Pir Refeeding PPT Final [PDF]

Citation preview

Refeeding Syndrome Christian D. Pulcini, MD, MEd, MPH Stacey Zettle, MS, RD, LDN Arvind Srinath, MD



Refeeding Syndrome • DEFINITION: metabolic & clinical changes arising from aggressive nutritional rehabilitation of a malnourished patient • Potentially DEVASTATING consequences • Thus, ESSENTIAL to: • Identify at-risk populations (risk factors) • Prevent • Evaluate • Recognize • Effectively manage • LITTLE consensus on pediatric evaluation & management



Refeeding Syndrome Epidemiology • Lack of precise definition for refeeding syndrome precludes accurate incidence/prevalence assessments • Deemed underreported • Hypophosphatemia most common complication



Refeeding Syndrome At-risk Populations General Malnutrition



Psychiatric



Renal/Endocrine



Gastrointestinal Losses



Other



• Prolonged • Anorexia • Diabetic fasting (≥5 nervosa hyperosmolar days) • Depression state • Acute weight • Chronic • Chronic loss ≥10% in 1alcohol & drug diuretic use 2 months use • Failure to thrive • Complex health needs • Kwashiorkor • Marasmus



• Inflammatory bowel disease • Chronic pancreatitis • Short bowel syndrome • Significant vomiting and/or diarrhea



• Social deprivation of food • Chronic infectious disease • Cystic fibrosis • Congenital heart disease • Malignancy



Starvation Pathophysiology Day 1 – Day 3: liver glycogen depleted, decreased insulin (small increase in glucagon and growth hormone) Day 7: catabolism of fat (lipolysis) and protein for hepatic gluconeogenesis → (anaerobic conversion of glucose to ATP can occur throughout this time period)



Day 8-10: source of energy shifts from fat to ketone bodies



Day 30 and beyond: muscle catabolism of lean muscle, leading to death • •



In small children, less liver glycogen, fat, and protein stores can hasten starvation process. The arrows represent continuation of the previous day(s) aforementioned processes until the next annotated day is highlighted.



Refeeding Syndrome Pathophysiology • Refeeding potentiates intracellular electrolyte shift to accommodate cellular processes Malnutrition/Starvation Gluconeogenesis, protein and glycogen catabolism



Protein, fat, vitamin, and mineral depletion; Salt, fluid, and electrolyte (notably phosphate, potassium, and magnesium) balance shifts



Nutritional Replacement Reestablishment of vital nutrients



Hyperglycemia; Insulin secretion - glucose uptake; Synthesis of protein & glycogen; Intracellular shift of phosphate, potassium, magnesium; Thiamine depletion



Refeeding Syndrome Hypophosphatemia, hypokalemia, salt and fluid retention; thiamine deficiency



Refeeding Syndrome Manifestations Hypophosphatemia



Hypokalemia



Hypomagnesemia



Vitamin/thiamine deficiency



Cardiac



• • • • •



Sudden death Arrhythmia Heart failure Hypotension Shock



• Arrhythmia



Pulmonary



• • •



Dyspnea Respiratory failure Impaired diaphragm function



• Respiratory failure



Musculoskeletal



• • •



Weakness Myalgia Rhabdomyolysis



• Weakness • Rhabdomyolysis • Muscle necrosis



• Weakness



• Weakness • Rhabdomyolysis • Muscle necrosis



Hematologic



• • •



Hemolysis, Thrombocytopenia Leukocyte dysfunction • Nausea • Vomiting • Constipation



• Nausea • Vomiting • Diarrhea



• Nausea • Vomiting • Constipation



• Paralysis



• • • •



Tremor Tetany Seizures Altered mental status • Coma



• Encephalopathy



• Paralysis



• Death



• Refractory hypokalemia & hypocalcemia • Death



• Lactic acidosis • Death



• Infection • Death



Gastrointestinal Neurologic



• • • • • •



Other



• Metabolic acidosis • Insulin resistance • Acute tubular necrosis



Confusion Delirium Paresthesia Paralysis Seizures Hallucinations



• Arrhythmia



Hyperglycemia • Hypotension



Fluid overload • Heart failure



Trace element deficiency • Arrhythmia • Heart failure



• Respiratory failure



• Edema



• Encephalopathy



• Death



• Metabolic acidosis



Refeeding Syndrome Prevention Feeding Initiation/Advancement • Begin enteral feedings as soon as possible • Higher infection risk associated with parenteral nutrition • SLOW initiation of feedings • General evidence consensus: Start at 50% of estimated caloric needs • For highest-risk patients: Start at 25% of estimated caloric needs • Advance diet over 3-7 days • 10%-25% increase in calories/day until goal



Refeeding Syndrome Prevention/Management • Remember to recognize at-risk populations • Multidisciplinary involvement essential • Physicians, nurses, pharmacists, and dietitians Clinical Monitoring



Biochemical Monitoring



• Continuous cardiorespiratory monitor • Regular physical examination • Focus on neurologic & cardiac • Strict intake and output • Calorie count • Daily weights



• Baseline and at least daily metabolic profile • Measure phosphorus, magnesium, potassium, sodium, glucose, and renal function • Frequency dependent on trends and needs for repletion • Consider: prealbumin, albumin, and zinc; urine electrolytes



Refeeding Syndrome Management Electrolyte Disturbance Hypophosphatemia



Severity Mild: 2.3-2.7 mg/dL



Maintenance (oral)



Treatment



0.3-0.6 mmol/kg/day



0.3-0.6 mmol/kg/day PO



Moderate: 1.5-2.2 mg/dL



0.08-0.24 mmol/kg IV over 6-12 hours



Maximum dose Single dose: 15 mmol/kg (IV) Daily: 1.5 mmol/kg (IV)



Administration Over 6-12 hours; measure phosphate 24 hours after infusion completion



Severe: