Der adipöse Patient auf der Intensivstation

Kernaussagen

• Die Prävalenz der Adipositas nimmt mit zunehmendem Alter zu. In den letzten Jahren stieg sie aber insbesondere bei den jüngeren Altersgruppen bis 35 Jahre an.

• Durch die Adipositas kommt es zu einer Abnahme der Lungenvolumina und zu einer deutlichen Steigerung der Atemarbeit und des Sauerstoffverbrauchs.

• Adipöse Intensivpatienten sind primär als Patienten mit schwierigem Atemweg ansehen.

• Bei stark adipösen Patienten können Arzneimittelverteilung sowie der Arzneimittelabbau und die Ausscheidung verändert sein.

• Auch bei adipösen Intensivpatienten sollte man möglichst früh und möglichst enteral mit der Ernährung beginnen.

• Selbst bei extremer Adipositas ist die Mortalität im Vergleich zu normalgewichtigen Intensivpatienten nicht erhöht.

• Literatur

• 1 WHO. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894: 1-253
• 2 Pai MP, Paloucek FP. The origin of the “ideal” body weight equations. Ann Pharmacother 2000; 34: 1066-1069
• 3 Lemmens HJ, Brodsky JB, Bernstein DP. Estimating ideal body weight – a new formula. Obes Surg 2005; 15: 1082-1083
• 4 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301-1308
• 5 Hume R. Prediction of lean body mass from height and weight. J Clin Pathol 1966; 19: 389-391
• 6 Statistisches Bundesamt. Mikrozensus – Fragen zur Gesundheit – Körpermaße der Bevölkerung. 2011
• 7 Robert-Koch-Institut. Studie zur Gesundheit Erwachsener in Deutschland. Im Internet: http://www.degs-studie.de/deutsch/ergebnisse/degs1/degs1-basispublikation.html , Stand 10.12.2013
• 8 Gosswald A, Lange M, Kamtsiuris P et al. DEGS: German Health Interview and Examination Survey for Adults. A nationwide cross-sectional and longitudinal study within the framework of health monitoring conducted by the Robert Koch Institute. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55: 775-780
• 9 Cunningham SA, Kramer MR et al. Incidence of childhood obesity in the United States. N Engl J Med 2014; 370: 403-411
• 10 Goodman CAA. What is known about the effectiveness of economic instruments to reduce consumption of foods high in saturated fats and other energy-dense foods for preventing and treating obesity?. Health Evidence Network report. Copenhagen: WHO Regional Office for Europe. Im Internet: http://www.euro.who.int/document/e88909.pdf , Stand 10.12.2013
• 11 Kurth BM. HBSC–Trend Supplement. Gesundheitswesen 2012; 74: S3
• 12 van Duijvenbode DC, Hoozemans MJ, van Poppel MN et al. The relationship between overweight and obesity, and sick leave: a systematic review. Int J Obes (Lond) 2009; 33: 807-816
• 13 Berrington de Gonzalez A, Hartge P, Cerhan JR et al. Body–mass index and mortality among 1.46 million white adults. N Engl J Med 2010; 363: 2211-2219
• 14 Whitlock G, Lewington S, Sherliker P et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373: 1083-1096
• 15 Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). S3-Leitlinie: Chirurgie der Adipositas. Im Internet: http://www.dgav.de/fileadmin/media/texte_pdf/caadip/leitlinie-chirurgie-der-adipositas_2010-06.pdf , Stand: 10.12.2013
• 16 Fischer L, Hildebrandt C, Bruckner T et al. Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg 2012; 22: 721-731
• 17 Kumar G, Majumdar T, Jacobs ER et al. Outcomes of morbidly obese patients receiving invasive mechanical ventilation: a nationwide analysis. Chest 2013; 144: 48-54
• 18 Singanayagam A, Chalmers JD. Obesity is associated with improved survival in community-acquired pneumonia. Eur Respir J 2013; 42: 180-187
• 19 Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol 2010; 108: 206-211
• 20 Powers MA. The obesity hypoventilation syndrome. Respir Care 2008; 53: 1723-1730
• 21 Pedoto A. Lung physiology and obesity: anesthetic implications for thoracic procedures. Anesthesiol Res Pract 2012; 2012: 154-208
