Obesity in Critical Care



Obesity, defined as a body mass index (BMI) greater than or equal to 30 m/kg2, is increasing in incidence, with more than one-third of American adults in the United States classified as obese and numbers projected to increase. Worse outcomes have been noted in both underweight (BMI <18 m/kg2) and obese critically ill patients. Other studies have associated obesity as an independent risk factor for mortality in the ICU. In addition, morbid obesity is an independent risk factor for the development of organ failure after trauma in the critically ill patient. Given the current obesity epidemic, the number of critically ill obese patients will continue to increase, and a greater understanding of the physiologic challenges associated with obesity in this setting will be needed. This chapter will discuss the multiple intersections and interactions between obesity and critical illness, as well as optimal evaluation and management strategies.


Obesity Morbid obesity Critical illness Body mass index Metabolic syndrome 


  1. 1.
    Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA. 2012;307:491–7.  https://doi.org/10.1001/jama.2012.39.CrossRefPubMedGoogle Scholar
  2. 2.
    Hogue CW, Stearns JD, Colantuoni E, Robinson KA, Stierer T, Mitter N, et al. The impact of obesity on outcomes after critical illness: a meta-analysis. Intensive Care Med. 2009;35:1152–70.  https://doi.org/10.1007/s00134-009-1424-5.CrossRefPubMedGoogle Scholar
  3. 3.
    Bercault N, Boulain T, Kuteifan K, Wolf M, Runge I, Fleury J-C. Obesity-related excess mortality rate in an adult intensive care unit: a risk-adjusted matched cohort study. Crit Care Med. 2004;32:998–1003.CrossRefGoogle Scholar
  4. 4.
    Ciesla DJ, Moore EE, Johnson JL, Burch JM, Cothren CC, Sauaia A. Obesity increases risk of organ failure after severe trauma. J Am Coll Surg. 2006;203:539–45.  https://doi.org/10.1016/j.jamcollsurg.2006.06.029.CrossRefPubMedGoogle Scholar
  5. 5.
    Shashaty MGS, Stapleton RD. Physiological and management implications of obesity in critical illness. Ann Am Thorac Soc. 2014;11:1286–97.  https://doi.org/10.1513/AnnalsATS.201404-159FR.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Tafelski S, Yi H, Ismaeel F, Krannich A, Spies C, Nachtigall I. Obesity in critically ill patients is associated with increased need of mechanical ventilation but not with mortality. J Infect Public Health. 2016;9:577.  https://doi.org/10.1016/j.jiph.2015.12.003.CrossRefPubMedGoogle Scholar
  7. 7.
    Frat J-P, Gissot V, Ragot S, Desachy A, Runge I, Lebert C, et al. Impact of obesity in mechanically ventilated patients: a prospective study. Intensive Care Med. 2008;34:1991–8.  https://doi.org/10.1007/s00134-008-1245-y.CrossRefPubMedGoogle Scholar
  8. 8.
    De Jong A, Molinari N, Pouzeratte Y, Verzilli D, Chanques G, Jung B, et al. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth. 2015;114:297–306.  https://doi.org/10.1093/bja/aeu373.CrossRefPubMedGoogle Scholar
  9. 9.
    Anzueto A, Frutos-Vivar F, Esteban A, Bensalami N, Marks D, Raymondos K, et al. Influence of body mass index on outcome of the mechanically ventilated patients. Thorax. 2011;66:66–73.  https://doi.org/10.1136/thx.2010.145086.CrossRefPubMedGoogle Scholar
  10. 10.
    Kaese S, Zander MC, Lebiedz P. Successful use of early percutaneous dilatational tracheotomy and the no sedation concept in respiratory failure in critically ill obese subjects. Respir Care. 2016;61:615.  https://doi.org/10.4187/respcare.04333.CrossRefPubMedGoogle Scholar
  11. 11.
    Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med. 2008;36:151–8.  https://doi.org/10.1097/01.CCM.0000297885.60037.6E.CrossRefPubMedGoogle Scholar
  12. 12.
    O’Brien JM, Philips GS, Ali NA, Aberegg SK, Marsh CB, Lemeshow S. The association between body mass index, processes of care, and outcomes from mechanical ventilation: a prospective cohort study. Crit Care Med. 2012;40:1456–63.  https://doi.org/10.1097/CCM.0b013e31823e9a80.CrossRefPubMedGoogle Scholar
  13. 13.
