High Risk Of Refeeding Syndrome Research Articles

1123 Incidence of Electrolyte Abnormalities in Patients Recovering Form Maxillofacial Resection and Free Flap Reconstruction

Abstract Aim Recovery from resection of head and neck malignancy is fraught with potential complications. Among these are electrolyte disturbances. The majority of junior trainees in Oral & Maxillofacial surgery have qualified in dentistry and will have had little exposure to this topic. We aim to examine the incidence of disturbances in Serum Sodium, Potassium, Calcium, Magnesium and Phosphate. This information will aid in prioritising information for robust induction and educational programmes in Maxillofacial oncology centres. Method Patients were identified in a single centre from January to November 2022 from theatre records. All patients were adults who underwent resection for Head and Neck malignancy with free flap reconstruction. A total of 65 patients were included. The electronic pathology system was integrated for results. Results The most common abnormal result was hypophosphatemia (<0.8 mmol/L) present in 53 patients (81%). The next most common was hypocalcaemia (<2.2 mmol/L) which was present in on 46 patients (71%) Potassium imbalances were seen in fewer patients, with 10 being high (>5.3 mmol/L and 17 low (<3.5mmol/L). Least common were issues with Sodium, being high (>145mmol/L) for 9 patients (14%) and low (<135 mmol/L) for 14 patients (21%). Conclusions Electrolyte abnormalities are commonly encountered when caring for Maxillofacial Head & Neck cancer patients. Prior to surgery many patients have undergone a period of malnutrition due the pain. This makes them high risk of re-feeding syndrome once nutrition is started. Induction programmes should familiarise dental core trainees with the trust’s Re-feeding guidelines and when to escalate more severe problems.

The Performances of SNAQ, GLIM, mNICE, and ASPEN for Identification of Neurocritically Ill Patients at High Risk of Developing Refeeding Syndrome.

We previously found that neurocritically ill patients are prone to refeeding syndrome (RFS), a potentially life-threatening complication. However, there is no unified or validated consensus on the screening tool for RFS so far. We aimed to validate and compare the performance of four screening tools for RFS in neurocritically ill patients. We conducted a single-center, observational, retrospective cohort study among neurocritically ill adult patients who were admitted to the neurocritical care unit (NCU), and who received enteral nutrition for 72 h or longer. They were scored on the Short Nutritional Assessment Questionnaire (SNAQ), the Global Leadership Initiative on Malnutrition (GLIM), the modified criteria of the Britain’s National Institute for Health and Care Excellence (mNICE), and ASPEN Consensus Recommendations for Refeeding Syndrome (ASPEN) scales to predict RFS risk via admission data. The performance of each scale in predicting RFS was evaluated. Logistic regression analysis was used to identify the independent risk factors for RFS, and they were added to the above scales to strengthen the identification of RFS. Of the 478 patients included, 84 (17.57%) developed RFS. The sensitivity of the SNAQ and GLIM was only 20.2% (12.6–30.7%), although they had excellent specificities of 84.8% (80.8–88.1%) and 86.0% (82.1–89.2%), respectively; mNICE predicted RFS with a sensitivity of 48.8% (37.8–59.9%) and a specificity of 65.0% (60.0–69.9%); ASPEN had the highest Youden index, with a sensitivity and specificity of 53.6% (42.4–64.4%) and 64.7% (59.8–69.4%), respectively. The Area Under the receiver operating characteristic Curves (AUC) of SNAQ, GLIM, mNICE, and ASPEN to predict RFS were 0.516 (0.470–0.561), 0.533 (0.487–0.579), 0.568 (0.522–0.613), and 0.597 (0.551–0.641), respectively. We identified age, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Glasgow Coma Scale (GCS) score as independent risk factors of RFS, and the combination of GCS and age can improve the AUC of ASPEN to 0.664 (0.620–0.706) for predicting RFS. SNAQ, GLIM, mNICE, and ASPEN do not perform well in identifying neurocritically ill patients at high risk of RFS, although ASPEN appears to have relatively a good validity among them. Combining GCS and age with ASPEN slightly improves RFS recognition, but it still leaves a lot of room for improvement.

