Treatment with intravenous hyperalimentation for severely anorectic patients and its outcome
Dr Takashi Tonoike, Department of Psychiatry, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan. Email: email@example.com
Abstract In treating patients with severe anorexia nervosa, it is important to improve their physical condition first. Patients who had lost close to 60% standard bodyweight (SBW) were candidates for inpatient treatment due to the mortality risk. With 80% SBW as the target for therapy, they were given both intravenous hyperalimentation and food by oral intake in order to improve their physical condition. In total, 51 patients were admitted. One died and four patients dropped out in the course of treatment. Forty-six patients who completed the inpatient treatment were reviewed. Although admitted with an average weight of approximately 60% SBW, they were discharged with a weight of approximately 80% SBW after approximately 60 days. An average follow up of 25.0 months was conducted, and two patients were found to have died. The mean weight, percentage resuming menstruation, and rehospitalization rate of the 44 survivors were 79% SBW, 23%, and 32%, respectively. The patients with the restricting type of anorexia had an earlier onset of the disorder and a better social outcome. Patients in whom onset occurred at a younger age had a better social outcome. After being discharged, the majority of the patients continued treatment as outpatients. Although the results were similar to those of conventional studies in terms of outcome, the shorter hospitalization was significant. Overall, in the treatment of patients with severe anorexia nervosa, it is important to begin psychotherapy while trying to improve their physical condition.
For patients with eating disorders accompanied by severe abiotrophy, comprehensive treatment, including physical treatment, individual psychotherapy, family therapy, and group therapy, is required.1,2 Anorexia nervosa is a common disorder today, and it is often necessary for physicians who work for a facility having no special treatment programs, to have to treat it. Many patients with advanced anorexia nervosa posing a mortality risk and needing inpatient treatment are examined at Nagoya Daini Red Cross Hospital. Such patients require catheterization of the middle cardiac vein for strict physical supervision. Because there is some risk associated with this catheterization, it is used only in life-threatening cases. However, there is no specific standard. We consider patients admitted with an average bodyweight of 60% standard bodyweight (SBW) or less to be at high risk. Considering the fact that this is a common disorder among adolescents, hospitalization should be as short as possible in order to minimize its effect on them scholastically. The authors have been treating severe cases of anorexia nervosa while searching for ways to improve patients’ physical condition as quickly as possible, as well as have them continue with further psychotherapy. Through trial and error, we began to develop a certain regimen for treating patients at Nagoya Daini Red Cross Hospital using middle cardiac vein catheterization. The purpose of the present study was to introduce our short-term treatment regimen and to examine its outcome.
Among severely anorectic patients who came to Nagoya Daini Red Cross Hospital between March 1996 and December 1999, the authors served as the attending psychiatrist for 51 of them. In the present study we review the treatment and short-term outcome of these 51 patients who have been treated with our regimen. The diagnosis was made according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV).3 Before beginning treatment, the regimen was presented to each patient to obtain informed consent. In the case of underage patients, both the patient's and her family's consent were required. Even though there were a few patients who had been treated with this regimen in the hospital more than once, only their first hospitalization was reviewed.
Candidates for inpatient treatment
At Nagoya Daini Red Cross Hospital, patients who have lost close to 60% SBW are considered severe cases, and inpatient treatment is in order. Hirata's formula was used to calculate patient weight because of its convenience (Table 1).4
Table 1. Calculation of patient weight
|>160 cm||(height − 100) × 0.9 = weight (kg)|
|<150 cm||height − 100 = weight (kg)|
|150–160 cm||50 + [height (cm) − 150] × 0.4 = weight (kg)|
For younger patients, a SBW table was used. Patients weighing more than 60% SBW with an electrolyte imbalance or sudden weight loss were also candidates for inpatient treatment.
The ultimate goal of the physical treatment was to gain up to 85% SBW. This level was adopted from the diagnostic criteria in the DSM-IV.3 This figure seemed to be the highest limit that most patients found acceptable. In addition, when patients could maintain this weight for a few months, their menstruation appeared to start again. If patients did not have any problems with vomiting or diuretics, their physical condition should be restored when they reach their target weights.
