Refeeding Syndrome Research Articles

Characteristics and outcome of patients with anorexia nervosa on medical nutritional therapy: an institutional study with review of literature.

Eating disorders (EDs) are debilitating mental illnesses that can lead to significant medical complications from malnutrition. Eating disorders are on the rise in Asia and the prevalence is expected to increase. The aim of this study was to understand the characteristics of local patients and evaluate our current inpatient nutritional rehabilitation protocol for anorexia nervosa (AN). Retrospective descriptive data were gathered from 47 patients diagnosed with AN. Patients with admissions were further stratified according to their nutritional management based on whether they were on the AN protocol or standard hospital care. Data on their rate of weight gain, length of stay and calorie prescription were collected. Similar to previous studies, the majority of AN patients were female (96.7%). However, the age at presentation of AN in this study, as compared with previous local studies, had decreased (14 vs. 16 years). We also found that patients on the AN protocol were prescribed a higher amount of calories than those given standard care (2,700 vs. 2,317 calories). Patients on the AN protocol achieved a higher rate of weight gain per week (1.15 vs. 0.29 kg) and had a shorter length of hospital stay (23 vs. 36 days). Patients with AN appear to be presenting at a younger age. Medical stabilisation of AN patients can be achieved more quickly through a higher calorie inpatient AN treatment protocol. Future local studies examining actual calorie consumption, its effect on weight gain trajectory, severity of refeeding syndrome and time to remission will be beneficial.

Reducing refeeding syndrome incidence among patients with head and neck cancer: A quality improvement initiative.

459 Background: Refeeding syndrome (RFS) constitutes a wide spectrum of electrolyte abnormalities and clinical symptoms following re-introduction of nutrition, specifically carbohydrate, in malnourished patients (pts). Refeeding phenomena (RFP) is the isolated decline in electrolyte levels (phosphate, potassium, or magnesium) following refeeding. Average incidence of RFS in head and neck cancer (HNC) pts is 20%. Early identification of high-risk pts and increasing awareness about RFP is crucial to avoid rapid nutritional replenishment and therefore reduce health care costs, morbidity, and mortality from RFS. We conducted a quality improvement (QI) project at a single academic university hospital with objective of reducing RFS incidence, length of hospital stay (LOS) and 30 day all-cause readmission and ED visit rates in HNC pts started on enteral nutrition (EN). Methods: We conducted a prospective observational study between Aug 2021 and Nov 2022 among pts with HNC admitted for feeding tube insertion. Pts determined to be high-risk for RFS according to ASPEN criteria were included. Serum electrolyte levels were obtained and monitored twice daily for 3 days following initiating continuous feeds with a standard, fiber free, 1.5 kcal/mL formula @ 20mL/h (’Safe start’). If low, electrolytes were promptly supplemented. Enteral thiamine supplements (100 mg daily for 5-7 days) were started. A registered dietitian conducted a nutrition assessment within 24 h of EN initiation to provide EN regimen and formula advancement recommendations, as well as EN needs for home. Case management was consulted within 24 h of EN initiation to facilitate timely discharge and delivery of home supplies. Data including LOS and 30-day all-cause readmission and ED visits were collected. ASPEN criteria were used to define mild, moderate, severe RFP. For comparison, similar data was retrospectively collected by reviewing medical records of 57 HNC pts (control group) admitted for feeding tube insertion between Dec 2017 and April 2021. Results: Of the 56 pts in the study group, 8 (14.3%) experienced RFS, 12 (21.4%) mild RFP, 7 (12.5%) moderate RFP, and 12 (21.4%) severe RFP. The average LOS in study group was 10 days compared to 13 in control group. 30-day all-cause readmission and ED visit rates were 21.4% and 12.5% in study group compared to 45.6% and 19.3% respectively in control group (Table 1). Conclusions: RFP/RFS is often underdiagnosed and undertreated in HNC pts. Through QI measures we were able to decrease RFS incidence rate to less than the reported average. Close collaboration between physicians, nurses, dietitians, and case managers facilitates timely intervention to prevent RFS, reduce LOS and readmissions.[Table: see text]

