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Model adherence is a key indicator of mental health care quality. This study investigates the degree of model adherence, as well as content and staging of care, among the first Youth Flexible Assertive Community Treatment (ACT) teams in the Netherlands. Model fidelity was assessed in sixteen teams with the Youth Flexile ACT model fidelity scale (2014 version). Mental health workers completed a ‘content of care questionnaire’ to map the interventions applied in the teams. Model fidelity scores revealed that twelve teams adhered to the Youth Flexible ACT standard with ‘optimal implementation’ (≥ 4.1 on a 5 point scale) and four teams with ‘adequate implementation’. Most disciplines were well integrated within the teams; however, several items regarding the involvement of specific disciplines and the availability of treatment interventions (peer support worker, employment and education specialist and programs, family interventions, integrated dual disorder treatment) scored below the optimum. Frequency of contact during ACT and the use of Routine Outcome Monitoring instruments scored below the optimum as well. The ‘content of care’ data showed that most clients received an individual psychological intervention, and nearly half of the client sample received scaled-up / intensified ACT care. The findings indicate a predominantly successful translation of care from the theoretical Flexible ACT framework into practice, covering both ACT and non-ACT functions. Further room for improvement lies in the incorporation of specialized disciplines in the personal and social recovery domains, including the peer support worker and employment and education specialist, as well as in specific protocolled interventions.

BackgroundBehavioural parent training (BPT) is a well-established intervention for children with attention-deficit/hyperactivity disorder (ADHD), but most programs are long, which may limit their accessibility. This could be improved by making programs shorter. Here, we studied (1) the feasibility of a new brief BPT program and its procedures, and (2) pre-post changes in daily rated problem behaviours (primary outcome), children’s disruptive behaviours, ADHD/ODD characteristics, impairment, and parents’ sense of parenting competence (secondary outcomes).MethodsWe conducted a nonrandomized pilot study including parents of 28 children (4-12 years) with impairing ADHD characteristics. We examined treatment drop-out, parent and therapist satisfaction, recruitment rates, study drop-out, measurement response and completion rates, acceptability of measurements according to parents, and treatment fidelity. Pre-post changes in the treatment group were compared to those in a historical control group using mixed model analysis, except for those outcomes that were not assessed in the control group. Within group differences were analysed for all outcomes. Results Feasibility of the program and study procedures were good. Treatment drop-out was 14.2%, parents and therapists were satisfied with the new program. We recruited 1.5 participants per month, study drop-out was 10.7%, response/completion rates ranged from 82% to 100%, measurements were acceptable for parents, and treatment fidelity was 96%. We found substantial within-group changes (d’s=.68-.77) and medium-sized between-group changes (d’s=.46-.48) on daily rated problem behaviours. We observed no changes on most of the secondary outcomes, except for disruptive behaviours and impairment. ConclusionOur newly developed brief BPT program was feasible and we observed improvements in children’s daily-rated problem behaviours. These results suggest that brief BPT might be beneficial for clinical practice if the findings are confirmed in large-scale randomised controlled trials.

Purpose This Multicenter Youth Flexible ACT Study examined the effect of Youth Flexible Assertive Community Treatment on symptomatic, social, and personal recovery outcomes of adolescents dealing with multifaceted psychiatric and social care needs who do not readily engage in regular office-based mental health services. Methods Newly admitted clients ( n = 199) aged 12–24 years from 16 Youth Flexible ACT teams participated in this observational prospective cohort study. Client and practitioner questionnaires were administered every 6 months, up to 18 months. Latent growth curve analyses were conducted to examine changes in symptomatic, social, and personal recovery outcomes throughout Flexible ACT. Results Our analyses of client-reported outcomes showed a decrease in overall psychosocial difficulties, depressive symptoms, and subclinical psychosis symptoms. Moreover, outcomes showed improved social interaction with peers, quality of life, and feelings of empowerment and fewer contacts with the police/legal system. In addition, analyses of clinician-reported outcomes showed a decrease in problems related to family life, peer relationships, school/work attendance, emotional symptoms, and attentional problems. Problems related to personal finance, school and work status, substance misuse, disruptive and aggressive behavior, self-injury, and self-care and independence remained unchanged. Conclusion Our results showed that clients participating in Youth Flexible ACT improved in symptomatic, social, and personal recovery outcomes over 18 months. With its integrated approach and personalized care, this service delivery model is promising for adolescents unable to engage successfully in regular (office based) mental health support services.

