Rezek SA1, Göbel A2
1Kantonsspital Winterthur, Institution for Physiotherapy, Winterthur, Switzerland, 2Kantonsspital Winterthur, Institution for physiotherapy, Winterthur, Switzerland
Background: Obesity is a major concern and a considerable burden for the healthcare system (Finkelstein et al. 2009). Approximately 25% of patients admitted to intensive care units (ICUs) are obese. These patients have higher resource utilization, ICU admissions, respiratory failure and tracheostomy (Westerly et al. 2003). Postoperative death and complications are more frequent in obese patients (Nasraway et al. 2006). Although evidence supporting feasibility, safety and benefits of mobilization and exercise of critically ill patients exists (Schweickert et al. 2009), challenges and benefits of this approach in ICU patients with morbid obesity has not been studied.
Case presentation: A 52-year-old morbidly obese man (BMI 77kg/m2) was admitted to ICU with septic shock by jejunum ischemia triggered by HIV. During the ICU stay (174 days), the patient presented nine septic episodes, recurrent infections and delirium, renal failure, depression and ICU-acquired weakness. Furthermore, he received mechanical ventilation four times (total 36 days) and underwent 18 operations due to resection of jejunum, abdominal VAC association and lavage, laparotomy and jejunostomy reversal. The patient stayed on the surgical ward for 97 days before being discharged to rehabilitation. Before hospital admission, patient could ambulatory 200m, couldn`t climb stairs and worked full time in an office.
Purpose: Describe physiotherapy management for a critically ill morbid obese “long stayer” to provide an example of successful outcome.
Methods: Retrospective case report.
Results:
Treatment: Physiotherapy started at day two. Due to cardiovascular instability, first mobilization on the edge of the bed with six person´s assistance was possible on day 8. On day 13 an interdisciplinary team of physiotherapists, occupational therapist, nurses and physicians created a daily rota and set-up special bed, mattress and chair with a standing feature and a MOTOmed®. Program, continuously adjusted to patient's condition, comprised twice-daily physiotherapy session and 3x/week occupational therapy. Mobilization and exercise included sitting on the edge of the bed, sitting in a chair, from sitting in a chair to standing, exercise in bed and chair and MOTOmed. On the surgical ward, the strict daily rota comprised increasingly frequent therapy sessions (from 2 up to 4/day). The sessions were intensified with standing up from the edge of the bed, ambulatory and increased exercise.
Outcome: No adverse events appeared due to mobilization and exercise. Patient mobility, measured with the ICU mobility scale, increased from 0 at time of ICU admission, to 3 at ICU discharge and 6 at hospital discharge. At hospital discharge (day 271), the patient (BMI 63 kg/m2) could ambulate six steps with gait-aid. At follow up (day 770) the patient (BMI 45 kg/m2) worked 70% at an office, could climb eight flight of stairs, ambulatory for 1km with crouches and 150m without any gait-aid.
Conclusion(s): Mobilization and exercise is feasible, safe and beneficial with critically ill morbid obese patients. Long-term successful outcome can be achieved through special equipment, a clear structure of daily activities with daily rota and good interdisciplinary communication and work.
Implications: Strict daily rota combined with knowledge of training physiology and diagnosis can lead to a successful outcome in critically ill morbid obese patients.
Keywords: Obesity, mobilization, management
Funding acknowledgements: No funding.
Case presentation: A 52-year-old morbidly obese man (BMI 77kg/m2) was admitted to ICU with septic shock by jejunum ischemia triggered by HIV. During the ICU stay (174 days), the patient presented nine septic episodes, recurrent infections and delirium, renal failure, depression and ICU-acquired weakness. Furthermore, he received mechanical ventilation four times (total 36 days) and underwent 18 operations due to resection of jejunum, abdominal VAC association and lavage, laparotomy and jejunostomy reversal. The patient stayed on the surgical ward for 97 days before being discharged to rehabilitation. Before hospital admission, patient could ambulatory 200m, couldn`t climb stairs and worked full time in an office.
Purpose: Describe physiotherapy management for a critically ill morbid obese “long stayer” to provide an example of successful outcome.
Methods: Retrospective case report.
Results:
Treatment: Physiotherapy started at day two. Due to cardiovascular instability, first mobilization on the edge of the bed with six person´s assistance was possible on day 8. On day 13 an interdisciplinary team of physiotherapists, occupational therapist, nurses and physicians created a daily rota and set-up special bed, mattress and chair with a standing feature and a MOTOmed®. Program, continuously adjusted to patient's condition, comprised twice-daily physiotherapy session and 3x/week occupational therapy. Mobilization and exercise included sitting on the edge of the bed, sitting in a chair, from sitting in a chair to standing, exercise in bed and chair and MOTOmed. On the surgical ward, the strict daily rota comprised increasingly frequent therapy sessions (from 2 up to 4/day). The sessions were intensified with standing up from the edge of the bed, ambulatory and increased exercise.
Outcome: No adverse events appeared due to mobilization and exercise. Patient mobility, measured with the ICU mobility scale, increased from 0 at time of ICU admission, to 3 at ICU discharge and 6 at hospital discharge. At hospital discharge (day 271), the patient (BMI 63 kg/m2) could ambulate six steps with gait-aid. At follow up (day 770) the patient (BMI 45 kg/m2) worked 70% at an office, could climb eight flight of stairs, ambulatory for 1km with crouches and 150m without any gait-aid.
Conclusion(s): Mobilization and exercise is feasible, safe and beneficial with critically ill morbid obese patients. Long-term successful outcome can be achieved through special equipment, a clear structure of daily activities with daily rota and good interdisciplinary communication and work.
Implications: Strict daily rota combined with knowledge of training physiology and diagnosis can lead to a successful outcome in critically ill morbid obese patients.
Keywords: Obesity, mobilization, management
Funding acknowledgements: No funding.
Topic: Critical care; Disability & rehabilitation
Ethics approval required: No
Institution: Kantonsspital Winterthur
Ethics committee: not applicable -> Information provided by clinical research office
Reason not required: No authorization by ethic committee required for case studies on individual persons that result in no generalizable findings (Swiss law).
All authors, affiliations and abstracts have been published as submitted.
