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Query: UMLS:C0028754 (obesity)
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Nutrition support in the critically ill patient is challenging but is even more difficult in a morbidly obese patient. This case report chronicles the care of a 6-foot-tall, 256-kg male (body mass index 76.5 kg/m(2)) who spent over a month in the intensive care unit for respiratory failure, sepsis, and acute renal failure. Parenteral nutrition was provided throughout his critical care course. One of the major difficulties encountered was determining his nutritional needs. A hypocaloric nutritional regimen was used, along with moderate protein provisions. Numerous electrolyte imbalances occurred, including hypercalcemia that did not resolve by eliminating calcium from the parenteral nutrition solution. Enteral nutrition was desired but was not used initially because of a need for vasopressors, a diagnosis of pancreatitis, difficulty in documenting feeding tube placement because of diagnostic limitations secondary to the patient's large size, and concern about managing stools. Eventually, oral intake and supplemental enteral feeding were initiated. Nutrition support team members worked closely with the interdisciplinary care team to develop strategies to manage the nutritional problems related to his obesity. A discussion of the various nutritional issues encountered in the care of this patient is provided. Reasonable nutritional status was achieved, but this case reflects some of the challenges encountered in caring for the nutritional needs of select patient populations in clinical practice and the need for increased research and guidelines in this area.
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PMID:Nutrition support in the morbidly obese, critically ill patient. 1621 17

Severe obesity is a chronic condition that is difficult to treat through diet and exercise alone. Gastrointestinal surgery for obesity (bariatric surgery) alters the digestive process by either restrictive surgical alterations or malabsorptive operations. Some 10-20% of patients who have weight-loss surgery require follow-up operations to correct complications. Hypoxemia after gastric bypass surgery for morbid obesity, a reported complication, can occur as early as 24 h post surgery. Two patients presented with severe hypoxia and were placed on veno-venous extracorporeal membrane oxygenation (ECMO). Patient No. 1 had an obstruction of the alimentary limb of the gastric bypass due to suture adhesions, and patient No. 2 had an incarcerated diaphragmatic hernia. While on ECMO, ventilation using a protective strategy (60% FiO2, pressure-controlled ventilation inspiratory pressure (PCV) IP 25-27, positive end-expiratory pressure (PEEP) 10-14, permissive hypercapnia) was employed. An inflow cannula to the level of the right atrium served as arterial outflow from the circuit to the patient, while the femoral vein served as venous inflow to the ECMO circuit. Although ECMO in adult respiratory failure is often used as the last resort due to serious associated adverse events, we report two patients with life-threatening complications from gastric bypass who were rescued, resuscitated to day 7, and uneventfully discharged from the hospital to home.
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PMID:Respiratory failure of two sp gastric bypass patients and subsequent rescue with extracorporeal membrane oxygenation. 1648 3

Prader-Willi Syndrome (PWS) is a complex neurogenetic disorder with considerable clinical variability, and is considered to be mainly the result of a hypothalamic defect. PWS is characterized by hyperphagia, obesity, mental retardation and hypogonadism from a young age. Hyperphagia is one of the most serious problems, which is organic in origin, inducing morbid obesity and leading to respiratory failure. Most studies attempting to control obesity in children with PWS by dietary management reported limited success due to difficulty in controlling foraging and food stealing. Here we report 16- and 20-year-old female patients with PWS who showed marked weight loss and improvement of respiratory failure by behavior modification and improvement of the environment.
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PMID:[Marked weight loss in two female patients with prader-willi syndrome by behavioral modification and improvement of the environment]. 1654 41

Bariatric surgery leads to sustainable long-term weight loss and may be curative for such obesity-related comorbidities as diabetes and obstructive sleep apnea in severely obese patients. The Roux-en-Y gastric bypass has become the most common procedure for patients undergoing bariatric surgery. The procedure carries a mortality risk of up to 1 percent and a serious complication risk of up to 10 percent. Indications include body mass index of 40 kg per m2 or greater, or 35 kg per m2 or greater with serious obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, coronary artery disease, debilitating arthritis). Pulmonary emboli, anastomotic leaks, and respiratory failure account for 80 percent of all deaths 30 days after bariatric surgery; therefore, appropriate prophylaxis for venous thrombo-embolism (including, in most cases, low-molecular-weight heparin) and awareness of the symptoms of common complications are important. Some of the common short-term complications of bariatric surgery are wound infection, stomal stenosis, marginal ulceration, and constipation. Symptomatic cholelithiasis, dumping syndrome, persistent vomiting, and nutritional deficiencies may present as long-term complications.
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PMID:Caring for patients after bariatric surgery. 2054 Apr 76

