Obese Patient in Intensive Care Unit

  • Antonia Koutsoukou
  • Magdalini Kyriakopoulou
  • Anastasia Kotanidou
  • Fotini Ekonomidou
Living reference work entry


The increasing prevalence of obesity in the general population, in addition to the high burden of comorbidities, has resulted in an increased number of obese patients requiring admission to the intensive care unit. Obesity is associated with important pathophysiological derangements of the respiratory, cardiac, and metabolic functions. A further multiorgan impairment is expected when these subjects are exposed to stresses of acute illness. The risk of ventilator-induced lung injury, the effect of chest wall in respiratory mechanics and hence in the selection of ventilatory settings, difficulties in hemodynamic monitoring, adequate thromboembolism prophylaxis, and dosing adjustments for specific drugs are the most challenging issues in the effective management of such patients.


Obese Patient Obese Subject Acute Respiratory Distress Syndrome Functional Residual Capacity Transpulmonary Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

List of Abbreviations


Acute respiratory distress syndrome


Body mass index


Blood pressure


Cardiac output


Closing volume


Expiratory flow limitation


Expiratory reserve volume


Fraction of inspired oxygen


Functional residual capacity


Ideal body weight


Intensive care unit


Metabolic syndrome


Airway pressure


Positive end-expiratory pressure


Intrinsic positive end-expiratory pressure


Pleural pressure


Plateau pressure


Recruitment maneuvers


Respiratory system resistance


Systemic vascular resistance


Total body weight


Transpulmonary pressure


Tidal volume


Venous thromboembolism


White adipose tissue


  1. Abernethy DR, Greenblatt DJ. Lidocaine disposition in obesity. Am J Cardiol. 1984;53(8):1183–6.PubMedCrossRefGoogle Scholar
  2. Abernethy DR, Greenblatt DJ, Smith TW. Digoxin disposition in obesity: clinical pharmacokinetic investigation. Am Heart J. 1981;102(4):740–4.PubMedCrossRefGoogle Scholar
  3. Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med. 2008;36(1):151–8.PubMedCrossRefGoogle Scholar
  4. Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci. 2001;321(4):225–36.PubMedCrossRefGoogle Scholar
  5. ARDSnet. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301–8.CrossRefGoogle Scholar
  6. Bastard JP, Jardel C, Delattre J, Hainque B, Bruckert E, Oberlin F. Evidence for a link between adipose tissue interleukin-6 content and serum C-reactive protein concentrations in obese subjects. Circulation. 1999;99(16):2221–2.PubMedGoogle Scholar
  7. Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998;54(8):621–5.PubMedCrossRefGoogle Scholar
  8. 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(4):998–1003.PubMedCrossRefGoogle Scholar
  9. Berghöfer A, Pischon T, Reinhold T, Apovian CM, Sharma AM, Willich SN. Obesity prevalence from a European perspective: a systematic review. BMC Public Health. 2008;8:200.PubMedCentralPubMedCrossRefGoogle Scholar
  10. Brook RD, Bard RL, Rubenfire M, Ridker PM, Rajagopalan S. Usefulness of visceral obesity (waist/hip ratio) in predicting vascular endothelial function in healthy overweight adults. Am J Cardiol. 2001;88(11):1264–9.PubMedCrossRefGoogle Scholar
  11. Cheymol G, Poirier JM, Carrupt PA, Testa B, Weissenburger J, Levron JC, et al. Pharmacokinetics of beta-adrenoceptor blockers in obese and normal volunteers. Br J Clin Pharmacol. 1997;43(6):563–70.PubMedCentralPubMedCrossRefGoogle Scholar
  12. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: a review. J Am Coll Surg. 1997;185(6):593–603.PubMedCrossRefGoogle Scholar
  13. Christoff PB, Conti DR, Naylor C, Jusko WJ. Procainamide disposition in obesity. Drug Intell Clin Pharm. 1983;17(7–8):516–22.PubMedGoogle Scholar
  14. D’Angelo E, Pecchiari M, Baraggia P, Saetta M, Balestro E, Milic-Emili J. Low-volume ventilation causes peripheral airway injury and increased airway resistance in normal rabbits. J Appl Physiol (Bethesda, Md : 1985). 2002;92(3):949–56.Google Scholar
