| | Resolution of vital sign instability: an objective measure of medical stability in anorexia nervosaAccepted 25 June 2002. Abstract PurposeTo determine the amount of time necessary for stabilization of blood pressure and heart rate in patients with anorexia nervosa (AN) and the percentage of ideal body weight (IBW) at which this occurs. MethodsA retrospective study was conducted on 36 adolescent patients (33 F, 3 M) with AN, restricting type (Diagnostic and Statistical Manual of Mental Disorders, Fourth edition [DSM-IV] criteria), admitted to a specialized eating disorders unit for nutritional rehabilitation between October 1996 and August 1998. Mean age was 16.5 ± 2.5 years, range 12–23 years. Each morning, pulse and blood pressure were measured supine and after standing for 2 minutes using an automated blood pressure/pulse measuring device (DynamapTM). Orthostasis was defined as a drop in systolic blood pressure > 20 mm Hg with or without a drop in diastolic blood pressure > 10 mm Hg or an increase in heart rate >20 bpm on standing. Time of resolution of orthostasis was defined as the day after which the patient was no longer orthostatic for 48 hours. ResultsOn admission mean pulse rate was 54.4 ± 14.8 bpm (range 38–78) and mean pulse rate slowly increased to 70 bpm by Day 12 of hospitalization. On admission, 60% of patients had orthostatic pulse changes and with refeeding, this number increased to 85% by Day 4 of admission. The mean number of days until patients were no longer orthostatic was 21.6 ± 11.1 days and resolution of orthostasis occurred when subjects reached 80.1 ± 5.7% of IBW. Orthostatic pulse changes were more sensitive indicators of hemodynamic instability than orthostatic blood pressure changes and took longer to resolve. ConclusionThis study demonstrates that of patients with AN, the majority have orthostatic pulse changes on admission. Normalization of orthostatic pulse changes was achieved after approximately 3 weeks of nutritional rehabilitation when subjects reached 80% of their IBW. Resolution of orthostasis can be used as one of the objective measures to determine medical stability and readiness for discharge to an alternate level of care.
Anorexia nervosa (AN) is a life-threatening eating disorder. The starvation experienced by persons with AN can cause damage to vital organs such as brain, heart, bones, and gastrointestinal system. Cardiovascular complications include bradycardia, hypotension, poor myocardial contractility, the prolonged QTc syndrome, tachyarrythmias, and sudden death 1, 2, 3, 4. Subjects with AN regularly have orthostatic changes, which, upon standing, place them at risk of syncope. They may complain of dizziness, weakness, lightheadedness, and unsteadiness.
The Society for Adolescent Medicine and the American Psychiatric association have identified indications for the hospitalization of patients with AN 5, 6, but there are no guidelines providing criteria for discharge to the community or to alternate levels of care. In particular, objective criteria clarifying what constitutes “medical stability” need to be developed. Vital sign instability is one of the indications for hospitalization in AN 5, 6. Resolution of vital sign instability may be one measure of medical stability and readiness for discharge from an inpatient unit.
Hill and Maloney studied orthostatic changes in six adolescents with AN and suggested that monitoring for orthostatic pulse changes is an effective method to measure cardiovascular stability and readiness for discharge from an inpatient unit [7].
The purpose of the present study is to determine the amount of time necessary for stabilization of blood pressure and heart rate and the percentage of ideal body weight (IBW) at which this occurs in a large cohort of adolescents with AN.
