1. Medical Nutrition Therapy for Refeeding Syndrome
Rachel Hammerling
Concordia College, Moorhead MN

2. Objectives Be able to describe refeeding syndrome (RFS)
Be able to describe the pathophysiology of starvation
Identify the main pathophysiologic features of RFS
Be able to identify signs & symptoms
Identify recommended treatment & standards of care
Be able to explain ethical issues involved with treatment & care

3. Discovery of RFS Observed & described after WWII
Victims of starvation experienced cardiac and/or neurologic dysfunction
After being reintroduced to food
Today, rarely see patients who are severely malnourished, as WWII victims were, in the 1st week
Neurologic signs & symptoms develop later

4. What is RFS? Potentially fatal shifts in fluids & electrolytes
May occur in malnourished patients receiving artificial refeeding
Enterally or parenterally
Complex syndrome
Sodium & fluid imbalance
Changes in glucose, protein, fat metabolism
Thiamine deficiency
Hypokalemia
Hypomagnesaemia

5. Understanding Starvation
Glucose = main fuel
Shifts to protein & fat
Insulin ↓ due to ↓ availability of glucose
Catabolism of protein → loss of cellular & muscle mass → atrophy of vital organs & internal organs
Respiratory & cardiac function ↓ due to muscular wasting & fluid/electrolyte imbalances
Body is now surviving by slowly consuming itself

6. How common is RFS? True incidence is unknown
Study of 10,197 patients, incidence of hypophosphatemia = 43 %
Malnutrition one of strongest risk factors
Parenteral patients = 100% incidence of hypophosphatemia

7. Pathogenesis Electrolytes & minerals involved Phosphorus Potassium
Magnesium
Glucose

9. Main Pathophysiologic Features
Disturbances of body-fluid distribution
Abnormal glucose & lipid metabolisms
Thiamine deficiency
Hypophosphatemia
Hypomagnesemia
Hypokalemia

10. Disturbances of Body-Fluid Distribution
CHO refeeding
↓ water & sodium excretion, resulting in weight gain
Protein & fat refeeding
Result in weight loss & urinary sodium excretion
Hypernatremia along with azotemia & metabolic acidosis
Can influence body functions:
Cardiac failure
Dehydration or fluid overload
Hypotension
Pre-renal failure
Sudden death

11. Abnormal Glucose & Lipid Metabolisms
Suppress gluconeogenesis → reduced AA usage
Less-negative N balance
Hyperglycemia
Glucose → fat (Lipogenesis)
Hypertriglyceridemia, fatty liver, & abnormal liver function tests

12. Thiamine Deficiency
Can result in Wernicke’s encephalopathy or Korsakov’s syndrome, associated with:
Ocular disturbance
Confusion
Ataxia
loss of ability to coordinate muscular movement
Coma
Short-term memory loss
Confabulation
Confusion of imagination with memory

13. Hypophosphatemia Predominant feature of RFS
Impaired cellular-energy pathways
Adenosine triphosphate
2,3-diphosphoglycerate
Impaired skeletal-muscle function
Including weakness & myopathy
Seizures & perturbed mental state
Impaired blood clotting processes & hemolysis also can occur

14. Hypomagnesemia Most cases not clinically significant Severe cases:
Cardiac arrhythmias
Abdominal discomfort
Anorexia
Tremors, seizures, & confusion
Weakness

15. Hypokalemia Features are numerous: Cardiac arrhythmias Hypotension
Cardiac arrest
Weakness
Paralysis
Confusion
Respiratory Depression

16. Signs & Symptoms Electrolyte imbalance
Hypokalemia
Hypophosphatemia
Hypomagnesemia
REMEMBER: Even an overweight or obese patient can be malnourished & a victim for RFS

17. Identifying Patients at High Risk of Refeeding Problems
NICE Guidelines (National Institute for Health & Clinical Excellence)
Either patient has 1 or more:
BMI <16
Unintentional weight loss >15% in past 3-6 mo
Little/no nutritional intake for 10 days
Low levels of potassium, phosphate, or magnesium before feeding
Or patient has 2 or more:
BMI <18.5
Unintentional weight loss >10% in past 3-6 mo
Little/no nutritional intake for >5 days
History of alcohol misuse or drugs

