Author Credentials

Yasir Jawaid MD Waseem Ahmed MD Damir Kusmic MD Aman Ajmeri MD Kanaan Mansoor MD Cristie Mannino MD Thomas Judge MD Larry E. Carter DO Akash V. Ajmera MD




Background: Obesity is one of the most widespread epidemics of our time. In fact, currently 65.7% of US adults age 20 and older are overweight, while 30.6% are obese. It has been well-established that obesity has numerous adverse effects on long-term health, however the specific effect on patients treated for sepsis and septic shock is unclear. Body Mass Index (BMI) is a measure of total body fat content and surrogate marker for obesity. In our study, we aimed to identify if BMI was an independent risk factor for poor survival or increased length of stay (LOS) in patients with sepsis.

Methods: We retrospectively selected patients with diagnostic codes of sepsis and septic shock who were admitted to the ICU over three years. These patients were further separated into groups of alive and deceased. Based on their perceived association with mortality in sepsis, numerous variables were investigated, such as BMI, LOS, age, cirrhosis, chronic kidney disease (CKD), lactate, age, multiple organ dysfunction syndrome (MODS), and APACHE II scores. Specifically, BMI was classified into sub-groups, including underweight (BMI30).

The alive and deceased groups were initially compared for any significant differences with univariate analysis. Thereafter, the significant variables were analyzed using multivariate analysis to assess whether any were able to independently predict mortality in sepsis.

Results: Our study selected 293 patients with sepsis, including 185 alive and 108 deceased. Interestingly, our univariate analysis revealed that underweight and obese patients exhibited slightly less mortality in sepsis compared to normal and overweight patients. However, these results did not reach statistical significance, with a p-value of 0.30; this was confirmed in multivariate analysis, which resulted in a p-value of 0.08. Additionally, underweight, overweight, and obese patients had a slightly decreased median LOS in the ICU and hospital compared to patients with normal BMI. Nevertheless, these results were not significant either, with ICU LOS p-value of 0.22 and hospital LOS p-value of 0.45.

Univariate analysis identified certain variables that reached statistical significance, including cirrhosis (p2 (p=0.03), median lactate (p=0.05), age (p>.01), and APACHE II scores (p>0.01). Multivariate analysis of these variables established that only the presence of cirrhosis (p=0.03), age (p

Conclusion: The data suggests that normal BMI in patients with sepsis may result in increased mortality and LOS both in the ICU and hospital, though this was not statistically significant. Other variables that were significant independent predictors for mortality in sepsis were cirrhosis, mean age, and mean APACHE II score. As the obesity epidemic continues to rise, further inquiry into the association of BMI and mortality in sepsis is needed.

Conflict(s) of Interest


References with DOI

1. Arabi YM, Dara SI, Tamim HM, Rishu AH, Bouchama A, Khedr MK, et al. Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study. Critical care (London, England). 2013;17(2):R72. https://doi.org/10.1186/cc12680

2. Hossain P, Kawar B, El Nahas M. Obesity and diabetes in the developing world--a growing challenge. The New England Journal of Medicine. 2007;356(3):213-5. https://doi.org/10.1056/nejmp068177

3. Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366(9497):1640- 9. https://doi.org/10.1016/s0140-6736(05)67663-5

4. Al-Baghli NA, Al-Ghamdi AJ, Al-Turki KA, El-Zubaier AG, Al-Ameer MM, Al-Baghli FA. Overweight and obesity in the eastern province of Saudi Arabia. Saudi Medical Journal. 2008;29(9):1319-25.

5. Katzmarzyk PT, Reeder BA, Elliott S, Joffres MR, Pahwa P, Raine KD, et al. Body mass index and risk of cardiovascular disease, cancer and all-cause mortality. Canadian Journal of Public Health = Revue canadienne de sante publique. 2012;103(2):147-51.

6. Cole TJ, Faith MS, Pietrobelli A, Heo M. What is the best measure of adiposity change in growing children: BMI, BMI %, BMI z-score or BMI centile? European Journal of Clinical Nutrition. 2005;59(3):419-25. https://doi.org/10.1038/sj.ejcn.1602090

7. Nguyen AT, Tsai CL, Hwang LY, Lai D, Markham C, Patel B. Obesity and mortality, length of stay and hospital cost among patients with sepsis: a nationwide inpatient retrospective cohort study. PloS One. 2016;11(4):e0154599.

8. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical Care Medicine. 2001;29(7):1303-10. https://doi.org/10.1097/00003246-200107000-00002

9. Gaulton TG, Marshall MacNabb C, Mikkelsen ME, Agarwal AK, Cham Sante S, Shah CV, et al. A retrospective cohort study examining the association between body mass index and mortality in severe sepsis. Internal and Emergency Medicine. 2015;10(4):471-9. https://doi.org/10.1007/s11739-015-1200-1

10. Sakr Y, Madl C, Filipescu D, et al. Obesity is associated with increased morbidity but not mortality in critically ill patients. Intensive Care Med. 2008;34:1999–2009. https://doi.org/10.1007/s00134-008-1243-0

11. Martino JL, Stapleton RD, Wang M, Day AG, Cahill NE, Dixon AE, et al. Extreme obesity and outcomes in critically ill patients. Chest. 2011;140(5):1198-206. https://doi.org/10.1378/chest.10-3023