Il supporto nutrizionale nell’anoressia nervosa

Paediatric departments are increasingly faced with adolescents with anorexia nervosa in severe nutritional and metabolic decompensation. Artificial nutritional support, often indispensable in the most critical phases of the course, requires careful evaluation of the clinical conditions at the time of hospitalization and equally punctual monitoring of blood chemistry variables during re-feeding. Prolonged reduced caloric intake and malnutrition, especially in its most extreme forms, can cause damage to various organs and systems and the refeeding syndrome must be kept in mind as a further comorbidity and aggravating factor of the patient's conditions. Through the description of a clinical case of particular complexity, some aspects related to the hospital treatment of anorexia nervosa are discussed.

SAT478 A Rare Case of Thyrotoxic Periodic Paralysis in a Patient with Concomitant Methimazole-Induced Agranulocytosis

Abstract Disclosure: K.S. Wei: None. S.M. Cannon: None. T.E. Angell: None. Introduction: Thyrotoxic state may precipitate sudden-onset unilateral or bilateral extremity weakness brought on by transient hypokalemia requiring specific management. Clinical Case: A 48-year-old woman presented to our hospital with fevers, sore throat, and sudden-onset bilateral leg weakness. Ten weeks prior, she was started on methimazole 20mg daily for a new diagnosis of Graves’ disease. Two days prior to presentation, she had consumed a carbohydrate-heavy meal and that night experienced acute-onset lower extremity weakness rendering her unable to walk. She also had been experiencing sore throat, odynophagia, and intermittent fevers. On admission, the patient was found to be febrile, tachycardic, and in shock with WBC <0.5 (ref: 4.5-10 K/cumm), potassium 2.6 (3.5-5.1 mmol/L), lactate 4.1 (0.5-2.2 mmol/L), TSH <0.01 (0.27-4.2 uIU/mL), fT4 4.04 (0.93-1.7 ng/dL) and was admitted to the ICU for neutropenic fever and septic shock. Computed tomography (CT) imaging of the thorax showed right lung consolidation suggesting pneumonia. Magnetic resonance imaging of the spine and CT head did not demonstrate an etiology for her weakness. She was diagnosed with thyrotoxic periodic paralysis (TPP) and treated with potassium. For severe hyperthyroidism with methimazole contraindication, she received broad spectrum antibiotics, lithium 300mg orally every 8 hours, and propranolol 10-20mg every 8 hours. Given minimal improvement in both weakness and hypokalemia after 48 hours of therapy, she was also diagnosed with refeeding syndrome and potassium repletion was intensified. The patient’s shock resolved, with slow improvement of lower extremity weakness over a two-week period and resolution of agranulocytosis and fevers. Conclusion: This rare presentation offers several distinct points regarding the patient’s care. Firstly, TPP is a rare hyperthyroidism-related hypokalemia that can cause weakening of the extremities due to a rapid intracellular shift of potassium (1) and is an important syndrome to consider on the differential for any thyrotoxic patient presenting with sudden-onset weakness. Secondly, gentle potassium repletion is recommended to prevent rebound hyperkalemia. However, our patient had both total body loss of potassium from refeeding syndrome and intracellular shift from TPP, requiring more aggressive potassium repletion to treat her paralysis than is typical for TPP alone. In settings where weakness and hypokalemia do not improve with beta blockade and gentle potassium repletion, it is important to investigate other causes of hypokalemia and consider concurrent overlapping diagnoses. Lastly, patients with methimazole-induced agranulocytosis may require alternative treatments, such as lithium to control hyperthyroidism. 1) Lin, Shih-Hua. Thyrotoxic Periodic Paralysis. Mayo Clin Proc. 2005;80(1):99-105. Presentation Date: Saturday, June 17, 2023

Assessment of refeeding syndrome definitions and 30-day mortality in critically ill adults: A comparison study.

