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BMJ Case Rep. 2010; 2010: bcr09.2009.2257.
Published online Mar 30, 2010. doi:  10.1136/bcr.09.2009.2257
PMCID: PMC3027523
Novel treatment (new drug/intervention; established drug/procedure in new situation)
Early mobilisation of intensive care unit patient: the challenges of morbid obesity and multiorgan failure
Radha Korupolu,1 Jennifer M Zanni,2 Eddy Fan,1 Martha Butler,2 and Dale M Needham1,3
1Johns Hopkins University, Pulmonary and Critical Care Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
2Johns Hopkins Hospital, Physical Medicine and Rehabilitation, Baltimore, MD 21205, USA
3Johns Hopkins University, Physical Medicine and Rehabilitation, Baltimore, MD 21205, USA
Correspondence to Dale M Needham, dale.needham/at/jhmi.edu
Abstract
A 44-year-old morbidly obese (body mass index 69 kg/m2) woman presented to our medical intensive care unit (ICU) with septic shock and multiorgan failure requiring mechanical ventilation, a vasopressor infusion, and haemodialysis. Before this admission, the patient reported being able to ambulate approximately 3 m with a walker. Intensive physical therapy was started on ICU day 2, and the patient was successfully mobilised throughout her ICU stay despite the extreme challenges posed by her morbid obesity and critical illness. After only a 9 day stay, the patient was discharged directly home from the medical ICU, walking a total distance of 37 m in a single physical therapy session.
The prevalence of obesity has risen dramatically over recent decades. Approximately 25% of patients in intensive care units (ICUs) are obese and nearly 7% are morbidly obese, with these rates projected to increase further.1,2 Critical illness in patients with morbid obesity presents unique challenges, including respiratory failure requiring prolonged ventilation, thromboembolic disease, pressure ulcers, greatly impaired physical function, and prolonged ICU and hospital length of stay.1,3 There is growing evidence to support the feasibility, safety, and benefits of early mobilisation of critically ill patients46; however, to our knowledge, the specific challenges and potential benefits of this approach to ICU care have not been specifically described in the context of patients with morbid obesity.
A 44-year-old woman with morbid obesity (body mass index 69 kg/m2; weight 191 kg; height 168 cm) and a past medical history of hypoventilation syndrome (requiring ventilatory support at night via tracheostomy (ventilator model-LTV 950, mode synchronised intermittent mandatory ventilation (SIMV), fractional inspired oxygen (FiO2) 30%, tidal volume 600 ml, and pressure support 12 cm H20)), diabetes, systemic hypertension, and chronic venothrombolic disease on anticoagulation therapy presented to the Johns Hopkins Hospital with cough, shortness of breath, chest discomfort, poor oral intake, and decreased mental status. Before admission, the patient could ambulate approximately 3 m with a walker, but reported using a wheelchair for general mobility. In the emergency department, the patient had fever (38.1°C), hypotension (80/62 mm Hg), tachycardia (110/min), tachypnoea (respiratory rate 24/min), and hypoxia (oxygen saturation 81% on room air). Respiratory examination was remarkable for obese body habitus, respiratory distress and diminished breath sounds.
Laboratory examination revealed leucocytosis (white blood cell count (WBC) 13.1×109/l), hyperkalaemia (serum potassium 5.7 mmol/l), and acute renal failure (serum creatinine 259 µmol/l and serum urea 10.7 mmol/l). Arterial blood gas analysis was as follows: pH=7.11, partial pressure of carbon dioxide (PCO2) 12.4 kPa (93 mm Hg), partial pressure of oxygen (PO2) 9.4 kPa (71 mm Hg), and bicarbonate 28 mmol/l on FiO2 of 1.0. A chest x-ray showed pronounced lung hypoinflation and cardiomegaly, but any additional evaluation was greatly limited due to the patient’s morbid obesity. Blood cultures were negative. Tracheal culture from the lower respiratory tract was positive for light–moderate Staphylococcus aureus.
Differential diagnosis
Septic shock with multiorgan failure including acute on chronic respiratory failure and acute renal failure was the presumed diagnosis at presentation.
The patient was transferred to the medical ICU for further management (table 1). In the medical ICU, the patient received mechanical ventilatory support via her pre-existing tracheostomy (obviating the need for endotracheal intubation and potentially higher levels of sedation) and placement of central venous and dialysis catheters for vasopressor and haemodialysis therapies which were provided for the first 48–72 h. On ICU day 2, a physiotherapist (PT) was consulted and the patient sat at the edge of bed with assistance. With the interdisciplinary team efforts of a PT, respiratory therapist (RT), and nurse, the patient received twice daily PT sessions and continued to increase her mobility despite requiring mechanical ventilation and ICU medical care. The patient’s activity events with PT included: therapeutic exercises, sitting on the edge of the bed, mobilisation from sitting to standing, sitting in a chair, and ambulation. During all treatments, the patient’s heart rate, respiratory rate and oxygen saturation were continuously monitored to ensure patient safety.
Table 1
Table 1
Physical medicine and rehabilitation interventions in medical intensive care unit
Outcome and follow-up
Continuous mechanical ventilation was discontinued on ICU day 6. On day 7, the patient walked a total distance of 37 m with two rest breaks and propelled a wheel chair for >23 m in a single PT session. There were no complications associated with any of the ICU PT sessions. On day 9, the patient was discharged to home directly from the medical ICU (without a stay on the ward or in a rehabilitation facility) with continued PT via homecare.
Critically ill patients are frequently exposed to prolonged bed rest in the ICU, which may play a significant role in ICU acquired neuromuscular complications.7 Obesity may further contribute to the harmful effects of bed rest including skin breakdown, deconditioning, deep vein thrombosis, and pulmonary complications (eg, atelectasis, prolonged mechanical ventilation, exacerbation of pre-existing obesity hypoventilation syndrome). Early mobilisation of critically ill, morbidly obese patients aims to maintain and improve physical function and prevent new complications associated with bed rest and obesity. To our knowledge there are no previously published studies or case reports that specifically assessed early mobility therapy in critically ill patients with morbid obesity. However, a study of 103 respiratory ICU patients that included morbidly obese patients (6% of sample) demonstrated the safety, feasibility, and functional benefits of early mobility therapy.4
In our case we report that, with interdisciplinary teamwork, early mobility therapy in a critically ill, morbidly obese patient was safe and feasible. The patient experienced no hospital acquired complications, had a relatively short length of stay, and discharged to home with improved ambulation over her pre-hospital baseline status.
Learning points
  • Early mobility therapy in patients with critical illness and morbid obesity may prevent complications associated with bed rest and obesity.
  • Intensive and early physical therapy in the intensive care unit is feasible, safe, and beneficial even in a patient with morbid obesity and multiorgan failure.
  • Interdisciplinary team work is key for successful delivery of early mobility therapy in morbidly obese patients with critical illness.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
1. Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med 2008; 36: 151–8. [PubMed]
2. Oliveros H, Villamor E. Obesity and mortality in critically ill adults: a systematic review and meta-analysis. Obesity (Silver Spring) 2008; 16: 515–21. [PubMed]
3. Charlebois D, Wilmoth D. Critical care of patients with obesity. Crit Care Nurse 2004; 24: 19–27. [PubMed]
4. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35: 139–45. [PubMed]
5. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36: 2238–43. [PubMed]
6. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373: 1874–82. [PubMed]
7. Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 2008; 300: 1685–90. [PubMed]
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