Outline of inpatient treatment
As a general principle for inpatients with a risk of mortality, our inpatient treatment was designed to improve the nutritional status of the patients by intravenous hyperalimentation (IVH) along with oral food intake in order to increase their weight. A total of 85% SBW was presented to the patients as ‘a provisional goal’. An outline of the treatment is described herein.
(1) Admission to the ward: on the day of admission, the patients are given approximately 1000 mL of a peripheral intravenous drip. Next they are served thin gruel as a meal at first. Those who have been hardly eating at all are started on a diet of concentrated liquid food. The number of calories consumed is not important because this period is intended to make sure that the patient can physically tolerate caloric intake.
(2) Insertion of central venous catheter (CV): the day after admission, a CV is inserted. The more severe a patient's physical condition is, the more careful one should be in increasing caloric intake. Along with oral intake, the total caloric intake starts between 2093 and 4186 kJ (500 and 1000 kcal) per day, and is gradually increased as their abnormal electrolyte levels are corrected. Resupplying nutrition and moisture too suddenly can cause congestive heart failure and pancreatitis. Impaired liver function with increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) is sometimes observed. Rhabdomyolysis, hepatic failure, cardiac failure, renal failure, delirium, or hemolytic anemia also can be fatal (refeeding syndrome5,6). The deficiency of phosphorus, potassium, and magnesium is considered to have an association with this syndrome.
(3) From the second week of hospitalization onward, as the patient's physical condition stabilizes, caloric intake through IVH increases. It should be increased to approximately 7535 kJ (1800 kcal) per day over the course of 1 month. Oral intake should also be increased little by little until the patient can eventually eat a regular meal. With approximately 14 650 kJ (3500 kcal) per day, their bodyweight will increase by 1.0–1.5 kg per week. Around this time we introduce psychotherapy with a clinical psychologist.
(4) Removing CV and discharge: patients generally reach close to 80% SBW after 2 months of inpatient treatment. Although our ultimate goal is 85% SBW, patients often start eating less or expressing a strong desire to leave the hospital at this point. Our response is to make sure that the patient understands that they are unhappy not only about weight gain, but that they also have a psychological resistance to being cured because they fear being abandoned by the people around them. We usually remove their IVH when their weight reaches a mean 80% SBW. The lack of insistence on meeting the 85% weight goal is to avoid a missed opportunity for early return to society and to avoid hindering treatment. This process of confrontation is very important. Patients are released from the hospital after they have agreed to continue psychotherapy once a week on an outpatient basis and to accept re-admission to the ward if their weight again falls to less than 70% SBW.
Demography of patients
All 51 patients were female. The mean age of onset was 18.0 years. The age of patients during hospitalization ranged between 13 and 38 years old, with a mean age of 21.0 years. Forty-one out of 51 patients had the restricting type of anorexia and 10 patients had the binge eating/purging type. One restricting-type patient who was transferred from another hospital died on the nineth day of inpatient treatment. Three patients requested discontinuance of the treatment and were discharged. One of them had the restricting type and two of them had the binge eating/purging type. An additional patient chose to discontinue inpatient treatment in order to enter college. In total, 46 out of 51 patients completed the full course of inpatient treatment.
We determined short-term outcome from the latest entry in these patients’ medical charts as of March 2001. Short-term physical conditions included bodyweight, overeating/vomiting, and restarting menstruation. For the social outcome, the following classification was used: A, could resume her place in society; B, could obtain a part-time job; and C, not rehabilitated.
When the outcome was determined, one of the restricting-type patients and one of the binge eating/purging type patients had already died. The former died of asphyxiation due to aspiration after 6 months, and the latter committed suicide 4 years later. The outcome of the remaining 44 patients was determined.
Results of inpatient treatment
For the 46 patients who completed our inpatient treatment, the mean age of onset was 17.9 years of age, and the mean age at the point of hospitalization was 21.0 years (Table 2). Within the restricting-type group, the mean age of onset and of hospitalization was 17.4 and 19.6 years old, respectively. Within the binge eating/purging-type group, the mean ages were quite different, at 20.1 and 27.6 years old, respectively, but the patients’ mean bodyweight upon hospitalization and discharge, as well as the mean duration of hospitalization, were very similar. Patients in both groups were admitted with an average bodyweight of 60% SBW, and were hospitalized for an average 60 days. They were discharged with an average bodyweight of 80% SBW.
