Medical Nutrition Therapy for Refeeding Syndrome

1. Medical Nutrition Therapy for Refeeding Syndrome Rachel Hammerling Concordia College, Moorhead MN

2. 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

3. 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

4. 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

5. 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

6. 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

7. Pathogenesis • Electrolytes & minerals involved • Phosphorus • Potassium • Magnesium • Glucose

9. Main Pathophysiologic Features • Disturbances of body-fluid distribution • Abnormal glucose & lipid metabolisms • Thiamine deficiency • Hypophosphatemia • Hypomagnesemia • Hypokalemia

10. 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

11. 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

12. 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

13. 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

14. Hypomagnesemia • Most cases not clinically significant • Severe cases: • Cardiac arrhythmias • Abdominal discomfort • Anorexia • Tremors, seizures, & confusion • Weakness

15. Hypokalemia • Features are numerous: • Cardiac arrhythmias • Hypotension • Cardiac arrest • Weakness • Paralysis • Confusion • Respiratory Depression

16. Signs & Symptoms • Electrolyte imbalance • Hypokalemia • Hypophosphatemia • Hypomagnesemia • REMEMBER: Even an overweight or obese patient can be malnourished & a victim for RFS

17. 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

18. 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

19. 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

20. 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

21. 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

22. Intervention: Objectives Cont. 6) Monitor for neurological, hematological, & metabolic complications • Of hypokalemia, hypophosphatemia, & hyperglycemia 7) Prevent sudden death

23. 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

24. 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

25. Common Drugs Used • Replacement of phosphorus, potassium, & magnesium • Insulin • Used to correct hyperglycemia levels • Monitor blood glucose levels during refeeding

26. Recommendation for Phosphate

27. Recommendation for Magnesium

28. 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

29. NICE Guidelines for Management

30. 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

32. 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

33. 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).