Refeeding Syndrome Policy

Refeeding Syndrome Policy

Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019 Page 1 of 33

It is your responsibility to check on the intranet that this printed copy is the latest version


Lead Author: Gavin Leahy, Pharmacy Operational Services Manager and

Kirstine Farrer, Consultant Dietitian Intestinal Failure

Additional author(s) On behalf of the Nutrition Steering Group

Division/ Department:: Pharmacy/Dietetics

Applies to: Salford Royal Care Organisation

Date approved: June 2019

Expiry date: June 2022

Contents

Contents

What is this policy about? ............................................................................................................ 3

Where will this document be used? ............................................................................................. 3

Why is this document important? ................................................................................................. 4

What is new in this version? ........................................................................................................ 4

Policy ........................................................................................................................................ 5

1. Definition of refeeding syndrome ................................................................................................ 5

2. Consent to Treatment ................................................................................................................. 5

3. Patients with Eating Disorders .................................................................................................... 5

4. Pathogenesis of starvation and the refeeding syndrome ............................................................. 7

5. Consequences of the refeeding syndrome .................................................................................. 7

6. Clinical Sequelae of Altered Electrolytes in Refeeding Syndrome ............................................... 9

7. Identification of patients at risk of refeeding syndrome .............................................................. 10

8. Initiation of oral or enteral tube feeding in patients at risk of developing refeeding syndrome.... 10

9. Initiation of parenteral nutrition in patients at risk of developing refeeding syndrome ................ 14

Roles and responsibilities ........................................................................................................ 155

Monitoring document effectiveness .......................................................................................... 166

Abbreviations and definitions ................................................................................................... 177

References and Supporting Documents .................................................................................. 188

Document Control Information ................................................................................................. 199

Equality Impact Assessment (EqIA) screening tool.................................................................... 20

Appendices .............................................................................................................................. 22

Group arrangements:

Salford Royal Care Organisation




Appendix 1 - Vitamin Supplementation ................................................................................... 22

Appendix 2 - Refeeding Syndrome Decision Tree .................................................................. 23

Appendix 3 - Electrolyte Replacement Therapy in Patients at Risk Of Refeeding Syndrome 244

Appendix 4 - Examples of Meal Plans................................................................................... 266




Document Summary Sheet

What is this policy about?

The NICE Guideline 32 (2006) - Nutrition Support in Adults1 highlighted the risks of refeeding

syndrome and produced guidance on the treatment of refeeding syndrome. Guidance has also

been produced by the Parenteral and Enteral Group of the British Dietetic Association on

refeeding syndrome.

The SRFT policy on Refeeding Syndrome is consistent with guidance from the above two

organisations.

While the SRFT policy follows the above two organisations' recommendation not to delay

feeding in order to correct mild electrolyte derangements, the SRFT policy also recommends

correction of severe degrees of electrolyte derangement prior to starting refeeding in addition to

during refeeding. Severely deranged electrolyte levels are defined as Phosphate <0.5mmol/L,

Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L.

The rationale for this is that:

the levels are so extreme as to constitute a hazard for any patient, regardless of whether

they are refeeding or not.

there is a high risk that the derangements would be aggravated further, even with the

cautious refeeding recommended in these and the above two organisations' guidelines.

Where will this document be used?

This policy applies to all clinical staff employed by Salford Royal Hospital NHS Foundation Trust. This policy applies to all adult patients admitted to Salford Royal Hospital and patients reviewed in outpatient clinics at Salford Royal Hospital.

Group arrangements:

Salford Royal Care Organisation




Why is this document important?

Due to homeostatic mechanisms it is not uncommon for serum levels of potassium,

magnesium and phosphate to be within normal parameters prior to feeding.

The aim of the policy is to:

Assist in the identification of patients at risk of refeeding syndrome.

Provide evidence-based guidance for the management of patients at risk of refeeding

syndrome.

What is new in this version?

Updated to the new NCA template

Removal of low levels of potassium, magnesium or phosphate prior to feeding as criteria

for identification of patients at extremely high risk of refeeding syndrome (as is already

criteria for identification of patients at high risk of refeeding syndrome).

Potassium requirements reduced to 1-2mmol/kg/day from 2-4mmol/kg/day

Clarification that feeding should not be started for patients with severely deranged

electrolytes until appropriate correction has taken place.

Addition of reference to the Salford Royal Care Organisation Intravenous fluid guideline

for resuscitation and maintenance for patients requiring additional intravenous fluids.

Addition of reference to Salford Royal Care Organisation Parenteral Nutrition (PN)

Referral and Administration policy.

Addition of reference to Salford Royal Care Organisation QRGs for hypokalaemia,

hypomagnesaemia, hypocalcaemia and hypophosphataemia.




