The Critically-ill Obese Patient

In this podcast, Dr. Mike Winters provides insights on managing obese patients in the ICU. He shares a case of a morbidly obese patient who suffered a cardiac arrest during intubation due to rapid desaturation.

Dr. Winters explains that obese patients have little pulmonary reserve and short safe apnea times. To maximize oxygenation, sit patients upright and use NIV or CPAP for pre-oxygenation. Give proper RSI dosing based on total or ideal body weight.

For mechanical ventilation, set tidal volume using ideal body weight. Start with higher PEEP of 10-15 cm H2O and consider a reverse Trendelenburg position. Obese patients have lower lung volumes and higher oxygen consumption.

Clinicians should understand the anatomical and physiological changes of obesity that lead to challenges with intubation and ventilation. Anticipating desaturation, optimizing positioning, and proper dosing of medications can help avoid complications and improve outcomes.

Takeaways

1. Obese patients have little pulmonary reserve and rapidly desaturate during intubation. Pre-oxygenate them upright and use NIV if possible.
2. Use proper dosing of RSI meds based on total body weight (etomidate) or ideal body weight (ketamine, rocuronium). Obese patients are often underdosed.
3. Set tidal volume based on ideal body weight, not total body weight. Consider a slightly higher respiratory rate.
4. Start with higher PEEP (10-15 cm H2O) and place in reverse Trendelenburg position after intubation.
5. Take a multidisciplinary approach involving specialists like cardiologists, surgeons, and intensivists when managing cardiogenic shock. Early diagnosis and treatment are key.