  15. D’Angelo E, Pecchiari M, Della Valle P, Koutsoukou A, Milic-Emili J. Effects of mechanical ventilation at low lung volume on respiratory mechanics and nitric oxide exhalation in normal rabbits. J Appl Physiol (Bethesda, Md : 1985). 2005;99(2):433–44.Google Scholar
  16. Day C. Diagnostic definitions-Metabolic Syndrome. Br J Diabetes Vasc Dis 2005;5:115–8.CrossRefGoogle Scholar
  17. Darvall KAL, Sam RC, Silverman SH, Bradbury AW, Adam DJ. Obesity and thrombosis. Eur J Vasc Endovasc Surg. 2007;33(2):223–33.PubMedCrossRefGoogle Scholar
  18. Douglas FG, Chong PY. Influence of obesity on peripheral airways patency. J Appl Physiol. 1972;33(5):559–63.PubMedGoogle Scholar
  19. Eichenberger A-S, Proietti S, Wicky S, Frascarolo P, Suter M, Spahn DR, et al. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg. 2002;95(6):1788–92.PubMedCrossRefGoogle Scholar
  20. El-Solh AA. Clinical approach to the critically ill, morbidly obese patient. Am J Respir Crit Care Med. 2004;169(5):557–61.PubMedCrossRefGoogle Scholar
  21. Farebrother MJ, McHardy GJ, Munro JF. Relation between pulmonary gas exchange and closing volume before and after substantial weight loss in obese subjects. Br Med J. 1974;3(5927):391–3.PubMedCentralPubMedCrossRefGoogle Scholar
  22. Ferrannini E, Natali A, Bell P, Cavallo-Perin P, Lalic N, Mingrone G. Insulin resistance and hypersecretion in obesity. European Group for the Study of Insulin Resistance (EGIR). J Clin Invest. 1997;100(5):1166–73.PubMedCentralPubMedCrossRefGoogle Scholar
  23. Ferretti A, Giampiccolo P, Cavalli A, Milic-Emili J, Tantucci C. Expiratory flow limitation and orthopnea in massively obese subjects. Chest. 2001;119(5):1401–8.PubMedCrossRefGoogle Scholar
  24. Finfer S, Chittock DR, Su SY-S, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97.PubMedCrossRefGoogle Scholar
  25. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–41.PubMedCrossRefGoogle Scholar
  26. Goldhaber SZ, Grodstein F, Stampfer MJ, Manson JE, Colditz GA, Speizer FE, et al. A prospective study of risk factors for pulmonary embolism in women. JAMA. 1997;277(8):642–5.PubMedCrossRefGoogle Scholar
  27. Gong MN, Bajwa EK, Thompson BT, Christiani DC. Body mass index is associated with the development of acute respiratory distress syndrome. Thorax. 2010;65(1):44–50.PubMedCentralPubMedCrossRefGoogle Scholar
  28. Guerin C, Koutsoukou A, Milic Emili J, D’Angelo E. Lung mechanics in disease. In: Papadakos P, Lachman B, editors. Mechanical ventilation: clinical applications and pathophysiology. Philadelphia: Saunders; 2008. p. 100–10.Google Scholar
  29. Habbu A, Lakkis NM, Dokainish H. The obesity paradox: fact or fiction? Am J Cardiol. 2006;98(7):944–8.PubMedCrossRefGoogle Scholar
  30. Hedenstierna G, Santesson J, Norlander O. Airway closure and distribution of inspired gas in the extremely obese, breathing spontaneously and during anaesthesia with intermittent positive pressure ventilation. Acta Anaesthesiol Scand. 1976;20(4):334–42.PubMedCrossRefGoogle Scholar
  31. Hedenstierna G, Strandberg A, Brismar B, Lundquist H, Svensson L, Tokics L. Functional residual capacity, thoracoabdominal dimensions, and central blood volume during general anesthesia with muscle paralysis and mechanical ventilation. Anesthesiology. 1985;62(3):247–54.PubMedCrossRefGoogle Scholar
  32. 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(7):1152–70.PubMedCrossRefGoogle Scholar
  33. Holley HS, Milic-Emili J, Becklake MR, Bates DV. Regional distribution of pulmonary ventilation and perfusion in obesity. J Clin Invest. 1967;46(4):475–81.PubMedCentralPubMedCrossRefGoogle Scholar
  34. Jonk AM, Houben AJHM, De Jongh RT, Serné EH, Schaper NC, Stehouwer CDA. Microvascular dysfunction in obesity: a potential mechanism in the pathogenesis of obesity-associated insulin resistance and hypertension. Physiology (Bethesda). 2007;22:252–60.CrossRefGoogle Scholar