Learning objectivesBy reading this article, you should be able to:•Detail the organ systems that are affected in patients with anorexia nervosa and the accompanying perioperative considerations.•Recognise refeeding syndrome, identify risks and take precautions to prevent complications.•Be aware of the cognitive situation of the patient with anorexia nervosa and the interaction with the anaesthetist.Key points•Anorexia nervosa (AN) is a psychiatric illness that affects most organ systems.•Anorexia nervosa carries a high risk of complications requiring admission to hospital.•The perioperative reintroduction of calories (including propofol) should be closely monitored to avoid refeeding syndrome, which is potentially fatal.•The focus of the relationship between an anaesthetist and a patient with AN is not the treatment of the eating disorder but to ensure a safe surgical procedure and postoperative recovery. By reading this article, you should be able to:•Detail the organ systems that are affected in patients with anorexia nervosa and the accompanying perioperative considerations.•Recognise refeeding syndrome, identify risks and take precautions to prevent complications.•Be aware of the cognitive situation of the patient with anorexia nervosa and the interaction with the anaesthetist. •Anorexia nervosa (AN) is a psychiatric illness that affects most organ systems.•Anorexia nervosa carries a high risk of complications requiring admission to hospital.•The perioperative reintroduction of calories (including propofol) should be closely monitored to avoid refeeding syndrome, which is potentially fatal.•The focus of the relationship between an anaesthetist and a patient with AN is not the treatment of the eating disorder but to ensure a safe surgical procedure and postoperative recovery. Anorexia nervosa (AN) is a psychiatric eating disorder characterised by a severe restriction of energy intake because of the intense fear of gaining weight.1Mitchell J.E. Peterson C.B. Anorexia nervosa.N Engl J Med. 2020; 382: 1343-1351Crossref PubMed Scopus (49) Google Scholar There are two subtypes: the ‘restricting’ type (weight loss through dieting, with or without excessive exercise) and the ‘binge eating and purging’ type (binge eating in combination with self-induced vomiting or laxatives). Although a low body mass index (BMI) is not part of the diagnosis, most patients are (severely) underweight (BMI <17 kg m−2). Anorexia nervosa predominantly affects women (>90%). The reported incidence of AN varies from 0.5 to 318 cases per 100,000 women-years, and it is suggested that the incidence of AN in young women is increasing.2Martinez-Gonzalez L. Fernandez-Villa T. Molina A.J. et al.Incidence of anorexia nervosa in women: a systematic review and meta-analysis.Int J Environ Res Public Health. 2020; 17: 3824Crossref PubMed Scopus (16) Google Scholar This phenomenon may be the result of several factors, including the increase in social media creating serious body image concerns and the COVID-19 pandemic with its associated consequences of increased social isolation, negatively influencing mental health and harmful eating habits. Although often diagnosed during adolescence, about 20% progress to chronic AN during adulthood.3Steinhausen H.C. The outcome of anorexia nervosa in the 20th century.Am J Psychiatry. 2002; 159: 1284Crossref PubMed Scopus (1264) Google Scholar Unfortunately, AN has the highest mortality rate of all psychiatric diagnoses, mainly resulting from the medical complications of chronic malnutrition.4Mehler P.S. Brown C. Anorexia nervosa—medical complication.J Eat Disord. 2015; 3: 11Crossref PubMed Scopus (136) Google Scholar The exact prevalence and type of surgery being undertaken in patients with AN are uncertain; to date, there are only 12 published case reports.5Hirose K. Hirose M. Tanaka K. Kawahito S. Tamaki T. Oshita S. Perioperative management of severe anorexia nervosa.Br J Anaesth. 2014; 112: 245-254Abstract Full Text Full Text PDF Scopus (16) Google Scholar However, anaesthetists may be confronted with a patient diagnosed with AN presenting for (semi)elective or emergency surgery. This review describes the pathophysiological consequences of AN and the perioperative issues for the anaesthetist caring for the patient with AN undergoing surgery . Chronic severe malnutrition affects the function of most organ systems. In addition, forced vomiting and laxative abuse can have severe and potentially life-threatening consequences. The most relevant pathophysiological changes per organ system are described as follows and summarised in Fig. 1. Anorexia nervosa is associated with multiple cardiac comorbidities. Because of a lack of nutritional intake and low metabolic rate, cardiac muscle mass is often decreased.6Kuwabara M. Niwa K. Yamada U. Ohta D. Low body mass index correlates with low left ventricular mass index in patients with severe anorexia nervosa.Heart Vessels. 