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A7044 - Weighing the Risks - Evaluation and Treatment for PE in the Super-Obese
Author Block: R. Hilton1, M. Baskind2, B. Hehn1; 1Pulmonary Critical Care, Thomas Jefferson University, Philadelphia, PA, United States, 2Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, United States.
INTRODUCTION: Super obesity describes an obese body habitus with life limiting severity. Current estimates are up to 50,000 Americans fall into this weight classification, with a BMI greater than 50. While there are many cases of patients requiring transport via forklift and scans using Zoo equipment, these are evaluative options that are not available in the acutely ill patient. We present the case of a patient weighing 744lbs who presented with concern for pulmonary embolism, and detail the numerous challenges to evaluation and treatment.
CASE: A 23-year-old male with history of obesity (BMI 113) with multiple pulmonary complications including OSA, OHS, chronic leg wounds, restrictive lung disease and pulmonary hypertension, who presented to the hospital with sepsis related to his chronic wounds. During hospitalization, the patient developed new onset tachycardia and hypoxia with concern for pulmonary embolism. A D-dimer was elevated, and given his age he was appreciated to be intermediate risk. CT-angiogram was contraindicated as the patient exceeded the weight maximum of the scanner. VQ scan table and IR venogram fluoroscopy tables could not accommodate his weight as well. Ultrasound of the lower extremities was indeterminate due to body habitus. Cardiac echo had poor visualization but showed possibly acute elevation of chronic pulmonary hypertension. While the patient had been on DVT prophylaxis therapy, it was unclear whether the appropriate dosing was meaningful at his weight. The determination was made to initiate anticoagulation, however choices were limited. Heparin was initiated and transitioned to warfarin which was well tolerated. Follow up echocardiogram two weeks later showed reduced pulmonary arterial pressures.
DISCUSSION: This case illustrates the challenges in the diagnostic evaluation of the super-obese patient. Recent estimates of obesity related medical costs from the CDC exceed 147 billion dollars, with obese patient care being $1429 more annually than those with normal weight. Estimates for the super-obese could be orders of magnitude higher, but data is limited. Hospitals across America have made accommodations including bariatric beds, open imaging suites, and high capacity tables and scanners. Despite this, caregivers can feel paralyzed while caring for the super-obese. Frequently, as in the case of PE, medical decisions are required without the benefit of modern medical testing, and without the utility of modern treatments. In this way, super-obese patients are unique in that they have high medical needs, limited diagnostic and treatment options, and challenge caregivers make decisions on presumed risks and limited data.