|Year : 2012 | Volume
| Issue : 2 | Page : 77-82
Nutritional and eating disorders: Clinical impact and considerations during anesthesia procedures
Ashish Kulshrestha, Sukhminder J. S. Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
|Date of Web Publication||22-Sep-2012|
Sukhminder J. S. Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
Source of Support: None, Conflict of Interest: None
An increasing proportion of patients coming for anesthesia and surgery have some form of nutritional deficiency disorder which can have extremely variable presentation ranging from anorexia nervosa to obesity. All these nutritional disorders produce various pathophysiological changes in cardiovascular, respiratory, renal, endocrine, and immune systems, which make these patients highly susceptible to various anesthetic complications. The serious biochemical alterations and interaction of anesthetic drugs with various psychiatric drugs used for treatment of psychiatric nutritional disorders should also be kept in mind while anesthetizing such patients. A careful preoperative planning and optimization of general condition of these patients is mandatory to prevent any catastrophe. The importance of intense perioperative and postoperative monitoring cannot be underestimated in preventing any untoward incident during this period.
Keywords: Anorexia nervosa, bulimia, malnutrition, nutrition, obesity
|How to cite this article:|
Kulshrestha A, Bajwa SJ. Nutritional and eating disorders: Clinical impact and considerations during anesthesia procedures. J Med Nutr Nutraceut 2012;1:77-82
|How to cite this URL:|
Kulshrestha A, Bajwa SJ. Nutritional and eating disorders: Clinical impact and considerations during anesthesia procedures. J Med Nutr Nutraceut [serial online] 2012 [cited 2020 Jul 6];1:77-82. Available from: http://www.jmnn.org/text.asp?2012/1/2/77/101290
| Introduction|| |
With the tremendous advancement over last few decades, more number of patients with some form of nutritional disorder come for elective or emergency surgical procedures. These nutritional disorders are diverse and can range from eating disorders to malnutrition and obesity. Although these disorders not life threatening, they can significantly affect the perioperative management, and a sound knowledge of the pathophysiological changes occurring in these disorders is essential for the attending anesthesiologist for proper management.  These nutritional disorders are broadly classified into the following:
- Eating disorders: They include anorexia nervosa, bulimia nervosa, and eating disorders not otherwise described, i.e. those disorders that do not meet the criteria for any specific disorder.
- Overnutrition or obesity
| Eating Disorders|| |
These are a group of psychiatric disorders characterized by severe disturbances in eating habits where the person remains on extremely reduced or an increased food intake. These are further subdivided into the following: 
It is defined as refusal to maintain body weight at or above a minimal normal weight for the corresponding age and height. According to the International Classification of Diseases, 10 th Revision (ICD-10), following five diagnostic criteria should be met for definitive diagnosis of the disease:
- Body weight is maintained at least 15% below the expected or body mass index (BMI) ≤17.5.
- Weight loss is self-induced by food avoidance and self-induced vomiting, purging, excessive exercising, or using appetite suppressants or diuretics.
- Body image is intrusive, overvalued fear of fatness, self-imposed low weight threshold.
- Widespread endocrine dysfunction involving the hypothalamic-pituitary-gonadal axis, manifesting as amenorrhea (women) and loss of libido (men).
- If the onset is before puberty, the sequence of pubertal events will be delayed.
The risk of development of the disorder in women is found to be 0.3-1%. About 10-29% of those affected are men. 
It is further divided into two main types which are found in equal proportions:
- Restricting type : There is a profound reduction in caloric intake and is often accompanied by excessive exercise.
- Binge eating/purging type : It is associated with self-induced vomiting and misuse of pharmacological agents such as laxatives, diuretics, etc. It is often associated with alcohol and substance abuse.
The contributing factors implicated are cultural influences, genetic factors, personality traits, and a family history of obesity. 
The various pathophysiological changes associated with anorexia nervosa are summarized in [Table 1]. 
Thus, anorexia nervosa is associated with derangements in most of the important systems in the body, a sound knowledge of which is mandatory for a successful perioperative anesthetic management.
Treatment of this condition is unique and involves not only the treatment of cognitive disturbances but also the nutritional supplementation of the patient. It involves psychotherapy of both the patient and the family members. The psychopharmacological agents used are selective serotonin reuptake inhibitors (SSRIs) and antipsychotics. 
It is a psychiatric disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory purging to prevent weight gain.  The episode of binge eating is characterized by the following:
- Eating, in discrete period of time, an amount of food that is larger than most people would eat during similar period of time and under similar circumstances.
