2. Objectives
Define the classifications of obesity and explain
the impact and costs related to obesity
Explain the considerations in caring for the
obese patients due to their pathophysiology
Identify health and safety risks associated with
the obese patient
Discuss treatment options for obesity and how to
provide weight sensitive care
2
3. What do we mean by the bariatric patient?
Bariatric comes from the Greek word baros
which means weight.
This means the patient of greater size,
usually a body mass index of >30.
3
4. Classifications of Obesity using
Body Mass Index (BMI)
Uses Patient’s Height and Weight
Correlates with Total Body Fat Content
Go to
http://www.sharp.com/tools/bmi.cfm
to calculate your own BMI
4
5. Morbid Obesity Defined
80-100 lbs Overweight
Body Mass Index=BMI
Acceptable Range 18.5 – 24.9
Overweight 25 – 29.9
Obese 30 – 34.9
Severe Obesity 35 – 39.9
Morbid Obesity 40 – 49.9
Super-Morbid Obesity 50 – +++
5
6. Measures to Assess Health Risks Related to
Obesity
Neck circumference: > 16-17 inches is related to greater risk
Obstructive Sleep Apnea (OSA).
Increased waist circumference
>40 inches for men or >35 inches for women is related to
greater metabolic risks.
6
7. Impact of Morbid Obesity
Causes 300,000 deaths per year in
the United States
Smoking and obesity are the leading
preventable causes of death in the
United States
Modern worldwide epidemic
American Obesity Association
7
8. Prevalence of Obesity
Over 67% of adult Americans are overweight
26% are obese or morbidly obese
In 2010, adult obesity rates increased and
reached 30 % in eight states
High BMI in the U.S. is approximately
10 % for infants and toddlers
18 % for adolescents and teenagers
Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008
8
http://healthyamericans.org/reports/obesity2010/
9. High Cost of Obesity
Currently, 9 % of all health care dollars are spent
for the treatment of obesity and its complications
Some estimate it will climb to 21% of all health care
dollars by 2018
Undetermined costs related to hospital worker
injury
9
http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
11. What is Morbid Obesity?
Chronic multi-factorial metabolic
disease
Life-long
Progressive
Degenerative
Life-threatening
Genetically related
http://win.niddk.nih.gov/statistics/index.htm
13
12. Morbid Obesity is a
Metabolic Disease
As BMI increases, adipose tissue becomes metabolically active
and secretes hormones
These hormones influence insulin resistance, hyperlipidemia,
inflammation, thrombosis, and hypertension
The mucosa of the stomach of obese persons secretes higher
levels of the hormone Ghrelin which increases appetite
14
13. The Disease of Morbid Obesity
Neuropeptides and neurotransmitters in the brain, mainly the hypothalamus, and
other hormones affect satiety, appetite and weight regulation
Interestingly, Leptin, a hormone that is secreted by adipose tissue and
decreases hunger, is found in higher levels for obese persons but it is believed
they are “leptin resistant”
The next two slides will demonstrate the complexity of this
disease!
15
14. Obesity and Neurohormonal Influences
Located in the brain
Orexogenic Mediators Anorexic Mediators
Affects hunger Affects satiety
Conserves energy Increases energy expenditure
Cannabinoid receptor activation POMC + α MSH
Orexin A Leptin receptors
MCH and AGRP CRH/Urocortin
Neuropeptide Y CNS Vagus nerve activation
Dynorphin Serotonin
Galanin Dopamine
Beacon gene activation CART (Cocaine Associated
CNS Sympathetic nerve activation Receptor Transcript)
16
16. Pathogenesis of Obesity
Behavior and lifestyle habits are often determinants
in the development of the disease
But, it is also extremely important to also
understand the metabolic mechanisms that
influence body weight
For persons who are overweight and mildly obese,
dieting and exercise are very effective for weight
loss
18
17. Challenges for the Morbidly Obese
Changes with hormones and the central nervous system
make it VERY CHALLENGING to sustain weight loss long
term by dieting and exercise alone.