• 22 Murphy C, Wong DT. Airway management and oxygenation in obese patients. Can J Anaesth 2013; 60: 929-945
• 23 Cook TM, Woodall N, Harper J et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011; 106: 632-642
• 24 Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anesthesia. Br J Anaesth 2011; 106: 617-631
• 25 Frat JP, Gissot V, Ragot S et al. Impact of obesity in mechanically ventilated patients: a prospective study. Intensive Care Med 2008; 34: 1991-1998
• 26 Aceto P, Perilli V, Modesti C et al. Airway management in obese patients. Surg Obes Relat Dis 2013; 9: 809-815
• 27 Hibbert K, Rice M, Malhotra A. Obesity and ARDS. Chest 2012; 142: 785-790
• 28 Keenan SP, Sinuff T, Burns KE et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ 2011; 183: E195-214
• 29 De Jong A, Molinari N, Sebbane M et al. Feasibility and effectiveness of prone position in morbidly obese patients with ARDS: a case–control clinical study. Chest 2013; 143: 1554-1561
• 30 Weig T, Schubert MI, Gruener N et al. Abdominal obesity and prolonged prone positioning increase risk of developing sclerosing cholangitis in critically ill patients with influenza A-associated ARDS. Eur J Med Res 2012; 17: 30
• 31 Petrucci N, De Feo C. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; 2 CD003844
• 32 Fanelli V, Ranieri VM. When pressure does not mean volume? Body mass index may account for the dissociation. Crit Care 2011; 15: 143
• 33 O'Brien Jr JM, Welsh CH, Fish RH et al. Excess body weight is not independently associated with outcome in mechanically ventilated patients with acute lung injury. Ann Intern Med 2004; 140: 338-345
• 34 Cheymol G. Effects of obesity on pharmacokinetics implications for drug therapy. Clin Pharmacokinet 2000; 39: 215-231
• 35 Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet 2010; 49: 71-87
• 36 Hirsh J, Guyatt G, Albers GW et al. Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 71S-109S
• 37 Wurtz R, Itokazu G, Rodvold K. Antimicrobial dosing in obese patients. Clin Infect Dis 1997; 25: 112-118
• 38 Erstad BL. Dosing of medications in morbidly obese patients in the intensive care unit setting. Intensive Care Med 2004; 30: 18-32
• 39 Servin F, Farinotti R, Haberer JP et al. Propofol infusion for maintenance of anesthesia in morbidly obese patients receiving nitrous oxide. A clinical and pharmacokinetic study. Anesthesiology 1993; 78: 657-665
• 40 Shibutani K, Inchiosa Jr MA, Sawada K et al. Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients: derivation of dosing weight (“pharmacokinetic mass”). Anesthesiology 2004; 101: 603-613
• 41 Slepchenko G, Simon N, Goubaux B et al. Performance of target-controlled sufentanil infusion in obese patients. Anesthesiology 2003; 98: 65-73
• 42 Leykin Y, Pellis T, Lucca M et al. The pharmacodynamic effects of rocuronium when dosed according to real body weight or ideal body weight in morbidly obese patients. Anesth Analg 2004; 99: 1086-1089
• 43 Schwartz AE, Matteo RS, Ornstein E et al. Pharmacokinetics and pharmacodynamics of vecuronium in the obese surgical patient. Anesth Analg 1992; 74: 515-518
• 44 Leykin Y, Pellis T, Lucca M et al. The effects of cisatracurium on morbidly obese women. Anesth Analg 2004; 99: 1090-1094
• 45 Schumann R. Anesthesia for bariatric surgery. Best Pract Res Clin Anaesthesiol 2011; 25: 83-93
• 46 Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102: 438-442
• 47 Van Lancker P, Dillemans B, Bogaert T et al. Ideal versus corrected body weight for dosage of sugammadex in morbidly obese patients. Anesthesia 2011; 66: 721-725
• 48 Rondina MT, Wheeler M, Rodgers GM et al. Weight–based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically–Ill patients. Thromb Res 2010; 125: 220-223