Methods  Subjects A retrospective study was conducted of 50 adolescents with AN who were consecutively admitted to the Eating Disorders Center of Schneider Children’s Hospital from October 1996 through August 1998 for nutritional rehabilitation. Inclusionary criteria for the study were: meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria for the diagnosis of AN, restricting type [8] and hospitalization for a minimum of 1 week. The latter was included to exclude those who were admitted for correction of acute medical problems such as electrolyte disturbances rather than for nutritional rehabilitation. Of the 50 adolescents who met diagnostic criteria for AN, 5 were excluded because they were discharged within the first week of hospitalization and 9 were excluded as they were either discharged or transferred to another program as mandated by their insurance companies, while still experiencing orthostatic hypotension. The study population, therefore, comprised 36 subjects, 33 female and 3 male. Data collection Data collected by chart review included the age, gender, weight, height on admission, length of hospitalization, and weight on discharge. Daily weights were measured on all subjects. Body weight was measured daily postvoiding and before breakfast using a digital scale with the patient in a hospital gown. Heart rates were monitored by cardiac telemetry until the patient no longer experienced orthostatic hypotension. Vital signs were monitored daily as follows: each morning at 6:00 am, pulse and blood pressure were measured supine and after standing for 2 minutes using an automated BP/pulse measuring device (DynamapTM). The first day’s pulse was counted to be the first AM after admission. Weight, pulse, and blood pressure (both systolic and diastolic) were recorded daily until orthostatic changes resolved. The study was approved by the North Shore-Long Island Jewish Health System Institutional Review Board. Definitions Orthostasis was defined as: a drop in systolic blood pressure of more than 20 mm Hg and/or a drop in diastolic blood pressure of >10 mm Hg or an increase in heart rate more than 20 beats per minute (bpm) after attaining an upright posture [9]. Resolution of orthostatis was defined as occurring on the day after which the patient no longer experience orthostatic changes for 48 hours. Mean pulse was defined as average of pulses of 36 patients taken at 6:00 AM while supine. Percent of IBW was defined as the percentage of median weight for height, age, and gender using the National Center for Health Statistics (NCHS) tables [10]. Data analysis Changes in weight and percent of IBW from admission to resolution of vital sign instability were analyzed using the paired Student’s t-test. Pearson correlation was used to examine the relationship among time to resolution of orthostasis, admission weight, and caloric intake. Pulse and blood pressure differences on standing were plotted against time. The percent of subjects with orthostatic changes was also plotted against time. Data are presented as mean ± SEM. Results The mean age of the subjects in the study was 16.4 ± 2 years with a range of 12–23 years. On admission, patients were malnourished (mean weight 91.7 ± 12.6 lbs., 73.7 ± 6.8 percent of IBW). At resolution of orthostasis, weight had increased to 99.6 ± 9.7 lbs. (p < .0001) and percent of IBW had increased to 80.1 ± 5.7% (p < .0001). The average length of time until resolution of orthostatis was 21.6 ± 11.1 days. Time of stabilization of orthostasis was directly related to admission weight (p = .003), percent of IBW on admission (p = .054), and not to caloric intake (p = .14). Patients were divided into two groups: those whose orthostasis resolved at 21 days and those whose orthostasis took longer than 21 days to resolve. The latter were of lower admission body weight (p = .04) and lower admission % IBW (p = .03), but not significantly different by age, caloric intake, or weight at normalization of vital signs, as shown in Table 1. On admission, mean baseline pulse was 54.4 ± 14.8 bpm (range 38–78) and gradually improved with nutritional rehabilitation reaching mean pulse rate of 70 bpm by Day 12 of admission (Figure 1). Both systolic and diastolic blood pressure measurements were low on admission and there were no appreciable changes in blood pressure evident during nutritional rehabilitation, as shown in Figure 2. When changing from supine to standing, orthostatic pulse changes were observed more frequently than a drop in blood pressure. On admission, 60% of patients had orthostatic pulse changes, whereas only 15% of patients demonstrated orthostatic blood pressure changes. The percent of subjects who showed a pulse difference of >20 bpm at 6:00 am increased to 86% by Day 4 of admission and slowly decreased to 70% by 2 weeks (Figure 3). | | |  | | Orthostasis Resolved by 21 days (N = 22) | Orthostasis Resolved >21 days (N = 14) | p | |
|---|
| Age (yrs) | 16.5 ± 2.2 | 16.7 ± 2.8 | .88 | |
| Admission weight (lbs) | 95.3 ± 13.2 | 86.5 ± 9.2 | .04 | |
