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Created page with "Refeeding REFEEDING SYNDROME (source: Management of Refeeding Syndrome in Medical Inpatients) Epidemiology 14.6% of 967 malnourished patients Pathophysiology (hypothetical) 1...."
Refeeding
REFEEDING SYNDROME (source: Management of Refeeding Syndrome in Medical Inpatients)
Epidemiology
14.6% of 967 malnourished patients
Pathophysiology (hypothetical)
1. Decreased insulin, increased glucagon
2. Glycogenolysis -› gluconeogenesis - › protein catabolism; vitamin deficiencies due
to reduced intake; lipolysis -› free fatty acids
-› ketogenesis in liver.
3. Carbohydrate reintroduction stimulates insulin secretion, anabolic processes.
4. Increased protein synthesis, Na+ retention, glucose uptake, thiamine use,
intracellular shift of P04, Mg2+, and K+
5. Hypophosphate, hypomagnesium, hypokalemia, hypothiamine (beriberi symptoms) ,
salt/H20 retention
Risk Factors
--A) Minor risk factors
---BMI < 18.5
----›10% unintentional weight loss in 3-6 months
----›5 days starvation
----h/o EtOH / drug abuse
--B) Major risk factors
-=--BMI < 16
----›15% unintentional weight loss in 3-6 months
----›10 days starvation
----LOW K+/P04/Mg2+ prior to feeding
--C) Very high risk factors
- - - -BMI < 14
----›20% weight loss
---›15 days starvation
--1 of A = LOW; 2 of A or 1 of B = HIGH; 1 of C = VERY HIGH
Clinical Presentation
1. First 72 hrs after nutritional therapy, regardless of feeding mode
2. Hyperglycemia
3. Electrolyte imbalances:
--Hypophosphatemia
--<0.32 mmol/L
--A central defining criterion in several studies
--Rhabdo, hemolysis, respiratory failure
-Hypokalemia, Hypomagnesemia
----<2.5 mmol/L, <0.50 mmol/L
- -Cardiac ARRHYTHMIA, paresis, rhabdo, confusion, respiratory insufficiency
4. Vit B1 deficiency
-Essential coenzyme in Krebs cycle
Refeeding
--Two weeks causes depletion of stores
-Glucose gets converted to lactate instead leading to MET ACIDOSIS
-Wernicke's encephalopathy (dry beriberi)
-Cardiovascular disorder (wet beriberi)
5. Salt retention
-K+ shift intracellularly leads to HYPERNATREMIA (Na+/K+-ATPase)
-Water retention
- -Noradrenaline/Angiotensin I lead to peripheral resistance and EDEMA
6. Tachycardia
7. Tachypnea
Diagnosis
-Electrolyte imbalances, either.
----Phosphate decreased >30% from baseline or
<0.6 mmol/L
-- Two electrolyte shifts below normal range (Mg2+, P04, K+)
-Plus clinical symptoms, any of.
---Tachycardia
- - Tachypnea
--Peripheral edema
Management
1. Level of evidence. Very few CTs, systematic review of case series,
retrospective, cohort, and case-control studies. National Institute for Health and
Care Excellence guidelines are often standard or care.
3. Nutritional support (Friedli et al. 2018 systematic review of 45 studies)
--10-15 kcal/kg/day (5 for high risk) [Dog et al 2015 RCT showed low calorie diet
was effectivel
--50-60% CHO, 30-40% fat, 15-20% protein
--20-30 mL/kg/day fluid © fluid balance
-Thiamine 200-300 mg IV or PO for 3 days and 10 days multivitamin.
4. Risk stratification = High risk, expert consensus treatment plan
--Check K, Mg, P04, Na, Ca
-Correct fluid deficit
--Correct electrolyte levels prior to feeding
- -Supplement vitamins 200% DV, and trace elements 100% DV prior to feeding
--Thiamine sould be given at least 30 minutes prior to feeding (see below)
--Calories
---Day 1-3: 10-15 kcal/kg/day
-Day 4-5: 15-25 kcal/kg/day
-Day 6: 25-30 kcak/kg/day
-Day 7+: full requirement
--Fluids
•-Day 1-3: 25-30 ml/kg/day
--Day 4+: 30-35 ml/kg/day
--Electrolytes
----Day 1-7: Na+ restriction, < 1 mmol/kg/day
--Vitamins
----Day 1-3: 200-300 mg thiamine
•---Day 1-10: Multivitamin
--Check daily body weights and hydration status
-Check electrolytes
REFEEDING SYNDROME (source: Management of Refeeding Syndrome in Medical Inpatients)
Epidemiology
14.6% of 967 malnourished patients
Pathophysiology (hypothetical)
1. Decreased insulin, increased glucagon
2. Glycogenolysis -› gluconeogenesis - › protein catabolism; vitamin deficiencies due
to reduced intake; lipolysis -› free fatty acids
-› ketogenesis in liver.