2018; 33: 89-93Crossref PubMed Scopus (12) Google Scholar Compared with young women with a normal BMI, patients with AN have a significantly lower preload, cardiac output and cardiac index, mainly a result of starvation in combination with low muscle mass and subsequently reduced venous return.7de Simone G. Scalfi L. Galderisi M. et al.Cardiac abnormalities in young women with anorexia nervosa.Br Heart J. 1994; 71: 287-292Crossref PubMed Google Scholar As a result, most patients with AN are hypotensive (systolic pressure <100 mmHg) and bradycardic. The bradycardia results from the activation of the parasympathetic nervous system at extremely low body weight. Despite the low blood pressure (BP), vascular resistance in AN is often high.7de Simone G. Scalfi L. Galderisi M. et al.Cardiac abnormalities in young women with anorexia nervosa.Br Heart J. 1994; 71: 287-292Crossref PubMed Google Scholar The combination of a high systemic vascular resistance with the decrease in cardiac muscle mass means that cardiac output is usually low.8Hirose K. Ogura M. Yamada Y. Anesthesia for a long-term anorexic patient with end-stage liver cirrhosis.J Med Invest. 2019; 66: 337-339Crossref PubMed Scopus (1) Google Scholar Cardiac arrhythmias can be caused by electrolyte deficits, such as potassium or calcium, and use of medications that may exaggerate a prolonged QT time. Caution must be taken when giving or prescribing arrhythmogenic drugs, such as catecholamines, neostigmine and atypical antipsychotics. In addition, cardiomyopathy could be the result of ingestion of ipecac syrup, an emetic drug that is used to induce vomiting. Ipecac is cardiomyotoxic, and when used regularly inflammatory changes may lead to degeneration and fibrosis of myocardial fibres.9Denner T. Anorexia nervosa: perioperative implications.Cont Educ Anaesth Crit Care Pain. 2009; 9: 61-64Abstract Full Text Full Text PDF Scopus (8) Google Scholar Cold extremities from peripheral vasoconstriction are common, as this is a heat-preserving mechanism during starvation. Self-induced vomiting may lead to dental caries, making airway management more challenging. Delayed gastric emptying and gastritis may occur, potentially increasing the risk of aspiration.10Heruc G.A. Little T.J. Kohn M.R. et al.Effects of starvation and short-term refeeding on gastric emptying and postprandial blood glucose regulation in adolescent girls with anorexia nervosa.Am J Physiol Endocrinol Metab. 2018; 315: E565-E573Crossref PubMed Scopus (26) Google Scholar In addition, constipation associated with abuse of laxatives may be seen. Aspiration pneumonia and pneumomediastinum have been reported as a result of binge eating and frequent vomiting.11Seller C.A. Ravalia A. Anaesthetic implications of anorexia nervosa.Anaesthesia. 2003; 58: 437-442Crossref PubMed Scopus (25) Google Scholar The presence of membranous tracheal stenosis has been observed in a patient with self-induced vomiting, likely as a result of frequent aspiration.11Seller C.A. Ravalia A. Anaesthetic implications of anorexia nervosa.Anaesthesia. 2003; 58: 437-442Crossref PubMed Scopus (25) Google Scholar,12Nakamura M. Hisamura M. Hashimoto M. et al.Membranous tracheal stenosis in a patient with anorexia nervosa and self-induced vomiting—challenges in securing the airway.Respir Med Case Rep. 2017; 19: 36-38Google Scholar Because of chronic gastrointestinal losses and the associated metabolic alkalosis, patients with AN often present with hypoventilation as a physiological response to maintain a normal acid–base balance. Renal failure and nephrolithiasis are common in patients with AN. A recent study in 148 patients with AN found that 72% presented with a glomerular filtration rate (GFR) <90% (chronic kidney disease stage II) and 13% with a GFR <60% (chronic kidney disease stage III).13Riva A. Pigni M. Nacinovich R. Renal dysfunction and clinical correlates in adolescents with restrictive anorexia nervosa.Clin Nutr ESPEN. 2021; 43: 230-234Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Electrolyte disturbances are common, especially in patients with self-induced vomiting or the use of diuretics. Dehydration triggers the renin–angiotensin–aldosterone system, which aggregates loss of total body potassium. During prolonged starvation, metabolism switches from using carbohydrate to using fat and proteins as the main source of energy production. In this catabolic state, the breakdown of fat and muscle tissue leads to a decrease in total cell mass (lean body mass) and a depletion in total body electrolytes. The presence of increased liver transaminases in the patient with AN in association with hypoglycaemia is an indicator of severe illness. Liver transaminases are often mildly increased during both fasting and refeeding. In starvation, hepatocytes are damaged, leading to cell death (starvation-induced liver disease), then during refeeding there is deposition of fat and glucose in the liver parenchyma (steatosis). An ultrasound can be helpful to distinguish between a small liver (fasting) and a large fatty liver (refeeding). Marked elevation of liver transaminases in severe AN (BMI <12 kg m−2) is often a sign of multiple organ failure. Although rare, fulminant liver failure can occur.14Harris H.R. Sasson G. Mehler P.S. Elevation of liver function tests in severe anorexia nervosa.Int J Eat Disord. 2013; 46: 369-374Crossref PubMed Scopus (39) Google Scholar Delayed gastric emptying (and acute gastric dilation) is common and may have implications for airway management. In severe cases, gastric dilation can lead to ischaemia and ultimately gastric perforation. In a patient with AN presenting with abdominal pain, bowel ischaemia caused by the superior mesenteric artery syndrome (SMAS) should always be considered. This rare complication of AN is caused by compression of the duodenum between the aorta and the mesenteric artery attributable to loss of intra-abdominal fat. Typical symptoms are upper abdominal pain, nausea and vomiting shortly after a meal.4Mehler P.S. Brown C. Anorexia nervosa—medical complication.J Eat Disord. 