MARSIPAN - Management of Really Sick Patients with Anorexia Nervosa

The Management of Really Sick Patients with Anorexia Nervosa working group came out of concerns that a number of patients with severe anorexia nervosa were being admitted to general medical wards, and sometimes deteriorating or dying there, due to either (or both of) medical complications or psychiatric problems.

The full MARSIPAN report (second edition) is published by the Royal College of Psychiatrists, and can be found on their website.

Information provided here is taken from the official report.

Scope of the guideline

• Patients with severe anorexia nervosa (BMI <15)
• Individuals admitted to medical wards or specialist eating disorder units.

Recommendations

1. Medical and psychiatric ward staff need to be aware that adult patients with anorexia nervosa being admitted to a medical ward are often at high risk. 
2. Physical risk assessment in these patients should include body mass index (BMI) and physical examination, including muscle power, blood tests and electrocardiography (ECG). 
3. Most adults with severe anorexia nervosa should be treated on specialist eating disorders units (SEDUs). 
4. Criteria for medical admission are the need for treatments not available on a psychiatric ward (such as intravenous infusion) or the unavailability of a suitable SEDU bed. 
5. The role of the primary care team is to monitor such patients and refer them early. 
6. The in-patient medical team should be supported by a senior psychiatrist, preferably an eating disorders psychiatrist. If an eating disorders psychiatrist is unavailable, support should come from a liaison or adult general psychiatrist. 
7. The in-patient medical team should contain a physician and a dietician with specialist knowledge in eating disorders, preferably within a nutrition support team, and have ready access to advice from an eating disorders psychiatrist. 
8. The key tasks of the in-patient medical team are to: 
• safely re-feed the patient 
• avoid re-feeding syndrome caused by too rapid re-feeding 
• avoid underfeeding syndrome caused by too cautious rates of re-feeding 
• manage, with the help of psychiatric staff, the behavioural problems common in patients with anorexia nervosa, such as sabotaging nutrition 
• occasionally to treat patients under compulsion (using Section 3 of the Mental Health Act, or provisions of equivalent legislation), with the support of psychiatric staff. 

Risk assessment (Extracts)

• BMI
• low risk: 15-17.5
• medium risk: 13-15
• high risk: <13
• Physical examination
• low pulse (higher risk if <40 bpm)
• low core temperature (higher risk if <35 deg c)
• muscle power reduced
• sit up-squat-stand (SUSS) test (higher risk if scores of 2 or less)
• Blood tests
• low sodium (higher risk if <130 mmol/L) - suspect water loading
• low potassium (higher risk if <3.0 mmol/L) - vomiting or laxative abuse, although low sodium and potassium can occur in malnutrition without water loading or purging)