title: Disparities in hemodynamic resuscitation of the obese critically ill septic shock patient.
abstract: With a growing obesity epidemic, the approach to care of this patient remains controversial and in many circumstances different than the general population. Appropriate hemodynamic support, although still controversial, remains a cornerstone of septic shock therapy. Catecholamines are currently recommended by guidelines without a preferred dosing strategy. However, the use of weight-based (μg kg-1min-1) or nonweight-based (μg/min) vasopressor drip rates may impact patient care in these populations.
  
  
  
  A multicenter retrospective chart review was conducted. Patients receiving nonweight-based catecholamine infusions for septic shock were grouped into nonobese (n = 112) or obese (n = 196), and evaluated based on hemodynamic resuscitation. For the primary outcome, groups were analyzed for the requirement of a secondary hemodynamic support agent to obtain a goal mean arterial pressure of greater than or equal to 65 mm Hg. Secondary outcomes included an evaluation of time to a secondary hemodynamic support agent, time to hemodynamic stability (HDS), ability to obtain HDS at 24 hours, and death due to cardiovascular collapse.
  
  
  
  With the exception of weight and sex, baseline characteristics were similar among groups. Early resuscitative fluids were given at a lower weight based, but not total volume dose in the obese group (nonobese, 34.8 mL/kg vs obese, 22.4 mL/kg; P < .0001). The primary end point of addition of any secondary hemodynamic support agent was significantly greater in obese patients when adjusted for institution (nonobese, 19% vs obese, 27%; adjusted odds ratio, 0.42; 95% confidence interval, 0.23-0.77). Time to HDS was also prolonged (nonobese, 3.5 hours vs obese, 5.3 hours; P = .006).
  
  
  
  This study calls into question the adequacy of a nonweight-based approach to hemodynamic support of critically ill obese patients. This strategy seems to result in less aggressive, lower weight-based vasopressor and fluid doses, and more diverse approach than their nonobese counterparts.
authors.affiliation: St Vincent's Medical Center Riverside, Jacksonville, FL 32204.
authors.forename: Chere
authors.initials: C
authors.lastname: Adams
authors.affiliation: St Vincent's Medical Center Riverside, Jacksonville, FL 32204.
authors.forename: Calvin
authors.initials: C
authors.lastname: Tucker
authors.affiliation: St Vincent's Medical Center Riverside, Jacksonville, FL 32204.
authors.forename: Bryan
authors.initials: B
authors.lastname: Allen
authors.affiliation: UF Health Jacksonville, Jacksonville, FL 32209.
authors.forename: Andrew
authors.initials: A
authors.lastname: McRae
authors.affiliation: UF Health Jacksonville, Jacksonville, FL 32209.
authors.forename: Julia
authors.initials: J
authors.lastname: Balazh
authors.affiliation: UF Health Jacksonville, Jacksonville, FL 32209.
authors.forename: Spencer
authors.initials: S
authors.lastname: Horst
authors.affiliation: UF Health Jacksonville, Jacksonville, FL 32209.
authors.forename: Donald
authors.initials: D
authors.lastname: Johnson
authors.affiliation: UF Health Jacksonville, Jacksonville, FL 32209. Electronic address: Jason.ferreira@jax.ufl.edu.
authors.forename: Jason
authors.initials: J
authors.lastname: Ferreira
mesh_terms: D000368:Aged; D062186:Arterial Pressure; D001835:Body Weight; D002395:Catecholamines / Q000008:administration & dosage*; D002423:Cause of Death; D015897:Comorbidity; D016638:Critical Illness; D054796:Drug Dosage Calculations; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009765:Obesity / Q000453:epidemiology / Q000503:physiopathology*; D012151:Resuscitation; D012189:Retrospective Studies; D012769:Shock / Q000401:mortality; D012772:Shock, Septic / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D002395:Catecholamines; D014662:Vasoconstrictor Agents
keywords: Catecholamine; Hemodynamics; Obesity; Shock; Vasoactive agents