Class 3: Refeeding Syndrome Liz Hudson MPH, RD
Case Study #1 NUTRITION ASSESSMENT: Consult PATIENT MEDICAL/HEALTH HISTORY: 49 y/o male with significant history of HTN, DM, and stage V CKD currently on ihd, admitted with gastroparesis refractory to Reglan and for consideration of J- tube placement. DIET HISTORY: Pt endorses poor appetite and inability to tolerate food. He reports nausea, emesis, abdominal pain, bloating and discomfort after eating. Intake described as bites of meals, estimates eating ¼ of baseline/usual intake. Pt states this has resulted in 100 lb wt loss over the past year. Pt denies trying any specific diet for helping to control his gastroparesis, but also does state that he is not able to tolerate most foods. NUTRITION FOCUSED PHYSICAL FINDINGS: Temporal hollowing and depression noted on physical exam. BODY COMPOSTION/WEIGHT HISTORY: HEIGHT: 182.9cm WEIGHT: 79.5kg (admit) IBW: 80.9kg UBW: 120.9kg (~ 1 year ago, per patient report) % WEIGHT CHANGE: BMI:
Case Study #2 NUTRITION ASSESSMENT: Consult PATIENT MEDICAL/HEALTH HISTORY: 56 y/o female with history of advanced stage III papillary serous carcinoma of the ovary s/p ex lap (exploratory laparotomy) with LOA (lysis of adhesions) and omentum biopsy (12/28/10), with carcinomatosis that is inoperable; status post 1 cycle of chemotherapy, started second cycle of carboplatin and taxol on 2/10/11. Admitted on 2/17/11 with diarrhea, hypokalemia and pancytopenia. GASTROINTESTINAL: N/V x 4 days. Stool loose and foul-smelling. DIET HISTORY: Pt endorses decreased intake since having surgery in December, and states she has been suffering from bouts of nausea and vomiting since starting chemotherapy. Pt estimates she is eating half of her usual intake. She does like Ensure, but has been only been consuming 1 daily. Pt reports eating ice cream with chocolate syrup and cottage cheese as meal replacements on the days she is feeling good. NUTRITION FOCUSED PHYSICAL FINDINGS: Cachectic; Overt muscle wasting noted on temporal and clavicular regions. Depression noted between ribs. BODY COMPOSTION/WEIGHT HISTORY: HEIGHT: 165.1cm WEIGHT: 44.9kg (admit) IBW: 56.8kg UBW: 50kg (12/27/10) % WEIGHT CHANGE: BMI:
Case Study #3 NUTRITION ASSESSMENT: Consult PATIENT MEDICAL/HEALTH HISTORY: 72 y/o female with no past medical history, who is admitted with new diagnosis of AML. Plan to initiate chemotherapy today. GASTROINTESTINAL: Pt reports taste changes, specifically things have been tasting off over the past 3-4 weeks. Denies any N/V/D/C. Thrush noted per H&P. DIET HISTORY: Pt states she has been eating a little less than usual over the past couple of weeks due to issues with food not tasting good. Pt noticed she is getting full on less food. Pt states she was still eating her meals, however only ¾ of them (no longer finishing her plate). Pt states she noticed her clothes are fitting looser than normal, but does not know if she has lost weight because she doesn t weigh herself. BODY COMPOSTION/WEIGHT HISTORY: HEIGHT: 149.9cm WEIGHT: 60.5kg IBW: 45.5kg UBW: 63.5kg (~4 weeks ago, per medical record) % WEIGHT CHANGE: BMI:
Case Study #4 NUTRITION ASSESMENT PATIENT MEDICAL/HEALTH HISTORY: Pt is a 60 y/o woman with a medical history significant for IBD here for acute exacerbation of her Ulcerative colitis. GASTROINTESTINAL: Pt experiencing worsening diarrhea and abdominal pain over the last 7 days. Bloody stools started 2 days which prompted patient to come to the ED. CRP markedly elevated upon arrival. DIET HISTORY: Patient reports decreased intake over the last week secondary to worsening abdominal pain and diarrhea. She has been trying to keep herself well hydrated. Prior to the onset of her symptoms, she says her ulcerative colitis was under good control, she was eating well. This past week she notes her intake to be ~75% of what she usually eats, some days may be less depending on severity of abdominal pain. FOOD INTAKE: NPO x 2 days. BODY COMPOSTION/WEIGHT HISTORY: HEIGHT: 164 cm ADMIT WEIGHT: 65.9kg (2/1) CURRENT WEIGHT: 64.6kg (2/11) % WEIGHT CHANGE: BMI:
