2 DefinitionSevere fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding.
3 Consequences of Starvation Decreased insulin and increased glucagon secretion. With a switch from glucose towards ketone bodies as a source of energyGlycogen stores usedBMR decreasesBrain adapts to using ketonesAtrophy of all organsReduced Lean Body MassAbnormal liver function
4 Consequences of starvation Deficiency of vitamins and trace elementsWhole body depletion of potassium, magnesium and phosphateIncreased intracellular and whole body sodium and waterImpaired cardiac, intestinal and renal reserve, leading to reduced ability to excrete excess sodium and waterSerum concentrations of electrolytes maintained within normal limits
5 RefeedingIncreased insulin release leads to increased uptake of glucose, phosphate and potassium into cells. Magnesium is used as a co-factor for cellular pump activityReactivation of the Na/K membrane pump leads to further movement of K into cells with a simultaneous movement of sodium and fluid out of cells
6 RefeedingReduced phosphate is associated with increased urinary magnesium excretionStimulation of protein synthesis leads to increased anabolic tissue growth which in turn leads to increased cellular demand for phosphate, potassium, glucose and water
7 RefeedingExcess glucose can lead to hyperglycaemia and fat abnormalitiesReduced sodium and water excretionIncreased cellular thiamine utilisation due to its role as a co-factor for carbohydrate metabolism
9 Incidence 0.2-5% hospital patients have hypophosphataemia Incidence is increased in certain groupsIncidence in patients receiving nutrition support has been reported to be 30-40%
10 Patients at Risk of Refeeding Those who have had very little or no food intake for >5 days especially if already undernourished (BMI <20 kg/m2, unintentional weight loss >5% within the last 3-6 months)
11 Patients at High Risk of Refeeding Patients with any of the following:BMI < 16 kg/m2Unintentional weight loss >15% within the last 3-6 monthsVery little or no nutrition for >10 daysLow levels of potassium, magnesium or phosphate prior to feeding
12 Patients at High Risk of Refeeding Patients with 2 or more of the following:BMI < 18.5 kg/m2Unintentional weight loss >10% within the last 3-6 monthsVery little or no nutrition for >5 daysA history or alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics
13 Feeding patients who are at risk Introduce feeding at maximum 50% of total energy requirements for the first 2 days before increasing to full requirements if no biochemical abnormalitiesMeet full requirements for fluid, electrolytes, vitamins and minerals from day 1 of feedingMonitor appropriate biochemistry including potassium, phosphate and magnesium (see chapter on monitoring)
14 Feeding patients who are at high risk Consider starting nutrition at maximum 10 kcal/kg and increase slowly to meet full requirements by 4-7 days.Any increase in feed should be dependent on trends in biochemistry
15 Feeding patients who are at high risk Potassium, magnesium and phosphate supplementation from the outset (unless blood levels are already high):Potassium (likely requirement 2-4 mmol/kg/day)Magnesium (likely requirement 0.2 mmol/kg/day IV, 0.4 mmol/kg/day oral)Phosphate (likely requirement mmol/kg/day)
16 Feeding patients who are at high risk Immediately before and during first 10 days of feeding:Oral thiamine mg/dayVitamin B co strong 1-2 tds or full dose IV vitamin BMultivitamin and trace element supplementRestore circulatory volume and monitor fluid balance closelyMonitor appropriate biochemistry including, potassium, phosphate and magnesium
17 Feeding patients who are at high risk In extreme case egBMI<14 kg/m2Very little or no nutrition for > 15 daysPre-feeding Hypokalaemia, hypophosphataemia or hypomagnesaemiaConsider starting feed at 5kcal/kgIt is not necessary to correct electrolyte levels prior to feeding if this cautious approach is useda level that will be safe even with pre-existing low plasma electrolytes, yet will encourage intra-cellular up-take of the phosphate and electrolyte supplementation that must be started at the same time (as above).
18 Feeding patients who are at high risk Beware of very malnourished, dehydrated patients with renal impairment and consequently normal or high potassium and phosphate levels.It is also easy to overlook significant renal impairment in patients with very low BMI and recent starvation who have very low creatinine and urea production.These can change in hours to very low levels due to the combined effects of dehydration and refeeding.They may therefore have only modestly raised plasma creatinine and urea levels
19 ReferencesBrook M.J. & Melnik G The Refeeding Syndrome: An approach to understanding its complications and preventing it occurrence. Pharmacotherapy 15(6):Crook M.A. et al The importance of the Refeeding Syndrome. Nutrition 17:632-7.Keys A. et al The Biology of Human Starvation vols 1,2. Minneapolis University of Minnesota Press.Marinella M.A The Refeeding Syndrome and Hypophosphataemia. Nutrition Reviews 61(9):320-3.NICE 2006 Nutrition Support in AdultsSolomon S.L. et al 1990 The Refeeding Syndrome: A Review. J. Parent. & Enteral Nutrition 14(1):90-7.Terelevich A. et al Refeeding Syndrome: Effective and safe treatment with phosphates polyfusor. Aliment. Pharmacol. Ther. 17:
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