  35. Kasper EK, Hruban RH, Baughman KL. Cardiomyopathy of obesity: a clinicopathologic evaluation of 43 obese patients with heart failure. Am J Cardiol. 1992;70(9):921–4.PubMedCrossRefGoogle Scholar
  36. Katsiari M, Koulouris NG, Orfanos SE, Maguina N, Sotiropoulou C, Koutsoukou A. Intercomparison of three recruitment maneuvers in acute respiratory distress syndrome: the role of body mass index. Minerva Anestesiol. 2012;78(6):675–83.PubMedGoogle Scholar
  37. Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab. 2004;89(6):2548–56.PubMedCrossRefGoogle Scholar
  38. Koutsoukou A, Koulouris N, Bekos B, Sotiropoulou C, Kosmas E, Papadima K, et al. Expiratory flow limitation in morbidly obese postoperative mechanically ventilated patients. Acta Anaesthesiol Scand. 2004;48(9):1080–8.PubMedCrossRefGoogle Scholar
  39. Ku CS, Lin SL, Wang DJ, Chang SK, Lee WJ. Left ventricular filling in young normotensive obese adults. Am J Cardiol. 1994;73(8):613–5.PubMedCrossRefGoogle Scholar
  40. Lapinsky SE, Mehta S. Bench-to-bedside review: recruitment and recruiting maneuvers. Crit Care (London, England). 2005;9(1):60–5.CrossRefGoogle Scholar
  41. Lewandowski K, Lewandowski M. Intensive care in the obese. Best Pract Res Clin Anaesthesiol. 2011;25(1):95–108.PubMedCrossRefGoogle Scholar
  42. Leykin Y, Miotto L, Pellis T. Pharmacokinetic considerations in the obese. Best Pract Res Clin Anaesthesiol. 2011;25(1):27–36.PubMedCrossRefGoogle Scholar
  43. Marini JJ, Amato M. Lung recruitment during ARDS. In: Marini JJ, Evans T, editors. Acute lung injury. Berlin: Springer; 1998. p. 236–57.Google Scholar
  44. Martell N, Rodriguez-Cerrillo M, Grobbee DE, López-Eady MD, Fernández-Pinilla C, Avila M, et al. High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension. Blood Press. 2003;12(3):149–54.PubMedCrossRefGoogle Scholar
  45. Martin SS, Qasim A, Reilly MP. Leptin resistance: a possible interface of inflammation and metabolism in obesity-related cardiovascular disease. J Am Coll Cardiol. 2008;52(15):1201–10.PubMedCrossRefGoogle Scholar
  46. McCool F, Rochester D. Non muscular diseases of the chest wall. In: Fishman A, Elias J, Fishman J, Crippi M, Kaiser L, Senior R, editors. Fishman’s pulmonary diseases and disorders. 3rd ed. New York: McGrow-Hill; 1998. p. 1555–60.Google Scholar
  47. Messerli FH, Ventura HO, Reisin E, Dreslinski GR, Dunn FG, MacPhee AA, et al. Borderline hypertension and obesity: two prehypertensive states with elevated cardiac output. Circulation. 1982;66(1):55–60.PubMedCrossRefGoogle Scholar
  48. Messerli FH, Nunez BD, Ventura HO, Snyder DW. Overweight and sudden death. Increased ventricular ectopy in cardiopathy of obesity. Arch Intern Med. 1987;147(10):1725–8.PubMedCrossRefGoogle Scholar
  49. Mottillo S, Filion KB, Genest J, Joseph L, Pilote L, Poirier P, et al. The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis. J Am Coll Cardiol. 2010;56(14):1113–32.PubMedCrossRefGoogle Scholar
  50. Naimark A, Cherniack RM. Compliance of the respiratory system and its components in health and obesity. J Appl Physiol. 1960;15:377–82.PubMedGoogle Scholar
  51. O’Brien JM, Welsh CH, Fish RH, Ancukiewicz M, Kramer AM. Excess body weight is not independently associated with outcome in mechanically ventilated patients with acute lung injury. Ann Intern Med. 2004;140(5):338–45.PubMedCrossRefGoogle Scholar
  52. 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(5):1456–63.PubMedCrossRefGoogle Scholar
  53. Oliveros H, Villamor E. Obesity and mortality in critically ill adults: a systematic review and meta-analysis. Obes (Silver Spring). 2008;16(3):515–21.CrossRefGoogle Scholar
  54. Pelosi P, Croci M, Ravagnan I, Vicardi P, Gattinoni L. Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest. 1996;109(1):144–51.PubMedCrossRefGoogle Scholar
  55. Pieracci FM, Barie PS, Pomp A. Critical care of the bariatric patient. Crit Care Med. 2006;34(6):1796–804.PubMedCrossRefGoogle Scholar
