Refeeding Syndrome - IrspenRefeeding Syndrome – inadequate awareness and confidence Knowledge of the refeeding syndrome poor among paediatric middle-grade doctors.Hudson et al 20%

Refeeding Syndrome

Dr Karen Boland MRCPI

Midlands Regional Hospital, Tullamore

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

Implementation of guidelines improved

patient identification and management

45.5% of those at high risk managed

appropriately (32% in the initial audit)

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