jennifer l. gaudiani, md, ceds - iaedp · • a 23 year old started an intense workout program with...
TRANSCRIPT
Jennifer L. Gaudiani, MD, CEDSAssistant Medical Director, ACUTE
Associate Professor of Medicine, University of Colorado
Who are ACUTE patients?Who are ACUTE patients?pp
• 17‐65 years old (average 26)• 10% men• Average BMI on admission 12.5 kg/m2• Wide variety of pre admission function• Wide variety of pre‐admission function• Average length of stay around 2 weeks• From all over the country
Falling through the cracksFalling through the cracksg gg g
Too medically sick for me… ytoo mentally ill for you
Objectives: Motivation!Objectives: Motivation!jj
• Help empower you to translate to your p p y yclient:– The medical complications of severe caloricThe medical complications of severe caloric restriction and underweight
– The medical complications of severe purgingp p g g– The best practices of refeeding and detoxification from purging (advocate, p g g (educator)
– How to use knowledge of medical problems to promote recovery
Format: Discuss…Format: Discuss…
• Two cases• (Some) pathophysiologyp p y gy• Best practices to manage/fix• What we say to our patients• What we say to our patients• Literature/evidence
What is definitive stabilization?What is definitive stabilization?
• Use best medical evidence to provide safe• Use best medical evidence to provide safe, sensible, supported multidisciplinary care until patients meet our discharge criteria: p g– 2000‐3500 (oral) a day: sufficient to be gaining >1 kg lean weight weekly
– Labs normal or normalizing– Completed refeeding syndrome and no longer on electrolyte repletionelectrolyte repletion
– Bowels working, minimal edema (fluid overload)– Physically strong enough to transfer to mental health y y g gsetting
Medical complicationsMedical complicationspp
• In AN‐R– Organ dysfunction due to under‐weight and malnutrition
– High risk for refeeding syndrome
• In purging (AN or BN) – Type of purging used, frequency, and durationyp p g g , q y,– Detox can be complicated too
The good news:The good news:gg
Nearly all medical complications canNearly all medical complications can resolve with consistent nutrition and
full weight restorationfull weight restoration
Case: ANCase: AN‐‐RR
• A 23 year old started an intense workout program with her sorority sisters…couldn’t stop
• Over two years weight 34 kg 163 cm tall 60% IBW BMIOver two years, weight 34 kg, 163 cm tall, 60% IBW, BMI 12.5 kg/m2
• Insists on outpatient care the whole time• Has good energy and works full‐time, volunteers minimal
symptoms except early fullness when she eatsL b “fi ” j t i i h li t t d• Labs are fine …just some increase in her liver tests and a low white blood cell count
• Finally team and family insist on admission to a programy y p g
Case: ANCase: AN‐‐RR
• On further questioning:– Episodes of feeling sweaty and lightheadedS d ki f k b h– Stopped working out a few weeks ago because she was too fatigued
• She struggles with any sense she’s ill• She struggles with any sense she s ill– Discounts words of concern and over‐values statements of normalcy/praise
ANAN‐‐RR
• Refeeding syndrome• Gastroparesis
O t i• Osteoporosis• Low cell counts• HepatitisHepatitis• Hypoglycemia• Vital sign abnormalities• Cardiac abnormalities
Refeeding syndromeRefeeding syndromeg yg y
Potentially deadly syndrome that occurs when a starved person begins to take in p g
nutrition
Refeeding syndromeRefeeding syndrome
Ph h
g yg y
PhosphorousFood (carbohydrates)
consumedconsumedMetabolism of food pulls
phosphorous into ll d fcells, used for
energy building blocks
Low serum phosphorous
Refeeding syndromeRefeeding syndromeg yg y
• Low phosphorous can be dangerous…or deadly• Full‐blown refeeding syndrome
i f il– Respiratory failure– Red and white blood cell dysfunction– Muscle breakdown– Seizures– Congestive heart failure– Cardiac arrestCardiac arrest
• Refeeding hypophosphatemia can be caught and corrected before complications
Refeeding syndromeRefeeding syndromeg yg y
• Close monitoring prevents full‐blown syndromeClose monitoring prevents full blown syndrome– Start calories around 1400‐2000/day, low salt, <40% kcals from carbohydrates
• Important Australian contributions at the leading edge
– Intensive dietician input and supportAdvance by 400 kcal every 3 days checking– Advance by 400 kcal every 3 days, checking phosphorus levels daily in week 1, replete <3 mg/dL
