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Anorexia NervosaCase Study Presentation

Roanna Martin, WVU Dietetic Intern

November 29, 2012

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Outline

• Anorexia Nervosa

• Assessment

• Diagnosis

• Intervention

• Monitor/Evaluate

• Conclusion

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An Diagnostic Criteria

• Refusal to maintain body weight at or above a minimally normal weight for age and height (< 85% IBW)

• Intense fear of gaining weight• Disturbed perception of body shape and/or size• Amenorrhea (absence of at least 3

consecutive periods)• Restricting Type: Accomplishes weight loss

through dieting, fasting, or excessive exercise.• Binge-Eating/Purging Type: Regularly

engages in binge-eating or purging behavior

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Physical Findings

• Skin and Extremities• Cold hands & feet• Dry skin• Lanugo• Alopecia• Acrocyanosis• Dependent

Edema

• Cardiovascular• Bradycardia• Hypotension• Orthostatic

hypotension• Cardiac

arrhythmiaas• Electrocardiogr

aphic abnormalities

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Physical Findings, continued

• Gastrointestinal• Salivary gland

enlargement• Delayed gastric

emptying• Constipation

• Bone• Decreased bone

mineral density

• Reproductive• Amenorrhea

• Plasma/serum values• Elevated BUN &

creatinine• Hyponatremia• Hypokalemia• Hypercholesterolemia• Hypoglycemia

• Low T3

• Low-normal T4

• Hypophosphatemia (during refeeding)

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Prognosis

• 50% of those diagnosed with anorexia will have full recovery with treatment

• Mortality is 0-21%

• Death results from complications of starvation, including:• Pneumonia• Weakened immune system• Heart, kidney, or multiple organ failure

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Care Team

• Physician

• Nurse

• RD

• Mental health professional (psychiatrist, psychologist)

• Other professionals as indicated

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Primary goal: Medical stabilization

• Close monitoring of electrolytes

• Fluid balance

• Other blood levels

• Weight regain

• Prescription of psychoactive medication

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Recommended nutrition Prescription

• Initiate at 1,200 kcal to 1,400 kcal• Energy gradually by 100 kcal to 200 kcal increments.

• Protein: 0.8-1.2 g/kg of recommended body weight.

• Goal: Weight gain of 1-2 lbs/week.

• Small, frequent meals. Vitamin, mineral supplements.

• Tube feeding may be necessary for severely malnourished patients (especially if refusing po intake).

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Assessment

• Food and eating history

• Biochemical laboratory values

• Anthropometric indices of nutritional status

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Patient

• 25 year old female

• Frequent hospitalizations

• 5’ 2” (157.48 cm)

• 82.72 lb (37.6 kg ) on 10/27• BMI: 15.2• IBW: 110.2 lb (50.1 kg)• 75% IBW

• Edentulous

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Admission 10/27

• Chief complaint “Weakness” and positive blood cultures

• Assessment and Plan• Fungemia/bacteremia

• gram negative organisms in bladder• yeast in blood

• CKD• GERD• Pulmonary Fibrosis• DVT Prophylaxis

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Microbiology

• Candida tropicalis (yeast)

• Enterococcus faecium

• Stenotrophomonas maltophilia

• Klebsiella pneumoniae

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Past Medical History

• Anorexia Nervosa (Lowest Weight: 58.3 lb (26.5 kg), BMI 10.7 on 5/31/11)

• Malnutrition

• CKD stage IV

• Liver disease

• Pulmonary fibrosis

• Right heart failure

• Hypothyroidism

• Depression

• Pancytopenia

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Past surgical history

• Cholecystectomy

• PEG placement and removal

• Tracheostomy placement and removal

• Infuse-A-Port placement and removal

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Social History

• 25 year old female

• Lives with both parents

• Smoker, 10 pack-year history

• Denies current alcohol or drug use• Admits previous history of IV drug use

• Sought treatment from eating disorder specialist. Dismissed for noncompliance.

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Relevant Supplements & Medications

• Calcium (Caltrate)

• Vitamin D

• Synthroid

• Protonix

• Phoslo

• Epoetin

• Heparin

• Lasix

• Prevacid

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Nutrition Diagnosis

•Malnutrition related to long history of anorexia nervosa as evidenced by BMI of 15.2, muscle wasting, and refusal to eat sufficient energy/protein to maintain a healthy weight.