12. Hutagalung R, Marques J, Kobylka K, Zeidan M, Kabisch B, Brunkhorst F, et al. The obesity paradox in surgical intensive care unit patients. Intensive Care Medicine. 2011;37(11):1793-9. https://doi.org/10.1007/s00134-011-2321-2

13. Pepper DJ, Sun J, Welsh J, Cui X, Suffredini AF, Eichacker PQ. Increased body mass index and adjusted mortality in ICU patients with sepsis or septic shock: a systematic review and meta-analysis. Critical care (London, England). 2016;20(1):181. https://doi.org/10.1186/s13054-016-1360-z

14. Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a metaanalysis. Critical Care Medicine. 2008;36(1):151-8. https://doi.org/10.1097/01.ccm.0000297885.60037.6e

15. Siiteri PK. Adipose tissue as a source of hormones. The American Journal of Clinical Nutrition. 1987;45(1 Suppl):277-82. https://doi.org/10.1093/ajcn/45.1.277

16. Ahima RS, Flier JS. Adipose tissue as an endocrine organ. Trends in Endocrinology and Metabolism: TEM. 2000;11(8):327-32. https://doi.org/10.1016/s1043-2760(00)00301-5

17. Engeli S, Schling P, Gorzelniak K, Boschmann M, Janke J, Ailhaud G, et al. The adipose-tissue reninangiotensin-aldosterone system: role in the metabolic syndrome? The International Journal of Biochemistry & Cell Biology. 2003;35(6):807-25. https://doi.org/10.1016/s1357-2725(02)00311-4

18. Goossens GH, Blaak EE, van Baak MA. Possible involvement of the adipose tissue renin-angiotensin system in the pathophysiology of obesity and obesity-related disorders. Obesity Reviews : an official journal of the International Association for the Study of Obesity. 2003;4(1):43-55. https://doi.org/10.1046/j.1467-789x.2003.00091.x

19. Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, et al. A randomized trial of protocol-based care for early septic shock. The New England Journal of Medicine. 2014;370(18):1683-93. https://doi.org/10.1056/nejmoa1401602

20. Mathison JC, Ulevitch RJ. The clearance, tissue distribution, and cellular localization of intravenously injected lipopolysaccharide in rabbits. Journal of Immunology (Baltimore, Md : 1950). 1979;123(5):2133-43.

21. Ulevitch RJ, Johnston AR, Weinstein DB. New function for high density lipoproteins. Isolation and characterization of a bacterial lipopolysaccharide-high density lipoprotein complex formed in rabbit plasma. The Journal of Clinical Investigation. 1981;67(3):827-37. https://doi.org/10.1172/jci110100

22. Kim YC, Nishida T. Nature of the interaction of dextran sulfate with high and low density lipoproteins in the presence of Ca2+. The Journal of Biological Chemistry. 1979;254(19):9621-6.

23. Winkler G, Kiss S, Keszthelyi L, Sapi Z, Ory I, Salamon F, et al. Expression of tumor necrosis factor (TNF)-alpha protein in the subcutaneous and visceral adipose tissue in correlation with adipocyte cell volume, serum TNF-alpha, soluble serum TNF-receptor-2 concentrations and C-peptide level. European Journal of Endocrinology. 2003;149(2):129-35. https://doi.org/10.1530/eje.0.1490129

24. Dinarello CA. Proinflammatory cytokines. Chest. 2000;118(2):503-8. https://doi.org/10.1378/chest.118.2.503

25. De Jong A, Molinari N, Pouzeratte Y, Verzilli D, Chanques G, Jung B, et al. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. British Journal of Anaesthesia. 2015;114(2):297-306. https://doi.org/10.1093/bja/aeu373

26. De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, et al. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. American Journal of Respiratory and Critical Care Medicine. 2013;187(8):832-9. https://doi.org/10.1164/rccm.201210-1851oc

27. Bloomfield R, Steel E, MacLennan G, Noble DW. Accuracy of weight and height estimation in an intensive care unit: Implications for clinical practice and research. Critical Care Medicine. 2006;34(8):2153-7. https://doi.org/10.1097/01.ccm.0000229145.04482.93

28. Maskin LP, Attie S, Setten M, Rodriguez PO, Bonelli I, Stryjewski ME, et al. Accuracy of weight and height estimation in an intensive care unit. Anaesthesia and Intensive Care. 2010;38(5):930-4.

29. Leary TS, Milner QJ, Niblett DJ. The accuracy of the estimation of body weight and height in the intensive care unit. European Journal of Anaesthesiology. 2000;17(11):698-703. https://doi.org/10.1097/00003643-200011000-00008

30. Wacharasint P, Boyd JH, Russell JA, Walley KR. One size does not fit all in severe infection: obesity alters outcome, susceptibility, treatment, and inflammatory response. Critical Care (London, England). 2013;17(3):R122. https://doi.org/10.1186/cc12794

31. Ormsbee MJ, Prado CM, Ilich JZ, Purcell S, Siervo M, Folsom A, et al. Osteosarcopenic obesity: the role of bone, muscle, and fat on health. Journal of Cachexia, Sarcopenia and Muscle. 2014;5(3):183-9 https://doi.org/10.1007/s13539-014-0146-x

Included in

Critical Care Commons