Policy

1. Definition of Refeeding Syndrome

The refeeding syndrome occurs as a result of severe fluid and electrolyte shifts (phosphate,

potassium, magnesium), vitamin deficiency and related metabolic implications including sodium

retention in malnourished patients undergoing refeeding orally, enterally, or parenterally2,3. The

limitation of the term “refeeding syndrome” only to patients receiving parenteral nutrition is not

justified, since these changes in metabolism have also been found in orally fed patients after

long-term starvation.

2. Consent to Treatment

All patients with a poor nutritional status should be actively involved in decision making

regarding their feeding plan and the management of potential refeeding risk. The Royal College

of Physicians (2010) state: “Those with intact cognitive function who are unable to eat or drink

must be involved in decision making as their perception of the process resulting from absence

of food will be different from those with absent cognitive function”4.

If there is a doubt about the patient’s mental capacity to consent to refeeding, the person

providing the treatment should undertake a formal assessment of capacity in line with the

Mental Capacity Act 20054. If the patient is found to lack capacity to make the decision for

themselves treatment may proceed in their best interests.

3. Patients with Eating Disorders

Patients with eating disorders are at significant risk of refeeding syndrome and may be being

admitted for ‘safe refeeding’ (although this may not be the only reason for an admission).

Some patients with an eating disorder may lack capacity to make a decision around treatment

because of an inability to understand or retain relevant information, or an inability to

communicate their decision. Moreover, the nature of eating disorders may increase the

likelihood that patients are unable to ‘use or weigh up’ relevant information. Whilst the patient

may understand information about the consequences of not eating, their compulsion not to eat




might be too strong for them to ignore and they would then not have the capacity to decide

whether or not to accept treatment. If the case is complex and there is uncertainty about the

patient’s capacity, then the patient should be referred to a psychiatrist5.

If a patient with an eating disorder is found to lack capacity then treatment may proceed in their

best interests. However, if a patient who lacks capacity indicates that they object to receiving

the treatment then the only way forward is to consider detention under the Mental Health Act

1983, which allows for compulsory treatment of patients with eating disorders (including in-

patient admission for re-feeding). An objection might be expressed verbally or be apparent from

the patient’s behaviour. Because an eating disorder is considered a mental disorder in terms of

the Mental Health Act 1983, patients with capacity who refuse treatment for their eating disorder

can be detained under the Mental Health Act and treated against their will as a life saving

measure, although this should rarely be required (MARSIPAN guidelines, 2014)5.




4. Pathogenesis of Starvation and the Refeeding Syndrome6

Starvation / Malnutrition ↓

Gluconeogenesis Protein catabolism, e.g. muscles

Negative protein balance ↓

Weight loss ↓

Water, vitamin and mineral depletion (N.B. serum concentrations of electrolytes may be normal because stores and hence depletion may be largely intracellular)

↓ Refeeding (oral, enteral or parenteral route)

↓ Conversion to glucose as major energy source

↓ Release of Insulin

↓ ↑ cellular glucose uptake

↑ protein synthesis (anabolic) ↓

Intracellular shifts and extracellular depletion of phosphate, potassium and magnesium

↓ ↑utilisation of thiamine that may already be low, may result in deficiency

↓ Clinical features of Refeeding Syndrome

5. Consequences of the Refeeding Syndrome2

Cardiac failure, pulmonary oedema and dysrhythmias

Acute circulatory fluid overload or circulatory fluid depletion

Hypophosphataemia

Hypokalaemia

Hypomagnesaemia and occasionally hypocalcaemia

Hyperglycaemia

Refeeding syndrome can occur in patients receiving oral, enteral or parenteral nutrition. It is less

likely to occur in those fed orally (although it is possible) since starvation is usually accompanied

by a reduction in appetite.




There have been reported cases of re-feeding syndrome occurring in patients with chronic

vomiting (hyperemesis gravidarum), prolonged diarrhoea, gastrointestinal obstruction,

malabsorption diseases, and poorly controlled diabetes.

Refeeding problems can also occur in overweight patients who have eaten nothing for

prolonged periods. Particular caution needed in bariatric surgical patients who have developed

complications resulting in a significant period of starvation or vomiting.

Beware of very malnourished, dehydrated patients with renal impairment and consequently

normal or high potassium and phosphate levels. The combined effect of rehydration and

refeeding can cause significant changes in biochemistry within hours to very low levels.




6. Clinical Sequelae of Altered Electrolytes in Refeeding Syndrome6

Electrolytes Cardiac Respiratory Hepatic Renal GI Neuromuscular Haematological

Low Phosphate

Altered myocardial function. Arrhythmia Congestive heart failure

Acute ventilatory failure

Liver dysfunction

- - Lethargy, weakness, seizures, confusion, coma, paralysis, rhabdomyolysis

Haemolytic anaemia, WBC dysfunction, thrombocytopenia, haemorrhage

Low Potassium

Arrhythmia, cardiac arrest

Respiratory depression

Exacerbation of hepatic encephalopathy

Decreased urinary concentrating ability. Polyuria and polydipsia. Decreased GFR

Constipation, Ileus

Paralysis Rhabdomyolysis Weakness

-

Low Magnesium

Arrhythmia, tachycardia

- - Potassium loss

Abdominal pain, anorexia, diarrhoea, constipation

Fits, ataxia, confusion, muscle tremors, weakness, tetany

-

Low magnesium also leads to decreased PTH secretion and effect, which leads to hypocalcaemia.