Patients in the intensive care unit (ICU) are at high risk for refeeding syndrome (RFS), yet there is uncertainty regarding how RFS should be operationalized in the ICU. We evaluated different definitions for RFS and tested how they associated with patient-centered outcomes in the ICU. This was a retrospective comparison study. Patients age ≥18 years were eligible if they were newly initiated on enteral feeding while hospitalized in the ICU. Eight definitions for RFS were operationalized, including that from the American Society for Parenteral and Enteral Nutrition (ASPEN), all based on electrolyte levels from immediately before until up to 5 days after the initiation of enteral nutrition. Patients were followed for death or for ICU-free days, a measure of healthcare utilization. In all, 2123 patients were identified, including 406 (19.1%) who died within 30 days of ICU admission and 1717 (80.9%) who did not. Prevalence of RFS varied from 1.5% to 88% (ASPEN definition) depending on the RFS definition used. The excess risk for death associated with RFS varied from 33% to 92% across definitions. The development of RFS based on the ASPEN definition was associated with a greater decrease in ICU-free days compared with other definitions, but the relationship was not statistically significant. Eight definitions for RFS were evaluated, none of which showed strong associations with death or ICU-free days. It may be challenging to achieve a standardized definition for RFS that is based on electrolyte values and predicts mortality or ICU-free days.

2118P Refeeding syndrome: A prospective analysis in adults admitted to an oncology hospital

2118P Refeeding syndrome: A prospective analysis in adults admitted to an oncology hospital

Preventing Refeeding Syndrome in IUGR Preterm Infants Receiving Parenteral Protein

Preventing Refeeding Syndrome in IUGR Preterm Infants Receiving Parenteral Protein

Is hyperemesis gravidarum a neuropsychiatric disorder?

Hyperemesis gravidarum occurs in up to 2 % of pregnancies. It is customary to regard the condition as purely an obstetric issue. However, there are reasonable grounds for reframing it as a neuropsychiatric state dependent upon genetic factors and involving peptides active within the central nervous system. Neurological abnormalities can also arise due to Wernicke's encephalopathy and the electrolyte abnormalities of refeeding syndrome. Aside from rehydration and antiemetic drugs, the condition can respond well to certain psychotropic medications and to psychological interventions, it may therefore be reasonable to regard hyperemesis of pregnancy as requiring both psychiatric and medical expertise for comprehensive management.

Refeeding Syndrome In Schizophrenia Case Report

Background Recent studies have shown growing concern for refeeding syndrome (RFS) among patients suffering from other medical conditions, although the exact incidence in this population is unknown. RFS occurs with the rapid reintroduction of calories to severely malnourished patients. It becomes critical for clinicians to have a high incidence of suspicion for prompt diagnosis and appropriate management to keep them alive if the malnutrition does not take their lives. Case presentation We report a case of a 53-year-old man with an 8-year history of schizophrenia and a 3-month history of poor feeding. He was admitted on account of refusal to feed or drink for two weeks prior to presentation. As a result, he was severely malnourished, and we started refeeding while dealing with his psychotic symptoms. He gained about 2kg within a week of admission, but that was fraught with metabolic derangements, which included, but were not limited to, hypophosphatemia, hypomagnesaemia, and hypocalcaemia. We revised his diagnosis to RFS in schizophrenia and managed it as such. Conclusion Diagnosis of RFS is based on a constellation of electrolyte deficiencies and clinical presentation as there are no agreed biomarkers. Unfortunately, one of the cardinal electrolyte deficiencies, hypophosphatemia, does not have readily available formulations for its correction, and this can lead to neurological, cardiovascular, and other complications, including sudden death. Delay in diagnosis worsens the prognosis, and the intuitive desire to feed a starved patient zealously leads them to death.

Refeeding Syndrome in Older Hospitalized Patients: Incidence, Management, and Outcomes.

