Traditional Resuscitative Practices Fail to Resolve Metabolic Acidosis in Morbidly Obese Patients After Severe Blunt Trauma

Winfield, Robert D.; Delano, Matthew J.; Lottenberg, Lawrence; Cendán, Juan; Moldawer, Lyle L.; Maier, Ronald V.; Cuschieri, Joseph

doi:10.1097/ta.0b013e3181caab6c

Cited by 31 publications

(29 citation statements)

References 43 publications

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“…While two recent studies raised the question of whether obese trauma patients may be under-resuscitated relative to normal weight patients, adjustment for measures of resuscitation (systolic blood pressure, crystalloid, or blood product volume) did not alter the association of adiposity with AKI in our study (44, 45). In addition, unlike studies of obese outpatients implicating visceral-predominant adiposity in metabolic disease risk, the obesity-associated AKI risk in our study was not clearly dependent on a specific adipose compartment (14, 15, 46).…”

Section: Discussioncontrasting

confidence: 76%

Computed Tomography–Defined Abdominal Adiposity Is Associated With Acute Kidney Injury in Critically Ill Trauma Patients*

Shashaty

Kalkan

Bellamy

et al. 2014

Critical Care Medicine

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Objective Higher body mass index (BMI) is associated with increased risk of acute kidney injury (AKI) after major trauma. Since BMI is non-specific, reflecting lean, fluid, and adipose mass, we evaluated the use of computed tomography (CT) to determine if abdominal adiposity underlies the BMI-AKI association. Design Prospective cohort study. Setting Level I Trauma Center of a university hospital. Patients Patients older than 13 years with an Injury Severity Score ≥16 admitted to the trauma intensive care unit were followed for development of AKI over five days. Those with isolated severe head injury or on chronic dialysis were excluded. Interventions None Measurements and Main Results Clinical, anthropometric, and demographic variables were collected prospectively. CT images at the level of the L4-5 intervertebral disc space were extracted from the medical record and used by two operators to quantitate visceral and subcutaneous adipose tissue (VAT and SAT, respectively) areas. AKI was defined by Acute Kidney Injury Network (AKIN) creatinine and dialysis criteria. Of 400 subjects, 327 (81.8%) had CT scans suitable for analysis: 264/285 (92.6%) blunt trauma subjects, 63/115 (54.8%) penetrating trauma subjects. VAT and SAT areas were highly correlated between operators (ICC>0.999, p<0.001 for each) and within operator (ICC>0.999, p<0.001 for each). In multivariable analysis, the standardized risk of AKI was 15.1% (95% CI 10.6%,19.6%), 18.1% (14%,22.2%), and 23.1% (18.3%,27.9%) at the 25th, 50th, and 75th percentiles of VAT area, respectively (p=0.001), with similar findings when using SAT area as the adiposity measure. Conclusions Quantitation of abdominal adiposity using CT scans obtained for clinical reasons is feasible and highly reliable in critically ill trauma patients. Abdominal adiposity is independently associated with AKI in this population, confirming that excess adipose tissue contributes to the BMI-AKI association. Further studies of the potential mechanisms linking adiposity with AKI are warranted.

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Section: Discussioncontrasting

confidence: 76%

Computed Tomography–Defined Abdominal Adiposity Is Associated With Acute Kidney Injury in Critically Ill Trauma Patients*

Shashaty

Kalkan

Bellamy

et al. 2014

Critical Care Medicine

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“…77,78 Interestingly, morbid obese trauma patient that were inadequately resuscitated during the first 48 hours remained longer in metabolic acidosis and developed multiple-organ failure at a rate higher than that of lean patients in similar conditions. 79 Similar findings were also reported in morbidly obese patients with severe burns. 73 Other investigations concentrated on examining the specific impact of abdominal obesity on organ failure.…”