7. Identification of Patients at Risk of Refeeding Syndrome1

7.1. Patients will be considered to be at high risk of refeeding syndrome if they have one or

more of the following:

Body Mass Index less than 16kg/m2

Unintentional weight loss of greater than 15% within the last 3-6 months

Little or no nutritional intake for more than 10 days

Low levels of potassium, magnesium or phosphate prior to feeding

Or two or more of the following:

Body Mass Index of less than 18.5kg/m2

Unintentional weight loss greater than 10% within the last 3-6 months


History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics(4)

7.2. Patients will be considered to be at extremely high risk of refeeding syndrome if they have one or more of the following:

BMI less than 14kg/m2


8. Initiation of Oral or Enteral Tube Feeding in Patients at Risk of Developing Refeeding Syndrome

In patients who are at risk of refeeding syndrome, oral feeding and enteral tube feeds should be

introduced slowly and the amount of food or the volume of feed should be increased gradually

over several days until nutritional requirements are met. In most cases, a tailored regimen will

be written by the ward Dietitian.

If a Dietitian is unavailable, an emergency tube feeding regimen can be used - these are found

in the appendix of the nasogastric feeding policy, nasojejunal feeding policy, gastrostomy tube

feeding policy and jejunal feeding policy.




8.1. ‘ High risk’ patients

Urgent biochemistry bloods to be checked. Request the TPN blood profile on the

electronic patient record (EPR).

Where possible the hospital guidance of the management of refeeding needs to be

followed in the community (patient’s own homes or nursing/ residential homes). However

it is accepted that on occasions the acute protocol and management of refeeding

syndrome may not be clinically appropriate in this setting. A request to the GP/lead

clinician must include magnesium, potassium, calcium and phosphate at the time

nutritional support is commenced. Any abnormal levels should be corrected and bloods

repeated as indicated by the GP/lead clinician. Any severely deranged levels defined as

Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium

<3.0mmol/L should result in the patient being admitted for correction of electrolytes. If

bloods are within the normal range, the patient should have daily bloods for 3

consecutive days and repeated as indicated by the GP/lead clinician.

Refer to the nutrition and dietetic department. Commence oral diet or nutrition support at

a maximum of 10kcal/kg/day, increasing levels slowly to meet full needs by 4-7 days.

Any increase in feed should be dependent on trends in biochemistry.

This level will be safe unless severely deficient with pre-existing low plasma electrolytes.

Patients who have severely deranged biochemistry (defined as Phosphate <0.5mmol/L,

Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should not

start feeding until they have received the appropriate electrolyte replacement (see

Appendix 2 and 3).

When feeding patients you must provide oral, enteral or intravenous supplements (as

appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding

plasma levels are high (e.g. renal impairment). The following recommendations have

been adapted from NICE Guidelines: Nutrition support in adults1 and the Salford Royal

Care Organisation Intravenous fluid guideline for resuscitation and maintenance7:

Potassium: 1-2mmol/kg/day orally, enterally or intravenously

Phosphate: 0.3-0.6mmol/kg/day orally, enterally or intravenously

Magnesium: 0.4mmol/kg/day orally or 0.2mmol/kg/day intravenously.




Provide multivitamins and trace element supplementation immediately before and during

the initial period of feeding. See appendix 1

8.2. ‘Extremely high’ risk patients

Where possible the hospital guidance of the management of refeeding needs to be

followed in the community (patient’s own homes or nursing/ residential homes). However

it is accepted that on occasions the acute protocol and management of refeeding

syndrome may not be clinically appropriate in this setting. A request to the GP/lead

clinician must include magnesium, potassium, calcium and phosphate at the time

nutritional support is commenced. Any abnormal levels should be corrected and repeated

as indicated by lead clinician / GP. Any severely deranged levels defined as Phosphate

<0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L

should result in the patient being admitted for correction of electrolytes. If bloods are

within the normal range, the patient should have daily bloods for 3 consecutive days and

repeated as indicated by the GP/lead clinician.

For hospital inpatients urgent biochemistry bloods need to be checked. Request the TPN

blood profile on the EPR.

Refer to the nutrition and dietetic department. Start oral or nutrition support at a

maximum of 5kcal/kg/day increasing levels slowly to meet full needs by 4-7 days. Any

increase in feeding should be dependent on trends in biochemistry. Monitor glucose

levels (BM’s) several times per day.

This level will be safe unless severely deficient with pre-existing low plasma electrolytes.



start feeding until they have received the appropriate electrolyte replacement (see

Appendix 2 and 3).

When feeding patients, you must provide oral, enteral or intravenous supplements (as

appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding

plasma levels are high (e.g. renal impairment). The following recommendations have




been adapted from NICE Guidelines: Nutrition support in adults1 and the Salford Royal

Care Organisation Intravenous fluid guideline for resuscitation and maintenance7:

Potassium: 1-2mmol/kg/day orally, enterally or intravenously

Phosphate: 0.3-0.6mmol/kg/day orally, enterally or intravenously

Magnesium: 0.4mmol/kg/day orally or 0.2mmol/kg/day intravenously.



Where ECG monitoring is available, monitoring of cardiac rhythm in this group who have

or may develop cardiac arrhythmias is recommended1. If the patient has significant

comorbidity e.g. infection, cardiac failure, abnormal ECG consider escalating to MHDU

bed.

Patients requiring additional fluids

Circulatory volumes should be replaced but care should be taken not to overload patients. Refer

to the Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and

maintenance7. However, consideration must be given to the fact that, on commencement of

feeding, renal sodium losses stop, leading to both sodium and water retention. Therefore, aim

for fluid replacement of 20-30ml/kg/day and restrict sodium to <1mmol/kg/day. Consideration

should be given to sodium and carbohydrate content of the fluid used e.g. 1L 5% dextrose

contains 200Kcal.




9. Initiation of Parenteral Nutrition

In patients required to start parenteral feeding (regardless of whether they are identified as

being at risk of refeeding syndrome or not) the following steps must be followed:

Referral to the Trust Nutrition hospital Team via EPR or, if outside normal working hours,

the on-call pharmacist via switchboard. Refer to the Parenteral Nutrition (PN) Referral

and Administration policy8.

Urgent biochemistry bloods to be checked. Request the TPN blood profile on the EPR





start feeding until they have received the appropriate electrolyte replacement. See

appendix 2 and 3.

Parenteral nutrition should not be commenced outside normal working hours and a

referral should be made to the Nutrition Support Team for the patient to be reviewed on

the next working day. Commencing parenteral nutrition using a standard bag without

additional electrolytes may put a patient at risk of refeeding syndrome and result in

greater risk of complications.

It is very rare that a patient needs to start parenteral nutrition outside normal working

hours8. Following authorisation from the on-call pharmacist, patients will be started on

1.2L out of 2.4L of the parenteral nutrition stock bag which contains 750kcals and 5gN.

The patient must be urgently referred to the Trust Nutrition Support Team on the next

working day via EPR.

To correct electrolytes patients may require additional intravenous fluids with

supplemented electrolytes. See appendix 2 and 3.

Patients at high risk or extremely high risk of refeeding syndrome should have their

biochemistry (TPN profile) checked daily until they are stable, when the frequency of

biochemical monitoring can be reduced. This would include frequent and close

monitoring of potassium, calcium, magnesium and phosphate.




Roles and Responsibilities

All clinical staff have responsibility for ensuring that the principles outlined within this document are universally applied. Director of nursing Executive responsibility for nutrition in the organisation. The Trust Medicines Management Group The Trust Medicines Management Group is responsible for approving the pharmaceutical aspects of the Refeeding Policy. Nutrition Steering Group

Development of operational policy. Sub-groups of the Nutrition Steering Group are established

when necessary to examine and address specific issues relating to nutrition. Reporting on

compliance against this guideline is via the Nutrition Steering Group.

Prescribers

Recognise and manage patients at risk of refeeding syndrome, including monitoring blood

biochemistry and prescribing replacement electrolytes. Referral to the Dietitian must be made to

support ongoing nutritional care.

Nursing staff

Through the nutritional screening process highlight to the consulting team patients at risk of

refeeding syndrome, follow prescribed feeding and electrolyte replacement regimens,

highlighting any problems on a day to day level.

Dietitians

Educate and train staff on refeeding syndrome, highlight patients at risk of refeeding syndrome,

support consulting team through provision of expert advice, feeding regimens and monitoring

nutritional status. Dietitians are able to recommend initiation of vitamin supplementation and

advise on doses, providing that the advice is consistent with the Trust refeeding policy.

Dietitians will not advise on the correction of electrolytes intravenously.

Pharmacists




Provision and advice on electrolyte and micronutrient prescriptions.

Biochemists

Advise on interpretation of test results and appropriate further investigations.

Other Allied Health Professionals

Highlight any patients at risk of refeeding syndrome to appropriate team members.

Training

Training / awareness sessions for medical staff and secondary care pharmacy teams will be led

by the hospital nutrition team, and dietetics. This will be implemented through a rolling education

programme in collaboration with learning and development and postgraduate department.

