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Beurton A, Kooistra EJ, De Jong A, Schiffl H, Jourdain M, Garcia B, Vimpère D, Jaber S, Pickkers P, Papazian L. Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review. Curr Obes Rep 2024:10.1007/s13679-024-00562-3. [PMID: 38573465 DOI: 10.1007/s13679-024-00562-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear. RECENT FINDINGS The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.
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Affiliation(s)
- Alexandra Beurton
- Department of Intensive Care, Hôpital Tenon, APHP, Paris, France.
- UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, Sorbonne Université, Paris, France.
| | - Emma J Kooistra
- Department of Intensive Care Medicine, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
| | - Audrey De Jong
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University Montpellier 1, Montpellier, France
- Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Helmut Schiffl
- Division of Nephrology, Department of Internal Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Mercedes Jourdain
- CHU Lille, Univ-Lille, INSERM UMR 1190, ICU Department, F-59037, Lille, France
| | - Bruno Garcia
- CHU Lille, Univ-Lille, INSERM UMR 1190, ICU Department, F-59037, Lille, France
| | - Damien Vimpère
- Anesthesia and Critical Care Department, Hôpital Necker, APHP, Paris, France
| | - Samir Jaber
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University Montpellier 1, Montpellier, France
- Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
| | - Laurent Papazian
- Intensive Care Unit, Centre Hospitalier de Bastia, Bastia, Corsica, France
- Aix-Marseille University, Marseille, France
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Huang X, Lin X. Impact of obesity on outcomes of extracorporeal membrane oxygenation support: a systematic review and meta-analysis. BMC Pulm Med 2024; 24:157. [PMID: 38549057 PMCID: PMC10976836 DOI: 10.1186/s12890-024-02971-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/18/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used when standard methods of standard treatment methods are not successful. Obese patients present unique challenges during ECMO due to large body size hindering sufficient flows, difficulties with patient positioning and anatomical landmark identification, and restricted radiology scans. This meta-analysis aims to investigate the impact of obesity on the outcomes of patients undergoing ECMO. METHODS Databases (PubMed, Embase, and Scopus databases) were searched to identify relevant studies published until July 2023. Data were reported as odds ratios (OR) with 95% confidence interval (CI), and the descriptive data were reported as standard difference of means (SDM) by a random effects model. RESULTS A literature search identified 345 studies. Of them, 18 studies met the inclusion criteria. The findings from the meta-analysis revealed no significant association between obesity and survival outcomes after ECMO (odds ratio (OR): 0.91, 95% confidence interval (CI): 0.70-1.17, p: 0.46). Moreover, no comparative significant differences were found between obese and non-obese individuals on the duration of ECMO procedure (standardized mean difference (SMD): 0.07, -0.03-0.17), length of hospital stay (-0.03, -0.19 to 0.12), and duration of ventilation support (-0.10, -0.44 to 0.24). CONCLUSION The meta-analysis findings suggest no significant impact of obesity on the survival outcomes after the ECMO procedure. There was no significant impact of obesity on the duration of ECMO procedures, length of hospital stay, and duration of ventilation support.
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Affiliation(s)
- Xinhua Huang
- Department of Geriatric, HuZhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, 2088 Tiaoxi East Road, Wuxing District, Huzhou City, Zhejiang Province, China
| | - Xiaoqing Lin
- Department of Geriatric, HuZhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, 2088 Tiaoxi East Road, Wuxing District, Huzhou City, Zhejiang Province, China.