Case Study #5 NUTRITION ASSESSMENT: LOS PATIENT MEDICAL/HEALTH HISTORY: 72 y/o male admitted for acute exacerbation of CHF with a medical history of moderate mitral regurgitation, acute on chronic systolic CHF, 3rd degree heart block, and iron deficiency anemia. Currently being diuresed. DIET HISTORY: Pt reports a variable appetite and intake, states he has good and bad days. He states he likes to graze throughout the day rather than eating large meals. He reports his weight fluctuates due to fluid status and it s not uncommon for his weight to go up and down 5 lbs from day to day. Pt noted to be eating a varied amount from meals (25-75% of meals) per nursing flowsheets. Pt states he has been missing meals due to tests/procedures while inpatient. BODY COMPOSTION/WEIGHT HISTORY: HEIGHT: 175.3cm ADMIT WEIGHT: 105.3kg CURRENT WEIGHT: 103kg UBW: 210-230 lbs (per pt report) % WEIGHT CHANGE: BMI:
Syndrome A disease is a pathophysiological response to internal or external factors. A disorder is a disruption to regular bodily structure and function. A syndrome is a collection of signs and symptoms associated with a specific health-related cause.
Refeeding Syndrome Constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved, severely malnourished or metabolically stressed due to severe illness.
Some definitions. EN Enteral Nutrition: provision of nutrition into the GI tract (either into stomach or small bowel) through a feeding tube PN Parenteral Nutrition: provision of nutrition to a person intravenously, bypassing the usual process of eating and digestion
Refeeding Syndrome What historical references do these articles discuss?
Brief Overview of fuel sources during starvation First 24hrs: Glucose is obtain through glycogen stored in the liver via glycogenolysis Once glycogen stores are depleted skeletal muscle is broken down to release amino acids for gluconeogenesis After ~72 hours, metabolic pathways shift to free fatty acid oxidation to preserve skeletal muscle
Depletion of vitamins and minerals Prolonged decreased nutrient intake can lead to depleted vitamin and mineral status, including phosphorus, potassium and magnesium Leads to loss of lean body mass, adipose tissue, and fluid With eventual reduction of visceral protein mass and function of vital organs Respiratory muscle wasting, reduced cardiac mass declined respiratory function, decreased cardiac output
Hypophosphatemia Results from cellular uptake of uptake of phosphorus, as well as increased need for phosphorylated intermediates for glycolysis (ATP, and 2,3-disphosphoglycerate) Can result in decreased oxygen delivery to cells, due to decreased levels of inorganic phosphates (2,3-DPG), which impairs oxygen release from hemoglobin Physiologic manifestations of hypophosphatemia can include neurologic, respiratory, cardiac, and immune function effects Normal range: 2.7-4.6 mg/dl Severe hypophosphatemia: <1 1.5 mg/dl
Hypokalemia Results from cellular uptake of potassium, induced by insulin produced in response to the nutritional load Effects of moderate hypokalemia (2.5 3.5 meq/l) include nausea, vomiting, constipation, and weakness Severe hypokalemia (<2.5 meq/l) may lead to respiratory failure, rhabdomyolysis and muscle necrosis, electrocardiogram (ECG) changes, cardiac arrhythmias, and paralysis
Hypomagnesemia Magnesium essential for a number of metabolic pathways including those involving ATP production If magnesium not addressed, may impact ability to correct serum phosphorus and potassium levels Reference range: 1.5-2.4 mg/dl Hypomagnesemia: <1.5 mg/dl
First Step: Identify patients at risk Primary goal is to preventing refeeding syndrome, which means identifying those that may be at risk Patients at risk for refeeding may include those with: Anorexia nervosa Classic marasmus/kwashiokor Residents admitted from skilled nursing facilities Patients who have been unfed for 7-10 days with evidence of stress/depletion Chronic disease causing undernutrition (examples?) History of excessive alcohol intake Morbid obesity with massive weight loss