Refeeding risks in patients requiring intravenous nutrition support: Results of a two-centre, prospective, double-blind, randomised controlled trial.

Refeeding syndrome can result following excessive feeding of malnourished patients. The syndrome remains poorly defined but encompasses a range of adverse effects including electrolyte shifts, hyperglycaemia and other less well-defined phenomena. There are additional risks of underfeeding malnourished individuals. Studies of refeeding syndrome have generally focussed on critical care environments or patients with anorexia nervosa. Here we have conducted a two-centre, prospective, double-blind, randomised controlled trial amongst all patients referred to hospital nutrition support teams for intravenous nutrition support. We sought to determine whether electrolyte and other abnormalities suggestive of refeeding syndrome risk varied depending on initial rate of intravenous feeding. Patients at moderate or high risk of refeeding syndrome, as defined by United Kingdom National Institute of Health and Care Excellence guidelines, were screened for inclusion. Patients were randomised to receive either high (30kcal/kg/day, 0.25gN/kg/day) or low (15kcal/day, 0.125gN/kg/day) rate feeding for the first 48h prior to escalation to standard parenteral nutrition regimens. The primary outcome was rates of potential refeeding risks within the first 7 days as defined by electrolyte imbalance or hyperglycaemia requiring insulin. Secondary outcomes included effects on QTc interval, infections and length of hospital stay. Statistical analysis was performed with χ2 or Wilcoxon rank sum tests and all analysis was intention-to-treat. Problems with study recruitment led to premature termination of the trial. Registered on the EU Clinical Trials Register (EudraCT number 2007-005547-17). 534 patients were screened and 104 randomised to either high or low rate feeding based on risk of refeeding syndrome. Seven patients were withdrawn prior to collection of baseline demographics and were excluded from analysis. 48 patients were analysed for the primary outcome with potential refeeding risks identified in 46%. No differences in risks were seen between high and low rate feeding (p>0.99) or high and moderate risk feeding (p=0.68). There were no differences in QTc abnormalities, infection rates, or hospital length of stay between groups. In this randomised trial of rates of refeeding risk, in patients pre-stratified as being at high or moderate risk, we found no evidence of increased refeeding related disturbances in those commenced on high rate feeding compared to low rate. No differences were seen in secondary endpoints including cardiac rhythm analysis, infections or length of stay. Our study reflects real world experience of patients referred for nutrition support and highlights challenges encountered when conducting clinical nutrition research.

Risk of refeeding syndrome. Case report

Introduction: Refeeding syndrome is an acute metabolic disorder that occurs during nutritional repletion. Although it has been known for years, the early detection of risk factors for its onset and the implementation of measures to prevent it are not common in nutritional care.Case presentation: 48-year-old male patient, in critical care for 6 days, with suspected Wernicke-Korsakoff encephalopathy and high risk of refeeding syndrome according to criteria of the National Institute of Health and Clinical Excellence. The subject received enteral nutrition with 14 kcal/kg for the first 3 days, with subsequent increases aiming to achieve a nutritional goal of 25 kcal/kg on day 5. He also received daily supplementation of thiamine 600mg, folic acid 5mg and pyridoxine 50mg. Blood phosphorus decreased from 3 mg/dL to 2 mg/dL the day after initiating the nutritional plan and normalized by day 3.Discussion: The patient did not present severe hypophosphatemia or clinical manifestations of refeeding syndrome. Hypophosphatemia was resolved by maintaining a stable caloric restriction during the first days. Some professionals consider this restriction as very conservative, and others think that it may lead to achieve significant improvements in mortality reduction.Conclusions: The strategy for assessing the risk of refeeding syndrome, nutritional management and implemented follow-up were successful in preventing the patient from developing a refeeding syndrome.