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Ripoll JG, ElSaban M, Nabzdyk CS, Balakrishna A, Villavicencio MA, Calderon-Rojas RD, Ortoleva J, Chang MG, Bittner EA, Ramakrishna H. Obesity and Extracorporeal Membrane Oxygenation (ECMO): Analysis of Outcomes. J Cardiothorac Vasc Anesth 2024; 38:285-298. [PMID: 37953169 DOI: 10.1053/j.jvca.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Christoph S Nabzdyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Tham E, Campbell S, Hayanga H, Ammons J, Fang W, Sappington P, McCarthy P, Toker A, Badhwar V, Hayanga JWA. The relationship between body mass index and mortality is not linear in patients requiring venovenous extracorporeal support. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01117-0. [PMID: 38042401 PMCID: PMC11136873 DOI: 10.1016/j.jtcvs.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/03/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Morbid obesity may influence candidacy for venovenous extracorporeal membrane oxygenation (VVECMO) support. Indeed, body mass index (BMI) >40 is considered to be a relative contraindication due to increased mortality observed in patients with BMI above this value. There is scant evidence to characterize this relationship beyond speculating about the technical challenges of cannulation and difficulty in optimizing flows. We examined a national cohort to evaluate the influence of BMI on mortality in patients requiring VVECMO for severe acute respiratory syndrome coronavirus 2 infection. METHODS We performed a retrospective cohort analysis on National COVID Cohort Collaborative data evaluating 1,033,229 patients with BMI ≤60 from 31 US hospital systems diagnosed with severe acute respiratory syndrome virus coronavirus 2 infection from September 2019 to August 2022. We performed univariate and multivariable mixed-effects logistic regression analysis on data pertaining to those who required VVECMO support during their hospitalization. A subgroup risk-adjusted analysis comparing ECMO mortality in patients with BMI 40 to 60 with the 25th, 50th, and 75th BMI percentile was performed. Outcomes of interest included BMI, age, comorbidity score, body surface area, and ventilation days. RESULTS A total of 774 adult patients required VVECMO. Of these, 542 were men, median age was 47 years, mean adjusted Charlson Comorbidity Index was 1, and median BMI was 33. Overall mortality was 47.8%. There was a nonsignificant overall difference in mortality across hospitals (SD, 0.31; 95% CI, 0-0.57). After mixed multivariable logistic regression analysis, advanced age (P < .0001) and Charlson Comorbidity Index (P = .009) were each associated with increased mortality. Neither gender (P = .14) nor duration on mechanical ventilation (P = .39) was associated with increased mortality. An increase in BMI from 25th to 75th percentile was not associated with a difference in mortality (P = .28). In our multivariable mixed-effects logistic regression analysis, there exists a nonlinear relationship between BMI and mortality. Between BMI of 25 and 32, patients experienced an increase in mortality. However, between BMI of 32 and 37, the adjusted mortality in these patients subsequently decreased. Our subgroup analysis comparing BMIs 40 to 60 with the 25th, 50th, and 75th percentile of BMI found no significant difference in ECMO mortality between BMI values of 40 and 60 with the 25th, 50th, 75th percentile. CONCLUSIONS Advancing age and higher CCI are each associated with increased risk for mortality in patients requiring VVECMO. A nonlinear relationship exists between mortality and BMI and those between 32 and 37 have lower odds of mortality than those between BMI 25 and 32. This nonlinear pattern suggests a need for further adjudication of the contraindications associated with VVECMO, particularly those based solely on BMI.
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Affiliation(s)
- Elwin Tham
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Stuart Campbell
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Heather Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Jeffrey Ammons
- West Virginia Clinical and Translational Science Institute, Morgantown, WVa
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, Morgantown, WVa
| | - Penny Sappington
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa.
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Rudym D, Pham T, Rackley CR, Grasselli G, Anderson M, Baldwin MR, Beitler J, Agerstrand C, Serra A, Winston LA, Bonadonna D, Yip N, Emerson LJ, Dzierba A, Sonett J, Abrams D, Ferguson ND, Bacchetta M, Schmidt M, Brodie D. Mortality in Patients with Obesity and Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation: The Multicenter ECMObesity Study. Am J Respir Crit Care Med 2023; 208:685-694. [PMID: 37638735 PMCID: PMC10515561 DOI: 10.1164/rccm.202212-2293oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/19/2023] [Indexed: 08/29/2023] Open
Abstract
Rationale: Patients with obesity are at increased risk for developing acute respiratory distress syndrome (ARDS). Some centers consider obesity a relative contraindication to receiving extracorporeal membrane oxygenation (ECMO) support, despite growing implementation of ECMO for ARDS in the general population. Objectives: To investigate the association between obesity and mortality in patients with ARDS receiving ECMO. Methods: In this large, international, multicenter, retrospective cohort study, we evaluated the association of obesity, defined as body mass index ⩾ 30 kg/m2, with ICU mortality in patients receiving ECMO for ARDS by performing adjusted multivariable logistic regression and propensity score matching. Measurements and Main Results: Of 790 patients with ARDS receiving ECMO in our study, 320 had obesity. Of those, 24.1% died in the ICU, compared with 35.3% of patients without obesity (P < 0.001). In adjusted models, obesity was associated with lower ICU mortality (odds ratio, 0.63 [95% confidence interval, 0.43-0.93]; P = 0.018). Examined as a continuous variable, higher body mass index was associated with decreased ICU mortality in multivariable regression (odds ratio, 0.97 [95% confidence interval, 0.95-1.00]; P = 0.023). In propensity score matching of 199 patients with obesity to 199 patients without, patients with obesity had a lower probability of ICU death than those without (22.6% vs. 35.2%; P = 0.007). Conclusions: Among patients receiving ECMO for ARDS, those with obesity had lower ICU mortality than patients without obesity in multivariable and propensity score matching analyses. Our findings support the notion that obesity should not be considered a general contraindication to ECMO.
