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Eating disorders characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Starvation results in physiological changes associated with adaptation to a chronic fasting state. Anorexia nervosa and bulimia nervosa are both multisystem disorders resulting in dysfunction in the cardiovascular, endocrinological, gastrointestinal, and renal systems.

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Examine records to note any changes in physiological parameters and issues with previous anesthetics

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If history reveals the use of ipecac, consider the risk of cardiomyopathy, and whether an echocardiogram may be indicated given the clinical picture. refl.in/jk

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ECG may reveal conduction deficits or arrhythmias. refl.in/jk

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Hypocalcaemia is frequently present, although hypokalemia prevents the development of tetany. It should be noted that once potassium levels are restored to normal, tetany can be precipitated. refl.in/jk

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Hypochloremia occurs in up to 25% of bulimic patients a result of vomiting and the use of diuretics or laxatives. The resulting metabolic alkalosis may cause increases in serum bicarbonate levels to concentrations up to 44 mmol/L. refl.in/jk

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Hypomagnesemia is frequently present. This may be due to diuretic abuse resulting in increased renal magnesium excretion, and decreased dietary intake of magnesium. refl.in/jk

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Hypotension (systolic blood pressures refl.in/jk

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Ventricular atrophy and dysfunction may be present in up to 80% of those patients on strict diets. Additionally, ipecac, used to induce vomiting, is cardiotoxic and has been associated with cardiomyopathy. refl.in/jk

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Enquire about use of amphetamines and other non-prescription drugs that may impact on anesthesia. refl.in/jk

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Patient is at risk of hypothermia. Warm the operating theater, place a warming blanket, and warm any administered fluids. refl.in/jk

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Avoid hyperventilation as this will reduce serum potassium. refl.in/jk

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Avoid any interventions that will result in hypokalemia as this will predispose the patient to arrhythmias. refl.in/jk

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Minimise the use of glucose containing intravenous fluids as this will reduce the serum potassium. refl.in/jk

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Hypokalemia and hypocalcemia can augment the effects of non-depolarising muscle relaxants, prolonging their expected duration of action. Consider using reduced doses and utilising neuromuscular monitoring during the case. refl.in/jk

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Patients often have delayed gastric emptying. Where possible, administer a proton pump inhibitor (eg ranitidine 150mg) 1hr before, induction, and sodium citrate 10 minutes prior, to induction. Consider securing the airway in a manner that minimises the risk of pulmonary aspiration of gastric contents. (eg rapid sequence intubation). refl.in/jk

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Perform a full blood count, electrolytes (including calcium, magnesium, and phosphate), blood glucose, and LFTs.

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Position patients with additional care as they are at significantly elevated risk of neuropraxias due to the absence of adequate soft tissue padding. refl.in/jk

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