Refeeding syndrome: an update and pragmatic approach to management

Refeeding syndrome is a potentially serious complication of starting nutritional support in patients who have had poor nutrition for more than 5 days or suffered significant unintentional weight loss over a short period of time. This clinical review aims to summarise the risk factors, pathophysiology, clinical and biochemical presentation and outline the management and prevention of refeeding syndrome. This looks at following guidelines, taking Malnutrition Universal Screening Tool (MUST) scores and providing nutrition support, as well as the role of nurses and the multidisciplinary team. Deficiencies in phosphate, magnesium, potassium and leukocytes related to refeeding syndrome are examined, with advice on their correction. Attention is also drawn to the fact that infection and sepsis are often hidden in patients who are at high risk of refeeding syndrome, and alternative signs that can point to infection in this group are outlined.

A case of refeeding syndrome during intradialytic parenteral nutrition

BackgroundRefeeding syndrome is a potentially fatal electrolyte shift in patients with rapid feeding after low-calorie intake. Although the key to diagnosing refeeding syndrome is hypophosphatemia after feeding, renal dysfunction might hide refeeding hypophosphatemia, especially in maintenance hemodialysis patients. Intradialytic parenteral nutrition (IDPN) is a therapeutic approach used to treat malnourished patients with maintenance hemodialysis. No earlier report describes a study of refeeding syndrome complicated with IDPN.Case presentationWe present a case of a 77-year-old man undergoing maintenance hemodialysis for 17 years. While IDPN was administered after 10 days fasting, ventricular tachycardia (VT) occurred, possibly because of a rapid intracellular shift of potassium mainly explained as refeeding syndrome in addition to potassium removal by hemodialysis. A greater decline of serum phosphate concentrations during hemodialysis on that day compared with that during usual hemodialysis session supports our inference of the contribution of refeeding syndrome to VT complicated with hypokalemia.ConclusionPhysicians should know that IDPN can induce refeeding hypophosphatemia and rapid intracellular shift of potassium. Synergic lowering effects of serum potassium both with intracellular shift caused by refeeding syndrome and potassium removal by hemodialysis might cause lethal arrhythmia in patients treated with IDPN. Before treating malnourished patients with IDPN, the risk of refeeding syndrome should be assessed in patients with high risk of refeeding syndrome.

Hypophosphatemia before endoscopic gastrostomy predicts higher mortality during the first week and first month post-gastrostomy: a risk marker of refeeding syndrome in gastrostomy-fed patients.

Introduction: starvation is usual in patients referred for endoscopic gastrostomy (PEG). A high risk of refeeding syndrome (RS) may contribute to poor prognosis. Objectives: this study aims to: a) evaluate serum phosphorus and magnesium when patients underwent PEG; b) determine the mortality rate during the first week and first month of enteral nutrition; and c) assess if hypophosphatemia or hypomagnesemia are associated with early mortality. Material and methods: retrospective study with patients followed in the Artificial Nutrition Clinic and died under PEG feeding. General nutritional assessment included NRS 2002, anthropometry and serum proteins. Serum phosphorus and magnesium were measured immediately before gastrostomy. Survival was recorded and compared to electrolyte and nutritional status. Results: one hundred and ninety-seven patients (137 men/60 women) aged 26-100 years. Most underwent PEG due to neurologic disorders (60.9%) and were malnourished according to body mass index (BMI) and serum proteins. Low phosphorus and magnesium were found in 6.6% and 4.6%, respectively. Hypophosphatemia was associated with malnutrition (p < 0.05). Mean survival was 13.7 ± 15.4 months. Mortality was 4.6% in the first week and 13.2% in the first month post-gastrostomy. Overall survival was shorter in malnourished patients but malnutrition did not directly influence early mortality (p > 0.05). Hypophosphatemia was associated with mortality during the first week (p = 0.02) and the first month of PEG feeding (p = 0.02). Conclusions: hypophosphatemia was uncommon but predicted early mortality after PEG. Although RS may be less frequent than expected, hypophosphatemia may be used as a RS marker and RS is the probable cause of increase early mortality in hypophosphatemic PEG-fed patients.