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Affiliation(s)
- Darya Rudym
- Department of Medicine, New York University Langone Health, New York, New York
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, Assistance Publique–Hôpitaux de Paris, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm U1018, Equipe d’Epidémiologie Respiratoire Intégrative, Centre d’Épidémiologie et de Santé des Populations, Villejuif, France
| | | | - Giacomo Grasselli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michaela Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew R. Baldwin
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jeremy Beitler
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Alexis Serra
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Desiree Bonadonna
- Perfusion Services, Duke University Health System, Durham, North Carolina
| | - Natalie Yip
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Logan J. Emerson
- Duke Respiratory Care Services, Duke University Hospital, Durham, North Carolina
| | - Amy Dzierba
- Center for Acute Respiratory Failure and
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | | | - Darryl Abrams
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Department of Physiology, and
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Respirology, University Health Network and Sinai Health, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt Medical Center East, Nashville, Tennessee
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30 RESPIRE, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris Hôpital Pitié–Salpêtrière, Paris, France; and
| | - Daniel Brodie
- Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Maryland
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Prasad NR, Elkholey K, Patel NR, Junqueira E, Cohen ES, Whitmore SP. Obesity associated with improved mortality of extracorporeal membrane oxygenation for severe COVID-19 pneumonia. Perfusion 2023:2676591231178896. [PMID: 37229525 PMCID: PMC10225801 DOI: 10.1177/02676591231178896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Determining a patient's candidacy for extracorporeal membrane oxygenation (ECMO) in severe COVID-19 pneumonia is a critical aspect of efficient healthcare delivery. A body mass index (BMI) ≥40 is considered a relative contraindication for ECMO by the Extracorporeal Life Support Organization (ELSO). We sought to determine the impact of obesity on the survival of patients with COVID-19 on ECMO. METHODS This project was a retrospective review of a multicenter US database from January 2020 to December 2021. The primary outcome was in-hospital mortality after ECMO initiation, with a comparison between patients classified into body mass index categories (<30, 30-39.9, and ≥40). Secondary outcomes included ventilator days, intensive care days, and complications. RESULTS We completed records review on 359 patients, with 90 patients excluded because of missing data. The overall mortality for the 269 patients was 37.5%. Patients with a BMI <30 had higher odds of mortality compared to all patients with BMI >30 (OR 1.98; p = 0.013), those with BMI 30-39.9 (OR 1.84; p = 0.036), and BMI ≥40 (OR 2.33; p = 0.024). There were no differences between BMI groups for ECMO duration; length of stay (LOS); or rate of bloodstream infection, stroke, or blood transfusion. Age, ECMO duration, and modified-Elixhauser index were not independent risk factors for mortality. CONCLUSIONS In patients receiving ECMO for severe COVID-19, neither obesity (BMI >30) nor morbid obesity (BMI >40) were associated with in-hospital mortality. These results are consistent with previous reports and held true after adjusting for age and comorbidities. Our data suggest further examination of the recommendations to withhold ECMO in patients who are obese.
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Affiliation(s)
- Navin R Prasad
- Department of Internal Medicine, TriStar Centennial Medical Center, Nashville, TN, USA
| | - Khaled Elkholey
- Department of Internal Medicine, TriStar Centennial Medical Center, Nashville, TN, USA
| | - Nilay R Patel
- Department of Internal Medicine, TriStar Centennial Medical Center, Nashville, TN, USA
| | | | - Elliott S Cohen
- Department of Critical Care Medicine, TriStar Centennial Medical Center, Nashville, TN, USA
| | - Sage P Whitmore
- Department of Critical Care Medicine, TriStar Centennial Medical Center, Nashville, TN, USA
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