Refeeding syndrome (RFS) is a serious metabolic disturbance that manifests after reintroducing nutrition to severely malnourished individuals. Especially susceptible are older patients, due to higher malnutrition rates, although the incidence remains uncertain. Our study aimed to assess the occurrence and management of RFS in malnourished older hospitalized patients. This prospective study included 156 malnourished older patients, with malnutrition identified using the Mini Nutritional Assessment-Short Form. We evaluated critical biochemical parameters at admission and for ten days after starting nutritional therapy. Using the consensus evidence-based approach, we managed and evaluated RFS. We also tracked mortality and unexpected hospital readmissions for six months after discharge. The average patient age was 82.3 ± 7.5 years, with 69% female. Patients showed hypophosphatemia (23%), hypomagnesemia (31%), and hypokalemia (6%) on admission. Prior to nutritional replenishment, patients were classified as being at low (64%), high (30%), or very high risk (6%) for RFS. After nutritional therapy, 14% and 5% developed imminent and manifest RFS, respectively. There were no significant differences in six-month post-discharge mortality rates or unexpected hospital readmissions between patients with or without RFS. Despite adherence to guideline-recommended management, RFS can persist. No elevated mortality was noted in RFS patients, potentially due to early diagnosis and treatment.

Putting the PENG 2018 refeeding syndrome guidance into practice

Putting the PENG 2018 refeeding syndrome guidance into practice

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.

Development, Design and Utilization of a CDSS for Refeeding Syndrome in Real Life Inpatient Care-A Feasibility Study.

The refeeding syndrome (RFS) is an oftentimes-unrecognized complication of reintroducing nutrition in malnourished patients that can lead to fatal cardiovascular failure. We hypothesized that a clinical decision support system (CDSS) can improve RFS recognition and management. We developed an algorithm from current diagnostic criteria for RFS detection, tested the algorithm on a retrospective dataset and combined the final algorithm with therapy and referral recommendations in a knowledge-based CDSS. The CDSS integration into clinical practice was prospectively investigated for six months. The utilization of the RFS-CDSS lead to RFS diagnosis in 13 out of 21 detected cases (62%). It improved patient-related care and documentation, e.g., RFS-specific coding (E87.7), increased from once coded in 30 month in the retrospective cohort to four times in six months in the prospective cohort and doubled the rate of nutrition referrals in true positive patients (retrospective referrals in true positive patients 33% vs. prospective referrals in true positive patients 71%). CDSS-facilitated RFS diagnosis is possible and improves RFS recognition. This effect and its impact on patient-related outcomes needs to be further investigated in a large randomized-controlled trial.

FTP4.3 Improving awareness of total parenteral nutrition administration in general surgical patients: a tertiary care hospital experience

Abstract Introduction Dieticians on the general surgical ward are valuable in providing recommendations to optimise patient nutrition, including the administration of total parenteral nutrition (TPN). Prescribing TPN is time-intensive as patients' clinical status and biochemical profile are assessed to avoid re-feeding syndrome. This needs adjustment of the dieticians’ recommendations, highlighting the importance of clinician awareness of patients recommended for TPN. Methods We carried out a quality improvement project (QIP) on the general surgical ward of a tertiary centre teaching hospital which involved two plan-do-study-act (PDSA) cycles. We used primary and secondary qualitative surveys to collect data. In the first cycle, we implemented a daily whiteboard handover system in the doctors’ office which displayed the patients recommended for TPN. In the second cycle, we added a TPN recommendation section to the daily patient handover / ward patient list. Results Pre-intervention respondents reported lack in awareness of patients recommended for TPN, and felt prescription was often delayed. Use of a whiteboard was well accepted by junior doctors as well as dieticians and improved awareness of patients on TPN. However, this duplicated the workload and information sources for dieticians and doctors. Use of the patient handover list resulted further improved awareness and subsequently quicker timeliness of TPN prescribing. Conclusions Both whiteboard displays & highlighting the potential TPN patients in the handover lists were well-accepted and effective ways to improve awareness of patients on TPN. Sustainable interventions should not result in duplication of workload or information. Future work could include quantitative analysis of the above interventions.