  56. Poirier P, Lemieux I, Mauriège P, Dewailly E, Blanchet C, Bergeron J, et al. Impact of waist circumference on the relationship between blood pressure and insulin: the Quebec Health Survey. Hypertension. 2005;45(3):363–7.PubMedCrossRefGoogle Scholar
  57. Rice TW. Obesity in acute lung injury: the “weight” is over. Chest. 2007;131(2):333–4.PubMedCrossRefGoogle Scholar
  58. Rochester D. Obesity and abdominal distension. In: Roussos C, editor. The thorax part C. New York: Marcel Dekker; 1994. p. 1951–73.Google Scholar
  59. Ryo M, Nakamura T, Kihara S, Kumada M, Shibazaki S, Takahashi M, et al. Adiponectin as a biomarker of the metabolic syndrome. Circ J. 2004;68(11):975–81.PubMedCrossRefGoogle Scholar
  60. Scholten DJ, Hoedema RM, Scholten SE. A comparison of two different prophylactic dose regimens of low molecular weight heparin in bariatric surgery. Obes Surg. 2002;12(1):19–24.PubMedCrossRefGoogle Scholar
  61. Serné EH, De Jongh RT, Eringa EC, IJzerman RG, Stehouwer CDA. Microvascular dysfunction: a potential pathophysiological role in the metabolic syndrome. Hypertension. 2007;50(1):204–11.PubMedCrossRefGoogle Scholar
  62. Sierra-Honigmann MR, Nath AK, Murakami C, García-Cardeña G, Papapetropoulos A, Sessa WC, et al. Biological action of leptin as an angiogenic factor. Sci (New York, NY). 1998;281(5383):1683–6.CrossRefGoogle Scholar
  63. Söderberg S, Olsson T, Eliasson M, Johnson O, Ahrén B. Plasma leptin levels are associated with abnormal fibrinolysis in men and postmenopausal women. J Intern Med. 1999;245(5):533–43.PubMedCrossRefGoogle Scholar
  64. Talmor D, Sarge T, Malhotra A, O’Donnell CR, Ritz R, Lisbon A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359(20):2095–104.PubMedCentralPubMedCrossRefGoogle Scholar
  65. Trayhurn P, Beattie JH. Physiological role of adipose tissue: white adipose tissue as an endocrine and secretory organ. Proc Nutr Soc. 2001;60(3):329–39.PubMedCrossRefGoogle Scholar
  66. Traynor AM, Nafziger AN, Bertino JS. Aminoglycoside dosing weight correction factors for patients of various body sizes. Antimicrob Agents Chemother. 1995;39(2):545–8.PubMedCentralPubMedCrossRefGoogle Scholar
  67. Tremblay LN, Slutsky AS. Ventilator-induced injury: from barotrauma to biotrauma. Proc Assoc Am Physicians. 1998;110(6):482–8.PubMedGoogle Scholar
  68. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67.PubMedCrossRefGoogle Scholar
  69. 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(20):2471–7.PubMedCrossRefGoogle Scholar
  70. Whitlock G, Lewington S, Sherliker P, Clarke R, Emberson J, Halsey J, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373(9669):1083–96.PubMedCrossRefGoogle Scholar
  71. WHO. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organization technical report series. World Health Organization, Geneva Switzerland, 2000;894:i–xii, 1–253.Google Scholar
  72. Yaegashi M, Jean R, Zuriqat M, Noack S, Homel P. Outcome of morbid obesity in the intensive care unit. J Intensive Care Med. 2005;20(3):147–54.PubMedCrossRefGoogle Scholar
  73. Zerah F, Harf A, Perlemuter L, Lorino H, Lorino AM, Atlan G. Effects of obesity on respiratory resistance. Chest. 1993;103(5):1470–6.PubMedCrossRefGoogle Scholar
  74. Ziccardi P, Nappo F, Giugliano G, Esposito K, Marfella R, Cioffi M, et al. Reduction of inflammatory cytokine concentrations and improvement of endothelial functions in obese women after weight loss over one year. Circulation. 2002;105(7):804–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Antonia Koutsoukou
    • 1
  • Magdalini Kyriakopoulou
    • 1
  • Anastasia Kotanidou
    • 2
  • Fotini Ekonomidou
    • 3
  1. 1.ICU, 1st Dept of Respiratory Medicine, Medical SchoolNational and Kapodistrian University of Athens, Sotiria HospitalAthensGreece
  2. 2.First Critical Care Department, Medical SchoolNational and Kapodistrian University of Athens, Evangelismos General HospitalAthensGreece
  3. 3.Leiden University Medical CenterLeidenNetherlands

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