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

2. 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

3. 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:
Stanga Z. Sobotka L. Refeeding syndrome. Basics in Clinical Nutrition 4th ed 2011; Galen Publishing, Czech Republic:

4. 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:

5. 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:

6. 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:

7. 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

8. 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

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

10. 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.

11. 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%

12. 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.
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 December 2014: 1-7 (n=179).

13. 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:

15. 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:

16. Management of Refeeding

17. Approaches
Blood sodium, potassium, magnesium and phosphorus daily for one week
Correct what is low:
Phosphate mmol/kg/day
Potassium mmol/kg/day
Magnesium mmol/kg/day
If patient is on parenteral nutrition lower calorie requirement to 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:

18. 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 mmol/kg/day
Potassium mmol/kg/day
Magnesium 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:

19. Day 4-6 (of 10-day management)
Energy: kcal/kg/day
Same ratios for protein, carbo and fat
Restore electrolyte levels using this regimen:
Phosphate < 0.6 mmol/L > give phosphate 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 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:

20. Day 7-10 (of 10-day management)
Energy: 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:

21. 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”

22. Thank You