Refeeding Hypophosphatemia in Oldest Old Critically Ill Patients.

Refeeding syndrome is characterized by metabolic and electrolyte alterations that result from the initiation of feeding after a period of inadequate caloric intake. Especially, in the elderly with acute and/or chronic illness, nutritional deficiencies are common, and diminished oral intake with effects of catabolic status yields malnutrition. This study was conducted to evaluate refeeding hypophosphatemia and its consequences on outcomes in the oldest old critically ill patients. This study was designed as a retrospective cohort study that included patients who were 80 years old or older admitted to ICU. Patients were grouped depending on whether hypophosphatemia occurred after 48 hours of admission who started feeding. The median age of all patients was 87[82-90] years and 61(73%) of them were female. Refeeding hypophosphatemia was observed in 25(30%) patients. When patients were grouped depending on the occurrence of hypophosphatemia, groups were similar according to the severity scores, and comorbidities. Neither ICU mortality nor hospital mortality was different between groups (p=0.76 and p=0.19, respectively). Refeeding hypophosphatemia incidence was similar to previous studies, although study patients were the highest risk group. Outcome parameters including mortality rate and length of ICU stay were not different between patients with or without refeeding hypophosphatemia.

Refeeding Syndrome in a Woman with Colorectal Cancer: A Case Report

In digestive surgery, nutritional management of an undernourished patient is nowadays systematic and well codified, and must be part of the initial management measures. However, it is not always risk-free, as inadequately managed renutrition of a patient during a period of undernutrition, or during the post-operative period, can have deleterious clinic-biological manifestations, all too often ignored by practitioners, which we group together under the name of refeeding syndrome. Refeeding syndrome reflecting the transition from catabolic to anabolic metabolism usually occurs within five days of refeeding in patients who have undergone prolonged fasting or in a postoperative context including digestive cancer surgery. Patients may present with water-electrolyte disorders, in particular hypophosphatemia and/or hypokalemia and/or hypomagnesemia, thiamine deficiency, as well as neurological, pulmonary, cardiac, neuromuscular and hematological complications, which can lead to the patient's death. Here we present the case of a patient who underwent surgery in the General Surgery Department at Mohamed 6 University Hospital in Tangier for colorectal cancer. The patient subsequently developed an inappropriate refeeding syndrome accompanied by shock and altered consciousness in the postoperative period. Unfortunately, the patient passed away within a few hours following these complications. This is a cause of mortality that can occur without any surgical complications but remains underdiagnosed in daily practice. The management of this syndrome involves first of all the identification of patients at risk and the prevention of it by careful clinic-biological monitoring, including special hydro electrolyte monitoring, as well as the development of feeding reintroduction protocols tailored to each patient's needs.

A Systematic Review to Manage Avoidant/Restrictive Food Intake Disorders in Pediatric Gastroenterological Practice.

Avoidant/Restrictive food intake disorder (ARFID) is a feeding disorder characterized by persistent difficulty eating, such as limited choices of preferred foods, avoidance or restriction of certain foods or food groups, and negative emotions related to eating or meals. Although ARFID mainly affects children, it can also occur in adolescents and adults. ARFID can have serious physical and mental health consequences, including stunted growth, nutritional deficiencies, anxiety, and other psychiatric comorbidities. Despite its increasing importance, ARFID is relatively underrecognized and undertreated in clinical practice. Treatment consists of a multidisciplinary approach involving pediatric gastroenterologists, nutritionists, neuropsychiatrists, and psychologists. However, there are several gaps in the therapeutic approach for this condition, mainly due to the lack of interventional trials and the methodological variability of existing studies. Few studies have explored the nutritional management of ARFID, and no standardized guidelines exist to date. We performed a systematic literature review to describe the different nutritional interventions for children and adolescents diagnosed with ARFID and to assess their efficacy and tolerability. We identified seven retrospective cohort studies where patients with various eating and feeding disorders, including ARFID, underwent nutritional rehabilitation in hospital settings. In all studies, similar outcomes emerged in terms of efficacy and tolerability. According to our findings, the oral route should be the preferred way to start the refeeding protocol, and the enteral route should be generally considered a last resort for non-compliant patients or in cases of clinical instability. The initial caloric intake may be adapted to the initial nutritional status, but more aggressive refeeding regimens appear to be well tolerated and not associated with an increased risk of clinical refeeding syndrome (RS). In severely malnourished patients, however, phosphorus or magnesium supplementation may be considered to prevent the risk of electrolyte imbalance, or RS.

