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Clinical Case Study of Refeeding Syndrome
Transcript of Clinical Case Study of Refeeding Syndrome
Cathy Dargitz, MS, RDN,CDE
Medical Nutrition Therapy...................
Additional Lab Values to Monitor
Who Is At Risk for Refeeding Syndrome?
Adenosine Triphosphate - ATP
Colon por enema
Ciclos de la Menstruación
Dolor abdominal a repetición
Refeeding Syndrome is a potentially life threatening electrolyte shift that can occur when reintroducing carbohydrates to a nutritionally depleted patient.
Note - Refeeding Syndrome is caused by reintroducing carbohydrates not lipids or protein
Patients who have
one or more
of the following:
• Body mass index <16
• Unintentional weight loss >15% in the past three to six months
• Little or no nutritional intake for >10 days
• Low levels of potassium, phosphate, or magnesium before beginning feeding
Or patients who have
two or more
of the following:
• Body mass index <18.5
• Unintentional weight loss >10% in the past three to six months
• Little or no nutritional intake for >5 days
• History of misuse of alcohol or drugs, including insulin, chemotherapy, antacids, or diuretics
The classic hallmark of Refeeding Syndrome is a drop in the laboratory phosphorous level soon after the reintroduction of carbohydrates.
Glucose metabolism requires an abundance of adenosine triphosphate (ATP), and phosphorus provides the phosphate in the ATP molecule .
Normal serum levels of phosphorus are: 2.5-4.5 mg/dL. When serum levels drop below 2.3mg/dl hypophosphatemia occurs.
Weakness, Lethargy, Confusion, Disorientation, Restlessness
Impaired Cardiac Function
Impaired Respiratory Function
Hemolysis (The destruction of red blood cells)
Rhabdomyolysis (A breakdown of muscle tissue which can lead to kidney damage)
During Refeeding Syndrome in addition to a drop in the serum values for phosphorus a drop in the following electrolytes may also be seen:
Magnesium levels <1.0mg/dL are considered severe.
Symptoms of hypomagnesemia include: weakness, anorexia, altered mental status, nausea, vomiting, diarrhea, tremors, muscle twitching, muscle cramps, vertigo, anemia, cardiac arrhythmia, paralysis, respiratory distress, and death.
Hypokalemia is considered a serum level of <3.5mEq/L, while potassium levels of less than 2. 5mEq/L can be life threatening.
Hypokalemia can lead to: nausea, vomiting, constipation, weakness, paralysis, respiratory compromise, cardiac arrest, hypotension, and sudden death.
Thiamine (Vitamin B1) deficiency can lead to Wernicke’s Encephalopathy, lactic acidosis, tachycardia, fatigue, muscle cramps, depression, confusion, fatigue, vertigo, abdominal pain, diarrhea, anorexia, and death.
Identifying Refeeding Syndrome
Physical signs and symptoms to look for include:
Shortness of breath,
Diarrhea, and Vomiting.
Lab values to look for include sudden drops in:
Patients suffering from anorexia nervosa
Patients who have had NPO status for > five days
Patients who suffer from acute illness are shown to be at increased risk; therefore patients in the ICU should be monitored carefully
In severe cases, Refeeding Syndrome can be fatal but is preventable and correctable with a team approach to treatment and with proper MNT.
If a patient is identified as having Refeeding Syndrome, the most important factor is the correction of electrolyte imbalances.
According to ASPEN guidelines the correct protocol is to halt advancement of feedings while electrolyte imbalances are corrected.
After proper repletion occurs, symptoms usually dissipate.
MB does not have any food allergies or difficulties chewing or swallowing.
He smokes a pack of cigarettes per day.
MB is a chronic alcoholic and he and his wife consume alcohol daily.
He typically drinks a six pack of beer each night.
Immediately prior to admission MB “Had out of town family up from the south staying with him and he binged on a six pack of beer plus a fifth (750ml) of vodka nightly for 8 days straight”.
MB is a 48 year old African American male.
He’s six foot four inches tall and he weighs 217lbs/98kg, BMI of 26.
MB is married and lives at home with his wife, they don’t have children.
He works as a truck driver which requires long hours on the road and he eats a lot of takeout foods.
MB’s spouse does all of the food shopping and cooking at home.
They follow a Regular diet, which includes take-out food several times per week.
MB’s prior medical history includes: high blood pressure, hypertension and hyperlipidemia. To treat this MB takes Lisinorpil and Simvastatin at home daily.
MB presented to the emergency room experiencing extreme left sided abdominal pain that was radiating to his back, nausea, and vomiting.
He was diagnosed with acute alcohol induced pancreatitis based upon a physical examination, a CT scan, and the results of bloodwork taken including: lipase of 193U/L (Normal range is 0-160U/L) and amylase of 599U/L (Normal range is 23-89U/L).
He has no prior history of pancreatitis.
At the time of the initial consultation, MB did not have edema and his skin was intact.
He was complaining of abdominal pain and he asked that his nurse be consulted about additional pain medication.
He was feeling hunger cues and requested “A big steak dinner”.
MB was admitted (without health insurance) to the hospital
and placed on NPO status to rest his pancreas.
He was started on IV Fluids with a “banana bag” containing a multivitamin, thiamine, and folic acid.
