PURPOSE: Morbid obesity poses challenges to the diagnosis and management of critical care conditions. Acute pulmonary embolism (PE) requires expedited evaluation that may be delayed by challenges posed by morbid obesity. Patients with morbid obesity may have difficulty fitting into CT machines, and vascular access for anticoagulation may be challenging. We evaluated the relationship between morbid obesity and the timing of acute PE diagnosis and management.
METHODS: We conducted a retrospective review of 400 patients who presented to a tertiary care emergency department, were diagnosed with acute PE by computer tomography (CT) angiography, and were treated with intravenous weight-based heparin. The time to diagnosis was defined by ED arrival to the time of CT diagnosis. Morbid obesity was defined as a body mass index (BMI) >40 kg/m2. Delayed diagnosis was defined as a CT obtained >12 hours after arrival. A multiple regression model was created with other variables associated with the timing of diagnosis and severity of illness. Median values, odds ratios (OR), intra-quartile ranges (IQR), and 95% confidence intervals (CI) are reported.
RESULTS: The median BMI was 29.5 (IQR 25.4 - 35.1), and 46 patients (12.0%) had BMI >40. The median time from arrival to diagnosis was 2.4 hours (IQR 1.4 - 7.6), and 73 patients (18.3%) had delayed diagnosis. Morbid obesity was a univariate risk for delayed diagnosis (OR 2.2, 95% CI 1.1 - 4.4; p=0.040). In multiple regression modeling including age, hypotension, coronary disease, COPD, deep vein thrombosis, Wells score >4, and malignancy, morbid obesity remained associated with delayed diagnosis (OR 1.7, 95% CI 1.0 - 2.8; p=0.046). Patients with morbid obesity had a longer time from arrival to heparin administration (median 3.6 [IQR 2.1 - 15.6] vs. 2.5 [1.7 - 3.6] hours, p=0.0061).
CONCLUSION: Morbid obesity was associated with delayed diagnosis and management of acute PE.
CLINICAL IMPLICATIONS: When patients present with acute cardiopulmonary symptoms, PE should be considered early in order to expedite evaluation and management.
DISCLOSURE: Sean Smith, No Financial Disclosure Information; No Product/Research Disclosure Information