- A sense of lack of control over eating is present.
These episodes of binge eating are followed by compensatory purging on an average for at least twice a week for a period of 3 months.
It usually begins in adolescence with the peak period of occurrence at around the age of 18 years.  The lifetime prevalence of this disorder is around 1% and the ratio of female to male patients ranges from 10:1 to 20: 1.  It is usually associated with other psychiatric disorders like anxiety disorder or depression.
The exact cause of this disorder is not certain, but some genetic factors are implicated in its causation.  Disturbances in serotonergic system involved in regulation of food intake might be implicated so as the cultural attitudes toward physical attractiveness.
The pathophysiological changes occurring in bulimia nervosa are summarized in [Table 2]. ,
The manifestations of bulimia nervosa closely resemble those of anorexia nervosa, but may be less intense as compared to the latter.
The strategies to treat bulimia nervosa involve treatment of medical complications like correction of electrolyte abnormalities, oral pilocarpine to treat sialadenosis, high-fiber diet and non-stimulating osmotic laxatives like lactulose for severe constipation, salt restriction to treat pseudo-Bartter's syndrome, and spironolactone may be required for hyperaldosteronism.  The psychiatric treatment of bulimia nervosa involves psychotherapy and behavioral therapy of the patient and the family members. Pharmacotherapy with various classes of antidepressant drugs has been found to relieve the symptoms of disease, with fluoxetine being the only drug approved by Food and Drug Administration (FDA). 
Anesthetic implications in eating disorders
Most of these patients are young and are devoid of any other co-morbid conditions, but various pathophysiological changes associated with these disorders as described above make these patients vulnerable to risks of anesthesia. The various anesthetic implications are as follows:
Thus, the patients with these eating disorders should have a careful preoperative assessment and stabilization before any surgical intervention and a careful monitoring intraoperatively to prevent any complications. 
- A thorough preoperative history must be obtained either from the patient or if necessary, from the family members regarding abuse of substances like laxatives, diuretics, amphetamines, etc.
- Due to various pathophysiological changes induced by these diseases, preoperative laboratory investigations should include complete blood count, renal function tests, serum electrolytes, liver function tests, serum calcium, magnesium, and glucose, and urine analysis to exclude any proteinuria.
- Cardiovascular investigations should include 12-lead electrocardiogram and, if it shows any abnormalities, then an echocardiogram should be done.
- All these patients should be rehydrated properly before any surgical procedures and any electrolyte abnormality should be corrected.
- These patients usually have gastric dilatation, so a nasogastric tube should be placed preoperatively to deflate the stomach for prevention of aspiration. Also, anti-aspiration prophylaxis should be provided with antacids and histamine receptor antagonists.
- Attenuation of pressor responses during laryngoscopy and intubation is highly desirable as it helps in suppression of various widespread autonomic and cardiovascular changes, thus minimizing the morbidity and mortality associated with these procedures. 
- Intraoperative monitoring should include electrocardiogram, non-invasive blood pressure, pulse oximetry, end-tidal carbon dioxide monitoring, temperature monitoring, and urine output monitoring.
- A rapid sequence induction and intubation is recommended in these patients with eating disorders.
- These patients are usually hypoalbuminemic, so an increased fraction of "free drug" occurs with highly protein-bound drugs and appropriate reduction in doses should be done.
- These patients are highly susceptible for intraoperative hypothermia and postoperative shivering which should be prevented by use of forced air warmers, fluid warmers, and maintaining the ambient temperature of operation theatre. Various anesthetic drugs have been tried to prevent postoperative shivering, and peri-op dexmedetomidine is the latest addition to the armamentarium of an anesthesiologist. 
- Due to markedly reduced subcutaneous fat, these patients are vulnerable to peripheral nerve injuries during positioning under anesthesia, so a careful padding of bony points should be done.
- Non-depolarizing neuromuscular blockers may have prolonged effects in these patients due to reduced weight, altered drug metabolism, and presence of hypokalemia and hypocalcemia, necessitating the use of neuromuscular monitoring.
- These patients are highly vulnerable for development of arrhythmia both intraoperatively and after reversal of neuromuscular blockade, so a careful monitoring is required.
- These patients should be extubated when fully awake and when laryngeal reflexes are fully intact.
| Malnutrition|| |
A large number of patients coming for surgery have some form of malnutrition and, as it is directly related to the increased perioperative mortality and morbidity, appropriate treatment of such condition is mandatory.  Malnutrition refers to an imbalance between intake and requirement of energy, proteins, and other nutrients, leading to an altered metabolism, impaired function, and loss of body mass.