Table 2. Patient clinical information
|Age at onset (years)|| 17.9|| 17.4|| 20.1|
|Age of inpatient treatment (years)|| 21.0|| 19.6|| 27.6|
|Age of outcome judgment (years)|| 23.0|| 21.5|| 30.6|
|Bodyweight at admission (kg)|| 30.8|| 30.7|| 31.1|
|Bodyweight at discharge (kg)|| 41.9|| 41.8|| 42.5|
|Bodyweight at admission (% SBW)|| 58.6|| 58.4|| 59.8|
|Bodyweight at discharge (% SBW)|| 80.3|| 80.0|| 81.5|
|Duration of inpatient treatment (days)|| 63.5|| 63.3|| 64.4|
Patient outcome was judged at a mean of 25.0 months after discharge (Table 3). The mean bodyweight of the 44 patients at the time of outcome was 79.1% SBW. Some 22.7% of the patients (n = 10) had resumption of menstruation, and 31.8% (14 patients) had been rehospitalized during the follow-up period. A total of 24.3% of patients with the restricting type and 71.4% of the patients with the binge eating/purging type were re-hospitalized. There was a large gap between the two groups. In the restricting-type group, the mean bodyweight at the time of outcome judgment was 77.3% SBW. In the binge eating/purging type group, the mean bodyweight at the point was 88.7% SBW. In terms of bodyweight the binge eating/purging-type group was comparatively better.
Table 3. Patient outcome
|Weight at outcome (kg) (%SBW)||42.3 (79.1)||41.6 (77.3)||46.1 (88.7)|
|Percentage resuming menstruation||22.7||21.6||28.6|
|Rehospitalization ratio (%)||31.8||24.3||71.4|
A total of 8.1% of the patients (three out of 37) who were categorized as having the restricting type during their inpatient treatment later presented with impulsive overeating and vomiting at outcome judgment. and 71.4% of the patients with binge eating/purging type had continued impulsive overeating and vomiting behavior at the time of outcome determination (five out of seven patients). Some 21.6% of the patients with restricting type (eight out of 37), and 28.6% of the patients with binge eating/purging type (two out of seven) had resumed menstruation.
Social outcomes are examined next (Table 4). A large difference was observed between the two groups; 73% of the patients with restricting type re-entered society as before, whereas only 14% of the patients with binge eating/purging type did so. Because patients with a later age of onset have a poorer social prognosis, we made 18 years of age a cut-off boundary. Among patients whose age at onset was younger than 18, 77% returned to society as before, whereas only 36% of those whose age at onset was 19 or older did so. Considering the two deaths during this period, both of which occurred in patients who had an age at onset of 19 or older, it is clear that the short-term outlook is better for those who are 18 or younger at onset.
Table 4. Social outcome
|Restricting type||37 (73)||5 (14)||5 (14)||37 (100)|
|Binge eating/purging type|| 1 (14)||4 (57)||2 (29)|| 7 (100)|
|≤18 years||23 (77)||5 (17)||2 (7)||30 (100)|
|≥19 years|| 5 (36)||4 (29)||5 (36)||14 (100)|
Patients with advanced abiotrophy need improvement in their physical condition because they are facing a life-threatening situation.7 Early physical treatment is also important because advanced abiotrophy or an electrolyte imbalance can cause permanent physical disorder. After seeing the development of renal failure and necessity for artificial dialysis in one patient, or the development of anaplastic anemia in another (both the result of long-term advanced abiotrophy), we strongly feel that severely anorectic patients should always undergo inpatient treatment in order to improve their physical condition.8
Although 70% SBW is generally the guideline used for inpatient treatment among anorectic patients, most would not seek treatment at that stage. In most cases, both the families and patients themselves do not visit psychiatric facilities until they realize the seriousness of the situation, when the patient's weight has come close to 60% SBW. At such a low weight, death is already imminent. This conclusion was reached based on the following experiences.