– Encourage leg elevation, compression stockingsg g p g
Whitelaw M, Gilbertson H, Lam PY, Sawyer SM. Does aggressive refeeding in hospitalized adolescents with anorexia
Kohn MR. Madden S. Clarke SD. Refeeding in anreoxa nervosa: increased safety and efficiency through
nervosa result in increased hypophosphatemia? J Adolesc Health 2010;46:577‐582
understanding the pathophysiology of protein calorie malnutrition. Curr OpinPediatr 2011;23:390‐394
GastroparesisGastroparesispp
• Loss of normal stomach peristalsis (movement)– Causes early fullness, nausea, bloating, gassiness
– Nearly universal in severe underweight– Rarely is a nuclear med emptying study needed in this population
GastroparesisGastroparesispp
W S ll lWorsens- High fiber diets
- Smaller meals- Liquids/semi‐solidsL fib- Long time
underweightHigh fat diet
- Low fiber- With caution, metoclopramide 2 5- High fat diet
- Large mealsmetoclopramide 2.5 mg before meals, or erythromycin…limit y ytime use
Helps
What we tell our patients:What we tell our patients:pp
• Your weight has fallen so low that your whole body is slowing down to conserve energybody is slowing down to conserve energy.
• This should fully resolve once you have restored your weight.your weight.
PancytopeniaPancytopeniay py p
• Gelatinous Marrow• Gelatinous Marrow Transformation
R l t f ll d i– Replacement of cell‐producing marrow with an acellular “goo” due to starvationgoo due to starvation
– All cell lines may be affected– Source of inappropriate– Source of inappropriate workup
What we tell our patients: What we tell our patients: pp
• Your bone marrow is so starved, it’s stopped producing blood cells
ll f ll h h• It will fully recover with weight restoration• You don’t need a bone marrow biopsy or any � di i t l t thi i ’t�medicines to s mulate your marrow…this isn’t a marrow problem, it’s a starvation problem.
Vital signsVital signsgg
• Vital signs abnormalities highly prevalent• Adaptive, compensatory responses to malnutrition, “hibernation mode”– Bradycardia at rest (vagal tone)– Tachycardia with movement
• Deconditioning, not orthostasis• Helps distinguish between “athetic” and “starved”heart
Hypotension hypothermia– Hypotension, hypothermia
What we tell our patients:What we tell our patients:pp
• Your heart rate is abnormally low and high because you are underweight and weak.
S dd di d th t f 30% f d th i– Sudden cardiac death accounts for 30% of deaths in anorexia, and we don’t exactly know what triggers the heart to stop.
• A human shouldn’t have hibernating vital signs. Your metabolism has slowed way down.– As soon as you you start to eat consistently, your furnace will turn back on.
OsteoporosisOsteoporosispp
• The one potentially irreversible complication– Onset of bone loss is rapid (2.5%/year) and severe
– By the end of the second decade, more than 90% of peak bone mass has been h d h l hachieved in healthy woman: in
adolescent‐onset AN this never occursHi hl l t– Highly prevalent
Mehler PS, Cleary BS, Gaudiani JL. Osteoporosis in anorexia nervosa. Eat Disord2011;19:194‐202
OsteoporosisOsteoporosispp
• Gold standard: weight restorationGold standard: weight restoration– Until resumption of menstrual cycle in women– 2010 Spanish study compared BMD improvement in p y p pAN patients restoring weight (20% mean increase in weight) with those who did not gain weight
A 2 i h d i d b d i 2• At 2 years, gainers had improved bone density 2 to 5%
• Non‐gainers had lost 1% to 4% bone densityNon gainers had lost 1% to 4% bone density
Olmos JM et al. Time course of bone loss in patients with anorexia nervosa. Int J Eat Disord 2010;43(6):537‐42
OsteoporosisOsteoporosispp
• EstrogenEstrogen– Virtually all RCTs conclude just say noconclude…just say no to estrogen
– Use obscures theUse obscures the benefits of natural menstrual cycle resumption (and precipitates monthly bl d l )blood loss)
Osteoporosis: ExerciseOsteoporosis: Exercisepp
• Doesn’t exercise help bone density?• Doesn t exercise help bone density?• While underweight: exercise worsens bone densitydensity
• Once restored: even intense exercise helps bone densitybone density
Waugh EJ et al. Effects of exercise on bone mass in young women with anorexia nervosa. Med Sci Sports Exerc. 2011 May;43(5):755‐63
What we tell our patients:What we tell our patients:pp
• Serious exercise is a privilege of recovery.
