Medical Nutrition Therapy for Refeeding Syndrome Rachel Hammerling Concordia College, Moorhead MN Objectives • Be able to describe refeeding syndrome (RFS) • Be able to describe the pathophysiology of starvation • Identify the main pathophysiologic features of RFS • Be able to identify signs & symptoms • Identify recommended treatment & standards of care • Be able to explain ethical issues involved with treatment & care Discovery of RFS • Observed & described after WWII • Victims of starvation experienced cardiac and/or neurologic dysfunction – After being reintroduced to food • Today, rarely see patients who are severely malnourished, as WWII victims were, in the 1st week – Neurologic signs & symptoms develop later What is RFS? • Potentially fatal shifts in fluids & electrolytes • May occur in malnourished patients receiving artificial refeeding – Enterally or parenterally • Complex syndrome – Sodium & fluid imbalance – Changes in glucose, protein, fat metabolism – Thiamine deficiency – Hypokalemia – Hypomagnesaemia Understanding Starvation • Glucose = main fuel – Shifts to protein & fat • Insulin ↓ due to ↓ availability of glucose • Catabolism of protein → loss of cellular & muscle mass → atrophy of vital organs & internal organs • Respiratory & cardiac function ↓ due to muscular wasting & fluid/electrolyte imbalances • Body is now surviving by slowly consuming itself How common is RFS? • True incidence is unknown • Study of 10,197 patients, incidence of hypophosphatemia = 43 % – Malnutrition one of strongest risk factors • Parenteral patients = 100% incidence of hypophosphatemia Pathogenesis • Electrolytes & minerals involved 1) 2) 3) 4) Phosphorus Potassium Magnesium Glucose Main Pathophysiologic Features • Disturbances of body-fluid distribution • Abnormal glucose & lipid metabolisms • Thiamine deficiency • Hypophosphatemia • Hypomagnesemia • Hypokalemia Disturbances of Body-Fluid Distribution • Can influence body functions: 1) Cardiac failure 2) Dehydration or fluid overload 3) Hypotension 4) Pre-renal failure 5) Sudden death • CHO refeeding – ↓ water & sodium excretion, resulting in weight gain • Protein & fat refeeding – Result in weight loss & urinary sodium excretion – Hypernatremia along with azotemia & metabolic acidosis Abnormal Glucose & Lipid Metabolisms • Glucose – Suppress gluconeogenesis → reduced AA usage • Less-negative N balance – Hyperglycemia • Glucose → fat (Lipogenesis) – Hypertriglyceridemia, fatty liver, & abnormal liver function tests Thiamine Deficiency • Can result in Wernicke’s encephalopathy or Korsakov’s syndrome, associated with: – Ocular disturbance – Confusion – Ataxia • loss of ability to coordinate muscular movement – Coma – Short-term memory loss – Confabulation • Confusion of imagination with memory Hypophosphatemia • Predominant feature of RFS • Impaired cellular-energy pathways – Adenosine triphosphate – 2,3-diphosphoglycerate • Impaired skeletal-muscle function – Including weakness & myopathy • Seizures & perturbed mental state • Impaired blood clotting processes & hemolysis also can occur Hypomagnesemia • Most cases not clinically significant • Severe cases: – Cardiac arrhythmias – Abdominal discomfort – Anorexia – Tremors, seizures, & confusion – Weakness Hypokalemia • Features are numerous: – Cardiac arrhythmias – Hypotension – Cardiac arrest – Weakness – Paralysis – Confusion – Respiratory Depression Signs & Symptoms • Electrolyte imbalance – Hypokalemia – Hypophosphatemia – Hypomagnesemia • REMEMBER: Even an overweight or obese patient can be malnourished & a victim for RFS Identifying Patients at High Risk of Refeeding Problems • NICE Guidelines (National Institute for Health & Clinical Excellence) • Either patient has 1 or more: – – – – BMI <16 Unintentional weight loss >15% in past 3-6 mo Little/no nutritional intake for 10 days Low levels of potassium, phosphate, or