Section: Obesity and Icu-associated Organ Failuresupporting

confidence: 76%

The obesity factor in critical illness

Gharib

Kaul

LoCurto

et al. 2015

Journal of Trauma and Acute Care Surgery

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T he prevalence of obesity has increased starkly during the last decades, and this trend includes every age, sex, race and socioeconomic group. 1,2 According to the most recent epidemiologic data, 1,2 approximately two thirds of the US population are either overweight or obese, of whom approximately 30% are obese and more than 5% are morbidly obese. Although some reports suggest that the trend of obesity may have begun to stabilize within some segments of the US population, 3 other studies project that obesity prevalence will continue to worsen, with as many as 50% of Americans potentially being obese by the year 2030. 4 Obesity has been linked to increased mortality resulting from acute and chronic comorbidities including diabetes, stroke, and cardiovascular diseases (CVDs). 5 The epidemic of obesity also has reached the intensive care unit (ICU), such that 33% of ICU patients are obese and 7% are morbidly obese. 6 Consequently, obesity complicates all aspects of health care in the ICU by increasing the complexity of management, nutritional support, and changes in the pattern of comorbidities. 7 Furthermore, obesity induces anatomic and physiologic changes that may interfere with the body response to injury and complicate any hospitalization. 7 In this article, we will review recent studies that have examined the impact of obesity in critical illness. PATIENTS METHODSA MEDLINE/PubMed search from 1990 TO 2014 was conducted using the National Library of Medicine MeSH search terms obesity, abdominal obesity, body mass index, critical illness, mortality, and organ failure. All publication types were searched, and relevant English-language studies, case reports, meta-analysis review articles, and short communications were then extracted and manually cross-referenced. Only clinical studies using explicit definitions of obesity, morbid obesity, or body mass index (BMI) were included. Throughout the review, obesity is defined as a BMI of 30 kg/m 2 or greater, morbid obesity as a BMI of 40 kg/m 2 or greater, and overweight as a BMI of 25 kg/m 2 to 29.9 kg/m 2 , unless specified otherwise. Underweight and healthy BMIs were defined as BMI less than 18.5 kg/m 2 and 18.5 kg/m 2 to 24.9 kg/m 2 , respectively. Studies pertaining to critical illness included an ICU length of stay (LOS) of 24 hours or longer. Although the main focus of this review is the impact of obesity on critical illness, an appreciation of fundamental physiologic derangements associated with obesity is essential to evaluate the response of obese patients to critical illness. We have thus structured our review as follows. We begin by discussing the development of pathologic conditions-associated with obesity. We then review available data on the impact of obesity on critical illness outcomes. When used for discussion, the term obesity refers to BMI of 30 kg/m 2 or greater. In many instances, data are available for one demographic group but not the other, and care is taken to make this distinction clear throughout the review.

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“…This finding is consistent with findings in the trauma literature in the obese population 5 . A persistent base deficit is known to correlate with a poor prognosis and may contribute to the higher mortality rate in the morbidly obese patient 25,13, 14 . Though the incidence of multi-organ failure was similar, there was a trend toward greater severity of dysfunction in the morbidly obese.…”

Section: Discussionmentioning

confidence: 99%

“…This is consistent with the observations in our cohort. It has also been noted that end points of resuscitation may be delayed in the severely injured obese patient 25 . Given that acidosis persists at 48 hours in obese patients, future studies should track metabolic derangements beyond the initial resuscitation phase.…”

Section: Discussionmentioning

confidence: 99%

Differences in Resuscitation in Morbidly Obese Burn Patients May Contribute to High Mortality

Rae¹,

Pham²,

Carrougher³

et al. 2013

Journal of Burn Care & Research

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Objective The rising number of obese patients poses new challenges for burn care. These may include adjustments in calculations of burn size, resuscitation, ventilator wean, nutritional goals as well as challenges in mobilization. We have focused this observational study on resuscitation in the obese patient population in the first 48 hours after burn injury. Prior trauma studies suggest a prolonged time to reach end points of resuscitation in the obese compared to non-obese injured patients. We hypothesize that obese patients have worse outcomes after thermal injury and that differences in the response to resuscitation contribute to this disparity. Methods We retrospectively analyzed data prospectively collected in a multi-center trial to compare resuscitation and outcomes in patients stratified by NIH/WHO BMI classification (BMI: normal weight 18.5-24.9, overweight 25-29.9, Obese 30-39.9, morbidly obese ≥40). Due to distribution of body habitus in the obese, total burn size was recalculated for all patients using the method proposed by Neaman and compared to Lund-Browder estimates. We analyzed patients by BMI class for fluids administered and end points of resuscitation at 24 and 48 hours. Multivariate analysis was used to compare morbidity and mortality across BMI groups. Results We identified 296 adult patients with a mean TBSA of 41%. Patient and injury characteristics were similar across BMI categories. There were no significant differences in burn size calculations using Neaman vs. Lund-Browder formulas. Although resuscitation volumes exceeded the predicted formula in all BMI categories, higher BMI was associated with less fluid administered per actual body weight (p=0.001). Base deficit on admission was highest in the morbidly obese group at 24 and 48 hours. Furthermore, these patients did not correct their metabolic acidosis as well as lower BMI groups (p-values 0.04 and 0.03). Complications and morbidities across BMI groups were similar, although examination of organ failure scores indicated more severe organ dysfunction in the morbidly obese group. Compared to normal weight patients, being morbidly obese was an independent risk factor for death (OR = 10.1; CI 1.94-52.5, p= 0.006). Conclusions Morbidly obese patients with severe burns tend to receive closer to predicted fluid resuscitation volumes for their actual weight. However, this patient group has persistent metabolic acidosis during the resuscitation phase and is at-risk of developing more severe multiple organ failure. These factors may contribute to higher mortality risk in the morbidly obese burn patient.

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Traditional Resuscitative Practices Fail to Resolve Metabolic Acidosis in Morbidly Obese Patients After Severe Blunt Trauma

Cited by 31 publications

References 43 publications

Computed Tomography–Defined Abdominal Adiposity Is Associated With Acute Kidney Injury in Critically Ill Trauma Patients*

Computed Tomography–Defined Abdominal Adiposity Is Associated With Acute Kidney Injury in Critically Ill Trauma Patients*

The obesity factor in critical illness

Differences in Resuscitation in Morbidly Obese Burn Patients May Contribute to High Mortality

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