Emergency Departments Shoulder Challenges of Providing Care, Preserving Dignity for the “Super Obese”

Impact of obesity on dialysis and transplant and its management

Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.

Feasibility of SPECT myocardial perfusion imaging in the super-obese using a multi-head semiconductor camera with attenuation correction

BACKGROUND

Obesity is not only associated with an increased risk of coronary artery disease, but also decreases the accuracy of many diagnostic modalities pertinent to this disease. Advances in myocardial perfusion imaging (MPI) have mitigated somewhat the effects of obesity, although the feasibility of MPI in the super-obese (defined as a BMI > 50) is currently untested. We undertook this study to assess the practicality of MPI in the super-obese using a multi-headed solid-state gamma camera with attenuation correction.

METHODS

We retrospectively identified consecutive super-obese patients referred for MPI at our institution. The images were interpreted by 3 blinded, experienced readers and graded for quality and diagnosis, and subjectively evaluated the contribution of attenuation correction. Clinical follow-up was obtained from review of medical records.

RESULTS

72 consecutive super-obese patients were included. Their BMI ranged from 50 to 67 (55.7 ± 5.1). Stress image quality was considered good or excellent in 45 (63%), satisfactory in 24 (33%), poor in 3 (4%), and uninterpretable in 0 patients. Rest images were considered good or excellent in 34 (49%), satisfactory in 23 (33%), poor in 13 (19%), and uninterpretable in 0 patients. Attenuation correction changed the interpretation in 34 (47%) of studies.

CONCLUSIONS

MPI is feasible and provides acceptable image quality for super-obese patients, although it may be camera and protocol dependent.

Obesity significantly increases the difficulty of patient management in the emergency department

OBJECTIVE

To determine which aspects of ED management are adversely affected by patient obesity, to determine the level of obesity above which management is made more difficult and to make recommendations on how these effects might be mitigated.

METHODS

This was a cross-sectional survey of patients and the staff caring for them in a single ED. Doctors, nurses and radiographers managing consecutive patients, during a range of enrolment periods, completed a self-administered questionnaire. Each was asked to record how the level of their patient's obesity increased the difficulty of specific management items, using a Likert scale. Staff also provided recommendations to mitigate the effects of obesity for each patient, if applicable. For each management item, body mass index (BMI) and management difficulty were correlated (Spearman's rank correlation).

RESULTS

Seven hundred and fifty patients and their ED carers were enrolled. Patient BMI was positively correlated with all aspects of ED clinical management examined (correlation coefficient range 0.28-0.57, P < 0.001). BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture (coefficient > 0.5, P < 0.001). Doctors reported more difficulties than nurses and radiographers. Generally, management difficulty did not increase until the BMI was in the obese or morbidly obese range. Most staff recommendations related to issues of patient mobility including equipment, staffing and bariatric devices.

CONCLUSION

Patient obesity significantly increases the difficulty of ED patient management. Staff recommendations to mitigate these effects were few but may inform changes in ED practice.

Dignity violation in health care

In this grounded theory analysis I sought to understand dignity violation in health care and to explore the context in which such violations take place. I found that dignity violation in health care occurs through processes of rudeness, indifference, condescension, dismissal, disregard, dependence, intrusion, objectification, restriction, labeling, contempt, discrimination, revulsion, deprivation, assault, and abjection. The conditions that promote these processes reside in the positions of the actors involved; in the asymmetrical relationships between the actors; in the health care setting itself, which is characterized by multiple tensions-including those between needs and resources, crisis and routine, experience and expertise, and rhetoric and reality; and in the embeddedness of health care in a broader social order of inequality. These findings suggest several interventions that might mitigate dignity violation in health care.

Challenges of treating a 466-kilogram man with acute kidney injury

Caring for super obese patients (body mass index > 50 kg/m(2)) presents a number of complex and unique clinical challenges, particularly when acute kidney injury is present. We describe our experience treating the heaviest individual with acute kidney injury requiring renal replacement therapy reported to date. A 24-year-old black man was admitted to our hospital with fever, vomiting, progressive weakness, shortness of breath, and hemoptysis. Admission weight was 1,024 lbs (466 kg), height was 6 ft 4 in (1.9 m), and body mass index was 125 kg/m(2). During hospitalization, the patient experienced oligoanuric acute kidney injury and required initiation of continuous and subsequently intermittent renal replacement therapy. This clinical scenario identifies the many challenges involved in caring for super obese patients with acute kidney injury and may be a harbinger of what awaits the nephrology community in the obesity pandemic era.