World Health Organization (WHO) has predicted that by the year 2015, the prevalence of malnutrition worldwide will be around 17.6%, with majority of them confined to developing nations. In India, about 47% of children exhibit some degree of malnutrition.
Malnutrition is also common in elderly population and hospitalized patients, with a prevalence of around 50% in hospitalized patients around the world. 
Malnutrition due to deficiency of protein and energy manifests as Kwashiorkor and Marasmus, while that due to deficiency of other macro- and micronutrients usually manifest as specific deficiency states.
Risk factors for malnutrition
- Inadequate weaning in premature infants
- Chronic illnesses and developmental delay in children
- Poverty and neglect by caregivers
- Adults with severe learning difficulties and mental health problems
- Adults with diseases affecting appetite, eating, and gastrointestinal functions leading to poor intake
- Catabolic states
The assessment of severity of malnutrition can be achieved by the use of four types of measurements: 
- Nutrient balance measurement : It involves complete dietary history, nitrogen balance, nutrient loss in excreta, and details of energy expenditure.
- Body composition measurement : It involves measurement of weight, height, weight for height, and BMI (weight in kilograms divided by height in meters squared). According to these measurements, the degree of malnutrition can be measured.
- Inflammatory activity measurement : It involves measurement of C-reactive protein, haemoglobin, and albumin levels.
- Fictional measurement : It involves measurement of immune, muscular, and cognitive functions.
Anesthetic implications and management
Thus, malnutrition causes multitude of changes in various systems in the body, and anesthetic management in such patients requires a sound knowledge of all such changes and their interaction with anesthesia.
- A careful pre-anesthetic assessment is mandatory to ascertain the degree of malnutrition and the probable cause as preoperative build-up of nutritional state can significantly reduce perioperative morbidity.
- Malnutrition results in alteration in the electrolyte composition of the body and any such electrolyte disturbances should be corrected preoperatively.
- Due to depression of cell-mediated immunity and altered cytokine metabolism leading to reduced lymphocyte proliferation, these patients are more prone to develop perioperative infections, stressing the need for antibiotic prophylaxis. 
- Chronic malnutrition leads to reduced and slowed mental functions. So, postoperatively, these patients can have enhanced incidence of disturbed cognitive functions.
- Reduction in the muscle mass and cells in malnutrition predisposes these patients to perioperative hypothermia which should be prevented by use of forced air warmers and warmed intravenous fluids with continuous temperature monitoring.
- Loss of cardiac muscle mass in malnutrition leads to reduction in cardiac output, hypotension, and bradycardia. So, any intraoperative fall in blood pressure should be treated with rapid infusion of fluids followed by use of vasopressors. 
- Reduced doses of anesthetic drugs should be employed due to decreased circulatory volume and hypoalbuminemia.
- Postoperatively, there are chances of impaired ventilatory functions and impaired ability to cough which can lead to postoperative mechanical ventilation requirements in these patients.
| Obesity|| |
Obesity is a chronic disease of excessive body fat described in terms of BMI as being greater than 30 kg/ m 2 .  Globally, obesity is present in 10-60% of adult population and usual age of occurrence is between 45 and 75 years.  Classification is done based on BMI as shown in [Table 3]. 
Obesity affects almost all the systems in the body. The various pathophysiological changes are summarized in [Table 4]. ,
| Causes|| |
The two most common causes of obesity are excessive food energy intake and limited physical activity. The other possible causes or contributors of obesity are:
Anesthetic implications and management
- Genetic factors
- Insufficient sleep and sleep disorders
- Endocrine disorders, e.g. hypothyroidism, Cushing's syndrome, growth hormone deficiency
- Eating disorders e.g. binge eating disorder, night eating disorder, etc.
- Medications, e.g. hormonal contraceptives, insulin, sulfonylurease, atypical antipsychotics, antidepressants, steroids, anticonvulsants (phenytoin, valproate), pizotifen 
The various changes in different organ systems make these patients highly vulnerable to perioperative anesthetic complications. The major anesthetic concerns are as follows:
- Difficult airway is the most important anesthetic concern in these patients due to redundant oropharyngeal tissue, small oral aperture, and short and thick neck with limited range of neck movements. The attending anesthesiologist should be prepared for any such difficulties with all the difficult airway adjuncts, in case the need arises.
- These patients are at higher risk for aspiration of gastric contents, and thus anti-aspiration prophylaxis should be given preoperatively.