    Wang TJ, Parise H, Levy D, D’Agostino RB, Wolf PA, Vasan RS, et al. Obesity and the risk of new-onset atrial fibrillation. JAMA. 2004;292:2471–7.  https://doi.org/10.1001/jama.292.20.2471.CrossRefPubMedGoogle Scholar
  14. 14.
    Rae L, Pham TN, Carrougher G, Honari S, Gibran NS, Arnoldo BD, et al. Differences in resuscitation in morbidly obese burn patients may contribute to high mortality. J Burn Care Res. 34:507–14.  https://doi.org/10.1097/BCR.0b013e3182a2a771.CrossRefGoogle Scholar
  15. 15.
    El Solh AA, editor. Critical care management of the obese patient. Oxford: Wiley-Blackwell; 2012.  https://doi.org/10.1002/9781119962083.CrossRefGoogle Scholar
  16. 16.
    Chang J, Corcelles R, Boules M, Jamal MH, Schauer PR, Kroh MD. Predictive factors of biliary complications after bariatric surgery. Surg Obes Relat Dis. 2015.  https://doi.org/10.1016/j.soard.2015.11.004.
  17. 17.
    Diehl AM. Hepatic complications of obesity. Gastroenterol Clin North Am. 2010;39:57–68.  https://doi.org/10.1016/j.gtc.2009.12.001.CrossRefPubMedGoogle Scholar
  18. 18.
    Virani SS, Nambi V, Lee V-V, Elayda MA, Pan W, Petersen LA, et al. Obesity: an independent predictor of in-hospital postoperative renal insufficiency among patients undergoing cardiac surgery? Texas Hear Inst J. 2009;36:540–5.Google Scholar
  19. 19.
    Cignarelli M, Lamacchia O. Obesity and kidney disease. Nutr Metab Cardiovasc Dis. 2007;17:757–62.  https://doi.org/10.1016/j.numecd.2007.03.003.CrossRefPubMedGoogle Scholar
  20. 20.
    Rutkowski P, Klassen A, Sebekova K, Bahner U, Heidland A. Renal disease in obesity: the need for greater attention. J Ren Nutr. 2006;16:216–23.  https://doi.org/10.1053/j.jrn.2006.04.017.CrossRefPubMedGoogle Scholar
  21. 21.
    Cirillo M, Anastasio P, De Santo NG. Relationship of gender, age, and body mass index to errors in predicted kidney function. Nephrol Dial Transplant. 2005;20:1791–8.  https://doi.org/10.1093/ndt/gfh962.CrossRefPubMedGoogle Scholar
  22. 22.
    Jamal MH, Corcelles R, Shimizu H, Kroh M, Safdie FM, Rosenthal R, et al. Thromboembolic events in bariatric surgery: a large multi-institutional referral center experience. Surg Endosc. 2015;29:376–80.  https://doi.org/10.1007/s00464-014-3678-4.CrossRefPubMedGoogle Scholar
  23. 23.
    Birkmeyer NJO, Finks JF, Carlin AM, Chengelis DL, Krause KR, Hawasli AA, et al. Comparative effectiveness of unfractionated and low-molecular-weight heparin for prevention of venous thromboembolism following bariatric surgery. Arch Surg. 2012;147:994–8.  https://doi.org/10.1001/archsurg.2012.2298.CrossRefPubMedGoogle Scholar
  24. 24.
    Juvin P, Blarel A, Bruno F, Desmonts J-M. Is peripheral line placement more difficult in obese than in lean patients? Anesth Analg. 2003;96:1218. table of contentsCrossRefGoogle Scholar
  25. 25.
    Gregg SC, Murthi SB, Sisley AC, Stein DM, Scalea TM. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Crit Care. 2010;25:514–9.  https://doi.org/10.1016/j.jcrc.2009.09.003.CrossRefPubMedGoogle Scholar
  26. 26.
    Moureau N, Chopra V. Indications for peripheral, midline and central catheters: summary of the MAGIC recommendations. Br J Nurs. 2016;25:S15–24.  https://doi.org/10.12968/bjon.2016.25.8.S15.CrossRefPubMedGoogle Scholar
  27. 27.
    Greene MT, Flanders SA, Woller SC, Bernstein SJ, Chopra V. The association between PICC use and venous thromboembolism in upper and lower extremities. Am J Med. 2015;128:986–993.e1.  https://doi.org/10.1016/j.amjmed.2015.03.028.CrossRefPubMedGoogle Scholar
  28. 28.
