Malnutrition, Weight Loss and Eating Disorders — Assess for Medical Instability/Criteria — Clinical Pathway: ICU and Inpatient

Malnutrition, Weight Loss and Eating Disorders Clinical Pathway — ICU and Inpatient

Assess for Medical Instability/Criteria Supportive of Inpatient Hospitalization in Malnutrition

Absolute Criteria for Admission

Inpatient medical care is absolutely indicated if the patient meets any one of the following criteria: bradycardia < 50 bmp, syncope, abnormal ECG, < 75% of a median BMI, or abnormal electrolytes (see below). Emergency Medicine providers can make independent decisions for inpatient stabilization if the patient meets one of those criteria. Otherwise, the decision for admission should be discussed with the adolescent medicine consult service based on the overall clinical assessment and the parameters below.

Criteria Supportive of Inpatient Hospitalization in Malnutrition

Inpatient medical care may be indicated when the patient meets any one of the following criteria
for medical instability:

Vital Signs
  • Heart rate
    • < 50 beats/min awake
    • ≤ 45 beats/min asleep
  • Systolic blood pressure
    • < 90 mm Hg
  • Temperature
    • < 96° F (35.6° C)
  • Orthostatic changes in
    • Heart rate (increase by > 20 beats/min)
    • or
    • Blood pressure (systolic or diastolic decrease by > 10 mm Hg)*
    Anthropometrics
    At high risk for
    refeeding syndrome
    • < 75% of a median BMI for age
    • > 10% weight loss in past 1-2 months
    • Significant ongoing weight loss despite intensive eating disorder management
    Symptoms
    • Syncope
    • Refusal to eat
      • i.e., no intake > 48 hours with objective signs like ketonuria, dehydration, dizziness
    • Acute medical complications of eating disorder behaviors
      • Seizures
      • Intractable vomiting
      • Hematemesis
    • Suicide risk
      • Only if another placement that can address eating and comorbidities is not available
    Labs/Testing
    • Abnormal or significant changes in electrolytes
      • Serum potassium < 3.2 mmol/L
      • Serum chloride < 88 mmol/L
      • Serum phosphorus < 3.0 mg/dL
      • Serum sodium < 132 mmol/L
    • Abnormal ECG/cardiac arrhythmias including but not limited to prolonged QTc and ventricular arrhythmias or aberrant beats

    *Note

    Orthostasis is considered in the full context of medical and nutritional stability, as there are multiple causes of orthostasis, and asymptomatic orthostasis by itself should not be a criterion for admission. Orthostatic heart rate and blood pressure should be obtained after having the patient lie flat and relaxed for 5 minutes, then after standing for 2 minutes. Please also document if the patient feels dizzy or lightheaded after standing.

    Discuss with Adolescent Medicine Before Admitting

    • Established patients of Adolescent Medicine or the Department of Children and Adolescent Psychiatry and Behavioral Sciences (DCAPBS)
    • Adult patients (≥ 18 years old) with severe malnutrition who are new to Adolescent Medicine

    Guidelines for Telemetry and ICU when Admitting Patients with Malnutrition

    Resource for Emergency Medicine Providers

    Eating Disorders: A Guide to Medical Care (See pages 14-15)


    Sources