A patient who visited us with a weight of 76% SBW had been treated as an outpatient. Soon after, she fainted in the bathroom and fractured a bone in her face. Her weight was 57% SBW at that time. Another patient who came for treatment with a weight of 57% SBW and reserved a hospital bed, was a few weeks later admitted to the intensive care unit in a hypoglycemic coma because her mother had cancelled her reservation. Even though she pulled through, she was left with severe brain damage. There was another patient who attended as an outpatient because her blood screening and vital signs were all normal. Her weight at the first visit was 64% SBW. When admitted with 59% SBW only 1 month later, she already had advanced liver dysfunction with a serum bilirubin level of 5.0 mg/dL.
Among chronic-stage eating disorder patients, there are those with stable weight at approximately or less than 60% SBW. However, many acute-stage patients rapidly worsen. Such cases led us to conclude that patients weighing close to 60% SBW in acute stage should be admitted immediately.
Intravenous hyperalimentation and duration of inpatient treatment
Particularly for patients who enter the acute stage soon after onset, a CV is inserted into the patient's middle cardiac vein in order to manage the general state of severe anorexia. Although patients may be fed very effectively through IVH, there are reported risks.9
First, the insertion of a CV and supply of the nutrients, water, and electrolytes is in itself considered a high risk by some. In terms of insert-related risks, it could possibly cause a pneumothorax or a centesis artery. At Nagoya Daini Red Cross Hospital only experienced physicians perform this procedure, and no serious problems have been reported thus far. Although there is also concern about congestive heart failure due to oversupply of water and the refeeding syndrome due to sudden resupply of nutrients, such can be prevented by increasing the amount of IVH, by monitoring very carefully the patient's weight change and electrolyte levels. Although IVH is used for many patients in facilities that treat a large number of serious cases, there have been no reports of serious mishaps or complications from IVH due to recent advances in treatment techniques
Second, there is the possibility of patients themselves manipulating the CV to change the IVH drip infusion or discarding the intravenous solution from a three-way tap. This could lead to an aeroembolism or infection. Thus, we always emphasize the risk of these behaviors, both in conversation and in a written statement upon admission. Although our procedure has been used for more than 100 IVH patients, we have never encountered any serious accidents. However, among patients needing repeated hospitalizations are some who discard the intravenous solution or pull out the cannula on their own. In such cases, IVH treatment should be discontinued, although these cases did not occur in the present study.
The advantages of IVH are as follows. First, it can shorten the duration of inpatient treatment. Although the patient must gain more than 10 kg in weight, it is extremely difficult to achieve 12 560 kJ (3000 kcal)/day via oral or nosogastric intake alone. However, nearly 16 740 kJ (4000 kcal)/day is feasible with both oral intake and IVH. The majority of these patients are still in school, and a long-term hospitalization might mean having to repeat an academic year. Inpatient treatment with IVH enables us to tell patients that they can leave leave the hospital after 2 months, if all goes well, when trying to persuade them to accept inpatient treatment.
One should never overlook the psychotherapeutic significance attached to IVH. Many patients may resist dietary intake or alimentation by nasogastric tube, but they show virtually no such resistance to having a catheter inserted into their main vein. They also do not seem to mind a high-calorie fluid intake through a catheter.2,10 The patient feels comfortable with the idea that instead of ‘putting on weight’, she is receiving the right treatment. The IVH stand with the large drip-infusion bag hanging on it offers reassuring proof that they are indeed ill, a genuine patient. Moreover, the patients with an eating disorder often complain ’I don’t know how much I should be eating’ or ’If I eat too much my stomach really will get big’. However, in this type of treatment, the meals are geared to the patient's age so this feeling can be avoided.
