Indexed hemodynamic measurements may be inappropriate at body surface area extremes
© BioMed Central Ltd 2012
Published: 4 September 2012
As the epidemic of obesity and morbid obesity  spreads and as more obese patients require intensive care, it is important to use appropriately body surface area (BSA) indexed hemodynamic measurements . The idea of adjusting for variation in heights and weights while making comparisons was first described by DuBois and Dubois in 1916. Unfortunately, they derived their widely used formula based on only nine patients, none of whom were morbidly obese. Since then, multiple formulae have been proposed based on larger sample sizes, including those by Mosteller, Haycock, Gehan and George, Boyd, Fujimoto, and Livingston . Only Livingston and colleagues made an explicit effort to include obese patients when deriving a BSA formula.
The best way to treat the morbidly obese critically ill patient is an active area of research. Generally, one does not treat the numbers knowing that BSA formulae are not empirically derived from a morbidly obese population. Livingston found that the DuBois and Dubois equation underestimated BSA by as much as 20% in obese patients , while Verbraecken and colleagues found a smaller but still significant underestimation in obese patients with this formula. Most hemodynamic monitors such as Vigileo®, LiDCO® and PiCCO® use the DuBois and DuBois formula to derive BSA, while the NiCOM® monitor uses the Mosteller formula .
We encourage colleagues to be aware of the extent of variation in the derivation of BSA, of the likelihood that the most commonly used formula is not appropriate for use in the morbidly obese patient population and of the fact that indexed measurements reported by typical monitors are not validated in the vulnerable morbidly obese population. We further recommend the use of unindexed values in the very morbidly obese.
body surface area.
- Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, Moore SC, Tobias GS, Anton-Culver H, Freeman LB, Beeson WL, Clipp SL, English DR, Folsom AR, Freedman DM, Giles G, Hakansson N, Henderson KD, Hoffman-Bolton J, Hoppin JA, Koenig KL, Lee IM, Linet MS, Park Y, Pocobelli G, Schatzkin A, Sesso HD, Weiderpass E, Willcox BJ, Wolk A, Zeleniuch-Jacquotte A, Willett WC, Thun MJ: Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010, 363: 2211-2219. 10.1056/NEJMoa1000367.View ArticlePubMed
- Westerly BD, Dabbagh O: Morbidity and mortality characteristics of morbidly obese patients admitted to hospital and intensive care units. J Crit Care. 2011, 26: 180-185. 10.1016/j.jcrc.2010.09.005.View ArticlePubMed
- Verbraecken J, Van de Heyning P, De Backer W, Van Gaal L: Body surface area in normal-weight, overweight, and obese adults. A comparison study. Metabolism. 2006, 55: 515-524. 10.1016/j.metabol.2005.11.004.View ArticlePubMed
- Livingston EH, Lee S: Body surface area prediction in normal-weight and obese patients. Am J Physiol Endocrinol Metab. 2001, 281: E586-E591.PubMed
- Cannesson M, Pestel G, Ricks C, Hoeft A, Perel A: Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care. 2011, 15: R197-10.1186/cc10364.PubMed CentralView ArticlePubMed