2015; 3: 11Crossref PubMed Scopus (136) Google Scholar Oesophageal complications of recurrent vomiting are oesophagitis, stenosis and oesophageal rupture. Coagulation disorders secondary to chronic malnutrition are common. The international normalised ratio (INR) is increased in 25% of patients, associated with an extremely low BMI and most caused by vitamin K deficiency. Prothrombin time is generally normal.15Sabel A.L. Gaudiani J.L. Statland B. Mehler P.S. Hematological abnormalities in severe anorexia nervosa.Ann Hematol. 2013; 92: 605-613Crossref PubMed Scopus (52) Google Scholar Prolonged starvation can lead to bone marrow depression, adversely affecting erythrocyte, leucocyte and platelet counts. In a cohort of 53 adult patients with AN, anaemia was the most common haematological abnormality (83%) followed by leucopenia (79%), neutropenia (29%) and thrombocytopenia (25%). Despite those abnormalities, there was no clinical report of abnormal bleeding or clotting complications.15Sabel A.L. Gaudiani J.L. Statland B. Mehler P.S. Hematological abnormalities in severe anorexia nervosa.Ann Hematol. 2013; 92: 605-613Crossref PubMed Scopus (52) Google Scholar Although brain volume reduction and non-specific EEG changes are commonly seen, neurological consequences are rare. Reductions in white and grey matter and the cerebellum are generally reversible but occasionally result in permanent damage. More recent studies have demonstrated alterations in gamma aminobutyric acid (GABA) receptors in the brains of patients with severe AN, and it has been suggested that this process might play a role in some of the behavioural disturbances seen.16Chidiac C.W. An update on the medical consequences of anorexia nervosa.Curr Opin Pediatr. 2019; 31: 448-453Crossref PubMed Scopus (19) Google Scholar Whether this process has consequences for GABA-ergic anaesthetic drugs has not been researched yet. Patients with AN often have severe comorbidities as a result of chronic malnutrition. Robust preoperative screening and optimisation are therefore essential. At present, there are no universally agreed criteria for deciding whether or not a patient is eligible for surgery. Careful evaluation of the different organ systems is therefore necessary to assess risk. It is also important to gather information on the course of the disease and whether self-inflicted vomiting or medication abuse (laxatives or diuretics) is involved. A thorough history, with focus on metabolic performance, orthostatic hypotension and collapse, should be performed. In the assessment of the airway, specific considerations should include the possibility of poor dentition, large salivary glands, oesophagitis and tracheal stenosis in patients with self-induced vomiting. A preoperative bronchoscopy may be indicated. A preoperative ECG and transthoracic ultrasound should be arranged to inform the clinician of arrythmias or structural cardiac disease. ECG abnormalities (prolonged QT-interval, atrioventricular block, T-wave inversion, ST depression, supraventricular tachycardias) are common in severe AN. The presence of a bradycardia <40 beats min−1 or a systolic pressure <80 mmHg is considered contraindication for elective surgery. Kidney function should be determined before surgery. It is important to realise that GFR is often estimated by a formula that is based on serum creatinine concentrations. The value of creatinine as a marker of kidney function is limited in patients with a low muscle mass, low intake of meat or altered volume status. In AN, the use of creatinine concentration as a marker of kidney function leads to an overestimation of GFR. The accurate estimation of the kidney function requires calculation of the creatinine clearance using the serum creatinine concentration and urinary creatinine secretion from a 24 h urine sample. Collecting 24 h urine may be challenging in the anorexic patient, so as a second-best alternative the GFR can be estimated by using the Cockcroft–Gault formula, which takes the patient's weight into account. If present, severe underlying electrolyte disturbances should be carefully corrected before surgery.9Denner T. Anorexia nervosa: perioperative implications.Cont Educ Anaesth Crit Care Pain. 2009; 9: 61-64Abstract Full Text Full Text PDF Scopus (8) Google Scholar,16Chidiac C.W. An update on the medical consequences of anorexia nervosa.Curr Opin Pediatr. 2019; 31: 448-453Crossref PubMed Scopus (19) Google Scholar Thyroid function is commonly reduced in patients with AN, especially the production of tri-iodothyronine (T3). Thyroid-stimulating hormone and thyroxine concentrations are usually normal, and T3 concentrations recover after the patient regains weight. Preoperative biochemical thyroid function analyses should be considered, as hypothyroidism and anaesthesia can result in life-threatening cardiovascular dysfunction and myxoedema coma. Day-case surgery is discouraged in patients with AN, as there are risks of postoperative refeeding syndrome, electrolyte disturbances and end-organ failure. Patients with a clinical suspicion of gastric distension (binge eating, delayed gastric emptying, and SMAS) should be considered at risk of aspiration.11Seller C.A. Ravalia A. Anaesthetic implications of anorexia nervosa.Anaesthesia. 