Implementation and Monitoring

The guideline will be cascaded to relevant medical staff through the Nutrition steering and

locality nutrition groups. Monitoring of this guideline will be through clinical audit

Monitoring document effectiveness

The following standards will form the basis of the annual audit of the Trust Refeeding Policy

carried out by the Trust Nutrition Steering Group:

All patients will be nutritionally screened using the ‘MUST’ within 6 hours of admission

and if identified at risk of malnutrition considered for nutrition support.

Patients identified as at risk of malnutrition should be assessed for risk of refeeding

syndrome.

All patients identified as at risk of refeeding syndrome will have the appropriate

monitoring and treatment, which will be documented on the EPR.

Monitoring and Review




The Refeeding syndrome policy will be audited on an annual basis by the Nutrition Steering

Group and the results reported to the Clinical Effectiveness Committee

Policy Implementation Plan

Kirstine Farrer, Consultant Dietitian, as Chair of the Nutrition Steering Group, will be responsible

for implementing this policy and the Nutrition Steering Group will keep the detailed

implementation plan and review progress.

The policy will be implemented via communication with senior nurse managers, matrons and

practice educators in the organisation.

Practice educators will ensure competence in this area.

Results of the implementation plan and review process will be reported to the Clinical

Effectiveness Committee on an annual basis.

For Pharmacy Staff, the Refeeding Policy will be incorporated into the Local Pharmacy

Induction Programme by the Principal Clinical Pharmacist.

Abbreviations and definitions

Any acronyms or technical terms that require explanation or definition should be listed here if

they have not been described elsewhere within the document.

PTH: Parathyroid Hormone

PN: Parenteral Nutrition

TPN: Total Parenteral Nutrition

MUST: Malnutrition Universal Screening Tool

EPR: Electronic Patient Record




References and Supporting Documents

1. NICE Guidelines: Nutrition support in adults, Clinical Guideline 32, February 2006

2. Crook MA, Hally V, Panteli JV. The importance of the Refeeding Syndrome. Nutrition

2001 17:632-637

3. Solomon SM and Kirby DF. The refeeding syndrome: A review. JPEN. 1990: 14:90-97.

4. Royal College of Physicians and British Society of Gastroenterology. (2010) Oral feeding

difficulties and dilemmas: A guide to practical care, particularly towards the end of life.

London: Royal College of Physicians.

5. The Royal Colleges of Psychiatrists, Physicians and Pathologists (2014) MARSIPAN:

Management of Really Sick Patients with Anorexia Nervosa, 2nd Edition

6. Dewar H, Horvath R. Refeeding Syndrome Guidelines. Oxford: Department of Nutrition

and Dietetics, Oxford Radcliffe Hospital, 2000.

7. Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and

maintenance (2018)

8. Salford Royal Care Organisation Parenteral Nutrition (PN) Referral and Administration

Policy (2019)




Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of the document prior to submission for upload.

Nominated Lead author:

Gavin Leahy Pharmacy Operational Services Manager

Lead author contact details:

0161 206 4308

[email protected]

Lead Author’s Manager:

Lindsay Harper Director of Pharmacy

Applies to:

Salford CO

Document developed in consultation with:

Nutrition Steering Group, Nutrition and Dietetic Department, Pharmacy Department, Intestinal Failure Clinical Director, Medicines Management Group.

Keywords/ phrases:

Refeeding, Nutrition, Parenteral, Enteral, Pabrinex

Communication plan:

To be cascaded through nursing, clinicians, dietetic and pharmacy communication channels

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: Add name of Committee and Chairpersons name and role: Nutrition Steering Group – Kirstine Farrer, Consultant Dietician Medicines Management Group – Dr Richard Cooper, Consultant Anaesthetist Clinical Effectiveness Committee – Dr Pete Turkington, Medical Director

June 2019

How approved: Chair’s actions Formal Committee decision X




Equality Impact Assessment (EqIA) screening tool

Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

Yes Consulting with medical, dietetic, biochemistry, pharmacy and nursing colleagues.

1b) Have any amendments been made as a result? If yes, specify what.

Yes Definition of severe electrolyte deficiency

2) Does this policy have the potential to affect any of the groups listed below differently? This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?) X

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?) X

Race (e.g. any specific needs identified for certain groups such as dress,

diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.) X

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?) X

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?) X

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?) X

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?) X

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?) X

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?) X

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

X




Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

X

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? (what action has been taken or will be taken, who is responsible for taking a future action, and when it will

be completed by – may include adjustment to wording of policy or leaflet to mitigate)

N/A 4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? (what action has been taken or will be taken, who is responsible for taking a future action, and when it will be completed by – may include adjustment to wording of policy or leaflet)

N/A

Will this policy require a full impact assessment? No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected])

Author: Type/sign: Gavin Leahy Date: 04.07.2019

Sign off from Equality Champion: Date: 04.07.2019

mailto:[email protected]




Appendices

Appendix 1 - Vitamin Supplementation

Patients with refeeding syndrome can suffer severe neurological and cardiac problems from thiamine (vitamin B1) deficiency. Before feeding is started a dose of appropriate vitamins should be given and continued as indicated below. For patients fed via the oral route/enteral tube feeding route

Thiamine tablets – 50mg four times a day for 10 days

and

Vitamin B Compound Strong tablets - 2 tablets three times a day for 10 days

For patients fed via an enteral feeding tube, Thiamine and Vitamin B Compound Strong tablets may be crushed and dispersed in water before administration down the tube. However, for patients with a fine bore feeding tube, a decision should be made on an individual patient basis on whether to administer medication via this route (due to the risk of blocking the tube).