At least 85 % regain their weight and more over time
19
18. Key Points
• Morbid Obesity is a chronic metabolic disease
• Diet and exercise are very effective for weight loss
for those who overweight and mildly obese
• Neurohormonal changes for the morbidly obese
make it very challenging for them to sustain
weight loss long term by dieting and exercise
alone
20
19. Test Your Knowledge
Ghrelin is a hormone which is secreted by
adipose tissue and decreases hunger
True
False
21
20. Co-Morbidities of Obesity
Co-morbidities are conditions or diseases
caused by or made worse by obesity
For example, asthma, gout, and arthritis may be
made worse due to the chronic inflammation
associated with obesity
It is important to educate patients about their
health risks associated with obesity
24
21. Metabolic Syndrome X is linked to Obesity
Insulin resistance
Hyperinsulinemia
Hyperglycemia
Hyperlipidemia
IR= Ins ulin
Res istan ce
ROS=Rea ctiv e
Oxy gen Species
Hypertension
Heart Disease
25
22. American Heart Association
Definition of Metabolic Syndrome
Increased waist circumference: > 40 inches for men or > 35
inches for women
Elevated triglycerides: Equal or > 150 mg/dL
Reduced HDL (“good”) cholesterol: < 40 mg/dl for men and
< 50 mg/dL for women
Elevated blood pressure: Equal to or greater than
130/85 mm Hg or use of medication for hypertension
Elevated fasting glucose: Equal to > 100 mg/dL
(5.6 mmol/L) or use of medication for hyperglycemia
26
23. Stroke
Increased risk for ischemic stroke in both men and women
Ischemic stroke increases progressively and is doubled in
those with a BMI > 30 when compared to those having a
BMI < 25
Obesity is not proven to be an increased risk for
hemorrhagic strokes 27
J. La State Med Soc. 2005, 156, S42-49.
24. Cardiovascular
Considerations
Increased total blood volume
Left ventricular hypertrophy and decreased ventricular
contractility can occur
About 75 % of individuals with hypertension have an
obesity link
28
American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1818
25. ECG Considerations
Increased fat deposits around the heart may lead to
degeneration of the conduction system which causes
lethal heart rhythms
Large body mass may cause difficulty with landmarks
for lead placement and inconsistent or decreased
voltage
Prolonged QT intervals
Non-specific flat/inverted T waves
in inferior leads
Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care Medicine, 34(6), 1796-1804.
Zacharias, A. Schwann. T. Riordan, C. et al (2005) Obesity and risk of new-onset of atrial fibrillation after cardiac surgery. Circulation 112 (32), 3247-3255
29
26. Diabetes Mellitus
Type 2 diabetes mellitus (DM) is strongly associated with
overweight and obesity in both genders and in all ethnic
groups
90 % of all patients with type 2 DM are overweight or obese
The risk for type 2 DM also increases in individuals with a
more central distribution of body fat (abdominal)
Modest weight loss (medical or surgical weight loss), even 5-
10% loss can have significant improvement of type 2 DM
Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales, & James S. Marks, (2003) Prevalence of Obesity, Diabetes, and
Obesity-Related Health Risk Factors, JAMA, (289),76-79.
30
27. Renal Impact
Some drugs may impact the renal system
in high BMI patients due to high glomerular
filtration rates
Increased intra-abdominal pressure may
lead to hypertension and insult to the kidney
If BMI is more than 30, nearly twice the risk for kidney failure
If BMI of 40 or above, seven times the risk of kidney failure
Blackwell Publishing Ltd. (2006, December 26). Obese Kidney Transplant Patients Twice As Likely To Die In The First Year Or Suffer Organ
Reference: June Journal of the American Society of Nephrology (2006) http://www.sciencedaily.com/releases/2006/01/060105082226.htm
31
28. Nonalcoholic Fatty Liver
If BMI > 40, the prevalence of:
Nonalcoholic fatty liver disease (NAFLD) is more than 95%
Nonalcoholic steatohepatitis (NASH) may be as high as 25%.