    Dossett LA, Dageforde LA, Swenson BR, Metzger R, Bonatti H, Sawyer RG, et al. Obesity and site-specific nosocomial infection risk in the intensive care unit *. Surg Infect (Larchmt). 2009;10:137–42.  https://doi.org/10.1089/sur.2008.028.CrossRefGoogle Scholar
  29. 29.
    Fezeu L, Julia C, Henegar A, Bitu J, FB H, Grobbee DE, et al. Obesity is associated with higher risk of intensive care unit admission and death in influenza A (H1N1) patients: a systematic review and meta-analysis. Obes Rev. 2011;12:653–9.  https://doi.org/10.1111/j.1467-789X.2011.00864.x.CrossRefPubMedGoogle Scholar
  30. 30.
    Huttunen R, Syrjänen J. Obesity and the risk and outcome of infection. Int J Obes (Lond). 2013;37:333–40.  https://doi.org/10.1038/ijo.2012.62.CrossRefGoogle Scholar
  31. 31.
    Semins MJ, Shore AD, Makary MA, Weiner J, Matlaga BR. The impact of obesity on urinary tract infection risk. Urology. 2012;79:266–9.  https://doi.org/10.1016/j.urology.2011.09.040.CrossRefPubMedGoogle Scholar
  32. 32.
    Marik PE, Desai H. Characteristics of patients with the “malignant obesity hypoventilation syndrome” admitted to an ICU. J Intensive Care Med. 28:124–30.  https://doi.org/10.1177/0885066612444261.CrossRefGoogle Scholar
  33. 33.
    Gharib M, Kaul S, LoCurto J, Perez M, Hajri T. The obesity factor in critical illness: between consensus and controversy. J Trauma Acute Care Surg. 2015;78:866–73.  https://doi.org/10.1097/TA.0000000000000597.CrossRefPubMedGoogle Scholar
  34. 34.
    Wacharasint P, Boyd JH, Russell JA, Walley KR. One size does not fit all in severe infection: obesity alters outcome, susceptibility, treatment, and inflammatory response. Crit Care. 2013;17:R122.  https://doi.org/10.1186/cc12794.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Lemmens HJM, Ingrande J. Pharmacology and obesity. Int Anesthesiol Clin. 2013;51:52–66.  https://doi.org/10.1097/AIA.0b013e31829a4d56.CrossRefPubMedGoogle Scholar
  36. 36.
    Mitrov-Winkelmolen L, van Buul-Gast M-CW, Swank DJ, Overdiek HWPM, van Schaik RHN, Touw DJ. The effect of roux-en-Y gastric bypass surgery in morbidly obese patients on pharmacokinetics of (acetyl)salicylic acid and omeprazole: the ERY-PAO study. Obes Surg. 2016;26:2051–8.  https://doi.org/10.1007/s11695-016-2065-8.CrossRefPubMedGoogle Scholar
  37. 37.
    Donohoe CL, Feeney C, Carey MF, Reynolds JV. Perioperative evaluation of the obese patient. J Clin Anesth. 2011;23:575–86.  https://doi.org/10.1016/j.jclinane.2011.06.005.CrossRefPubMedGoogle Scholar
  38. 38.
    Schaefer GP, Pender J, Toschlog EA, Waibel BH, Cohen KC. Endoscopically-assisted tube thoracostomy placement in a super-morbidly obese patient with penetrating thoracoabdominal trauma. Am Surg. 2011;77:119–20.PubMedGoogle Scholar
  39. 39.
    Gaarder C, Kroepelien CF, Loekke R, Hestnes M, Dormage JB, Naess PA. Ultrasound performed by radiologists-confirming the truth about FAST in trauma. J Trauma. 2009;67:323–7. ; discussion 328-9.  https://doi.org/10.1097/TA.0b013e3181a4ed27.CrossRefPubMedGoogle Scholar
  40. 40.
    Tsai P-JS, Loichinger M, Zalud I. Obesity and the challenges of ultrasound fetal abnormality diagnosis. Best Pract Res Clin Obstet Gynaecol. 2015;29:320–7.  https://doi.org/10.1016/j.bpobgyn.2014.08.011.CrossRefPubMedGoogle Scholar
  41. 41.
    Sakai H, Sheer TA, Mendler MH, Runyon BA. Choosing the location for non-image guided abdominal paracentesis. Liver Int. 2005;25:984–6.  https://doi.org/10.1111/j.1478-3231.2005.01149.x.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Massachusetts General Hospital, Department of General SurgeryBostonUSA
  2. 2.Digestive Disease and Surgery InstituteCleveland ClinicClevelandUSA

Personalised recommendations