1 / 15

Refeeding Syndrome Management Issues

Refeeding Syndrome Management Issues. Stella Hahn Pulmonary/Critical Care Fellow 2013. Case Presentation.

tehya
Download Presentation

Refeeding Syndrome Management Issues

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Refeeding Syndrome Management Issues Stella Hahn Pulmonary/Critical Care Fellow 2013

  2. Case Presentation 35F with anxiety and depression presents with weakness. Patient began to have dysphagia 5 days prior to admission, initially with solids then with liquids. Unable to tolerate anything PO for 3 days prior to admission per report. Fiance had to carry her around as she was too weak to get around

  3. Case Presentation • PMH: Anxiety, Depression, Past history of hospitalization for malnutrition • PSH: None • VS on admission: Afebrile, 73/47, 107, 14, 97% • Admission labs:

  4. Refeeding Syndrome • In significantly malnourished patients, initial stage of nutritional replenishment causes electrolyte and fluid shifts that may precipitate disabling or fatal complications • Hypophosphatemia • Hypokalemia • Hypomagnesemia • Vitamin and trace mineral deficiencies • Volume overload • Edema

  5. Hypophosphatemia • Hallmark of refeeding syndrome • Stores of phosphate are depleted during episodes of starvation • When nutritional replenishment begins and patients are fed carbohydrates, insulin is released which triggers cellular uptake of phosphate (and potassium and magnesium) • Insulin also causes cells to produce molecules that require phosphate (ATP and 2,3-diphosphoglycerate) • Lack of phosphorylated intermediates causes tissue hypoxia and resultant myocardial dysfunction and respiratory failure

  6. Vitamin and Trace Minerals • Deficiencies are due to starvation • Exacerbated by onset of anabolic processes that accompany refeeding

  7. Volume Overload • Begins with increase in insulin secretion during the early stages of refeeding • This eventually increases renal sodium reabsorption and retention, and then fluid retention

  8. Risk Factors • Directly related to amount of weight loss and rapidity of weight restoration • Patients who weigh less than 70 percent of ideal body weight • Low serum levels of phosphate, potassium or magnesium prior to refeeding the patient • Little or no nutritional intake for 5-10 days • Highest risk in the first two weeks or nutritional replenishment and weight gain

  9. Cardiovascular Complications • Most fatalities due to cardiac complications • Impaired contractility • Decreased stroke volume • Heart failure • Arrhythmias • Atrophy of heart during starvation renders patient more vulnerable to fluid overload and heart failure

  10. Cardiovascular Complications • Bradycardia expected in anorexia nervosa • A normal heart rate may be harbinger of cardiac compromise • During early stages of refeeding, a heart rate > 70 may suggest heart failure and refeeding syndrome

  11. Pulmonary Complications • Impaired diaphragmatic contractility • Dyspnea • Respiratory failure and need for mechanical ventilation are rare • Heart failure may secondarily lead to respiratory symptoms and failure

  12. Muscular Complications • Impaired contractility • Weakness • Myalgia • Tetany • Hypophosphatemia may cause rhabomyolysis

  13. Gastrointestinal Complications • Mildly elevated AST/ALT, alkaline phosphatase, bilirubin during first few weeks of refeeding due to excessive calories and fat deposition • Usually not clinically signifcant • Resolve by reducing rate of nutritional replenishment • More calories may be reintroduced once liver tests normalize (malnutrition and hepatic apoptosis can also elevate liver enzymes which normalize with nutritional replenishment) • Diarrhea, due to atrophy of intestinal mucosa and pancreatic impairment • Nausea/vomiting • Abdominal pain • Constipation due to delayed gastric emptying and prolonged colonic transit time

  14. Neurologic Complications • Tremors, paresthesias, delirium, seizures due to electrolyte abnormalities • Wernicke’s encephalopathy • Oculomotor dysfunction • Gait ataxia • Encephalopathy • Thiamine (100mg) should be given at least 30 minutes before starting nutritional replenishment

  15. Prevention • Restore weight with calories close to and above and resting energy expenditure • Electrolyte deficiencies should be corrected prior to initiating refeeding

More Related