Out of the 51 patients who were reviewed for the present study, 46 completed their inpatient treatment with a mean hospital stay of approximately 64 days. Patients with the restricting type and the binge eating/purging type had a similar course of treatment and were discharged after a mean of 2 months. We originally suspected that the patients with the binge eating/purging type might need a longer course of treatment because of their behavioral problems, but this was incorrect. According to reports, the mean hospital stay of patients at special facilities for eating disorders is also a few months.11 In contrast, in the study by Denda et al. the mean hospital stay of 12 patients treated with IVH was approximately 5 months.2 It is not easy to compare studies because each facility has different criteria for judging the need for inpatient treatment, the type of treatment regimen, and standard for discharge. However, it was significant that the bodyweight of the present anorectic patients could be increased up to 80% SBW in 2 months, which reflects a certain measure of success in a short hospitalization.
Outpatient treatment after discharge
In treatment of eating disorders on an outpatient basis, it is critical to establish a patient–therapist relationship at the beginning of treatment.12 One can introduce them to psychotherapy rather smoothly by focusing on their resistance to treatment and their anxiety about a cure as their physical condition improves. This might determine whether treatment can continue. In the present cases, almost all of the patients continued outpatient treatment after discharge. This was true of patients whether their initial prognosis was poor or good.
For patients with more than 65% SBW upon their first visit, we normally chose outpatient treatment. We also reviewed patients who came to Nagoya Daini Red Cross Hospital during the same period when the subjects of the present study were admitted. Twenty anorectic patients who consulted the authors for the first time were not admitted. Nine of the 20 continued their outpatient treatment for a mean 22.3 months. However, the remaining 11 patients dropped out after one or two visits. We interpreted this to mean that they might be less severely ill patients who came to the hospital to try out the treatment. The more severe patients who required admission were less likely to drop out from the overall treatment.
For the evaluation standard of anorexia nervosa, even though the Global Clinical Score by Garfinkel et al.13 or the Morgan–Russell Outcome Assessment Schedule14 could be used, these evaluation systems tend to be too detail-oriented. Moreover, the Morgan–Russell outcome criteria (MRC) are very useful for assessing recovery but do not take into account social adjustment.15 Many patients with anorexia nervosa manage to attend school and hold a job despite their severe emaciation. In contrast, there are many patients who neither go to school nor have a job, yet are well enough to resume a normal life. This makes it difficult to determine their physical and social outcome on a single scale.
Strober et al. conducted a prospective study on 93 cases of anorexia nervosa.16 Using the MRC to assess recovery, they indicated that partial and full recovery increased with the years after discharge, reaching a plateau of 87% and 73%, respectively, after 10 years. There was not much change thereafter. From our recovery survey, we found that 20.5% of the present patients had reached normal bodyweight, reflecting the great difficulty associated with weight normalization. Moreover, only 22.7% of them had resumed menstruation. Weight normalization and resumption of menstruation reportedly increased rapidly between the fourth and fifth year. This should be examined further over a longer time. The mean bodyweight of their patients was 69.9%, against the much lower 58.6% of the present patients at the time of hospitalization. A straightforward comparison is not possible. There thus appears to be a need for ongoing recovery surveys.
Tanaka et al. conducted a follow-up study (mean 8.3 years) on 61 anorexia nervosa patients.17 Using the MRC, 31 cases had a good outcome, eight had an intermediate outcome, 15 had a poor outcome, and seven died. Factors in their poor prognosis included late onset (>20 years of age), low minimum weight, and impulsive behavior. Because their mean weight at the time of hospitalization was around 65% of SBW, their overall body condition was better than that of the present patients. Despite the difficulty of comparison, they obtained the same results: the higher the age of onset, the less favorable the prognosis.
Three among 51 patients died during the present study. Although there are few reports on short-term mortality rates, Tanaka et al. reported two deaths among 23 patients between 1 and 3 years after discharge.18 Although simple comparison is inappropriate due to the differences in length of hospitalization and treatment, we consider the mortality rate in the present study to be small. In a search of the literature we could find no reports of recovery surveys of patients with an SBW of <60%.
Patients with serious anorexia nervosa whose weight is less than 60% SBW at initial treatment face life-threatening risk and should be treated by IVH to supply nutrients and manage their general condition. This method addresses the psychological as well as the physical needs of the patient, and with careful administration compares favorably with other reports even in regard to mortality rate.