- Preoperative investigations should include routine investigations with special attention to the cardiovascular and endocrine systems due to a high degree of association with obesity.
- These patients are at high risk for development of deep vein thrombosis, so thromboprophylaxis is a must, especially for major surgeries. The low molecular weight heparins (LMWH) are ideal for prophylaxis and should be administered according to the total body weight. There is concern about the absorption of LMWH from the subcutaneous route due to variable peripheral perfusion in obese individuals. So, the activity of anticoagulation should be closely monitored preferably using levels of anti-Xa factor. ,
- All the sedative drugs should be used judiciously in these patients due to the respiratory depression effects which are enhanced in obese patients. A newer alpha 2 agonist drug, dexmedetomidine, is very effective as a sedating agent in these patients due to its minimal respiratory depression effects. 
- Ideal body weight (IDW) should be used while calculating doses for drugs like propofol, fentanyl, remifentanyl, benzodiazepines, atracurium, and vecuronium due to their lipophilic nature.
- Total body weight (TBW) should be used for dosing schedule of drugs like succinylcholine, rocuronium, unfractionated heparin, LMWH, and vancomycin.
- A difficult venous access should always be anticipated in these patients due to excess subcutaneous fat and preparations should be made accordingly.
- Epidural analgesia is preferable in these patients as it provides excellent analgesia both intraoperatively and postoperatively and has opioid-sparing effect, thus preventing any postoperative sedation associated with opioid use. The technical difficulties in positioning and needle placement due to excess subcutaneous fat should be anticipated in these patients. However, with the use of new safer drugs such as ropivacaine and addition of adjuvants like dexmedetomidine and clonidine, the safety margin has increased tremendously. Even the dose of the anesthetics gets reduced with such adjuvants, which further helps in decreasing the morbidity and mortality associated with anesthetic drugs. ,,,
- Due to a reduced functional residual capacity in these patients, high chances of rapid desaturation can be anticipated. So, these patients should always be preoxygenated for sufficient time before the induction of anesthesia.
- The non-compliant chest wall in obese patients decreases the static pulmonary compliance, and thus, the ventilatory strategies in these patients include adjusting the tidal volume to 8 ml/kg IBW and increasing the respiratory rate to prevent any hypoxia and hypercapnia.
- The extubation in obese patients should only be done when all the protective reflexes are regained and the patient is fully awake as premature extubation can have deleterious consequences.
- Postoperatively, these patients should be monitored in high-dependency units for any respiratory depression or cardiovascular event. Obese patients have high chances of postoperative atelectasis and should be encouraged for incentive spirometry, while non-invasive ventilation has also been tried in these patients, but requires a fully cooperative patient. 
| Conclusion|| |
In conclusion, the nutritional disorders cause multitude of pathophysiological changes in most of the organ systems of the body, leading to alteration in circulatory blood volume, cardiac instability, depressed immune functions, and other functional disorders. These alterations make these patients highly vulnerable for serious perioperative complications which can be prevented by a careful preoperative planning and a vigilant intraoperative as well as postoperative monitoring of these patients.
| References|| |
|1.||Bajwa SJ, Jindal R, Kaur J, Singh A. Psychiatric diseases: Need for an increased awareness among the anesthesiologists. J Anaesthesiol Clin Pharmacol 2011; 27:440-6. |
|2.||American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4 th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000. |
|3.||Denner AM, Townley SA. Anorexia nervosa: Perioperative implications. CEACCP 2009; 9:61-4. |
|4.||Seller CA, Ravalia A. Anaesthetic implications of anorexia nervosa. Anaesthesia 2003; 58:437-43. |
|5.||Divvuri V, Kaye WH. Anorexia nervosa. FOCUS 2009; 4:455-62. |