A retrospective audit to evaluate the advice implemented and management for patients at high risk or extremely high risk of refeeding syndrome

A retrospective audit to evaluate the advice implemented and management for patients at high risk or extremely high risk of refeeding syndrome

Evidence supporting the safety of rapid refeeding protocols, using a food based approach, in a paediatric inpatient eating disorder program

Historically, a cautious approach to refeeding has been taken due to lack of evidence about refeeding syndrome. The aim of this study was to evaluate outcomes following the introduction of a more aggressive feeding protocol in a paediatric eating disorder program. This included commencing at a higher energy intake, more rapid energy increases and macronutrient manipulation of meal plans while maintaining a food based approach. A restrospective audit of 38 Austin Hospital patients admitted for medical stabilisation of their eating disorder, using rapid refeeding proto cols, were compared to previous refeeeding protocols. Thirty-seven patients (97%) were commenced on 8.2 megajoules (MJ) or more and increased to 11 MJ within one week. Previously, 23 patients (60%) had commenced on 6.8 MJ or less. With more intensive feeding 30 patients (79%) gained more than the target of 1 to 1.5 kilograms per week (compared to 35% previously). Evidence of refeeding syndrome was identified and treated in only two patients (5%). Only one patient required a lower energy intake (6.5MJ) with reduced contribution to energy from carbohydrates (40%) due to high risk of refeeding syndrome. These findings suggest more rapid refeeding can be achieved safely with a food based approach in this patient group. This abstract was presented in the Care in Inpatient and Community Settings stream of the 2013 ANZAED Conference.

Mo2116 Development of Institutional Guidelines for the Identification and Management of Refeeding Syndrome Among Acutely Admitted Patients

Refeeding Syndrome refers to biochemical and physical abnormalities, arising as a result of shifts in electrolytes and fluid balance in malnourished individuals following the initiation of feeding. This is an acute complication of malnutrition among hospitalised patients with the potential for significant morbidity and mortality. We audited the percentage of patients admitted over 6 days at a tertiary referral centre at high risk of Refeeding Syndrome. Analysis of identification and management centred on NICE (National Institute of Clinical Excellence) Guidelines, CG32. 102 patients were included and 22 (21.5%) patients were at a high risk for developing Refeeding Syndrome. 8 patients from the high risk group did not have electrolyte levels monitored. Of the 14 high-risk patients who had bloods assayed, their treating physician prescribed only 7 patients thiamine. Only 32% of patients at high risk of Refeeding Syndrome were managed according to best practice, and 9% of the patients at high risk progressed to develop Refeeding Syndrome with one mortality. Following these findings, we formed amultidisciplinary committee comprisingmembers from the Department of Gastroenterology and Hepatology, Department of Nutrition and Dietetics, Department of Pharmacy and Nursing Administration. We developed institutional guidelines derived from literature review and NICE Guidelines for the identification and management of Refeeding Syndrome. We also developed guidelines for repletion of electrolytes with specific reference to formulations and doses appropriate to the levels of repletion required. A programme of education for nursing and clinical staff alike was undertaken, with the addition of regular patient weights applied to nursing charts and more streamlined dietician referral practices applied throughout the hospital. Flowcharts for expedient clinical intervention were available on all wards and the accident and emergency department, as were the above-mentioned electrolyte repletion guidelines. We are pleased to report that a repeated audit after initial implementation of these guidelines revealed that 11/54 patients (20%) were at high risk of Refeeding Syndrome. 45.5% of these patients were managed according to the guidelines, receiving both thiamine and appropriate blood investigations, which is comparable to 32% in the initial audit. This demonstrates progress after only 2months of widespread implementation of these guidelines at our institution. This audit cycle highlights the importance of identification and management of patients at risk of Refeeding Syndrome. The application of formal guidelines generated in a multidisciplinary manner as demonstrated at our institution yields improvements in patient management, giving clear recommendations and improving clinical education and awareness of malnutrition.