The constellation of neonatal hypotonia, developmental delay, hypogonadism and obesity caused by hyperphagia was first reported in 1956 and subsequently termed Prader-Willi syndrome (PWS). Genetic analysis has demonstrated abnormalities of chromosome 15. Anesthesia concerns of PWS include morbid obesity, the potential for difficulties with airway management, risk for perioperative respiratory failure, abnormalities in the central control of ventilation and temperature, rare reports of primary myocardial involvement, aggressive and at times violent behavior and glucose intolerance. For the first time, we report the use of regional anesthesia in four patients with PWS. A lumbar plexus catheter was used to provide postoperative analgesia in one patient while regional anesthesia (fasica iliaca block, spinal anesthesia, and lateral vertical infraclavicular block) was used to provide primary intraoperative anesthesia in three other patients while avoiding the need for general anesthesia. Previous reports of the anesthesia care of patients with PWS are reviewed and the potential perioperative implications of the sequelae of PWS are discussed.
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PMID:Anesthesia and Prader-Willi syndrome: preliminary experience with regional anesthesia. 1687 13

Respiratory failure as a result of overload and/or reduced capacity of the respiratory muscles is the most common cause of unsuccessful weaning and the need for long term mechanical ventilation. Chronic obstructive pulmonary disease (COPD) is the most common underlying cause leading into long term mechanical ventilation. The most important clinical parameter for fatigue of the respiratory muscles is the rapid shallow breathing index. Other essential factors which impact weaning failure, are the underlying diseases (e. g. neuromuscular disease or heart failure), micro- and macro aspiration, malnutrition, anemia and obesity. A protocol based strategy to discontinue mechanical ventilation and the use of weaning predictors are helpful. Nonetheless the experienced physician is irreplacable in the weaning process. Reconditioning of the respiratory muscles is the main focus during weaning after long term mechanical ventilation and all therapeutic measures should be targeted to unload the fatiguing respiratory muscles. With the widely used assisted ventilation modes, the inspiratory work of breathing is still significantly increased. Only controlled mechanical ventilation (pressure- or volume controlled), which may also be applied to unsedated patients when individually adapted, offers the best possible relief and recovery of the respiratory muscles. Additional strategies, such as the balancing of anemia, reduction of the respiratory drive with i. e. morphine derivates, oxygen therapy during spontaneous-breathing trials and supine position for patients with obesity contribute to the recovery. Particularly patients with chronic lung diseases with hypercapnia benefit from the use of non invasive ventilation (NIV) after extubation to prevent postextubation failure and even after tracheostomy. However, NIV should only be applied under close monitoring and in cooperative patients, always considering the limits of the method. Dying under mechanical ventilation in the end stage illness is still a challenge for all involved persons. In the end stage of their disease for some patients it is possible to discontinue mechanical ventilation so they can spend the last period of their lives on a normal ward or even at home.
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PMID:[Difficult weaning]. 1704 78

Prader-Willi syndrome (PWS) is characterized by obesity, mild mental retardation or learning disability, and behavior problems, especially in association with food and eating. A 19 year-old man, 150 cm, 140 kg (body mass index [BMI], 62.2 kg.m(-2)), whose condition had been diagnosed as PWS, received 41-day mechanical ventilation because of respiratory failure, chiefly due to morbid obesity. Because the patient frequently developed bronchoconstriction, metered-dose inhalers of a corticosteroid (beclomethasone dipropionate) and a beta2 agonist (salbutamol) were needed. To achieve adequate sedation, which was also crucial to control the bronchoconstriction, the concurrent use of midazolam, fentanyl, ketamine, and propofol was required. Pressure-control ventilation was useful to avoid high airway pressure due to low respiratory system compliance associated with the morbid obesity. Because it appeared that the basic problem leading to respiratory failure in this patient was morbid obesity, body weight reduction was considered to be mandatory. Thus, caloric intake was limited to 1000 kcal.day(-1), resulting in body weight reduction by 50 kg during the patient's stay in the intensive care unit (ICU). The patient was successfully extubated on ICU day 35.
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PMID:Respiratory failure due to morbid obesity in a patient with Prader-Willi syndrome: an experience of long-term mechanical ventilation. 1707 95