|6.||Pryor T. Diagnostic criteria for eating disorders: DSM-IV revisions. Psychiatr Ann 1995;25:40-5. |
|7.||Lewinsohn PM, Striegel-Moore RH, Seeley JR. Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2000; 39:1284-92. |
|8.||Woodside DB, Garfinkel PE, Lin E, Goering P, Kaplan AS, Goldbloom DS, et al. Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry 2001; 158:570-4. |
|9.||Bulik CM, Devlin B, Bacanu SA, Thornton L, Klump KL, Fichter MM, et al. Significant linkage on chromosome 10p in families with bulimia nervosa. Am J Hum Genet 2003; 72:200-7. |
|10.||Wolfe BE, Metzger ED, Levine JM, Jimerson DC. Laboratory screening for electrolyte abnormalities and anaemia in bulimia nervosa: A controlled study. Int J Eat Disord 2001; 30:288-93. |
|11.||Crow SJ, Thuras P, Keel PK, Mitchell JE. Long-term menstrual and reproductive function in patients with bulimia nervosa. Am J Psychiatry 2002; 159:1048-50. |
|12.||Hay PJ, Bacaltchuk J. Extracts from "Clinical evidence": Bulimia nervosa. BMJ 2001; 323:33-7. |
|13.||Bajwa SS, Kaur J, Singh A, Parmar SS, Singh G, Kulshrestha A, et al. Attenuation of pressor response and dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine. Indian J Anaesth 2012; 56:123-8. |
|14.||Bajwa SJ, Gupta S, Kaur J, Singh A, Parmar SS. Reduction in the incidence of shivering with perioperative dexmedetomidine: A randomized prospective study. J Anaesthesiol Clin Pharmacol 2012; 28:86-91. |
|15.||Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008;27:5-15. |
|16.||Tai ML, Goh KL, Mohd-Taib SH, Rampal S, Mahadeva S. Anthropometric, biochemical and clinical assessment of malnutrition in Malaysian patients with advanced cirrhosis. Nutr J 2010; 9:27-33. |
|17.||Muscaritoli M, Fanfarillo F, Luzi G, Sirianni MC, Lebba F, Laviano A, et al. Impaired nutritional status in common variable immunodeficiency patients correlates with reduced levels of serum IgA and of circulating CD4+ T lymphocytes. Eur J Clin Invest 2001; 31:544-9. |
|18.||El-Sayed HL, Nassar MF, Habib NM, Elmasry OA, Gomma SM. Structural and functional affection of the heart in protein energy malnutrition patients on admission and after nutrition nutritional recovery. Eur J Clin Nutr 2006; 60:502-10. |
|19.||WHO. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. WHO Technical Report Series 894. Geneva: 2000. |
|20.||Stevens J. Ethnic-specific cutpoints for obesity vs countryspecific guidelines for action. Int J Obes Relat Metab Disord 2003;27:287- 8. |
|21.||Bajwa SS, Sehgal V, Bajwa SK. Clinical and critical care concerns in severely ill obese patient. Indian J Endocrinol Metab 2012;16:740-8. |
|22.||Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth 2000; 85:91-108. |
|23.||Zammit C, Liddicoat H, Moonsie I, Makker H. Obesity and respiratory diseases. Int J Gen Med 2010; 3:335-43. |
|24.||Haslam DW, James WP. Obesity. Lancet 2005; 366:1197-209. |
|25.||Nutescu EA, Spinler SA, Wittkowsky A, Dager WE. Low-molecularweight heparins in renal impairment and obesity: Available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother 2009;43:1064-83. |
|26.||Borkgren-Okonek MJ, Hart RW, Pantano JE, Rantis PC Jr, Guske PJ, Kane JM Jr, et al. Enoxaparin thromboprophylaxis ingastric bypass patients: Extended duration, dose stratification, and antifactorXa activity. Surg Obes Relat Dis 2008; 4:625-31. |
|27.||Sudheesh K, Harsoor SS. Dexmedetomidine in anaesthesia practice: A wonder drug? Indian J Anaesth 2011; 55:323-4. |
|28.||Bajwa SJ, Bajwa SK, Kaur J, Singh G, Arora V, Gupta S, et al. Dexmedetomidine and clonidine in epidural anaesthesia: A comparative evaluation. Indian J Anaesth 2011; 55:116-21. |
|29.||Bajwa SJ, Kaur J, Bajwa SK, Bakshi G, Singh K, Panda A. Caudal ropivacaine-clonidine: A better post-operative analgesic approach. Indian J Anaesth 2010; 54:226-30. |
|30.||Bajwa S, Arora V, Kaur J, Singh A, Parmar SS. Comparative evaluation of dexmedetomidine and fentanyl for epidural analgesia in lower limb orthopedic surgeries. Saudi J Anaesth 2011; 5:365-70. |
|31.||Bajwa SJ, Bajwa SK, Kaur J. Comparison of epidural ropivacaine and ropivacaine clonidine combination for elective cesarean sections. Saudi J Anaesth 2010; 4:47-54. |
|32.||Masa JF, Celli BR, Riesco JA, Hernández M, Sánchez De Cos J, Disdier C. The obesity hypoventilation syndrome can be treated with noninvasive mechanical ventilation. Chest 2001; 119:1102-7. |
[Table 1], [Table 2], [Table 3], [Table 4]