2003; 58: 437-442Crossref PubMed Scopus (25) Google Scholar Precautionary measures should be taken (gastric tube and rapid-sequence induction). Airway management is unlikely to be difficult. Respiratory compensation of metabolic alkalosis (commonly caused by loss of acid in vomitus) can be observed, and the ventilator settings should account for this when mechanical ventilation is used. Frequent arterial blood sampling is required to optimise the ventilator settings, as hyperventilation can exaggerate the pre-existing alkalosis, leading to hypokalaemia and increasing risk of arrhythmias.11Seller C.A. Ravalia A. Anaesthetic implications of anorexia nervosa.Anaesthesia. 2003; 58: 437-442Crossref PubMed Scopus (25) Google Scholar As such, ventilator settings should be set in a way that maintains homeostatic balance. Pressure-controlled ventilation could be helpful to avoid pulmonary overdistension. Measuring oxygenation using a pulse oximeter placed on fingers or toes may be challenging, as peripheral vasoconstriction is common. Ear lobes, nostrils and cheeks are useful alternative sites; arterial blood gas analysis can be useful to quantify oxygenation when needed. Perioperative non-invasive haemodynamic monitoring (e.g. invasive BP monitoring or cardiac output monitoring) may be useful in the critically ill patient to inform the clinician about the patient's cardiac output and fluid status. Patients with AN are likely to be hypovolaemic, and it is important to optimise preoperative fluid balance judiciously. Fluid overload must be avoided at all times, as the combination of a low preload and systolic cardiac dysfunction carries the risk of acute congestive heart failure if there is a sudden expansion in plasma volume.7de Simone G. Scalfi L. Galderisi M. et al.Cardiac abnormalities in young women with anorexia nervosa.Br Heart J. 1994; 71: 287-292Crossref PubMed Google Scholar Intraoperative transoesophageal echocardiography, with the focus on the fluid status and left ventricular function, might be helpful in understanding the haemodynamic response to noxious stimulation and anaesthetic drugs and to intervene appropriately. A case of Takotsubo cardiomyopathy associated with AN, resulting in life-threatening arrhythmias, such as torsades de pointes and ventricular tachycardia, has been described.17Kawano H. Kinoshita M. Kondo A. Yamada Y. Inoue M. Torsades de pointes associated with Takotsubo cardiomyopathy in an anorexia nervosa patient during emergence from general anesthesia.Middle East J Anaesthesiol. 2016; 23: 557-561PubMed Google Scholar Based on this case, the authors suggested that a defibrillator should be available at all times in the perioperative period. The balance between a high vagal tone and an increased catecholaminergic response secondary to the persistent hypoglycaemic state, however, may lead to a highly fluctuating haemodynamic situation resulting in both hypo- and hypertension. Careful positioning is very important. The lack of subcutaneous fat means nerves (e.g. the ulnar nerve) are more susceptible to pressure damage caused by poor positioning while under anaesthesia. Caution should be taken during the moving and handling of these patients, as osteoporosis is common in AN secondary to dysregulation of the parathyroid glands, meaning patients are at increased risk of bone fracture.9Denner T. Anorexia nervosa: perioperative implications.Cont Educ Anaesth Crit Care Pain. 2009; 9: 61-64Abstract Full Text Full Text PDF Scopus (8) Google Scholar Temperature measurement and fluid warming devices (e.g. forced air warming, resistive polymers, etc.) should be available even during surgery of short duration, as thermoregulation is severely impaired by a lack of fat tissue. Little is known about the pharmacological consequences of being severely underweight. The multisystemic impact of AN coupled with the changes in body composition (e.g. percentage of body fat, muscle mass, and total body water) seen in severely underweight patients affects the pharmacokinetics and pharmacodynamics in a variety of ways. Absorption is unpredictable because of a lack of subcutaneous fat and muscle, which has significant consequences for i. m. and s. c. drug injections. The volume of distribution of drugs is affected by reduced body fat, potentially increasing their free (active) fractions in the plasma. Despite these concerns, the evidence suggests that the pharmacodynamic effects of altered body composition are relatively limited.18van den Berg J.P. Vereecke H.E.M. Proost J.H. et al.Pharmacokinetic and pharmacodynamic interactions in anaesthesia. A review of current knowledge and how it can be used to optimize anaesthetic drug administration.Br J Anaesth. 2017; 118: 44-57Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Decreased basal metabolic rate and reduced renal or liver function may impair elimination and clearance of drugs.9Denner T. Anorexia nervosa: perioperative implications.Cont Educ Anaesth Crit Care Pain. 2009; 9: 61-64Abstract Full Text Full Text PDF Scopus (8) Google Scholar As such, medication dosing should be based on the true weight, instead of other derivatives, preferably in a lower dosing range, especially with cardio-depressive drugs.9Denner T. Anorexia nervosa: perioperative implications.Cont Educ Anaesth Crit Care Pain. 2009; 9: 61-64Abstract Full Text Full Text PDF Scopus (8) Google Scholar Because of muscle weakness and possible disturbances in serum potassium concentrations, depolarising neuromuscular blocking agents should be avoided. As patients with AN are susceptible to life-threatening arrhythmias, sugammadex may be superior for reversal of neuromuscular block.5Hirose K. Hirose M. Tanaka K. Kawahito S. Tamaki T. Oshita S. Perioperative management of severe anorexia nervosa.Br J Anaesth. 