Introduction: Obesity in critically ill remains a challenge in terms of effective hemodynamic monitoring, imaging, pharmaceutical therapy, and the diverse tasks performed by nursing staff.
Description: A 46-year-old male with COPD and morbid obesity (BMI 76.3 kg/m²) presented with 5 days of dyspnea, fever, malaise, and dry cough. Exam revealed respiratory distress, bilateral crackles, and pitting edema. Oxygen saturation was 92% on 4L NC. Labs: WBC 18.6 (left shift), lactic acidosis, D-dimer 2.1. ABG showed chronic respiratory acidosis with metabolic alkalosis. EKG noted atrial fibrillation with RVR. Troponin was elevated, BNP was normal, and echocardiogram was limited. CXR demonstrated bilateral consolidations and vascular congestion. Wells/Geneva scores suggested pulmonary embolism (PE), but CT/V/Q scans were impossible due to body habitus. Venous duplex was limited. After intubation, care relied on CXR/ultrasound. Treated for pneumonia (meropenem/vancomycin/doxycycline) and empiric enoxaparin (0.67 mg/kg) for suspected PE/DVT. He died after 57 days in ICU with multiorgan failure.
Discussion: This case highlights critical barriers in managing extreme obesity, where the obesity paradox was not observed. Instead, diagnostic limitations due to body habitus—including inability to perform CT-PE, V/Q scans, or adequate venous duplex—directly impacted care. Only 10% of nonacademic and 28% of academic hospitals have bariatric-capable CT scanners, delaying life-saving interventions. The lack of universal guidelines for weight-based drug dosing (e.g., enoxaparin) and empiric anticoagulation challenges further complicated therapy. Comorbidities like COPD and atrial fibrillation, combined with acute sepsis and suspected PE, accelerated mortality, underscoring how extreme obesity exacerbates risk beyond the paradox. Obesity-driven comorbidities (e.g., diabetes, OSA) contribute to higher death rates, while environmental constraints in diagnostics/therapeutics remain underaddressed. We emphasize the urgent need for bariatric-capable imaging equipment, standardized protocols for pharmacotherapy, and specialized training for ICU teams to mitigate these gaps.
