Category: Professional Posters
Title: Management of Pickwickian syndrome in obese patients
Authors: Pritesh Kalola, Pharmacy Student1; Amy Li, PharmD2, Simon Tarpav, PharmD2
1Mercer University, WellStar Atlanta Medical Center, Atlanta, GA
2WellStar Atlanta Medical Center, Atlanta, GA
LH is a 49 y.o. female with a past medical history of diabetes mellitus, hypertension, ovarian cancer, thyroid cancer, chronic deep vein thrombosis, opioid abuse, osteoarthritis and Pickwickian syndrome (i.e. Obesity Hypoventilation Syndrome or OHS). The patient is currently morbidly obese at 184 kg (405 lbs) and has multiple admissions for hypercapnic respiratory failure. For the patient’s current admission, her chief complaint was altered mental status. The patient reported taking MS Contin, Percocet, Neurontin and Klonopin before boarding the airplane. Upon arrival in the ED, the patient’s blood pressure was 159/91 mmHg, ABG: pO2-61, pCO2-65, pH-7.33, HCO3-34, O2 sat -88%. The patient was placed on biPAP for OHS. At admission, the patient also experienced encephalopathy and hypercapnic condition due to her Pickwickian syndrome as well as the adverse effects of multiple pain medications. Pickwickian syndrome can cause hypoventilation leading to low O2 and high CO2 levels. Cardinal symptoms of OHS include daytime sleepiness, lack of energy, breathlessness, and nighttime snoring. There isn’t a specific cause for OHS, but studies indicate that morbidly obese patients have the highest risk of developing OHS, which can worsen over time if left untreated. Due to the lack of effective blood circulation in OHS, vital organs cannot get adequate oxygen supply in areas such as the brain, heart, joints and other essential organs. Thus, secondary health complications can develop, such as hypertension, diabetes mellitus, altered mental status, and osteoarthritis.
Literature recommends that optimal management for OHS patients is the multidisciplinary approach with different medical and possibly surgical interventions. The first line treatment option recommended is extensive weight loss management. Diet, exercise, and sufficient sleep are recommended for weight loss treatment. The patient is currently managed by strict protein and calories diet. Upon discharge, the weight loss management education will be counseled to patient and family caregivers. The second suggested treatment is the positive pressure ventilation (PAP), which improves gas exchange and functional status in patients with chronic respiratory failure. It also alleviates daytime and nocturnal symptoms. The patient PaCO2 and PaO2 levels have improved with the use of BiPAP compared to the levels at admission. As far as pharmacological intervention, two agents were previously used for OHS treatment. They were medroxyprogesterone and acetazolamide. Medroxyprogesterone increases ventilation rates, which helps to drop the PaCO2 level and raise the PaO2 level. Acetazolamide is a weak diuretic that drives mild metabolic acidosis leading to a rise in minute ventilation. Thus, it leads to a reduction in the PaCO2 level. However, due to non-existent long-term safety data, we currently do not recommend either agent for treatment of OHS. The best available treatment approaches which remain for OHS are weight reduction and positive air pressure.
The patient’s encephalopathy and hypercapnia associated with Pickwickian syndrome have improved. Compared to PaCO2 and PaO2 levels at admission, current PaCO2 and PaO2 levels have improved with BiPAP therapy. Additionally, weight reduction therapy should be counseled to the patient. By losing weight and maintaining an ideal body weight, the patient’s other chronic conditions will also improve.