Refeeding Syndrome Refeeding is a complication of surgery which is not immediately considered when patients show problems after initiating feeding.

Objectives To discuss the pathophysiology of refeeding syndrome To diagnose refeeding syndrome To discuss prevention and management of refeeding syndrome The objectives of this presentation are: To define and explain the pathophysiology of refeeding syndrome To identify patients who are likely to develop refeeding To discuss the prevention and/or management of refeeding

Definition of refeeding syndrome Electrolyte abnormality(ies) due to refeeding which result to the following complications: respiratory failure, cardiac arrhythmias, and encephalopathy which may lead to death when not immediately diagnosed and managed. The main electrolyte abnormality is usually hypophosphatemia This condition usually occurs in severely malnourished patients Refeeding syndrome is primarily an electrolyte abnormality due to refeeding resulting to the following complications: respiratory failure, cardiac arrhythmias, and encephalopathy which may lead to death when not immediately diagnosed and managed. REFERENCE: Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic: 427-32. Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic: 427-32.

Diagnosis of refeeding syndrome Mustofa N et al. Refeeding syndrome: frequency of hypophosphatemia and other electrolyte abnormalities – experience from a private tertiary care hospital in the Philippines. Available at: http://www.philspenonlinejournal.com/POJ_0028.html

Diagnosis of refeeding syndrome Mustofa N et al. Refeeding syndrome: frequency of hypophosphatemia and other electrolyte abnormalities – experience from a private tertiary care hospital in the Philippines. Available at: http://www.philspenonlinejournal.com/POJ_0028.html

Diagnosis of refeeding syndrome Mustofa N et al. Refeeding syndrome: frequency of hypophosphatemia and other electrolyte abnormalities – experience from a private tertiary care hospital in the Philippines. Available at: http://www.philspenonlinejournal.com/POJ_0028.html

Diagnosis of refeeding syndrome High index of suspicion: “This problem may not be only cardiac . . .” Severely malnourished Elderly On parenteral nutrition with/without high glucose load When you have all of the above – request for phosphate and magnesium blood test

Pathophysiology of refeeding syndrome Glycogenolysis / Gluconeogenesis / Protein catabolism Starvation / Malnutrition Protein, fat, mineral, electrolyte and vitamin depletion – salt and water intolerance REFEEDING SYNDROME Hypophosphatemia Hypomagnesemia Thiamine deficiency Salt & water retention - edema Refeed – fluid, salt, nutrients (carbo – main energy source) Switch to anabolism Pancreas > insulin

Complications of refeeding syndrome From the lecture on Malnutrition, Starvation and Refeeding Syndrome by K. Jeejeebhoy (Wikipedia)

Refeeding syndrome in the Philippines To bring home the point of considering this clinical entity and complication – we have a report on refeeding syndrome in the Philippines.

Prevalence of Refeeding = 30/341 or 9% This report is published in the Philippine Online Journal of Parenteral and Enteral Nutrition. Prevalence of Refeeding = 30/341 or 9%

Nutritional assessment tool Lacuesta-Corro L et al. The results of the validation process of a Modified SGA (Subjective Global Assessment) Nutrition Assessment and Risk Level Tool designed by the Clinical Nutrition Service of St. Luke’s Medical Center, a tertiary care hospital in the Philippines. http://philspenonlinejournal.com/POJ_0002.html Sensitivity: 94.7% Specificity: 96.2% Positive Predictive Value: 95.7% Nutritional assessment tool SGA A (normal) B (mild/mod malnutrition) C (severe malnutrition) Nutrition Risk Score: 1-3: Low Risk 4-6: Moderate Risk 7-9 High Risk The Philippine Society of Parenteral and Enteral Nutrition developed a nutritional assessment tool which it validated for use in the country. It is called the modified Subjective Global Assessment tool and is adopted by the Committee on Surgical Nutrition in the PSGS and PCS for their nutritional assessment purposes. It determines a patient’s severity of malnutrition and the level of nutrition risk. Validation studies showed the tool to have a sensitivity of 94.7%, specificity of 96.2% and positive predictive value of 95.7%. Reference: Lacuesta-Corro L et al. The results of the validation process of a Modified SGA (Subjective Global Assessment) Nutrition Assessment and Risk Level Tool designed by the Clinical Nutrition Service of St. Luke’s Medical Center, a tertiary care hospital in the Philippines. (Article 12 | POJ_0002.html) Issue February 2012 - December 2014: 1-7 (n=179).

