Inpatient Management

Admission Criteria - Gates of Care

• Medical Instability:
  • Weight < 75% IBW or rapid, persistent loss.
  • Vitals: HR < 40 bpm, BP < 80/60 mmHg, Temp < 35.5°C.
  • Labs: K+ < 3 mmol/L, PO4 < 0.65 mmol/L (critical for refeeding), ECG changes.
• Psychiatric Instability:
  • Acute suicidal risk (intent/plan).
  • Severe comorbid conditions (e.g., psychosis, major depression).
• Treatment Context:
  • Failure of less intensive treatment levels.
  • Need for structured refeeding & medical monitoring.

⭐ Hypophosphatemia is a hallmark of refeeding syndrome, a critical risk during initial inpatient nutritional rehabilitation.

Initial Assessment - Patient Profiling

• History:
  • Psychiatric: Co-morbidities (depression, anxiety), suicide risk.
  • Medical/Dietary: Weight hx, amenorrhea, intake patterns, purging (frequency, methods).
  • Social: Support system, stressors, family dynamics.
• Examination:
  • MSE: Body image distortion, insight, mood, suicidality.
  • Physical: BMI, vitals (bradycardia, hypotension, hypothermia), signs of malnutrition (lanugo, hair loss), purging (Russell's sign, dental erosion).
• Key Risks: Suicidality, medical instability, refeeding syndrome (e.g., BMI <16 kg/m², rapid weight loss).
• Baseline Investigations: CBC, electrolytes (K, PO4, Mg), LFTs, RFTs, glucose, ECG.

⭐ SCOFF Questionnaire (Sick, Control, One stone, Fat, Food): Score ≥2 indicates a likely case of Anorexia Nervosa or Bulimia Nervosa. Useful for quick screening.

Nutritional Rehab - Refuel & Rebuild

• Goal: Restore weight, normalize eating, correct deficiencies.
• Initial Calories: Start low: 1200-1800 kcal/day (or 30-40 kcal/kg/day).
• Increase: Gradually by 300-400 kcal every 3-4 days, based on tolerance.
• Weight Gain Target (Inpatient): 1-1.5 kg/week. (Outpatient: 0.5-1 kg/week).
• ⚠️ Refeeding Syndrome: High risk in severely malnourished. Key sign: hypophosphatemia (e.g., serum P $<0.65$ mmol/L).
  • Monitor: Serum Phosphate, Potassium (K), Magnesium (Mg).
  • Thiamine: Prophylactic 100-300mg IV/IM daily before feeds & for 3-5 days.
  • Correct electrolyte imbalances pre-feed.

⭐ The primary biochemical hallmark of refeeding syndrome is hypophosphatemia, often seen within the first 72 hours.

Medical Complications - Code Red Alerts

• Cardiovascular:
  • Bradycardia (HR <40 bpm)
  • Hypotension (SBP <80 mmHg)
  • QTc prolongation (>500ms)
  • Arrhythmias
• Electrolyte Imbalance (⚠️ Refeeding Syndrome):
  • Hypokalemia <3.0 mmol/L
  • Hypophosphatemia <0.65 mmol/L
  • Hypomagnesemia <0.6 mmol/L
• Hematological:
  • Severe neutropenia (<1.0 x 10⁹/L)
• Other Critical Signs:
  • BMI <13 kg/m² or rapid weight loss (>1kg/wk for 2 wks)
  • Hypothermia (<35°C)
  • Seizures, delirium
  • Persistent food/fluid refusal

⭐ Hypophosphatemia is a hallmark of refeeding syndrome and can precipitate cardiac failure and arrhythmias.

Psycho-Social Support & Discharge - Mind Matters Most

• Multidisciplinary Team (MDT) Approach: Psychiatrist, psychologist, dietitian, social worker, occupational therapist.
• Therapies:
  • Individual: CBT-ED, IPT, psychodynamic therapy.
  • Family: Essential, especially for adolescents (e.g., Maudsley Method/FBT).
  • Group therapy: Peer support, psychoeducation.
• Psychoeducation: For patient and family about illness, nutrition, relapse prevention.
• Discharge Planning:
  • Gradual transition: Day-care, halfway homes.
  • Relapse prevention plan: Identify triggers, coping strategies.
  • Regular follow-up: Monitor weight, mental state, adherence.
  • Support groups: e.g., EDA (Eating Disorders Anonymous).

⭐ Family-Based Therapy (FBT), particularly the Maudsley approach, has the strongest evidence base for adolescents with Anorexia Nervosa, often leading to better outcomes than individual therapy alone during inpatient and post-discharge phases.

• 📌 MDT CARE: Motivation, Diet, Therapy, Coping, Aftercare, Relapse prevention, Education.

High‑Yield Points - ⚡ Biggest Takeaways

• Admit for severe malnutrition (BMI < 15), physiological instability (HR < 40, Temp < 35°C, electrolyte imbalance), or suicidality.
• Critical risk: Refeeding syndrome. Monitor electrolytes (K, PO4, Mg); refeed slowly.
• Goals: medical stabilization, nutritional rehabilitation via structured, supervised meals.
• Target weight gain: 0.5-1 kg/week once stable.
• Multidisciplinary team (medical, psychiatric, dietitian) is crucial.
• Manage co-morbidities and initiate psychotherapy (e.g., CBT-E).