3. Carbohydrate reintroduction stimulates insulin secretion, anabolic processes.
4. Increased protein synthesis, Na+ retention, glucose uptake, thiamine use,
intracellular shift of P04, Mg2+, and K+
5. Hypophosphate, hypomagnesium, hypokalemia, hypothiamine (beriberi symptoms) ,
salt/H20 retention
Risk Factors
--A) Minor risk factors
---BMI < 18.5
----›10% unintentional weight loss in 3-6 months
----›5 days starvation
----h/o EtOH / drug abuse
--B) Major risk factors
-=--BMI < 16
----›15% unintentional weight loss in 3-6 months
----›10 days starvation
----LOW K+/P04/Mg2+ prior to feeding
--C) Very high risk factors
- - - -BMI < 14
----›20% weight loss
---›15 days starvation
--1 of A = LOW; 2 of A or 1 of B = HIGH; 1 of C = VERY HIGH
Clinical Presentation
1. First 72 hrs after nutritional therapy, regardless of feeding mode
2. Hyperglycemia
3. Electrolyte imbalances:
--Hypophosphatemia
--<0.32 mmol/L
--A central defining criterion in several studies
--Rhabdo, hemolysis, respiratory failure
-Hypokalemia, Hypomagnesemia
----<2.5 mmol/L, <0.50 mmol/L
- -Cardiac ARRHYTHMIA, paresis, rhabdo, confusion, respiratory insufficiency
4. Vit B1 deficiency
-Essential coenzyme in Krebs cycle
Refeeding
--Two weeks causes depletion of stores
-Glucose gets converted to lactate instead leading to MET ACIDOSIS
-Wernicke's encephalopathy (dry beriberi)
-Cardiovascular disorder (wet beriberi)
5. Salt retention
-K+ shift intracellularly leads to HYPERNATREMIA (Na+/K+-ATPase)
-Water retention
- -Noradrenaline/Angiotensin I lead to peripheral resistance and EDEMA
6. Tachycardia
7. Tachypnea
Diagnosis
-Electrolyte imbalances, either.
----Phosphate decreased >30% from baseline or
<0.6 mmol/L
-- Two electrolyte shifts below normal range (Mg2+, P04, K+)
-Plus clinical symptoms, any of.
---Tachycardia
- - Tachypnea
--Peripheral edema
Management
1. Level of evidence. Very few CTs, systematic review of case series,
retrospective, cohort, and case-control studies. National Institute for Health and
Care Excellence guidelines are often standard or care.
3. Nutritional support (Friedli et al. 2018 systematic review of 45 studies)
--10-15 kcal/kg/day (5 for high risk) [Dog et al 2015 RCT showed low calorie diet
was effectivel
--50-60% CHO, 30-40% fat, 15-20% protein
--20-30 mL/kg/day fluid © fluid balance
-Thiamine 200-300 mg IV or PO for 3 days and 10 days multivitamin.
4. Risk stratification = High risk, expert consensus treatment plan
--Check K, Mg, P04, Na, Ca
-Correct fluid deficit
--Correct electrolyte levels prior to feeding
- -Supplement vitamins 200% DV, and trace elements 100% DV prior to feeding
--Thiamine sould be given at least 30 minutes prior to feeding (see below)
--Calories
---Day 1-3: 10-15 kcal/kg/day
-Day 4-5: 15-25 kcal/kg/day
-Day 6: 25-30 kcak/kg/day
-Day 7+: full requirement
--Fluids
•-Day 1-3: 25-30 ml/kg/day
--Day 4+: 30-35 ml/kg/day
--Electrolytes
----Day 1-7: Na+ restriction, < 1 mmol/kg/day
--Vitamins
----Day 1-3: 200-300 mg thiamine
•---Day 1-10: Multivitamin
--Check daily body weights and hydration status
-Check electrolytes