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11/1: Initial Assessment

• Subjective: Pt. reported eating some breakfast and lunch. Snacks in bed with her, and she did not like chocolate Ensure at last admission.

• Objective: 37.6 kg, BMI 15.2 (PEM Grade III)• No skin breakdown.• Calcium, Vitamin D, Diflucan, Synthroid, Protonix, Celexa• Order: Regular

• Assessment:• 1233-1850 kcal (30-45 kcal/kg)• 53-78 gm protein (1.3-1.9 gm/kg)

• Plan:• Goal: Improve protein status, intake 50% or greater, promote

weight gain.• Intervention: Continue to provide regular diet, catering

assistant will visit, encourage intake.

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Patient Interview 11/5

• (Fiancée present in room, bag of Cheetos in bed)• Today I ate:

• All of macaroni & cheese (except shared 4 Tbsp)

• Typical day:• Breakfast: Bowl of cereal, ½ sausage sandwich or

egg with sausage and toast, snacks• Lunch: Sandwich and chips, water and an orange• Dinner: whatever Mom cooks• Snack: dry cereal

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11/6: Consult

• Subjective: Visited with patient and patient’s fiancee for extended amount of time. Discussed eating complex carbohydrates.

• Objective: 37.6 kg, BMI 15.2• No skin breakdown.• Calcium, Vitamin D, Phoslo, Heparin, Protonix• Order: Regular, with high protein milk shake, low volume every 6

hours.

• Assessment• 1233-1850 kcal (30-45 kcal/kg)• 53-78 gm protein (1.3-1.9 gm/kg)

• Plan: If intake does not improve, recommend enteral nutrition.

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11/9: Follow Up• Subjective: Patient transferred to ICU. Spoke with physician.

• TF on hold secondary to being placed on CPAP. Possible CRRT.

• Objective:• No skin breakdown.• D10 NS w/ 3 amps NaBicarb @ 25 mL/hr = 204 kcal• Calcium, Vitamin D, Lasix, Synthroid, Protonix• Order: Suplena @ 5 mL/hr = 215 kcal, 5 gram protein, 89

mL free water

• Assessment: Total protein, albumin levels low. Elevated BUN/Creatinine. Hyperphosphatemia, Hypoglycemia noted (pt on D10NS).

• Plan: Recommend Suplena @ goal 35 mL/hr = 1512 kcal, 38 gm protein, 622 mL free water.

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Nephrology Consult

• 11/10/12 08:58

• Acute on chronic renal failure, Metabolic acidosis

• Hypoxia, PO2 = 44 (Normal range 80-100)

• Urine output 225 mL

• Trace to minimal edema.

• No strong indication for dialysis at this point

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Respiratory Arrest& Metabolic Acidosis

• 17:15• pH 6.98 (7.35-7.45)• pCO2 69 (35-45)• O2 Saturation 34% (95-100%)

• 17:34 • Endotracheal intubation

• Subsequent insertion of OG tube

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11/14: Follow Up

• Subjective: Patient remains intubated with TF at goal rate via OG tube. No residual noted.

• Objective: 44 kg, BMI 17.7 (PEM Grade I)

• Stage II breakdown on sacrum.

• D10 NS @ 25 mL/hr = 204 kcal

• Lasix, Synthroid, Prevacid

• Order: Suplena @ 35 mL/hr

• Assessment

• 1170-2340 kcal (30-60 kcal/kg)

• 31-55 gm protein (.8-1.4 gm/kg)

• BUN 57, Cr 2.9, eGFR 20, Phosphorus: 3.6 (WNL)

• Plan: Increase rate of Suplena @ goal 40 mL/hr = 1435 kcal, 43 gm pro, 688 mL free water.

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11/19: Consult/ follow Up

• Subjective: Patient extubated since last assessment, but remains on TF. Oral diet started this am. Consult secondary to diarrhea from current TF. Diarrhea improving 11/18 per physician note.

