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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

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medical nutrition therapy for refeeding syndrome

Medical Nutrition Therapy for Refeeding Syndrome

Rachel Hammerling

Concordia College, Moorhead MN

objectives
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
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
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
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
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
Pathogenesis
  • Electrolytes & minerals involved
    • Phosphorus
    • Potassium
    • Magnesium
    • Glucose
main pathophysiologic features
Main Pathophysiologic Features
  • Disturbances of body-fluid distribution
  • Abnormal glucose & lipid metabolisms
  • Thiamine deficiency
  • Hypophosphatemia
  • Hypomagnesemia
  • Hypokalemia
disturbances of body fluid distribution
Disturbances of Body-Fluid Distribution
  • Can influence body functions:
    • Cardiac failure
    • Dehydration or fluid overload
    • Hypotension
    • Pre-renal failure
    • 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
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
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
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
Hypomagnesemia
  • Most cases not clinically significant
  • Severe cases:
    • Cardiac arrhythmias
    • Abdominal discomfort
    • Anorexia
    • Tremors, seizures, & confusion
    • Weakness
hypokalemia
Hypokalemia
  • Features are numerous:
    • Cardiac arrhythmias
    • Hypotension
    • Cardiac arrest
    • Weakness
    • Paralysis
    • Confusion
    • Respiratory Depression
signs symptoms
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
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
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
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
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
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 cont22
Intervention: Objectives Cont.

6) Monitor for neurological, hematological, & metabolic complications

  • Of hypokalemia, hypophosphatemia, & hyperglycemia

7) Prevent sudden death

intervention food nutrition
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 nutrition24
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
Common Drugs Used
  • Replacement of phosphorus, potassium, & magnesium
  • Insulin
    • Used to correct hyperglycemia levels
    • Monitor blood glucose levels during refeeding
intervention nutrition education counseling care management
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
ethical issues with rfs
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
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
References

Crook, M. A., Hally, V., & Panteli, J. V. (2001). The importance of the

refeeding syndrome. Nutrition (Burbank, Los Angeles County, Calif.), 17(7-8),

632-637.

De Silva, A., Smith, T., & Stroud, M. (2008). Attitudes to NICE guidance on

refeeding syndrome. BMJ (Clinical Research Ed.), 337, a680.

Escott-Stump, S. (2008). Nutrition and diagnosis-related care: sixth ed. (Baltimore, Maryland), 578-580.

Fan, C., Li, J. (2003). Refeeding syndrome in patients with gastrointestinal fistula. Nutrition (Burbank, Los Angeles County, Calif.), 24(6), 604-606.

Gariballa, S. (2008). Refeeding syndrome: A potentially fatal condition but remains underdiagnosed and undertreated. Nutrition, 24(6), 604-606.

Khardori, R. (2005). Refeeding syndrome and hypophosphatemia. Journal of Intensive Care Medicine, 20(3), 174-175.

Mehanna, H. M., Moledina, J., & Travis, J. (2008). Refeeding syndrome: What it is, and how to prevent and treat it. BMJ (Clinical Research Ed.), 336(7659), 1495-1498.

Nelms, M., Sucher, K.,& Long, S.(2007). Nutrition therapy and pathophysiology (Belmont, Calif.). 166-167, 194-195.

Walker, R. (2006). Alcohol and the liver. Sports Line, 28(6), 21-22.

Yantis, M. A., & Velander, R. (2008). How to recognize and respond to refeeding syndrome. Nursing, 38(5).