2014; 112: 245-254Abstract Full Text Full Text PDF Scopus (16) Google Scholar Pharmacokinetic–pharmacodynamic (PKPD) models for i.v. anaesthetics and subsequently target-controlled infusion systems are not validated for the underweight patient and may consequently misestimate the intended drug doses.19Lee Y.H. Choi G.H. Jung K.W. et al.Predictive performance of the modified Marsh and Schnider for propofol in underweight patients undergoing general anaesthesia using target-controlled infusion.Br J Anaesth. 2017; 118: 883-891Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Recent studies regarding the optimisation of PKPD models in the underweight patient show that in patients with a BMI <18.5 kg m−2, the rapid distribution (i.e. a mathematical description in a frequently used three-compartment PKPD model for the distribution towards more vascularised tissue, such as muscle) has a more prominent role than in the patient with normal weight, whereas the slower distribution (i.e. a mathematical description for less vascularised tissue, such as fat) is negatively influenced.20Park J.H. Choi S.M. Park J.H. et al.Population pharmacokinetic analysis of propofol in underweight patients under general anaesthesia.Br J Anaesth. 2018; 121: 559-566Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar This finding could be explained by the reduction in fat tissue (i.e. described by the ‘slower’ compartment) and leads to the risk of inadvertent underdosing and overdosing of propofol. As such, careful drug titration towards effect is needed.21Hebbes C.P. Thompson J.P. Pharmacokinetics of anaesthetic drugs at extremes of body weight.BJA Educ. 2018; 18: 364-370Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar EEG-based depth of anaesthesia monitors (e.g. bispectral index, qCON etc.) and neuromuscular transmission monitoring should be used to measure the pharmacodynamic effects of drugs used during i. v. anaesthesia and find the optimal dose–response relationship for each particular patient. In contrast, volatile anaesthesia dosing relies on the measurement of end-tidal anaesthetic concentrations, which incorporates the entire underlying pharmacokinetic mechanisms. The ability to measure end-tidal volatile anaesthetic concentrations could be an argument for using volatile agents in the underweight patient. Locoregional techniques can be used in a patient with anorexia, although drug doses (and toxic doses) should be calculated based on the patient's actual body weight. The lack of subcutaneous fat tissue could complicate ultrasound-guided blocks. There is no available literature on neuraxial techniques in patients with AN. Coma, seizures and dysfunction of thermoregulation may occur in the postoperative period. Coma may occur from severe hypo- or hyperglycaemia or as a result of an exaggerated respiratory alkalosis. Seizures commonly result from electrolyte disturbances. Hypothermia may occur, as thermoregulation is commonly disturbed.11Seller C.A. Ravalia A. Anaesthetic implications of anorexia nervosa.Anaesthesia. 2003; 58: 437-442Crossref PubMed Scopus (25) Google Scholar Neuropathies and generalised weakness should be recognised before surgery and taken into account during postoperative care. The rapid reintroduction of calories in a patient in catabolic state can lead to refeeding syndrome. This potentially life-threatening but often overlooked condition is triggered by a sudden increase in glycolysis, the metabolic pathway that converts glucose into pyruvate, which then enters the Krebs cycle for energy production. This process requires large amounts of phosphate. In a patient who is already phosphate depleted, this condition can rapidly lead to severe hypophosphataemia (i.e. <0.5 mmol L−1), the hallmark of refeeding syndrome. Clinical symptoms range from muscle weakness and paraesthesia to severe cardiac failure, seizures and diaphragmatic paralysis. Glycolysis also requires thiamine (vitamin B1) as a coenzyme, without which pyruvate is not able to enter the Krebs cycle and is instead converted into lactate. This process can lead to severe lactate acidosis, Wernicke encephalopathy and beriberi (symmetrical neuropathy with or without cardiac failure). In addition, a sudden increase in glucose intake leads to increased insulin concentrations. This process promotes the intracellular shifts of potassium, magnesium and phosphate, which are already depleted. Renal sodium and fluid retention is another symptom of the refeeding syndrome; it can lead to fluid overload, oedema and cardiac failure.22Mehanna H.M. Moledina J. Travis J. Refeeding syndrome: what is it, and how to prevent and treat it.BMJ. 2008; 336: 1495-1498Crossref PubMed Scopus (422) Google Scholar A recent consensus statement defined refeeding syndrome as a decrease in serum phosphate, potassium or magnesium concentrations by 10–20% (mild), 20–30% (moderate) or >30% (severe), or organ dysfunction resulting from a decrease in any of these or because of thiamine deficiency within 5 days of increasing energy provision.23da Silva J.S.V. Seres D.S. Sabino K. et al.ASPEN consensus recommendations for refeeding syndrome.Nutr Clin Pract. 