Sustained liver injury leads to progressive fibrosis and cirrhosis in
10% to 25% of affected individuals.
http://bariatrictimes.com/2010/01/21/nutrition-in-the-management-of-nonalcoholic-fatty-liver/
http://www.ccjm.org/content/71/8/657.full.pdf
32
29. Obesity Related Cancer
Obesity related cancer death rates are 14% for men
and 20% for women
Obese women have a 50% increase risk for breast
cancer after menopause
Obese men are 30-50% more likely as lean men to
develop colon cancer
Obesity related cancers include prostate, lymphoma,
liver, pancreas, and gallbladder
American Cancer Society
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119
33
30. Reproductive Impact
Imbalance of the sex hormones especially androgens
and estrogen leads to:
Irregular menstrual cycles
Increased androgenization and facial hair
Polycystic ovarian syndrome (PCOS)
Decreased conception rates after fertility treatments
34
31. Physiological changes in the obese patient
increases their risk for adverse events and
potential complications
It is extremely important to consider these
changes in the way you provide care!
35
32. High Risk for Blood Clots
Obesity is characterized by:
Chronic inflammation
Decreased immunity
Hypercoagulability
This is due to:
• Decreased antithrombin-III
• Increased tumor necrosis factor α and interleukin-6
• Impaired neutrophil function
• Increased blood volume
36
Critical Care Medicine 2006 Jun;34(6):1796-804.
33. Prevent Blood Clots by Early
Ambulation
Mobilize patients early and frequently
The efficacy of sequential
compression devices and TED hose
for obese individuals is unknown
Chronic inflammation and
hypercoagulation increase the clot
risk
There are limited studies about
anticoagulation and the obese
The weight of the large pannus
(abdominal fold) creates pressure
on the deep vessels and increases
the risk
Critical Care Medicine 2006 Jun;34(6):1796-804.
37
34. Test Your Knowledge
Which statement is not true about the increased risk for blood
clots and the obese individual?
A. The weight of the abdomen on deep vessels increases
the risk
B. Little is known about the efficacy of SCDs and TED
hose
C. Studies on anticoagulation and obesity are limited
D. There is no increased risk
38
35. Pulmonary Considerations
Obese patients desaturate very rapidly due to decreased
respiratory reserve and lung capacity.
Assess reasons oxygen saturation levels are less than 92 %.
Immediate intervention is critical.
The reverse trendelenberg position is the optimal position as
it drops the pannus (abdominal fold) from the diaphragm.
Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory Rate and Tidal
41
volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal of Critical Care, (3), 102-106.
36. Pulmonary Considerations
Preoxygenate before procedures such as suctioning. It is vital.
Keep upright or semi-recumbent as long as possible before
procedures.
Plan rest periods during most activities as dyspnea is common.
42
37. Obstructive Sleep Apnea (OSA)
Rates of OSA are high, about 71-77% if morbidly obese If also
diabetic, it is about 86% and often undiagnosed
Assess if patient has symptoms of OSA:
• Snoring
• Patient has been told they stop breathing for periods of time
during sleep
• Daytime sleepiness
Ask the patient if they use a CPAP machine at home
43
38. OSA and Obesity
Obtain order for Pulmonary Services if patient
uses CPAP at home
Patients may also require:
• continuous oxygenation saturation monitoring
• planning for difficult airway management
44
39. RAMP (Rapid Airway Management
Position) for Procedures
Align the top of the ear with the sternal notch
Ramp up or raise
the occipital area
using pillows or towels
Form a trapezoid shape
beneath the back of the head
Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260 45
Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni
40. Regional Anesthesia
Considerations
Increased abdominal pressure may decrease cerebral
spinal fluid volume which may lead to higher
neuroaxial blockade
Monitor patients closely for respiratory compromise
46
41. Weight and Drugs
Caution must be used for drugs highly soluble
in fat, especially with extended time duration,
> 12-24 hours include:
Opiate analgesics (Morphine, Dilaudid, etc)
Carbamazepine (Tegretol)
Propofol
Fentanyl
Midazolam (Versed)
47
42. Pain Management
Avoid Intramuscular injections
Pain medication in the obese patient is largely
unknown
Narcotics may lead to “Resedation Phenomenon”
Adipose tissue leads to unpredictable absorption
and a delayed response of these drugs
Assess sedation levels and for respiratory
depression very closely especially if patient has
OSA
48
43. Drugs and the Obese Patient
Pharmacodynamic and kinetic data are not available for
many medications such as antibiotics, pain medications, etc.
