refeeding syndrome - irspenrefeeding syndrome – inadequate awareness and confidence knowledge of...
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Refeeding Syndrome
Potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving feeding resulting in hormonal and metabolic changes causing serious clinical complications.Mehanna et al
Clinical recognition dating back to Far Eastern prisoners of war.
Presented with oedema, cardiac failure and sudden death.
0.45% in hospitalised patients – malnutrition strongest risk factor.Camp et al
34% of ICU patients in one prospective cohort study.Marik et al
Gluconeogenesis and fatty acid metabolism
predominate in starvation In
sulin
leve
ls d
rop
Glucagon levels rise
Glycogen store utilisation
Gluconeogenesis
Altern
ativ
e e
nerg
y so
urc
es Ketones
Free fatty acids enrolled as primary energy source
Levels of gluconeogenesis fall
Conse
quence
s Catabolism and loss of lean body mass
Intracellular mineral depletion
Micronutrient deficiency
Glycaemia induces profound changes with
serious clinical consequences
• Metabolic acidosis
• Hyperosmolar states
• Ketoacidosis
Deranged glucose metabolism
• Na+ excretion
• Cardiac decompensation
• Pre-renal failure
Initial fluid intolerance
• Interference with enzyme cascades
• Neurological complications
• Leukocyte dysfunction
• Susceptibility to infection
Micronutrient and mineral deficiency
Refeeding Syndrome – inadequate
awareness and confidence
Knowledge of the refeeding syndrome poor among paediatric middle-grade doctors.Hudson et al
20% unable to define it at all
21% able to identify some clinical features
57% aware of potential phosphate abnormalities
Higher levels of confidence in gastroenterologists vs general physicians Lindorff Larsen et al
60% reported insufficient clinical knowledge to manage malnutrition and its complications
Both nurses and doctors report lack of confidence recognising and managing patients with malnutrition Rasmussen et al
Beaumont Hospital
Karen Boland, FE
Murray
21.5% at high risk
11.2% - 2 minor risk
factors
9% - >/= 1 major
risk factor
32% of those at high risk
treated according to
guidelines
Thiamine
Electrolytes
2 patients – Refeeding
Syndrome
Clinical issue – ID of at-risk patients
Refeeding hypophosphataemia is more common in enteral
than parenteral feeding in adult inpatientsZeki, Nightingale et al
Current or recent cancer diagnosis
Eating disorders and chronic dieters
Chronic debilitating disease
Post gastrointestinal or head-and-neck surgery
Alcohol Dependence Syndrome
Elderly patients living alone
Chronic gastrointestinal symptomsCrook et al
NICE Guidelines CG32
Minor Risk Factors Major Risk Factors
BMI <18.5 kg/m2 BMI <16 kg/m2
Unintentional weight loss of 10-15%
over the last 3-6 months
Unintentional weight loss of >15%
over the last 3-6 months
Little or no nutritional intake for
more than 5 days
Little of no nutritional intake for
more than 10 days
History of alcohol abuse or chronic
use of diuretics, antacids,
chemotherapy or insulin
Low levels of phosphate, potassium or
magnesium prior to feeding
2 or more minor risk factors or 1 major risk factor
Malnutrition in Western hospitals as reflected by low BMI not
the main risk factor in development of RS Nightingale et al
Phosphate replacement:
In hypophosphataemic patients at high risk of refeeding syndrome with normal renal function, give 500ml of Phosphate Polyfusor® over 24 hours, with close monitoring for complications.
Phosphates Polyfusor® 500ml contains; 50mmol PO4-2, 9.5mmol K+, 81 mmol Na+.
Guidelines for electrolyte repletion key to
optimise care
Perceived lack of knowledge and confidence
Non consultant hospital doctors
Consultant physicians and surgeons
Few concise guideline resources available
Lobo, Dube et al Ann R Coll Surg Engl 2002; 84: 156-160
730 consultant surgeons
22% junior staff given written guidelines
16% felt staff were appropriately trained
70% believed not all patients received adequate fluid and
electrolytes
Improving patient care
Education
Training colleges – RCPI & RCSI
Intra-institutional
Guideline support and availability
Wards and Intranet
Awareness among doctors and nursing staff alike
Electrolyte repletion
Guidelines, focus on fluid balance
Acknowledgements
• Department of Gastroenterology and Hepatology, Beaumont Hospital • Professor FE Murray
• Department of Nutrition and Dietetics, Beaumont Hospital • Carmel O Hanlon, Dietician
• Grainne Corrigan, Dietician
• Paula O Connor, Dietician
• Department of Pharmacy, Beaumont Hospital • Damodar Solanki
• Nurse Practice Development • Marie Hennigan
References Mehanna, H. M., Moledina, J., and Travis, J. (2008) BMJ 336, 1495-1498
Johansson, U., Rasmussen, H. H., Mowe, M., and Staun, M. (2009) Clinical Nutrition 28, 129-133
Lindorff-Larsen, K., Højgaard Rasmussen, H., Kondrup, J., Staun, M., and Ladefoged, K. (2007) Clinical Nutrition 26, 371-378
Amanzadeh, J., and Reilly, R. F. (2006) Nat Clin Pract Neph 2, 136-148
Marik Pe, B. M. (1996) Archives of Surgery 131, 1043-1047
NICE. (2006) Guideline for the Management of Refeeding Syndrome (Adults) 2nd edition. (Excellence, N. I. f. H. a. C. ed., NHS Foundation Trust
Boland K, O. H. C., Flynn S, Corrigan G, Solanki S, Murray FE. (2013) The identification of acutely admitted patients at risk of refeeding syndrome. in pending submission
Marinella, M. A. (2008) Int J Clin Pract 62, 460-465
Lobo, D. N., Dube, M. G., Neal, K. R., Allison, S. P., and Rowlands, B. J. (2002) Ann R Coll Surg Engl 84, 156-160
Geerse, D., Bindels, A., Kuiper, M., Roos, A., Spronk, P., and Schultz, M. (2010) Critical Care 14, R147
Gaasbeek, A., and Meinders, A. E. (2005) The American Journal of Medicine 118, 1094-1101
Crook, M. A., Hally, V., and Panteli, J. V. (2001) Nutrition 17, 632-637
Klein, S. (2002) Gastroenterology 122, 1677-1687
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