From the Guidelines
The prognosis for severe dashboard injuries in morbidly obese patients weighing 150 kg or more is generally poorer compared to non-obese patients, with increased risk of complications and prolonged recovery periods. According to the study by the Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia 1, outcomes of obese patients in critical care remain controversial, but obesity is associated with a prolonged requirement for mechanical ventilation, tracheostomy, and prolonged length of stay in a critical care unit.
Key Considerations
- Airway interventions in the obese are associated with an increased risk of hypoxia and complications, and should only be undertaken by appropriately skilled personnel 1.
- Mechanical ventilation requires careful calculation of tidal volume based on ideal body weight to avoid peak inspiratory pressures exceeding 35 cmH2O 1.
- Enteral absorption of drugs is not altered in the morbidly obese, but monitoring of serum levels is crucial to ensure therapeutic ranges are maintained due to altered pharmacokinetics 1.
- Prophylaxis against venous thromboembolism (VTE) is vital, and early aggressive rehabilitation and physiotherapy are essential to prevent complications and promote early mobilization 1.
Management Strategies
- Custom-made tracheostomy tubes with adjustable flanges may be necessary to ensure adequate length and fit 1.
- Hypocaloric feeding regimens can achieve adequate nitrogen balance with more favorable outcomes in critically ill obese patients 1.
- Multidisciplinary care involving trauma surgeons, bariatric specialists, nutritionists, and physical therapists is crucial for optimizing outcomes in these complex cases.
Complications and Challenges
- Deep vein thrombosis, pulmonary embolism, wound infections, and respiratory issues are more frequent in morbidly obese patients with dashboard injuries.
- Specialized bariatric equipment and modified surgical approaches may be required, and higher doses of medications calculated based on actual or adjusted body weight may be necessary.
From the Research
Severe Dashboard Injury in Morbidly Obese Patients
Prognosis
- Morbidly obese patients (body mass index >40 kg/m2) admitted to intensive care units have higher rates of mortality, nursing home admission, and intensive care unit complications, and have longer stays in the intensive care unit and time on mechanical ventilation 2.
- The impact of obesity in critically ill patients may vary by type of critical illness, obesity severity, and obesity-associated co-morbidities, with critically ill obese patients being at higher risk for acute cardiovascular, pulmonary, and renal complications in comparison to non-obese patients 3.
- Morbidly obese patients present significant physical and language challenges for intensive care practice, requiring staff to adapt care practices and use specific knowledge of the patient's body size and shape to keep patients safe and comfortable 4.
- Haemodynamic monitoring of morbidly obese intensive care unit patients may be challenging due to technical and practical difficulties, but the interpretation of haemodynamic data should not be different from that in non-obese patients when indexed for body surface area or predicted lean body mass 5.
- The choice of opioid infusion agent, such as fentanyl versus morphine, may affect clinical outcomes in mechanically ventilated patients, with fentanyl infusion significantly increasing the median number of ventilator-free days at Day 28 6.