinetic properties of analgesic medications, and pain management strategies. This article explores factors affecting pharmacokinetics in obese patients, trends in pain management, and treatment strategies for the obese patient.

The impact of obesity on critical care resource use and outcomes

Obese patients in the ICU present unique challenges to the health care team and specific challenges to nurses. This article reviews the science and art of resource use for obese patients in the ICU. Staff nurses and advanced practice nurses can make important contributions in evaluating optimal resource use and improving outcomes in this population of vulnerable patients.

Obesity-related risks and prevention strategies for critically ill adults

In America today, more than one third of adults are obese. Increasingly, obese patients are admitted to critical care units. Critical care nurses must have additional knowledge and skills to identify health risks to obese patients and implement interventions to prevent untoward problems. Critical care nurses are also at risk when taking care of obese patients. The purpose of this article is to identify risks to both patients and nurses and to provide recommendations to address those risks.

Successful management of a morbidly obese patient for electroconvulsive therapy with elective tracheostomy

Electroconvulsive therapy (ECT) is a treatment for affective catatonia and requires multiple general anesthetics. Morbid obesity is an increasingly prevalent condition that may complicate the standard anesthetic management of a patient undergoing ECT. We report the successful airway management of a morbidly obese ECT patient via elective tracheostomy.

Management of acute postoperative hemorrhage in the bariatric patient

Bariatric surgery is one of the treatment options for achieving and preserving weight loss and managing medical complications related to obesity. After bariatric surgery, early or late adverse events, such as intraluminal or extraluminal gastrointestinal hemorrhage, can occur. Early gastrointestinal bleeding is more often a complication associated with Roux-en-Y gastric bypass surgery than other bariatric procedures and usually arises from the gastrojejunal anastomosis. Early postoperative bleeding may be potentially life threatening, although death after postbariatric surgery as a consequence of acute bleeding is uncommon. Although early postoperative intraluminal bleeding can usually be managed conservatively, endoscopic therapy may be required.

Vascular procedures in the critically ill obese patient

The increasing societal prevalence of obesity is consequential to the increasing number of critically ill obese patients. Vascular procedures are an essential aspect of care in these patients. This article reviews the general, anatomic, and physiologic considerations pertaining to vascular procedures in critically ill obese patients. In addition, the use of ultrasonography for these procedures is discussed.

Addressing the need for research on bariatric patient

During the past 3 decades numerous studies have documented the high prevalence of patient handling-related musculoskeletal injuries among healthcare workers and evaluated ergonomic interventions using mechanized equipment for lifting and moving patients. A great deal of research-based evidence now demonstrates the effectiveness of ergonomic interventions to reduce injury risk among healthcare workers who handle patients of average weights and sizes. In contrast, there is a lack of evidence-based research that evaluates ergonomic interventions for handling bariatric patients, whose extreme weights and sizes necessitate specialized handling equipment. The obesity epidemic, along with special medical and therapeutic concerns regarding bariatric patients, exacerbates healthcare workers' patient handling demands. The National Institute for Occupational Safety and Health is conducting a new study to evaluate bariatric patient handling hazards and interventions and identify evidence-based best practices for handling this population.

Management of aminoglycosides in the intensive care unit

Antibacterial resistance is increasing throughout the world, while the development of new agents is slowly progressing. In addition, the increasing prevalence of fluoroquinolone resistance may force many practitioners to choose an aminoglycoside agent in gram-negative regimens. Aminoglycosides are bactericidal agents with potent activity against gram-negative infections and activity against gram-positive infections when added to a cell wall active antimicrobial-based regimen. These agents may be dosed multiple times a day or consolidated as high-dose, extended-interval dosing to maximize pharmacokinetic and pharmacodynamic properties to achieve possible improved efficacy with reduced toxicity. Clinical application includes the treatment of bacteremia, endocarditis, health-care and nosocomial pneumonias, intra-abdominal infections, and others. Nephrotoxicity and ototoxicity are potential risks of aminoglycoside therapy that may be minimized with serum monitoring and short courses of therapy.

Emergency department management of the airway in obese adults

Airway management in obese adults can be challenging, and much of the literature on this subject focuses on elective surgical cases, rather than acutely ill patients. In this article, we review the emergency department evaluation of the airway in obesity, discussing anatomy, physiology, and pharmacology. In addition, we describe techniques and devices used to improve intubating conditions in the obese patient. After our review of the relevant literature, we conclude that research in this particular area of acute care remains in its infancy.

Contraceptive use among women with a history of bariatric surgery: a systematic review

BACKGROUND

Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years.

STUDY DESIGN

We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery.

RESULTS

From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon.

CONCLUSIONS

Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified.

Intensive care unit stay not required for patients with obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Many programs admit morbidly obese patients with obstructive sleep apnea (OSA) to the intensive care unit after laparoscopic gastric bypass (LGB), fearing pulmonary complications. Our practice has been to admit these patients to the surgical floor. Our objective was to compare the perioperative course and outcomes in morbidly obese patients with OSA to those of patients without OSA undergoing LGB in a physician-led health system with a 325-bed community teaching hospital serving 19 counties.

METHODS

We retrospectively reviewed the medical records of 650 patients who had undergone LGB from 2001 to 2008 and divided them into 2 groups: patients with OSA as confirmed by polysomnography (OSA group) and those without OSA (non-OSA group). The patients who reported a diagnosis of OSA without documentation confirming the diagnosis were excluded. The statistical analysis included t tests and chi-square tests.

RESULTS

A total of 217 patients met the inclusion criteria for the OSA cohort and 368 for the non-OSA cohort. Of the 650 patients, 65 reported a history of OSA without confirmation and were excluded from the present study, leaving 585 patients. The demographic data were similar between the 2 groups, and no difference was found between the OSA and non-OSA groups for the length of postanesthesia care unit stay (105.4 versus 106.3 minutes), length of hospital stay (2.2 days for both groups), and 30-day major complication rate (3.7% versus 5.2%). No deaths and no intensive care unit admissions for pulmonary complications occurred in either group.

CONCLUSION

The results of our study have shown that morbidly obese patients with OSA undergoing LGB have a perioperative course and postoperative pulmonary complication rate similar to that of patients without OSA. Thus, routine admission to the intensive care unit after LGB in patients with OSA is not indicated.