Forceval (or Forceval soluble) 1 tablet daily should be given from initiation of the

refeeding regimen for 10 days.

For patients on Parenteral Nutrition (or for those who an oral/enteral tube feeding route is inappropriate):

Pabrinex, 1 pair of vials, IV once daily for 3 days

Note – Forceval is not needed for patients on parenteral nutrition.




Appendix 2 – Refeeding Syndrome Decision Tree

Yes No

Establish the likelihood of refeeding syndrome risk: High risk – see section 7.1 Extremely high risk – see section 7.2

Seek assistance from hospital nutrition team, pharmacists or dietitians.

Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1

Establish the route the patient or resident will be fed – Oral, tube feeding or Parenteral Nutrition

Refer to suggested meal plans in Appendix 4 of the policy or starter regimens in nasogastric, gastrostomy or jejunostomy policies. Patients at high risk should commence nutrition at a maximum of 10kcal/kg/day increasing to meet needs by 7 days. Extremely high risk patients are those with BMI<14kg/m² or prolonged poor intake of >15 days and should commence at a maximum of 5kcal/kg/day. The more rapidly calories are delivered and the rate increased, the greater the demand on circulating electrolytes; thus there will be an increased risk of re-feeding syndrome.

Commence parenteral nutrition via appropriate venous access. Refer to the Parenteral Nutrition (PN) Referral and Administration policy Repeat nutrition profile of bloods daily.

Measure electrolytes. Do not start feeding if severely deranged electrolytes (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L). When starting feeding, replace potassium, phosphate and magnesium. Only withhold supplementation if levels are high. Monitor glucose (BMs) several times per day, and observe potassium, calcium, magnesium, phosphate and sodium closely. Keep fluid input low, but enough to maintain renal function. Restrict sodium replacement.

Is patient to be fed orally/enterally?




Appendix 3 - Electrolyte Replacement Therapy in Patients at Risk Of Refeeding Syndrome

WHY MAKE THESE RECOMMENDATIONS? Why do we measure electrolytes? Potassium, magnesium and phosphate are mainly intracellular ions and are affected by shifts across compartments, renal excretion and changes in acid-base status of the patient. Serum electrolyte concentrations are a poor reflection of total body stores, particularly in nutritionally depleted patients. When one electrolyte level is low there is an increased chance of other electrolyte abnormalities (Whang et al. 1984). Each electrolyte has essential roles and specific consequences in nutritional replacement. Sodium is the principal extracellular cation and maintains extracellular fluid balance. It is functional in acid-base balance and maintaining osmotic pressure. Sodium, calcium and potassium help maintain the electrical potential of membranes involved in neuromuscular transmission. Measurement of sodium is used to evaluate fluid-electrolyte balance, acid-base balance, and in the investigation of renal, adrenal and neuromuscular diseases. Water deficit can cause hypernatraemia and water overload can result in hyponatraemia. Potassium is the principal intracellular cation and primary intracellular buffer. It maintains the neuromuscular electrical potential and is important in acid-base balance (with hydrogen ions) and osmotic pressure (with sodium). Potassium is essential for the function of the Na-K-ATPase which uptakes solutes into the cell, including glucose. Abnormalities of potassium concentration affect cardiac excitability and hypo- or hyperkalaemia can lead to arrhythmias. Magnesium is primarily an intracellular electrolyte critical in metabolic processes. It is a cofactor for many enzymes including ATP-dependent cation transport (calcium and sodium). It interacts with calcium to affect the neuromuscular excitability and membrane potentials. Hypomagnesaemia is associated with other electrolyte deficiencies, particularly hypokalaemia and hypophosphataemia (Whang et al 1984). Phosphorus is present in the body mainly as phosphates or esters. It is an essential component of DNA, RNA and vitamins and is crucial in glycolysis and oxidative phosphorylation. Phosphate concentration is controlled by calcium concentration, parathyroid hormone, vitamin D and renal function. Nutritionally depleted patients have a higher phosphate requirement and are at risk of clinically significant hypophosphataemia (Marshall et al 1987). Calcium is the most abundant mineral in the body and 99% is within the skeleton. Serum calcium can be bound to proteins, complexes with other ions or remain as free ions. The functions of calcium include the structural role in bones, regulation of membrane potentials, and as a co-factor for coagulation. Hypercalcaemia is recognised in patients receiving parenteral nutrition. The most likely causes are metabolic bone disease and abnormal vitamin D metabolism, although other causes should be considered (Marshall et al 1987). Hyperammonemia can be prevented by increasing energy supply slowly during re-feeding. During prolonged starvation a reduction in protein degradation in muscle and other tissues is the consequence of adaptive metabolic mechanisms. The activity of enzymes of amino-acid metabolism is reduced, which can lead to an increased plasma concentration of amino acids