Generally, dose to a patient’s ideal body weight plus 40% of
the excess body weight
Start “low and go slow” is the best approach
49
44. Venous Access
Landmark vessels may be hard to palpate or visualize.
Consider Infusion Services to avoid multiple IV
sticks. Midline and PICC catheters may be a better
option depending on the length of therapy.
Assess carefully for signs of phlebitis due to excess
skin, subcutaneous fat and moisture in skin folds.
Assess if standard 1.5-in needles are long enough.
50
45. GI Impact
Monitor for greater aspiration risk due to high:
gastric fluid volume
GI reflux
incidence of Hiatal Hernia
High Incidence of Gallstones
Normally, acids in bile keep cholesterol from
forming into stones
With obesity, cholesterol in the bile increases
beyond the ability of acids to maintain the
cholesterol in suspension, the cholesterol
crystallizes and form stones
51
46. Skin Care Considerations
Inspect for moisture and irritation in skin folds as this may lead
to infection
Ask the patient if they are able to perform their personal
hygiene:
Obtain adaptive supplies and consult skin team if needed
Offer assistance
Move all lines, tubes, catheters (if possible) and the pannus
(abdominal fold) every 2 hours to prevent atypical ulcers
Assess for wound healing since adipose tissue less
vascularized
52
Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications: Edgemont, PA.
47. Musculoskeletal
Considerations
Patients have increased:
joint trauma/pain
disuse and atrophy of musculature
Prevent injury to yourself and the patient by using size
appropriate equipment. Obtain order for Physical Therapy
as needed.
Look for the weight capacity labels on patient equipment to
help select the right equipment (coming soon)
53
49. Treatment of Obesity
If BMI is 25-26.9 with co-morbidities:
Advise patient of treatment options for diet, physical
activity, and behavioral change
If BMI is 27-29.9 with co-morbidities or 30-34.9
without co-morbidities:
Consider pharmacotherapy in addition to diet, physical
activity, and behavioral change
If BMI 35 or greater with two co-morbidities or BMI
>40:
Consider Bariatric or Weight Loss Surgery in addition
to above noted treatments
57
50. Important Points
Morbid obesity is a chronic disease. Conventional
dieting is often not effective long term for the
morbidly obese patient.
Currently, medications are successful for about a
5-10% decrease of excess body weight.
Surgical weight loss overall results in a decrease in
at least 50-60% and more of excess body weight
and a profound resolution of serious co-morbidities.
Surgery is a “tool” for weight loss success, not a
cure.
58
53. Weight Bias in Healthcare
A recent study reported that only 2% of the
dietitian students had a neutral or positive attitude
about obese persons
In one study among nurses:
31% “would prefer not to care for obese patients”
24 % agree that obese patients “repulsed them”
12 % “would prefer not to touch obese patients”
Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society
61
54. Physicians and Weight Bias
In several anonymous self report surveys, they view obese
patients as:
“Noncompliant, lazy, lacking self control, unsuccessful,
unintelligent, and dishonest”
In a large study, 2,449 overweight and obese women
reported that 52% had been stigmatized more than once by
their physician
Overall, physicians:
spent less time with patients
assigned more negative symptoms
had reluctance to perform certain screenings
Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society
62
55. Impact on Patient Care
Patients may delay seeking or cancel
preventative health services and exams
Discrimination in every social aspect leads to
depression, low self esteem, and more
Fear of worker injury and extra time to mobilize
leads to resentment, impatience, and less
mobilization by providers
Reference: Rebecca M. Puhl, PhD and Kelly D. Brownell, PhD and the Obesity Society
63
56. Providing Weight Sensitive Care
Ask permission from the patient when you:
discuss their weight or BMI
weigh them
Acknowledge the challenges of losing weight
with the patient
Briefly explain why morbid obesity is a disease.
Many patients are not aware.
64
57. Providing Weight Sensitive Care
Avoid demeaning phrases such as “fluffy”, “fat”,
etc
Use the term “bariatric” or “extended capacity
equipment” instead of “big boy” equipment
Provide the appropriate sized equipment and
supplies
65
58. Patient Education
If a patient is interested in weight loss options
at Sharp, the patient may attend an out-
patient class. These are two options:
Go to www.sharp.com, classes and events
then bariatrics-weight loss or
Register at 1-800-82-Sharp, ask for medical
or surgical weight loss classes
66
59. Test Your Knowledge
Since the topic of obesity is frequently in the
news, weight bias is rare among health
care providers
True
False
67
60. Claims of Negligence
Failure to:
Educate medical providers about risks of obesity
Provide policies about care of the obese patient
Obtain essential bariatric equipment
70
61. Claims of Negligence
Failure to:
Provide nonjudgmental, weight sensitive care
Adequately prepare for emergencies of the obese
patient
Educate patients about appropriate weight loss
resources
71
62. How are we providing the
best care
at Sharp Healthcare?
72
63. System Task Force
Safe Care of the Bariatric Patient
Recommended and supported by CNOs and System
Safety Steering Committee based on identified risks of
this patient population
Comprised of representatives across the system:
SMH
Cheryl Holsworth RN, Senior Specialist, Bariatric Surgery
Michael Drafz RN, Lead, Vascular Access Services
Judd Feiler, Lead, Physical Therapy
SGH
Bethanie Martin RN, Lead 5 East
Ron Owen, Manager, Pulmonary Services
SCOR
Bryn Hogan RN, Lead ACC
MBHWN
Ellen Fleischman RN, RD, Manager MIS
Bernadette Bongato RN, Nursing Specialist OR
SCVMC
Deanna White RN, Manager, Acute Care
Marquet Johnson RN, CNS, PCU
System Representatives
Albert Rizos, PharmD, System Senior Clinical Pharmacy Specialist
Cheryl Dailey RN, Director, Patient Safety
Francine Parent RN, Senior Specialist, System Supply Chain Services
73
64. Focus Areas of Bariatric Task Force
Ensure that our clinical staff have ready access to
supplies, products and equipment which are weight
and size appropriate
Label weight capacity of equipment using weight
sensitive stickers. (Implementation has begun at
SMH and planned for all of Sharp Healthcare)
Offer comprehensive programs for medical and
surgical weight loss (Surgical programs offered at
SMH and SCV)
Implement use of difficult airway kits
74
65. Focus Areas
Provide education to our staff, patients,
employees, and physicians for the management
and care of this patient population
Provide education about ways to provide weight
sensitive care
Spread entity best practices across the
organization
Provide educational and resource information
available to staff via Sharp Intranet and other
venues
75
66. Bariatric Resources
Bariatric Website (under construction)
http://sharpnet/hospitals/memorial/bariatricProgram/index.cfm
www.sharp.com go to classes and events, look for
bariatrics
Resource Experts
Cheryl Holsworth, RN, MSA, CBN
Senior Specialist Bariatric Program
Phone 858-939-3083, Cheryl.holsworth@sharp.com
Thomas Hayes
Administrative Coordinator Bariatric Program
Phone 858-939-3010, Thomas.hayes@sharp.com
76
67. Conclusions about Morbid Obesity
It is a metabolic disease
It results in multisystem problems
Care of the patient requires customization
of care and thoughtfulness
Refer patients to out-patient resources for
medical/surgical weight loss options
77
69. References
American Society of Metabolic and Bariatric Surgery
American Cancer Society
American Journal of Respiratory and Critical Care Medicine (2004). (169), 557-561.
Alspach, J.G. (editor) (2006). Core Curriculum for Critical Care Nursing (6 th edition). Saunders
Elsevier: St. Louis, MO.
Barr, J. & Cunneen, J. (2001). Understanding the Bariatric Client and Providing a Safe Hospital
Environment. Clinical Nurse Specialist, 15(5): 219-223.
Hahler, B. (2002). Morbid Obesity: A Nursing Care Challenge. Medsurg Nursing, 11(2): 85-90.
Hurst, S., Blanco, K., Boyle, D. Douglass, L. & Wikas, A. (2004). Bariatric Implications of Critical Care
Nursing. Dimensions of Critical Care Nursing, 23(2): 76-83.
Marik, P. & Varon, J. (1998). The Obese Patient in the ICU. Chest, 113, 492-498.
National Institutes of Health. (2000). The Practical Guide: Identification, Evaluation and Treatment of
Overweight and Obesity in Adults. National Institutes of Health national Heart, Lung, and Blood
Institute North American Association for the Study of Obesity.
Pieracci, F.M., Barie, P.S., & Pomp, A. (2006). Critical Care of the Bariatric Patient. Critical Care
Medicine, 34(6), 1796-1804.
Reto, C.S. (2003). Psychological Aspects of Delivering Nursing Care to the Bariatric Patient. Critical
Care Nurse Quarterly, 26(2), 139-149.
Vachharajani, V. & Vital, S. (2006). Obesity and Sepsis. Journal of Intensive Care Medicine, 21, 287-
295.
Varon, J. & Marik, P. (2001). Management of the Obese Critically Ill Patient. Critical Care Clinics ,
17(1).
Wilson, J.A. & Clark, J.J. (2003). Obesity: Impediment to Wound Healing. Critical Care Nurse
Quarterly, 26(2), 119-132.
Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical
Communications: Edgemont, PA.
79
70. References Continued
http://emedicine.medscape.com/article/123702-treatment
Bagchi, D. & Preuss, H. (2007) Obesity: Epidemiology, Pathophysiology, and Prevention. (CRC
Press, Taylor & Francis Group, LLC). Boca Raton, Fl.
http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
American Obesity Association
http://win.niddk.nih.gov/statistics/index.htm
Simoni, R. Brazilian Journal of Anesthesiology (2005). Tracheal Intubation of Morbidly Obese
Patients, (55)2, 256-260.
Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea
(May 2006). Anesthesiology (104) 5, 1081-93.
Bell, R. & Rosenblum, S. (2005). Postoperative Considerations for Patients with Obesity and Sleep
Apnea, Anesthesiology Clin. N. America (23), 493-500.
www.cdc.gov/obesity
Burns, S.M., Egloff, MB. Ryan, B. & Carpenter, R. (1994). Effect of Body Position on Respiratory
Rate and Tidal volume in Patients with Obesity, Abdominal Distention, and Acites. American Journal
of Critical Care, (3), 102-106.
L. Ben-Noun, A. Laor. (January, 2003). Relationship of neck circumference to cardiovascular risk
factors. Obesity Research (11), 226-231.
Frey, W.C. & Pilcher, J. (2003) Obstructive Sleep Apnea in Patients evaluated for Bariatric Surgery,
Obesity Surgery, (13), 676-683.
Pływaczewski R, Bieleń P, Bednarek M, Jonczak L, Górecka D, Sliwiński P. (2008). Pneumonol Alergol Pol.
(76)5, 313-320.
Ali H. Mokdad, Earl S. Ford, Barbara A. Bowman, William H. Dietz, Frank Vinicor, Virginia S. Bales,
& James S. Marks, (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk
Factors, JAMA, (289),76-79.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1761119
80
71. Author Information
Cheryl Holsworth, RN, MSA, CBN
Senior Specialist Bariatric Program
Sharp Memorial Hospital
Special thanks to the following SHC specialists for their valuable input:
Rossanne Decastro, RN, PHN, MSNc, Acute Care Specialist, SCVMC
Karen Harmon, RNC, MSN, CNS, Perinatal Clinical Nurse Specialist,
SMBHW
Steve Leary, RN, MSN, Senior Specialist Acute Care, SMH
Susan Moore, RN, MSA, Senior Specialist Acute Care, SMH
Paul Neves, RN, BSN, ONC, Acute Care Nursing Specialist, SGH
Tanna Thomason, RN, MSN, Clinical Nurse Specialist, SMH
81
72. Exit
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Hinweis der Redaktion
Line 2: Due to adipose tissue, there is an increase in blood volume, preload of the heart, stroke volume, cardiac output and myocardial workload to meet perfusion demands. Line 3: With increased blood volume, there is increased RBC’s thus increased viscosity of the blood, so increased risk for thrombophlebitis. A BMI >29 heightens the prevalence of Pulmonary Embolism. DVT appears twice as often in Obese patients compared to nonobese patients. (Gallagher 2006). Baylor College in Texas confirmed that at one year, CHF patients at 1 year who died were less likely to be obese or have metabolic syndrome. U of M at Ann Arbor, MI reported that obese individuals had more than 3 X the risk for the composite end point of death, cardiac transplant or ventricular assist devices
One cause of arrhythmias with persons of higher BMI may be the increased sympathetic activity caused by leptin. Leptin is shown to increase mean arterial pressure and heart rate in laboratory rats. It appears to sensitize adrenergic receptors to catecholamines.
Obese individuals are twice as likely to die after the first year after a transplant and have organ failure. It becomes greater after 5 years. There is accumulating evidence that the sympathetic nervous system plays a role in the development of obesity-related hypertension. Both animal and human studies have shown that excess weight gain is associated with increased renal sympathetic activity, resulting in sodium retention. An activated RAS also contributes to enhanced oxidative stress,vascular remodeling, and pressor response to exercise.The sympathetic nervous system activation associated with obesity is mediated in part by the adipocyte-derived hormone, leptin, which increases in proportion to the degree of adiposity.An increase of leptin in hypertensive individuals is associated with elevated plasma renin activity, aldosterone, andangiotensin concentrations.
Scientists at Geneva University in Switzerland conducted a population-based study in which they evaluated the impact of obesity on presentation, diagnosis and treatment of breast cancer. Among all women diagnosed with invasive breast cancer in Geneva between 2003 and 2005, they identified those with available information on body mass index and categorized them into groups they identified as normal/underweight (BMI <25kg/m), overweight (BMI >/=-30kg/m), and obese (BMI >30kg/m). They compared tumor, diagnosis and treatment characteristics between the groups. They found that obese women presented significantly more often with stage III and stage IV disease, with an odds ratio of 1.8. This means they were 180% more likely to have later stage breast cancer than those women in the normal/underweight group. Women in the obese group were 240% more likely to have tumors that were equal to or greater in size than 1 centimeter compared to the women in the normal/underweight group. They were also a whopping 510% more likely to have positive lymph nodes suggesting their cancers may have spread to other parts of their bodies. In another study, obese women were 20 percent more likely to have false-positive results from mammograms -- readings that can lead to unnecessary biopsies and anxiety. Being overweight can get in the way of effective cancer treatment, too, experts say. The problem: under dosing. "Oncologists usually base chemo on patients' ideal weight rather than their true weight, partly because chemo is so toxic and partly because drug trials typically include only average women, so we don't know the correct dose for bigger women," says Kellie Schneider, M.D., a gynecologic oncologist at the University of Alabama at Birmingham. "But underdosing can mean the difference between life and death."
Obese patients normally have smaller cerebrospinal fluid (CSF) volumes than normal weight patients, and these changes are further exaggerated in the obese parturient. Decreased CSF volume due to increased abdominal pressure (obesity or pregnancy) may produce more-extensive neuraxial blockade due to diminished dilution of anesthetic. The mechanism by which increased abdominal pressure decreases CSF volume is probably inward movement of soft tissue in the I Intervertebral foramen displacing CSF.[55] The epidural space volume is also reduced, due to adipose I infiltration and increased venous distension from aortocaval compression and increased intra-abdominal pressure, resulting in higher spread of local anesthetic and in higher risk of hypotension and respiratory difficulty.[54]