• Objective: 40.2 kg, BMI 16.2 (PEM Grade II)• No new breakdown noted.• None.• Caltrate, Prevacid• Order: Mechanical soft chopped diet, Ensure Plus at 35 mL/hr

• Assessment• 1170-2340 kcal (30-60 kcal/kg)• 31-55 gm protein (.8-1.4 gm/kg)

• Plan: Recommend continue TF, Suplena @ 40 mL/hr

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Calorie Count

11/21 11/22 11/23

Breakfast Kcal 630 205 560

Protein (gm) 13 7 20

Lunch Kcal 580 270 275

Protein (gm) 20 8 10

Dinner Kcal 725 120

Protein (gm) 26 4

Total Kcal 1935 (114%)

595 (35%)

Total Protein (gm)

59 (118%) 19 (38%)

Estimated Needs: 1700 kcal, 50 gm protein

*Food reported by patient’s mother

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Operations

• 10/29: Removal of infected right femoral AV graft

• 10/31: Transesophageal echocardiogram• No vegetations, mural thrombus or shunt• Biventricular systolic dysfunction noted

• 11/6: Incision and drainage of abscess with evacuation of hematoma right thigh.

• 11/8: Insertion of Dobhoff feeding tube

• 11/10: Endotracheal intubation• Indications: respiratory arrest, hypoxia in low 30’s.

• 11/13: Insertion of triple lumen catheter in right internal jugular vein

• 11/15: Vent removed

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Nutrition Interventions

• 10/27-11/9 Regular Diet

• 11/9-11/16: Suplena

• Initiate @ 5 mL/hr = 215 kcal, 5 gm protein, 89 mL free water

• Increase 5 mL every 8 hours to goal of 30 mL/hr

• 35 mL/hr = 1512 kcal, 38 gm protein, 622 mL free water

• 11/16-11/19: Suplena out of stock, change to Ensure Plus @ 35 mL/hr = 1260 kcal, 45 gm protein, 605 mL free water.• Some diarrhea, improving per physician note on 11/18

• 11/19: Diet: mechanical soft, chopped

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Refeeding Syndrome

• Hypophosphatemia (11/18: 2.5)

• Drops in potassium and magnesium

• Glucose intolerance

• Hypokalemia

• GI dysfunction

• Cardiac arrhythmias

• Congestive heart failure

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Cardiac Function

• EKG on 11/21• Left atrial abnormality• Right ventricular hypertrophy. • Lateral T wave inversions are new since

previous EKG,• Ischemia should be considered

• 11/22: BNP >10000• Indicator for CHF

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Monitoring and Evaluation

• Critical Labs

• Intake

• Weight Change

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Blood Glucose

Date Value

11/7 143, 42, 129, 56, 34, 152, 97, 65, 72, 72

11/8 67, 60, 159, 78, 72, 71, 65, 159, 75, 49, 212, 118

11/9 47, 54, 53, 166, 94, 121, 58, 71, 61, 78

11/12 91, 101, 81, 106, 75, 95, 102, 90, 114, 131, 108, 114

11/13 92, 111, 92, 108, 94, 67

Normal Glucose: 70-108

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Critical Labs

Labs Normal 27-Oct 3-Nov 9-Nov 17-Nov 24-Nov

Glucose 70-108 128 33 68 101 61

Na 136-146 139 133 137 137 138

K 3.5-5.1 3.9 5.1 5.4 3.5 4.8

Albumin 3.5-5.0 1.7 1.5 2

Ca 8.4-10.2 7.1 7.5 7.6 8.2 7.7

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Renal Labs

Labs Normal 27-Oct 3-Nov 9-Nov 17-Nov 24-Nov

BUN 7-18 20 21 39 55 58

Cre 0.5-1.2 2.1 1.9 3.2 2.7 2.5

eGFR >60 29 32 18 21 23

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Weight Change

10/27

11/7

11/8

11/10

11/11

11/12

11/16

11/18

11/19

11/20

11/21

11/22

11/23

11/24

05

101520253035404550

37.63739.340.5

44.444 43.142.340.240.939.2

33 31.33

36.91

Date

Weig

ht

(Kg

)

IBW: 50.1 kg(110.2 lb)

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Clinical Notes

• 11/23: “Explained importance of eating protein. encouraged patient to eat eggs, when turned my back to wash hands patient was throwing food from tray in trash, then stated she had eaten her eggs… will continue to monitor patient while eating.” - RN

38Source: Nationaleatingdisorders.org

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Sources

• Nelms, Sucher, Long, “Nutrition Therapy and Pathophysiology.”

• Academy of Nutrition and Dietetics. “Nutrition Care Manual”