during refeeding. The concentration of amino acids in blood can exceed the capacity of the urea cycle and thus, hyperammonemia may occur. The death of patients with severe malnutrition refed with a protein-rich diet has been attributed to this metabolic derangement. Refer to the following Quick Reference Guides (QRGs) before prescribing electrolyte replacement:

1. Hypocalcaemia QRG

2. Hypokalaemia QRG

3. Hypomagnesaemia QRG

4. Hypophosphataemia QRG In the case of complex patients with multiple deranged electrolytes, contact your ward

pharmacist or, if out of hours, the on call pharmacist via switchboard




Appendix 4 - Examples of Meal Plans

Examples of Meal Plans for Patients at high risk of refeeding syndrome

Sample Meal Plan. Suitable for patients more than 35kg

This is a guide only for short term use. Please inform the Dietitian on the next working day and

an individual meal plan can be developed

Day 1 Provide half portions of all meals from menu Include 1 starter, 1 main and 1 dessert

course

Day 2 Provide full meals from menu Include 1 starter, 1 main and 1 dessert course

Day 3 onwards Provide full meals from menu Include 1 starter, 1 main and 1 dessert course

Consider nourishing fluids & snacks if additional calories required for weight gain

Oral diet regimen: Quick reference flow chart for patients at ‘High risk’ of refeeding

syndrome

High Risk

Patient has one or more of the following:

BMI <16kg/m²

Unintentional weight loss > 15% within the previous 3-6 months

Very little or no nutritional intake for > 10 days

Low levels of potassium, phosphate or magnesium prior to feeding

Or patient has two or more of the following:

BMI < 18.5kg/m²

Unintentional weight loss > 10% within the previous 3-6 months

Those with very little or no intake for > 5 days

A history of alcohol or drug abuse including insulin, antacids or diuretics and patients on

chemotherapy.

Initial Management

1. Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding.

2. Provide multivitamins and trace element supplementation immediately before and during the

initial period of feeding. See appendix 1

3. Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate

and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal

impairment). Patients who have severely deranged biochemistry (defined as Phosphate

<0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should




not start feeding until they have received the appropriate electrolyte replacement. See

appendix 2 and 3.

4. Introduce feeding at a maximum of 10kcal/kg/day, increasing slowly to meet full

requirements by 4-7 days. (e.g. for a 50 kg patient – 10 x 50 = 500kcal/day).




Sample meal plan - Based on 35kg Weight. Classified as ‘at high risk’ of refeeding syndrome.

This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual meal plan can be

developed

Day 1 – (approx) 300Kcals Day 2 – (approx) 600Kcals Day 3 – (approx) 850 Kcals

BREAKFAST:

3 tbsp cereal or 1 weetabix with 100ml semi-

skimmed milk

OR ½ slice bread or toast with margarine and

1 pot diet yoghurt

OR 100Kcals via Ensure Plus or Ensure

Compact

BREAKFAST:


skimmed milk & 100mls fruit juice

OR 1 slice bread or toast with margarine and

100ml milk

OR 1 creamy yogurt and 100ml fruit juice

OR 200Kcals Ensure Plus or Ensure

Compact

BREAKFAST:

3 tbsp cereal with 100ml semi-skimmed milk,

100ml fruit juice & ½ slice bread / toast with

margarine

OR 2 Weetabix with 100mls semi-skimmed

milk & 100ml fruit juice

OR 250Kcals from Ensure Plus or Ensure

Compact

LUNCH:

1oz portion of meat / fish / poultry e.g. 1 small

slice ham / beef or ½ oz cheese OR 2

Tablespoons of vegetarian dish

Above served with either 1scoop mashed

potato / ½ small jacket potato / 2 egg size

boiled potatoes served with 1 tbsp of

vegetables or salad

LUNCH:


slice ham / beef or 1oz cheese OR 3

Tablespoons of vegetarian dish

Above served with either 2 scoops mashed

potato / small jacket potato/ 4 egg size boiled

potato served with 2 tbsp of vegetables or

salad

LUNCH:

3oz portion of meat / fish / poultry e.g. 1 slice

ham / beef or 1oz cheese Or 4 Tablespoons

of vegetarian dish


potato / 1 small jacket potato / 4 egg size

boiled potato served with 2 tbsp of vegetables

or salad




OR 100Kcals via Ensure Plus or Ensure

Compact


Compact

and 1 Portion fruit e.g. Banana or fruit salad


Compact

EVENING MEAL

Sandwich – 1 slice of bread with meat / fish /

cheese / egg filling

OR ½ small jacket potato with ½ oz cheese or

2 tbsp beans or 1oz tuna with mayonnaise /

salad cream or 1 tbsp ‘hot filling’ when

available e.g. Curry


Compact

EVENING MEAL


cheese / egg filling and 1 portion fruit

OR 1 slice toast with 1oz cheese or 2 tbsp

baked beans or 1 egg scrambled and 1

portion fruit of fruit salad

OR Small Jacket Potato with 1oz cheese or 2-

3 tbsp beans or 2oz tuna or 2 tbsp ‘hot filling’

when available e.g. Curry


Compact

EVENING MEAL

1 Sandwich – 2 slices of bread with meat / fish

/ cheese / egg filling and 1 portion fruit or

small pot fruit salad

OR 2 slices toast with 1 oz cheese or 3 tbsp

baked beans or 1 egg scrambled And 1

portion fruit

OR ½ medium jacket potato with 1 oz cheese

or 2-3 tbsp beans or small pot tuna or 2 tbsp

‘hot filling’ when available eg. Curry and 1

portion fruit

OR 300Kcal from Ensure Plus or Ensure

Compact




ADULT PATIENT IDENTIFIED AS EXTREMELY HIGH RISK OF REFEEDING SYNDROME

Oral diet regimen: Quick reference guide

Severely Extremely High risk (Extreme cases)

Patient has one or more of the following: BMI < 14kg/m²

Negligible intake for > 15 days

Initial management

1. Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding.

2. Provide multivitamins and trace element supplementation immediately before and during


3. Provide oral, enteral or intravenous supplements (as appropriate) of potassium,

phosphate, calcium and magnesium from the outset unless pre-feeding plasma levels

are high (e.g. renal impairment)). Patients who have severely deranged biochemistry

(defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and

Potassium <3.0mmol/L) should not start feeding until they have received the appropriate

electrolyte replacement. See appendix 2 and 3.

4. Introduce feeding at a maximum of 5kcal/kg/day, increasing slowly to meet full requirements by 4-7 days. (e.g. for a 50kg patient – 5 x 50 = 250kcal/day




SAMPLE MEAL PLAN - Based on 30 Kg: This is a guide only for short term use. Please inform the Dietitian on the next working day

and an individual meal plan can be developed. This is for patients at extremely high risk of refeeding syndrome

Day 1 – (approx) 200Kcals Day 2 – (approx) 350Kcals Day 3 – (approx) 500Kcals

BREAKFAST:

2 tablespoon cereal with 30mls semi-skimmed

milk

OR ½ weetabix with 30mls semi-skimmed

milk

OR ½ Slice bread/toast with spread


Compact

BREAKFAST:


skimmed milk

OR ½ slice bread or toast with margarine and

1 pot diet yoghurt / 100mls semi-skimmed

milk


Compact

BREAKFAST:


skimmed milk

OR ½ slice bread / toast with margarine and 1

pot diet yoghurt / 100ml semi-skimmed milk


Compact

LUNCH:

1 tablespoon of main meat / chicken / fish

course

OR 1 tablespoon vegetarian option (must

contain cheese or egg

Above served with either ½ scoop mashed

LUNCH:


slice ham / beef or ½ oz cheese

OR 2 Tablespoons of vegetarian dish

Above served with either 1scoop mashed

potato / ½ small jacket potato / 2 egg size

boiled potatoes served with 1 tbsp of

LUNCH:


slice ham / beef or 1oz cheese

OR 3 Tablespoons of vegetarian dish


potato / small jacket potato/ 4 egg size boiled

potato served with 2 tbsp of vegetables or




potatoes / 1 boiled potato

Served with 1 tablespoon vegetables


Compact

vegetables or salad


Compact

salad


Compact

Evening meal:

1 tablespoon of main meat / chicken / fish

course

OR 1 tablespoon vegetarian option (must

contain cheese or egg)

Above served with either 1 scoop mashed

potato / 2 boiled potatoes

Served with 1 tablespoon vegetables


Compact

EVENING MEAL:


cheese / egg filling

OR ½ small jacket potato with ½ oz cheese or

2 tbsp beans or 1oz tuna with mayonnaise /

salad cream or 1 tbsp ‘hot filling’ when

available e.g. Curry


Compact

EVENING MEAL:


cheese / egg filling and 1 portion fruit

OR 1 slice toast with 1oz cheese or 2 tbsp

baked beans or 1 egg scrambled and 1

portion fruit of fruit salad

OR Small Jacket Potato with 1oz cheese or 2-

3 tbsp beans or 2oz tuna or 2 tbsp ‘hot filling’

when available e.g. Curry


Compact