We report a patient with respiratory failure due to expiratory central airway collapse successfully treated with airway stents. A 74-year-old male with obesity and obstructive sleep apnea had recurrent episodes of acute respiratory failure. Noninvasive positive-pressure ventilation failed because of patient intolerance and lack of improvement, and soon after he stopped using the noninvasive ventilator he developed severe respiratory failure that required a tracheostomy. He was transferred to our institution one month later. Fiberoptic bronchoscopy revealed diffuse expiratory central airway collapse of both main bronchi and the lower two thirds of the trachea, caused by bulging of the posterior airway membrane. During rigid bronchoscopy we inserted studded silicone stents in the right and left mainstem bronchi and in the distal trachea. The patient was weaned from mechanical ventilation 72 hours later and discharged to a long-term care facility. Expiratory central airway collapse should be considered in the differential diagnosis of patients with respiratory failure, especially when weaning from mechanical ventilation is difficult.
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PMID:Respiratory failure due to expiratory central airway collapse. 1752 65

Knowledge of patients' opinions and beliefs about their illness is fundamental in interdisciplinary health care interventions. The IPQ and its revised version (IPQ-R) are questionnaires designed to assess components of the mental representation of illness described in Leventhal's self-regulation model. To validate the IPQ-R in the Italian population, verifying its psychometric properties and focusing on Part II of the instrument (opinions about disease), we enrolled 277 inpatients (216 males and 61 females) affected by myocardial infarction (n=70), coronary artery by-pass graft surgery (n=52), chronic heart failure (n=47), valve replacement (n=20), obstructive sleep apnoea syndrome associated to obesity (n=53) and respiratory failure (n=35). All patients completed the Italian version of the IPQ-R obtained by means of 3 translations and a back version. IPQ-R scores were compared to patients' scores on the SF-36 and AD schedule (on anxiety and depression). Structural validity and reliability (both internal and test-retest) of the Italian IPQ-R were assessed. The validity of Part II of the IPQ-R was confirmed. As in the original version, 7 factors were extracted. ANOVA revealed statistically significant differences between the different diseases. Correlations between IPQ-R and, respectively, the SF-36 and AD schedule were statistically significant and coherent with the constructs analyzed. Finally statistically significant correlations emerged between the IPQ-R factors. The test-retest reliability and internal consistency of the questionnaire were confirmed. The psychometric properties of the Italian version of the IPQ-R were demonstrated to be robust. Hence, the Italian version of the IPQ-R, which resulted homogeneous with the original version, could be useful in assessing the cognitive factors involved in patients' adjustment to various chronic illnesses.
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PMID:[Contribution to the Italian validation of the IPQ-R]. 1765 Jul 45

The authors analyzed the medical records of 1414 patients aged 60 +/- 14 years, who were examined in a specialized cardiological clinic within a one-year period. Among the patients, 41.2% complained of dyspnea; the number of women with dyspnea prevailed over the number of men. Dyspnea was caused by chronic heart failure in 42.2% of patients, by transient myocardial ischemia in 12.3% of patients, and by paroxysmal tachyarrhythmia in 6.3% of patients. In 45.6% of the patients, mostly in women, significant non-cardial factors were revealed: obstructive or restrictive respiratory failure (20.6%), obesity (14.7%), thyroid gland dysfunction (3.9%), pulmonary arterial thromboembolism, anemia etc. A combination of two or more etiological factors took place in 22.6% of cases. The reason for respiratory discomfort remained unclear in 21.3% of the patients, mostly women. Symptom-limited load test with gas analysis (ergospirometry) was performed in 70 patients with dyspnea of unclear origin. According to its results, in 75% of elderly patients with essential hypertension and postinfarction cardiosclerosis, who did not have significant systolic dysfunction, restrictive diastolic dysfunction, valvular disorder, or atrial fibrillation, dyspnea was caused by hyperventilation, obesity, and respiratory pathology.
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PMID:[Chronic dyspnea in cardiological patients: prevalence and etiology]. 1768 90


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