He was given pain medication for his severe abdominal
The dietetic department received a consultation on day
two of his stay for nausea and vomiting.
Due to his NPO status MB was determined to be at high risk for complications, therefore I saw him every three days throughout his hospital stay.
MB’s daily nutritional needs were calculated as follows: Based upon the critical care guidelines for acute pancreatitis: 25-30 kcal/kg and 1.5g pro/kg and 25-30mL/kg fluids daily.
His actual body weight of 98kg was used to assess his needs as: 2, 450-2,940 kcals, 147 g protein daily and 2,450-2,940mL of fluid.
Admitted to hospital with
Acute Alcohol Induced Pancreatitus
Step One - Carbohydrates are reintroduced to the nutritionally depleted patient and are then converted to glucose. The reintroduced carbohydrates can be in the form of enteral, parenteral, oral feeding of either food or supplementation, or in the form of IV fluids (D5).
Step Two - The pancreas releases insulin in response to the newly reintroduced glucose.
The Mechanism Behind Refeeding Syndrome
Step Three - Insulin in the bloodstream causes a cellular uptake of the glucose from the bloodstream into the nutritionally depleted cells. Electrolytes (P, K+, Mg++) in the bloodstream accompany the glucose into cells causing an electrolyte imbalance in the bloodstream.
MB never reached his goal rate of 80mL/hr.
He continued to receive electrolyte replenishment for his length of stay.
MB never progressed to solid foods.
MB checked himself out AMA due to lack of insurance.
Refeeding Syndrome is a potentially fatal electrolyte shift that is caused by the reintroduction of carbohydrates to a nutritionally depleted patient.
The hallmark of Refeeding Syndrome is a drop in phosphorus levels.
Refeeding Syndrome has been shown to occur in up to 34% of cases.
Refeeding Syndrome is preventable and correctable with proper MNT.
The registered dietitian plays a key role in the identification and treatment of Refeeding Syndrome.
Progression of TF halted &
Replenishment of electrolytes begins
What is Refeeding Syndrome?
Signs of Hypophosomatemia
Nutritional Depletion Etiology
1. When the body is not taking in glucose,
glycogen stores are depleted during the
first 24-72 hours.
3. In response to decreased carbohydrate intake, the pancreas decreases insulin production.
4. Concurrently, electrolytes are
depleted inside of cells.
In the beginning stages of nutritional
depletion laboratory serum values for
electrolytes may appear within
normal range due to their continued
2. After glycogen stores are depleted,
the body begins utilizing amino acids from muscle
stores and fatty acids from lipid stores for fuel.
In this study it was noted that some malnourished prisoners of war released from Japanese prison camps developed cardiac failure after being reintroduced to food.
The first study detailing the effects of the Refeeding Syndrome was published in 1951 in the Annals of Intern Medicine entitled “A CLINICAL STUDY OF MALNUTRITION IN JAPANESE PRISONERS OF WAR”.
How Often Does RS Occur?
One study showed that 34% of critically ill patients experienced hypophosphatemia when feedings were initiated after a period of as little as 48hrs without nutrition.
Start feedings slowly and progress slowly.
According to ASPEN guidelines the proper protocol for enteral feedings is to initiate at 10mL to 20mL/hr. with increases of 10-20mL/hr over a period of three to five days until goal rate is reached.
In another study 243 participants who had risk factors were started on nutrition support.
Three of the participants “Developed severe electrolyte shifts, acute circulatory fluid overload and disturbance to organ function following artificial nutrition support and were diagnosed with Refeeding Syndrome”
Monitor lab values for phosphorus, potassium, and magnesium levels and replete any deficiencies prior to the introduction of carbohydrates.
Request that electrolyte levels for phosphorous, magnesium, and potassium be drawn daily for the first three days of feeding and every third day after.
If elecrolyte defeciencies develop halt the progression of feedings and replete.
• Normal serum levels of phosphorus are: 2.5-4.5 mg/dL. When serum levels drop below 2.3mg/dl hypophosphatemia occurs.
Hypokalemia is considered a serum level of <3.5mEq/L, while potassium levels <2. 5mEq/L can be life threatening.
Tube Feeding Initiated 3/26
MB's enteral nutrition recommendation was for
Vital AF 1.2 Cal @ a goal rate of 80ml/hr x 24hrs.
This would provide: 1920mL TV, 2340kcal, 144 grams of protein, 1555mL free water.
As part of his nutrition recommendations labs were requested for: potassium, magnesium, and phosphorus with repletion if necessary before starting the TF.
MB was NPO for 2.5days until Vital AF 1.2 was initiated at noon on the third day of his stay.
Enteral nutrition was started at 20mL/hr. with 20mL increases Q 8 to goal.
Prior to starting the feed MB's
electrolyte lab values for: Phosphorus, Magnesium, and Potassium
were checked and all were
within normal limits.
MB's TF was halted at 60mL/hr
He received potassium
Phosphorus replenishment began
Initial Dietary Assessment
Lab values for P, K below normal limits
Identify the Patients at Greatest Risk Upon Admission
Remember that lab values may appear within normal limits at first and that a drop in electrolyte lab values, especially in the phosphorus level after feeding has begun is the hallmark of Refeeding Syndrome.
Continually Monitor Lab Values
Start Slow and Go Slow