18. Patients at high risk: Anorexia nervosa Chronic alcoholism
Oncology patients
Postoperative patients
Elderly
Uncontrolled diabetes mellitus
Chronic malnutrition:
Marasmus
Prolonged fasting or low energy diet
Morbid obesity with weight loss
Long term antacid users
Long term diuretic users

19. Gastrointestinal Fistula patients
Usually reveals chronic malnutrition
Due to damaged Gl tract & severe abdominal sepsis
High risk for RFS
Be aware of condition & treat the same
Diarrhea commonly occurs & can be treated by enteral nutrition

20. Intervention: Objectives
1) Gradually correct starvation
Use less than full levels of calorie & fluid requirements
2) Advance calories & volume
Monitor cardiac & respiratory side effects
3) Correct vitamin & mineral deficiencies
Especially with symptoms

21. Intervention: Objectives Cont.
4) Nutrition support in patients at risk should be increased slowly
Assuring adequate amounts of vitamins & minerals
5) Organ function, fluid balance, & serum electrolytes
Monitor daily during 1st week & less frequently after

22. Intervention: Objectives Cont.
6) Monitor for neurological, hematological, & metabolic complications
Of hypokalemia, hypophosphatemia, & hyperglycemia
7) Prevent sudden death

23. Intervention: Food & Nutrition
Begin 20 kcal/kg for 1st 3 days
Progress to 25 kcal/kg
Gradually ↑ by 7th day
Protein start slow, ↑ gradually
To protect & restore lean body mass
Restrict CHO to g/day
To prevent rapid insulin surge
CHO in PN
Initiate at 2 mg/kg/min
Fat calories should make up the difference

24. Intervention: Food & Nutrition
Maintain fluid balance
Adjust when edema exists
Adjust for sodium & potassium
Depending on lab values until normal
Supplements
Thiamin
Other vitamins & minerals as needed

25. Common Drugs Used Replacement of phosphorus, potassium, & magnesium
Insulin
Used to correct hyperglycemia levels
Monitor blood glucose levels during refeeding

26. Recommendation for Phosphate
Dose
Maintenance requirement
mmol/kg/day orally
Mild hypophosphatemia
( mmol/l)
Moderate hypophosphatemia
( mmol/l)
9 mmol infused into peripheral vein over 12 hours
Severe hypophosphatemia
(<0.3 mmol/l)
18 mmol infused into peripheral vein over 12 hours

27. Recommendation for Magnesium
Dose
Maintenance requirement
0.2 mmol/kg/day intravenously (or 0.4 mmol/kg/day orally )
Mild to moderate hypomagnesaemia ( mmol/l)
Initially 0.5 mmol/kg/day over 24 hours intravenously, then 0.25 mmol/kg/day for 5 days intravenously
Severe hypomagnesaemia
(<0.5 mmol/l)
24 mmol over 6 hours intravenously, then as for mild to moderate hypomagnesaemia (above)

28. Intervention: Nutrition Education, Counseling, & Care Management
Focus on adequate nutrient intake
Consider referral if food insecurity is a concern
Offer guidelines according to discharge intervention plan
Physician may suggest long-term medication use or therapies

29. NICE Guidelines for Management

30. Ethical Issues with RFS
Roles between dietitian, counselor, nurse, doctor, and other professionals
Working with anorexia patients, oncology patients or older patients
Ethnic & religious differences
Muslim patients
Non-English speaking patients

32. Summary Points
RFS is caused by rapid refeeding after a period of undernutrition
Characterized by hypophosphatemia
Patients at high risk: undernourished, little or no energy intake for > 10 days
Start refeeding at low levels
Correction of electrolyte & fluid imbalances before feeding IS NOT necessary

33. References
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Gariballa, S. (2008). Refeeding syndrome: A potentially fatal condition but remains underdiagnosed and undertreated. Nutrition, 24(6),
Khardori, R. (2005). Refeeding syndrome and hypophosphatemia. Journal of Intensive Care Medicine, 20(3),
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