Patients at risk for refeeding syndrome In order to prevent refeeding syndrome, this identification should occur prior to the initiation of nutrition support What are some considerations when evaluating lab values of minerals prior to initiation of nutrition support? Do normal levels mean there is not depletion? Normal serum levels may not be reflective of actual stores, these patients are likely to have depletion
Preventing Refeeding Syndrome Once nutrition support is initiated, it is essential to avoid overfeeding Rule of thumb: start low and go slow Day initiation recommendations: Start at 25% of estimated goal energy needs Gradually increase to goal over 3-5 days, maybe longer Any electrolyte abnormalities should corrected prior to initiation
Other considerations. Total fluid volume needs to be considered when making your recommendations These patients may have diminished cardiac reserve and are susceptible to fluid overload, fluid and sodium may need to minimized initially Good rule of thumb: Keep fluid 1000ml or less in first few days Monitor weight as well, weight gain >1kg/week may indicate fluid retention
Prevention: Identify those at risk Conservative initiation of nutrition support along with aggressive monitoring and replacement of electrolytes via IV Can use kcal/kg or % of total calorie goal Must keep in mind delivery of carbohydrate, as well as total fluid
Prevention Nutrition support should begin at 25% of estimated energy needs and advanced gradually to goal over the next 3-5 days Serum potassium, phosphorus and magnesium should be monitored closely twice daily during the first few days while advancing to goal Electrolytes should be supplemented preferably via IV, or via oral supplementation when appropriate. Why? Thiamine supplementation should be started without need to check serum or whole blood thiamine levels (100mg/day for at least the first week) Also usually receive 1mg folic acid daily for 7 days as water soluble vitamin deficiencies can occur rapidly
Treatment Patient starts to exhibit signs or symptoms of refeeding, what next? What do we do with regard to their nutrition support? Aggressive electrolyte replacement When and how should we restart nutrition support?
Example in article MH is a 73-year-old nursing home resident. She has a history of cerebrovascular accident approximately four months prior to admission resulting in dysphagia; she has been on a pureed diet with thickened liquids. Since that time her medical history includes hypertension, atrial fibrillation and asthma. MH is admitted to the hospital with fever, aspiration pneumonia, and dehydration. She is made NPO; IV fluids are started (D5, 1 2NS). A modified barium swallow demonstrates aspiration with all consistencies. Nasogastric feedings are initiated according to standard protocol. A weight obtained the following day is 56 kg; her weight at the time of her stroke four months earlier was 65 kg. The following day, MH developed worsening respiratory distress and was transferred to the ICU for further care. The results of her blood chemistries were: phosphorous 1.1 magnesium 1.3 potassium 2.9
Summary of important points After prolonged malnutrition or starvation, the provision of parenteral or enteral nutrition support results in a sudden and dramatic shift back to glucose as a primary fuel. Insulin levels also increase to drive glucose into cells for use An increased demand for phosphorylated intermediates of glycolysis, such as adenosine triphosphate (ATP), results.
Summary of important points Increased insulin secretion results in rapid entrance of phosphorus, potassium, and magnesium into cells, exacerbating already low levels of these electrolytes. Furthermore, insulin exerts an antidiuretic effect, leading to sodium and water retention that result in the expansion of the extracellular water compartment.
Summary of Important Points Important to identify persons at risk for refeeding and take steps to prevent it Initiation of nutrition support at conservative goal with gradual progression over several days to goal Close monitoring of serum electrolyte levels Aggressive repletion of electrolytes as indicated and as well as supplementation of thiamin