Refeeding syndrome Table 3: Disease Profile (n=30) Cancer N Percent Non-Cancer GI cancer 8 27% Gastrointestinal 4 13% Urologic 3 10% Neuro Female repro system Pulmonary 2 7% Breast Renal 1 3% Others Ortho Trauma Total 17 17/30 or 57% 13 13/30 or 43% Patient profile: Half are cancer patients Severely malnourished Elderly Parenteral nutrition with high glucose load What to do? Nutritional assessment Baseline electrolytes: Sodium Potassium Magnesium Mustofa N et al. Refeeding syndrome: frequency of hypophosphatemia and other electrolyte abnormalities – experience from a private tertiary care hospital in the Philippines. Available at: http://www.philspenonlinejournal.com/POJ_0028.html

http://www.dpsys120991.com/LL005_Tolentino_et_al.pdf

Outcomes of refeeding syndrome Number (%) Length of Stay 1-7 days 11 (37%) 8-15 days 12 (40%) 16-25 days 5 (17%) 26-35 days 4 (13%) ICU admission 6 (29%) Ventilator support 10 (33%) Arrhythmias 7 (23%) Mortality Discharged improved 23 (83%) Discharged unimproved 2 (7%) Mustofa N et al. Refeeding syndrome: frequency of hypophosphatemia and other electrolyte abnormalities – experience from a private tertiary care hospital in the Philippines. Available at: http://www.philspenonlinejournal.com/POJ_0028.html

Management of Refeeding

Approaches Blood sodium, potassium, magnesium and phosphorus daily for one week Correct what is low: Phosphate 0.5-0.8 mmol/kg/day Potassium 1-2.2 mmol/kg/day Magnesium 0.3-0.4 mmol/kg/day If patient is on parenteral nutrition lower calorie requirement to 15-20 kcal/kg actual body weight and only increase when the electrolytes have reached normal levels Parenteral nutrition regimen should have vitamin and trace element supplementation Increase should be gradual even reaching a week Intake monitoring of nutrients and fluid should be strict Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic: 427-32.

Day 1-3 (of 10-day management) Energy: start at 10 kcal/kg/day gradually increasing to 15 kcal/kg/day Protein: 15-20%, Carbo: 50-60%, Fat: 30-40% Measure electrolytes after 4-6 hours then daily while feeding Correction: Phosphate 0.5-0.8 mmol/kg/day Potassium 1-2.2 mmol/kg/day Magnesium 0.3-0.4 mmol/kg/day Vitamins and trace element supplementation daily Restrict fluids Restrict sodium to 1 mmol/kg/day Weigh patient daily ECG monitoring advised Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic: 427-32.

Day 4-6 (of 10-day management) Energy: 15-20 kcal/kg/day Same ratios for protein, carbo and fat Restore electrolyte levels using this regimen: Phosphate < 0.6 mmol/L > give phosphate 30-50 mmol IV for 12h Magnesium < 0.5 mmol/L > give magnesium sulfate 24 mmol IV for 12h Potassium < 3.5 mmol/L > give potassium chloride 20-24 mmol IV for 12h Vitamins and trace element supplementation daily Remeasure electrolytes Check weight daily, strict fluid balance ECG monitoring Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic: 427-32.

Day 7-10 (of 10-day management) Energy: 20-30 kcal/kg/day Same percentages for protein, carbo and fat Monitor electrolytes, ECG, weight 2x/week Supplement minerals, vitamins daily. Iron should be supplemented from day 7 onwards Fluids at 30 ml/kg/day > strict “0” fluid balance Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic: 427-32.

Recap Severely malnourished patient Check the following blood values: Na, K, Cl, P, Mag (= Check all four!) When phosphate and/or magnesium is low, Diagnosis = Refeeding Start the 10-day management for refeeding – “Start very small and very slow” > very gradual increase until goals are reached on day 10”

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