Feasibility trial for the management of severe acute malnutrition in older children with sickle cell anemia in Nigeria

AbstractChildren with sickle cell anemia (SCA) living in Nigeria are at an increased risk of malnutrition, which contributes to increased morbidity and mortality. However, evidence-based guidelines for managing malnutrition in children with SCA are lacking. To address this gap, we conducted a multicenter, randomized controlled feasibility trial to assess the feasibility and safety of treating children with SCA aged from 5 to 12 years and having uncomplicated severe acute malnutrition (body mass index z score of <−3.0). Children with SCA and uncomplicated severe acute malnutrition were randomly allocated to receive supplemental ready-to-use therapeutic food (RUTF) with or without moderate-dose hydroxyurea therapy (20 mg/kg per day). Over a 6-month enrollment period, 3190 children aged from 5 to 12 years with SCA were evaluated for eligibility, and 110 of 111 children who were eligible were enrolled. During the 12-week trial, no participants withdrew or missed visits. One participant died of unrelated causes. Adherence was high for hydroxyurea (94%, based on pill counts) and RUTF (100%, based on the number of empty sachets returned). No refeeding syndrome event or hydroxyurea-related myelosuppression occurred. At the end of the trial, the mean change in body mass index z score was 0.49 (standard deviation = 0.53), and 39% of participants improved their body mass index z score to ≥−3.0. Our findings demonstrate the feasibility, safety, and potential of outpatient treatment for uncomplicated severe acute malnutrition in children with SCA aged from 5 to 12 years in a low-resource setting. However, RUTF sharing with household and community members potentially confounded the response to malnutrition treatment. This trial was registered at clinicaltrials.gov as #NCT03634488

Use and safety of enteral nutrition protocols in acute care: A scoping review of literature and retrospective audit of practice.

Standardised enteral nutrition protocols are recommended in critical care, however their use and safety are not well described in other inpatient populations. This mixed methods study reports on the use and safety of enteral nutrition protocols for non-critically ill adults. A scoping review of published literature was conducted. In addition a retrospective audit of practice at an Australian tertiary teaching hospital with an existing hospital-wide standardised enteral nutrition protocol was performed. Data on use, safety and adequacy of enteral nutrition prescription were collected from medical records for patients receiving enteral nutrition on acute wards (January-March 2020). Screening of 9298 records yielded six primary research articles. Studies were generally low quality. Published literature suggested that protocols may reduce time to enteral nutrition initiation and goal rate, and improve adequacy of nutrition provision. No adverse outcomes were reported. From the local audit of practice (105 admissions, 98 patients), enteral nutrition commencement was timely (median 0 (IQR 0-1) days from request; goal rate: median 1 (IQR 0-2) days from commencement and adequate (nil underfeeding), without prior dietitian review in 82% of cases. Enteral nutrition was commenced per protocol in 61% of instances. No adverse events, including refeeding syndrome, were observed. Most inpatients requiring enteral nutrition can be safely and adequately managed on enteral nutrition protocols. Evaluation of protocols outside of the critical care setting remains a gap in the literature. Standardised enteral nutrition protocols may improve delivery of nutrition to patients, whilst allowing dietitians to focus on those with specialised nutrition support needs.

Refeeding syndrome in the elderly: is it an exclusively hospital problem?

Refeeding syndrome in the elderly: is it an exclusively hospital problem?