magnesium before feeding • Or patient has 2 or more: – – – – BMI <18.5 Unintentional weight loss >10% in past 3-6 mo Little/no nutritional intake for >5 days History of alcohol misuse or drugs Patients at high risk: • • • • Anorexia nervosa Chronic alcoholism Oncology patients Postoperative patients • Elderly • Uncontrolled diabetes mellitus • Chronic malnutrition: – Marasmus – Prolonged fasting or low energy diet – Morbid obesity with weight loss • Long term antacid users • Long term diuretic users Gastrointestinal Fistula patients • Usually reveals chronic malnutrition – Due to damaged Gl tract & severe abdominal sepsis • High risk for RFS • Be aware of condition & treat the same – Diarrhea commonly occurs & can be treated by enteral nutrition Intervention: Objectives 1) Gradually correct starvation – Use less than full levels of calorie & fluid requirements 2) Advance calories & volume – Monitor cardiac & respiratory side effects 3) Correct vitamin & mineral deficiencies – Especially with symptoms Intervention: Objectives Cont. 4) Nutrition support in patients at risk should be increased slowly – Assuring adequate amounts of vitamins & minerals 5) Organ function, fluid balance, & serum electrolytes – Monitor daily during 1st week & less frequently after Intervention: Objectives Cont. 6) Monitor for neurological, hematological, & metabolic complications – Of hypokalemia, hypophosphatemia, & hyperglycemia 7) Prevent sudden death Intervention: Food & Nutrition • • • • Begin 20 kcal/kg for 1st 3 days Progress to 25 kcal/kg Gradually ↑ by 7th day Protein start slow, ↑ gradually – To protect & restore lean body mass • Restrict CHO to 150-200 g/day – To prevent rapid insulin surge • CHO in PN – Initiate at 2 mg/kg/min – Fat calories should make up the difference Intervention: Food & Nutrition • Maintain fluid balance – Adjust when edema exists • Adjust for sodium & potassium – Depending on lab values until normal • Supplements – Thiamin – Other vitamins & minerals as needed Common Drugs Used • Replacement of phosphorus, potassium, & magnesium • Insulin – Used to correct hyperglycemia levels – Monitor blood glucose levels during refeeding Recommendation for Phosphate Phosphate Dose Maintenance requirement 0.3-0.6 mmol/kg/day orally Mild hypophosphatemia (0.6-0.85 mmol/l) 0.3-0.6 mmol/kg/day orally Moderate hypophosphatemia (0.3-0.6 mmol/l) 9 mmol infused into peripheral vein over 12 hours Severe hypophosphatemia (<0.3 mmol/l) 18 mmol infused into peripheral vein over 12 hours Recommendation for Magnesium Magnesium Dose Maintenance requirement 0.2 mmol/kg/day intravenously (or 0.4 mmol/kg/day orally ) Mild to moderate hypomagnesaemia Initially 0.5 mmol/kg/day over 24 (0.5-0.7 mmol/l) hours intravenously, then 0.25 mmol/kg/day for 5 days intravenously Severe hypomagnesaemia (<0.5 mmol/l) 24 mmol over 6 hours intravenously, then as for mild to moderate hypomagnesaemia (above) Intervention: Nutrition Education, Counseling, & Care Management • Focus on adequate nutrient intake • Consider referral if food insecurity is a concern • Offer guidelines according to discharge intervention plan • Physician may suggest long-term medication use or therapies NICE Guidelines for Management Ethical Issues with RFS • Roles between dietitian, counselor, nurse, doctor, and other professionals • Working with anorexia patients, oncology patients or older patients • Ethnic & religious differences – Muslim patients – Non-English speaking patients Summary Points • RFS is caused by rapid refeeding after a period of undernutrition • Characterized by hypophosphatemia • Patients at high risk: undernourished, little or no energy intake for > 10 days • Start refeeding at low levels • Correction of electrolyte & fluid imbalances before feeding IS NOT necessary References Crook, M. 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