Centropontine Myelinolysis Related to Refeeding Syndrome in an Adolescent Suffering from Anorexia Nervosa

Centropontine myelinolysis (CPM) is a rare neurologic disorder defined by symmetric demyelination in the central pons, mostly due to alcoholism, malnutrition, or water-electrolyte abnormalities. We report an unusual case of CPM likely due to hypophosphatemia, related to a refeeding syndrome in the context of mental anorexia. A 15-year-old girl with mental anorexia presented with hypophosphatemia in the following days of enteral refeeding, and then suffered from confusion, neurological signs, and typical MRI lesions of CPM. Hypophosphoremia may be considered as a causative agent in CPM related to refeeding syndrome. This clinical observation also highlights the importance of recognizing patients at high risk of refeeding syndrome to initiate a balanced nutrition with careful monitoring.

An Audit on the Identification of Patients at High Risk of Refeeding Syndrome Among the Acutely Admitted Patient Population at a Large Teaching Hospital

An Audit on the Identification of Patients at High Risk of Refeeding Syndrome Among the Acutely Admitted Patient Population at a Large Teaching Hospital

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia?

Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group. A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded. The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007). These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.

Nutritional Management of Patients Undergoing Surgery following Diagnosis with Encapsulating Peritoneal Sclerosis

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD). Gastrointestinal (GI) symptoms affect appetite and dietary intake. Adequate nutrition is especially important if surgical interventions are required. To investigate the nutritional management of 23 EPS patients that underwent surgical intervention between 1999 and 2005 at Manchester Royal Infirmary, United Kingdom. EPS was recognized by GI symptoms and diagnostically confirmed by laparotomy, computed tomographic scanning, or biopsy. Mean time on PD was 74 months (interquartile range 42-89 months). During the 12 months pre-diagnosis, 65% of the group showed significant weight loss (p = 0.0001), with 8 patients losing >10% of body weight; 74% of patients experienced significant albumin decrease (p = 0.001); and 56% of patients experienced GI symptoms during the 6 months pre-diagnosis. Nasogastric (NG) feeding was recommended for 8 patients but continued in only 1. 15 patients (mean albumin 27 g/L) commenced parenteral nutrition (PN); 9 patients recovered, with albumin increasing over the 6-month follow-up. Mean hospital time was 62 days for the group receiving neither NG nor PN, compared with 124.3 for the PN/NG group (p = 0.04). In patients that died of EPS, albumin continued to fall at 3 months post-diagnosis. There is currently little guidance for nutritional management of EPS. From this study we recommend (1) a high level of clinical suspicion for EPS, especially if PD patients have weight loss; (2) PN may be better than NG feeding but further studies into dual enteral nutrition and PN are needed; (3) aggressive nutritional supplementation pre- and postoperatively; and (4) dietitians need to recognize the high risk of refeeding syndrome.

From malnutrition to refeeding during anorexia nervosa

Anorexia nervosa is one of the most common forms of malnutrition observed in Western society in individuals without physical diseases, with an average risk of mortality of 20% in a younger population aged between 15 and 25 years. It is characterised by an initial dramatic decrease in food intake that leads to profound depletion in muscle and fat mass. During the course of the disease, the resting energy expenditure decreases proportionally to the loss of lean body mass with a decrease in thyroid hormone secretion. The metabolic adaptation during anorexia nervosa is similar to that observed during starvation with a relative sparing of protein stores. After an initial weight loss, the total energy expenditure is similar to that in normal individuals, with a decrease in resting energy expenditure and an increased energy-related physical activity. At the end stage of wasting, however, physical activity dramatically decreases as well as energy intake. This metabolic adaptation of semi-starvation is impaired during refeeding with an increase in the thermic effect of food and a high risk of refeeding syndrome with severe hypophosphatemia.