2020; 35: 178-195Crossref PubMed Scopus (129) Google Scholar As until recently, there had been no universally accepted definition, and the true incidence of refeeding syndrome in patients with AN is unknown. A cohort study, including 68 patients with AN admitted to the intensive care unit, found seven patients developed refeeding syndrome (10%).24Vignaud M. Constantin J.M. Ruivard M. et al.Refeeding syndrome influences outcome of anorexia nervosa patients in intensive care unit: an observational study.Crit Care. 2010; 14: R172Crossref PubMed Scopus (74) Google Scholar Five of these patients died of multi-organ failure related to refeeding. In addition to low BMI and starvation, risk factors include a history of alcohol abuse, low electrolyte concentrations and a low albumin concentration. The severity of malnutrition correlates with the severity of the hypophosphataemia. Most cases of refeeding syndrome occur within 72 h of initiating nutritional therapy. Hypoglycaemia may occur as a result of prolonged starvation and may lead to hypoinsulinaemia. The latter is known to be an indicator of adaptation to malnutrition.5Hirose K. Hirose M. Tanaka K. Kawahito S. Tamaki T. Oshita S. Perioperative management of severe anorexia nervosa.Br J Anaesth. 2014; 112: 245-254Abstract Full Text Full Text PDF Scopus (16) Google Scholar Proactive glucose supplementation is not recommended, as it could lead to a severe reactive hypoglycaemia.10Heruc G.A. Little T.J. Kohn M.R. et al.Effects of starvation and short-term refeeding on gastric emptying and postprandial blood glucose regulation in adolescent girls with anorexia nervosa.Am J Physiol Endocrinol Metab. 2018; 315: E565-E573Crossref PubMed Scopus (26) Google Scholar Repeated measurement of plasma glucose and regulation are necessary to prevent severe disturbance of the glucose–insulin balance. Elective surgery should be postponed and consultation with an endocrinologist considered in patients with severe preoperative hypoglycaemia.5Hirose K. Hirose M. Tanaka K. Kawahito S. Tamaki T. Oshita S. Perioperative management of severe anorexia nervosa.Br J Anaesth. 2014; 112: 245-254Abstract Full Text Full Text PDF Scopus (16) Google Scholar The complications of refeeding syndrome are preventable when closely monitored and managed. Before surgery and the initiation of calories, potassium, magnesium and phosphorus should be checked and corrected. In addition, thiamine 100 mg should be given and continued for 5–7 days or longer in patients at high risk. After this, calories can be given, commencing with 10–20 kcal kg−2 for the first 24 h and increased by 33% every 1–2 days.23da Silva J.S.V. Seres D.S. Sabino K. et al.ASPEN consensus recommendations for refeeding syndrome.Nutr Clin Pract. 2020; 35: 178-195Crossref PubMed Scopus (129) Google Scholar Vital signs should be monitored every 4 h after the initiation of calories, including total intake and output. Continuous cardiorespiratory monitoring is recommended for those patients with severe deficiencies or unstable haemodynamics. Electrolytes should be measured twice a day during the first 72 h. For the anaesthetist, it is important to realise that propofol and medications formulated in dextrose have caloric value (e.g. propofol lipid emulsion=1.1 kcal ml−2). Those calories should be taken into account when calculating the maximal caloric intake per day to prevent overfeeding.25Dickerson R.N. Buckley C.T. Impact of propofol sedation caloric overfeeding and protein inadequacy in critically ill patients receiving nutrition support.Pharmacy (Basel). 2021; 9: 121Crossref PubMed Google Scholar There is conflicting evidence on the risk of infection in patients with AN. In general, there is an increased risk of surgical site infection in underweight patients, although no increased risk has been shown in patients with AN. This condition might be explained by the underdiagnosis of infections, as they may not show the classic symptoms (fever and leucocytosis). Despite advances in treatment, the prognosis of AN is still poor. In a large cohort of 5334 patients, mortality was 5%. Of those surviving, 20% remained chronically ill.3Steinhausen H.C. The outcome of anorexia nervosa in the 20th century.Am J Psychiatry. 2002; 159: 1284Crossref PubMed Scopus (1264) Google Scholar Predictors of poor outcome are vomiting, bulimia, chronicity of illness and an obsessive–compulsive personality. In 60% of those patients who died, the cause of death was related to a medical complication (circulatory collapse in 38%). Suicide was the most common non-natural cause of mortality (10% in AN). Admission to hospital is recommended in the case of unstable vital signs (e.g. bradycardia <40 beats min−1 and systolic BP <80 mmHg), BMI <14 kg m−2 and signs of organ failure or refeeding syndrome. The aim of admission to hospital is to stabilise vital signs and treat multi-organ failure. A multidisciplinary approach is recommended. The in-hospital mortality of patients with AN admitted for disease-related complications was described by Nakamura and colleagues.26Nakamura M. Yasunaga H. Shimada T. Horiguchi H. Matsuda S. Fushimi K. Body mass index and in-hospital mortality in anorexia nervosa: data from the Japanese Diagnosis Procedure Combination database.Eat Weight Disord. 