Jo Prickett
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Transcript of Jo Prickett
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Refeeding Syndrome
Joanna Prickett
North Bristol NHS Trust
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Definition
Severe fluid and electrolyte shifts andrelated metabolic complications in
malnourished patients undergoing
refeeding.
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Consequences of Starvation
Decreased insulin and increased glucagon secretion. With aswitch from glucose towards ketone bodies as a source ofenergy
Glycogen stores used
BMR decreases
Brain adapts to using ketones
Atrophy of all organs
Reduced Lean Body Mass
Abnormal liver function
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Consequences of starvation
Deficiency of vitamins and trace elements
Whole body depletion of potassium, magnesium and phosphate
Increased intracellular and whole body sodium and water
Impaired cardiac, intestinal and renal reserve, leading to reduced
ability to excrete excess sodium and water
Serum concentrations of electrolytes maintained within normal limits
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Refeeding
Increased insulin release leads to increased
uptake of glucose, phosphate and potassium
into cells. Magnesium is used as a co-factor for
cellular pump activity
Reactivation of the Na/K membrane pump leads
to further movement of K into cells with asimultaneous movement of sodium and fluid out
of cells
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Refeeding
Reduced phosphate is associated withincreased urinary magnesium excretion
Stimulation of protein synthesis leads toincreased anabolic tissue growth which in turnleads to increased cellular demand forphosphate, potassium, glucose and water
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Refeeding
Excess glucose can lead to hyperglycaemia and
fat abnormalities
Reduced sodium and water excretion
Increased cellular thiamine utilisation due to its
role as a co-factor for carbohydrate metabolism
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Consequences of electrolyte
abnormalitiesElectrolytes Consequence
PO4 Acute ventilatory failureArrythmias
Confusion
Congesive heart failure
Lethargy, weaknessRhabdomyolysis
K+ Arrythmias
Cardiac arrestConstipation / ileus
Polyuria / polydipsia
Respiratory depressionWeakness
Mg+4 Anorexia
ArrythmiasConfusion
Diarrhoea / constipation
Weakness
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Incidence
0.2-5% hospital patients have
hypophosphataemia
Incidence is increased in certain groups
Incidence in patients receiving nutrition support
has been reported to be 30-40%
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Patients at Risk of Refeeding
Those who have had very little or no food
intake for >5 days especially if alreadyundernourished (BMI 5% within the
last 3-6 months)
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Patients at High Risk of
RefeedingPatients with any of the following:
BMI < 16 kg/m2
Unintentional weight loss >15% within the last 3-6
months
Very little or no nutrition for >10 days
Low levels of potassium, magnesium or phosphate
prior to feeding
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Patients at High Risk of
RefeedingPatients with 2 or more of the following:
BMI < 18.5 kg/m2
Unintentional weight loss >10% within the last 3-6
months
Very little or no nutrition for >5 days
A history or alcohol abuse or some drugs including
insulin, chemotherapy, antacids or diuretics
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Feeding patients who are at
riskIntroduce feeding at maximum 50% of total energy
requirements for the first 2 days before increasing to full
requirements if no biochemical abnormalities
Meet full requirements for fluid, electrolytes, vitamins and
minerals from day 1 of feeding
Monitor appropriate biochemistry including potassium,phosphate and magnesium (see chapter on monitoring)
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Feeding patients who are at
high riskConsider starting nutrition at maximum 10
kcal/kg and increase slowly to meet full
requirements by 4-7 days.
Any increase in feed should be dependent on
trends in biochemistry
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Feeding patients who are at
high riskPotassium, magnesium and phosphate supplementation
from the outset (unless blood levels are already high):
Potassium (likely requirement 2-4 mmol/kg/day)Magnesium (likely requirement 0.2 mmol/kg/day
IV, 0.4 mmol/kg/day oral)
Phosphate (likely requirement 0.3-0.6
mmol/kg/day)
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Feeding patients who are at
high riskImmediately before and during first 10 days of feeding:
Oral thiamine 200-300mg/day
Vitamin B co strong 1-2 tds or full dose IV vitamin
B
Multivitamin and trace element supplement
Restore circulatory volume and monitor fluid balance
closely
Monitor appropriate biochemistry including, potassium,
phosphate and magnesium
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Feeding patients who are at
high riskIn extreme case eg
BMI 15 days
Pre-feeding Hypokalaemia, hypophosphataemia or
hypomagnesaemia
Consider starting feed at 5kcal/kg
It is not necessary to correct electrolyte levels prior to
feeding if this cautious approach is used
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Feeding patients who are at
high riskBeware of very malnourished, dehydrated patients with
renal impairment and consequently normal or high
potassium and phosphate levels.
It is also easy to overlook significant renal impairment in
patients with very low BMI and recent starvation who have
very low creatinine and urea production.
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References
Brook M.J. & Melnik G 1995. The Refeeding Syndrome: An approach tounderstanding its complications and preventing it occurrence. Pharmacotherapy15(6):713-26.
Crook M.A. et al 2001. The importance of the Refeeding Syndrome. Nutrition
17:632-7.
Keys A. et al 1950. The Biology of Human Starvation vols 1,2. MinneapolisUniversity of Minnesota Press.
Marinella M.A. 2003. The Refeeding Syndrome and Hypophosphataemia. NutritionReviews 61(9):320-3.
NICE 2006 Nutrition Support in Adults
Solomon S.L. et al 1990 The Refeeding Syndrome: A Review. J. Parent. & EnteralNutrition 14(1):90-7.
Terelevich A. et al 2003. Refeeding Syndrome: Effective and safe treatment withphosphates polyfusor Aliment Pharmacol Ther 17:1325-1329