| Admission, percent of IBW | 74.9 ± 7.1 | 70.2 ± 4.1 | .03 | |
| Caloric intake (Kcals/day) | 1560 ± 415 | 1400 ± 200 | .29 | |
| Weight at which orthostasis resolved (lbs) | 101 ± 10.1 | 100 ± 8.5 | .35 | |
| Percent at which orthostasis resolved | 79.5 ± 6.2 | 80.6 ± 4.3 | .6 | | | | |
Discussion The complications of AN are numerous and frequent. The most frequent medical complications include dehydration, hypothermia, bradycardia, dysrythmias, marked orthostatic pulse, and blood pressure instability [11]. Adolescents with AN resist treatment and may die from complications of their illness. Mortality remains between 5% and 15% [12]. Management of medical dangers and restoration of normal nutrition makes the treatment of AN prolonged and costly. Given the desire to contain costs, there is a need for objective and reproducible criteria to determine medical stability and readiness for discharge from inpatient units. Patients with AN regularly have orthostatic changes in blood pressure, which, upon standing, place them at increased risk of syncope [11]. Improvement in orthostatic changes occurs with weight gain. Patients who are discharged while underweight have a worse outcome and more frequent rate of rehospitalization than those who achieve a stable weight [13]. Nutritional rehabilitation results in weight gain, reversal of orthostatic changes, and medical stability. This study provides data that show that normalization of vital signs takes approximately 3 weeks and occurs when subjects reach 80% of their IBW. Our results are in agreement with those of Hill and Maloney, who in a smaller sample of patients, found that the mean number of days until patients were no longer orthostatic was 27 days and the mean percent of IBW was 79.5%. Both studies indicate that resolution of vital sign instability is an objective measure of medical stability for the purpose of transfer to a less intensive level of care. Continued weight gain until treatment goal weight is achieved is essential but this can take place in partial hospitalization or intensive outpatient settings. We have previously demonstrated that 90% of IBW is a reasonable goal weight and 86% of patients who achieve this weight resume menses within 6 months [14]. Pulse is a more sensitive indicator of vital sign stability than blood pressure. Our study shows that orthostatic changes take the principal form of an increase in heart rate >20 bpm without significant hypotension in patients with AN. Among these patients, almost every patient had pulse increase >20 bpm when changing from supine to a standing position. These results are consistent with observations made in subjects with AN by Palla and Litt, who found that in greater than half of these patients (57%), heart rate doubled and occasionally tripled upon standing [11]. One hypothesis to explain this phenomenon is that starvation leads to loss of body weight, resulting in atrophic peripheral muscles, resulting in decreased venous return to the heart [15]. Upright posture causes peripheral venous pooling, which leads to decrease in cardiac output and stimulation of aortic, carotid, and cardiopulmonary baroreceptors. This stimulation reflexively increases sympathetic outflow and inhibits parasympathetic activity. These adjustments lead to an increase in heart rate and vascular resistance to maintain systemic arterial pressure upon standing upright [9]. Limitations Limitations include small sample size and retrospective nature of the study. The latter, in particular, made it difficult to obtain accurate information about variables such as caloric intake and exercise performed in the days before hospital admission. Finally, vital sign stability does not necessarily imply medical stability nor does this suggest that AN patients can be expected to become stable in 3 weeks of hospitalization. However, this study provides valuable information on objective physical parameters that can be used to guide decisions regarding levels of care for patients with AN. Conclusion Our study demonstrates that in patients with AN admitted for nutritional rehabilitation, normalization of orthostatic vital signs was achieved after approximately 3 weeks when subjects reached 80% of their IBW. Resolution of vital sign instability can be used as one of the objective measures to determine medical stability and readiness for discharge from inpatient unit. Acknowledgements We thank David Rosenberg, M.D. for providing help with the graphs and Anne Marie O’ Reiley, R.N., whose daily efforts helped support research activities such as these. References 1.
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Arch Intern Med. 1984;144:773–774. MEDLINE a Division of Adolescent Medicine, Schneider Children’s Hospital, North Shore-Long Island Jewish Health System, New Hyde Park, New York, USA  Address correspondence to: Tabassum Shamim, M.D., Charter Oak Family Health Center, 21 Grand Street, Hartford, CT 06106, USA.
PII: S1054-139X(02)00533-5 © 2002 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved. | |
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