OsteoporosisOsteoporosispp
• Men– Men typically have 1/3 the rate
f t ti hi d t b lof osteoporotic hip and vertebral fracture rates of women
– Men with AN had greater loss ofMen with AN had greater loss of bone than women even though men typically had shorter duration of their disorderduration of their disorder
– Men may fracture at higher bone density level than womeny
Mehler PS et al. High risk of osteoporosis in male patients with eating disorders. Int J Eat Disord2008;41(7):666‐72.
HepatitisHepatitispp
• Liver function tests (LFTs) are often elevated in severe AN• *Starvation mediated*:
• Autophagy on biopsy, recovers with p gy p y,refeeding.
• More common. • Often worsens for 1st week of refeeding.
• Refeeding mediated: S h i i i h l d f di• Steatohepatitis, recovers with slowed refeeding
HypoglycemiaHypoglycemiayp g yyp g y
P i ll d dl• Potentially deadly–Glucoses < 60 mg/dL are low– In underweight, result from depletion of glucose “building blocks” in liverg g
– Liver tests > 3 x normal predict hypoglycemiahypoglycemia
Case: PurgingCase: Purgingg gg g
• A 46 year old woman with a lifetime of AN‐BP presents again for admission. She has a BMI of 14 kg/m2.
Case: PurgingCase: Purgingg gg g
• 50 stimulant laxatives daily• Purges by vomiting “up to 30 times daily”• GP has prescribed lots of oral potassium pills• In treatment may gain 5‐10 kg of water weight within days
• Often fails to have a BM for 2 weeks straight• Her cheeks typically swell painfully in treatment• She leaves AMA a lot
Case: PurgingCase: Purgingg gg g
• Sodium 123, potassium 1.9, bicarb 42, BUN 31 and Cr is 1.1
d h h• Parotid hypertrophy
Purging (AN or BN)Purging (AN or BN)g g ( )g g ( )
• Properly managing volume depletion (dehydration)
d l l d• Avoiding volume overload• The potassium problem• Constipation and the perils of laxatives
PseudoPseudo‐‐Bartter SyndromeBartter Syndromeyy
S d• Secondary hyperaldosteronism
• Responsible for swelling• Responsible for swelling after purging cessation
• Causes urinary K loss• Causes urinary K loss• Resolves after 2 weeks of hydrated stateof hydrated state
Bahia A. Mascolo M. Gaudiani JL. Mehler PS. PseudoBartter syndrome in eating disorders. Int J Eat Disord 2012;45(1): 150‐3
PseudoPseudo‐‐Bartter SyndromeBartter Syndromeyy
• Key points to treat1. Stop purging2. Slowly give IV fluid (no faster than 50 ml/hr)3. (Or follow low sodium diet and 2‐3 liters
fluid a day), feet up4. Treat the hormone over‐production until
body downregulates
PseudoPseudo‐‐Bartter SyndromeBartter Syndromeyy
• To prevent edema from Pseudo‐Bartter pSyndrome
Perils of stimulant usePerils of stimulant use
• Constipation universal in severe underweightunderweight–Slowed GI transit
• High fiber worsens at low weights
ConstipationConstipationpp
• Manage expectantly– Set expectations for normal range of p gbowel function
–Polyethylene glycol no stimulantsPolyethylene glycol, no stimulants– Intestine works best at K of 4.5 or so
XX‐‐ray promiseray promisey py p
XX‐‐ray promiseray promisey py p
• Minimal stool?
• Lots of stool?• Lots of stool?
Cathartic Colon SyndromeCathartic Colon Syndromeyy
A.K.A “Why we don’t taper stimulant laxatives…we STOP them”laxatives…we STOP them
Questions?Questions?QQ