• 49 Diepstraten J, Hackeng CM, van Kralingen S et al. Anti-Xa Levels 4 h After Subcutaneous Administration of 5,700 IU Nadroparin Strongly Correlate with Lean Body Weight in Morbidly Obese Patients. Obes Surg 2012; 22: 791-796
• 50 Honiden S, McArdle JR. Obesity in the intensive care unit. Clin Chest Med 2009; 30: 581-599
• 51 Dickerson RN, Boschert KJ, Kudsk KA et al. Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition 2002; 18: 241-246
• 52 Miller JP, Choban PS. Feeding the critically ill obese patient: the role of hypocaloric nutrition support. Respir Care Clin N Am 2006; 12: 593-601
• 53 Joffe A, Wood K. Obesity in critical care. Curr Opin Anaesthesiol 2007; 20: 113-118
• 54 Elamin EM, Camporesi E. Evidence–based nutritional support in the intensive care unit. Int Anesthesiol Clin 2009; 47: 121-138
• 55 Elamin EM. Nutritional care of the obese intensive care unit patient. Curr Opin Crit Care 2005; 11: 300-303
• 56 Ridley EJ, Davies AR. Practicalities of nutrition support in the intensive care unit: the usefulness of gastric residual volume and prokinetic agents with enteral nutrition. Nutrition 2011; 27: 509-512
• 57 Casaer MP, Mesotten D, Hermans G et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365: 506-517
• 58 Doig GS, Simpson F, Sweetman EA et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013; 309: 2130-2138
• 59 Choban P, Dickerson R, Malone A et al. A. s. p. e. N. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. J Parenter Enteral Nutr 2013; 37: 714-744
• 60 Frankenfield DC, Ashcraft CM, Galvan DA. Longitudinal prediction of metabolic rate in critically ill patients. J Parenter Enteral Nutr 2012; 36: 700-712
• 61 Rand CS, Macgregor AM. Morbidly obese patients’ perceptions of social discrimination before and after surgery for obesity. South Med J 1990; 83: 1390-1395
• 62 Hurst S, Blanco K, Boyle D et al. Bariatric implications of critical care nursing. Dimens Crit Care Nurs 2004; 23: 76-83
• 63 Korupolu R, Zanni JM, Fan E et al. Early mobilisation of intensive care unit patient: the challenges of morbid obesity and multiorgan failure. BMJ Case Rep 2010;
• 64 McGrath TM, Farabaugh EA, Pickett MJ et al. Obesity hinders ultrasound visualization of the subclavian vein: implications for central venous access. J Vasc Access 2012; 13: 246-250
• 65 Gregg SC, Murthi SB, Sisley AC et al. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Crit Care 2010; 25: 514-519
• 66 Zochios VA, Wilkinson J, Dasgupta K. The role of ultrasound as an adjunct to arterial catheterization in critically ill surgical and intensive care unit patients. J Vasc Access 2013; ; PMID:24101422
• 67 Maxwell MH, Waks AU, Schroth PC et al. Error in blood–pressure measurement due to incorrect cuff size in obese patients. Lancet 1982; 2: 33-36
• 68 Westerly BD, Dabbagh O. Morbidity and mortality characteristics of morbidly obese patients admitted to hospital and intensive care units. J Crit Care 2011; 26: 180-185
• 69 McCague A, Aljanabi H, Wong DT. Safety analysis of percutaneous dilational tracheostomies with bronchoscopy in the obese patient. Laryngoscope 2012; 122: 1031-1034
• 70 Romero CM, Cornejo RA, Ruiz MH et al. Fiberoptic bronchoscopy-assisted percutaneous tracheostomy is safe in obese critically ill patients: a prospective and comparative study. J Crit Care 2009; 24: 494-500
• 71 Guinot PG, Zogheib E, Petiot S et al. Ultrasound-guided percutaneous tracheostomy in critically ill obese patients. Crit Care 2012; 16: R40
• 72 Kiraly L, Hurt RT, Van Way 3rd CW. The outcomes of obese patients in critical care. J Parenter Enteral Nutr 2011; 35: 29S-35S
• 73 Martino JL, Stapleton RD, Wang M et al. Extreme obesity and outcomes in critically ill patients. Chest 2011; 140: 1198-1206
• 74 Wacharasint P, Boyd JH, Russell JA et al. One size does not fit all in severe infection: obesity alters outcome, susceptibility, treatment, and inflammatory response. Crit Care 2013; 17: R122