2013; 18: 437-439Crossref PubMed Scopus (12) Google Scholar In a cohort of 669 admitted patients (BMI ≤16.5 kg m−2), mortality was 0.7%, with an extremely low BMI (BMI <11 kg m−2) as a strong predictor. There was no information provided on the cause of death in this study. The number of patients with AN presenting for surgery is increasing. To our knowledge, there are no studies on the management and outcomes of patients with AN undergoing surgery. Some case reports describe the surgical management of specific disease-related (emergency) complications of AN, such as bowel ischaemia, valve disorders and fractures having a high mortality rate. Only a few reports focus on anaesthetic management. In 2019, Hirose and colleagues described the challenging case of a patient with chronic AN with end-stage liver cirrhosis, in which anaesthesia for an endoscopic procedure was complicated by severe hypotension.8Hirose K. Ogura M. Yamada Y. Anesthesia for a long-term anorexic patient with end-stage liver cirrhosis.J Med Invest. 2019; 66: 337-339Crossref PubMed Scopus (1) Google Scholar The postoperative period was uneventful, and the patient was discharged on the fourth postoperative day. Another case describes the management of AN in a 26-yr-old patient (BMI 8.6 kg m−2) scheduled for a surgical fixation of a tibial fracture. Surgery was postponed because of severe metabolic derangements and a history of hypoglycaemic collapse and leucopenia. After 7 months of treatment (BMI increased to 11.6 kg m−2), she was rescheduled for surgery, which was uneventful.5Hirose K. Hirose M. Tanaka K. Kawahito S. Tamaki T. Oshita S. Perioperative management of severe anorexia nervosa.Br J Anaesth. 2014; 112: 245-254Abstract Full Text Full Text PDF Scopus (16) Google Scholar The focus of the relationship between an anaesthetist and a patient with AN is not the treatment of the eating disorder but the safe surgical procedure and postoperative recovery. Eating disorders commonly occur in conjunction with other psychological disorders, such as autism and post-traumatic stress disorder. It is important to realise that patients with eating disorders, particularly those severely underweight, feel insecure and are sensitive and vulnerable during social interactions. These patients have difficulty adapting to changing circumstances. Hospitals, medical procedures and anonymous healthcare providers create tension, a significant driver for eating disorders. Fostering a safe and respectful environment should be the cornerstone of the patient–doctor relationship in anaesthesia, thereby creating a positive experience for the patient. This experience could be a meaningful contribution to their lives and future treatment. Although most patients with AN have the capacity for decision-making, they do suffer from difficulties with maintaining attention, concentration and imprinting.27Lena S.M. Fiocco A.J. Leyenaar J.K. The role of cognitive deficits in the development of eating disorders.Neuropsychol Rev. 2004; 14: 99-113Crossref PubMed Scopus (134) Google Scholar It may be helpful to write important things down before surgery, for example during the preoperative assessment. Be aware that a patient's decision-making in severe AN may be mainly based on the short-term rather than the long-term consequences.28van Elburg A. Danner U.N. Sternheim L.C. Lammers M. Elzakkers I. Mental capacity, decision-making and emotion dysregulation in severe enduring anorexia nervosa.Front Psychiatry. 2021; 12545317Crossref PubMed Scopus (14) Google Scholar It may be useful to extend the established trust relationship in the preoperative period by aiming to schedule the same anaesthetist for the surgical procedure. In the immediate perioperative period, it is important to recognise that seemingly trivial issues may be very important to the patient, and these issues may be resolved by providing pragmatic and flexible care (e.g. if the bladder catheter is a stressor, consider inserting the catheter after induction and removing it before emergence from anaesthesia). Induction and emergence from anaesthesia require special attention in these often afraid or traumatised patients and should take place in a supportive, calming, quiet and controlled manner by experienced staff. Postoperatively, the anaesthetist should be aware of the fact that anxiety and insecurity could intensify pain. Therefore, it is important to take time to address worries and insecurities and provide the feeling of control by informing patients about the why and how of their treatment and (drug) choices and involve them in decision-making, including those choices concerning nutritional intake. Finally, it is likely that patients with AN are receiving treatment with psychoactive drugs, such as selective serotonin reuptake inhibitors (SSRIs), atypical anti-psychotics or tricyclic antidepressants. These drugs may have interactions with anaesthetic drugs, and stopping these drugs could be necessary in the perioperative period, preferably in consultation with the patients' psychiatrist.29Peck T. Wong A. Norman E. Anaesthetic implications of psychoactive drugs.Cont Educ Anaesth Crit Care Pain. 2010; 10: 177-181Abstract Full Text Full Text PDF Scopus (26) Google Scholar If this technique is deemed necessary, restarting these drugs after surgery should not be forgotten to prevent withdrawal and emotional instability. Patients with AN should be considered critically ill, as this disease significantly affects almost all organ systems. Although little is known about the exact prevalence and aetiology of surgical procedures in patients with AN, anaesthetists can be confronted with a patient with AN requiring surgery in the elective or acute setting. This review describes the pathophysiological and psychological changes and practical perioperative considerations.