A patient who hasn’t eaten in two weeks. Spoke with a nutritionist and recommends.
-Start with CLD and small portions for 1-2 days. Get CMP with Mg and Phosphorus every 12 hours
-Next start patient on GI soft liquids.
“The refeeding syndrome is defined as the clinical complications that can occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients.”
-Hypophosphatemia is the hallmark biochemical feature of refeeding syndrome and predominant cause of the syndrome. “However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalemia; and hypomagnesemia.”
Features of refeeding syndrome are:
- Hypophosphatemia
- Hypokalemia
- Vitamin (eg, thiamine) deficiencies
- Congestive heart failure
- Peripheral edema
- Rhabdomyolysis
- Seizures
- Hemolysis
The refeeding syndrome is marked by hypophosphatemia and volume overload. As such, go slow with both food and fluids and replace phosphorus. [Check the idea of going slow on fluids when these patients who haven’t eaten or drank in weeks would be expected to be dehydrated]
“Diarrhea may occur during the early stages of refeeding, due to atrophy of the intestinal mucosa and pancreatic impairment. The diarrhea generally resolves within the first few weeks of refeeding as the villous surface is reconstituted.” UTD
Refeeding syndrome can be life-threatening if not treated promptly. Making the diagnosis, calling it what it is, helps to make sure that the patient is given adequate care.
Although refeeding syndrome is more common with parenteral nutrition, it occurs with enteral and oral nutrition as well.
“Baseline blood tests should include CBC, glucose, urea electrolytes, magnesium, phosphate, calcium, albumin, liver function, iron, vitamin B12, vitamin D, zinc, copper, folate, and an INR.” AFP 2011
“In patients receiving established long-term nutrition support, occasional tests should include iron, ferritin, zinc, copper, folate, vitamin B12, and vitamin D1”
“Refeeding syndrome is a complication that may occur during aggressive administration of specialized nutrition support in patients who are malnourished. Although it is more common with parenteral nutrition, refeeding syndrome occurs with enteral and oral nutrition as well, and can be life-threatening if not treated promptly. It is caused by rapid reintroduction of large amounts of carbohydrate, which shifts metabolism from catabolic to anabolic resulting in insulin release; cellular uptake of potassium, phosphate, and magnesium; and water retention. Severe hypophosphatemia, hypokalemia, hypomagnesemia, and edema occur, and monitoring and correcting these electrolyte abnormalities are essential. In patients at risk of refeeding syndrome, nutrition support should start at one-third or one-fourth of nutritional needs and gradually increased over five to seven days. Thiamine is often deficient in these patients and should be provided intravenously at 100 mg per day in the first week” AFP 2011
Read these links
Life in the fast lane – Refeeding Syndrome.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
http://www.aafp.org/afp/2015/0101/p46.html
http://www.aafp.org/afp/2011/0115/p173.html
https://www.uptodate.com/contents/anorexia-nervosa-in-adults-and-adolescents-the-refeeding-syndrome