Difficulties in managing the surgical patient who is morbidly obese

Managing patients who are morbidly obese in the intensive care unit is associated with a variety of problems uncommonly experienced with the those who are not morbidly obese. Clinicians experience a myriad of unique problems and circumstances, from the need for special beds and lifts to unusual and unknown volumes of distribution resulting in unclear drug dosing. This review examines several issues including sedation, invasive monitoring, venous thromboembolism prophylaxis, surgical infections, nutritional support, and other complications that may be of particular importance to the critically ill patient who is morbidly obese. In many cases, care is altered based on the complicating issues surrounding morbid obesity. In other cases, the presence of obesity suggests no alterations in our routine critical care delivery. A comprehensive review of the literature is undertaken, data are critically considered, and overall opinion is rendered based on the available peer-reviewed literature. In many cases, data are not available that address the specific patient population in question, so related papers (like gastric bypass data) are considered. Many issues do not have definitive answers based on randomized controlled trials, and much is left to treating clinician opinion and local practice patterns. Where good data exist, however, one should consider carefully and individually deviation from the evidence-based approach.