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Refeeding syndrome Nutrition Department Definition • Refeeding syndrome is a potentially fatal condition,caused by rapid initiation of refeeding after a period of undernutrition • characterised by hypophosphataemia, associated with fluid and electrolyte shifts and metabolic and clinical complications Refeeding syndrome • Refeeding syndrome is a well described but often forgotten condition. • No RCT of treatment have been published • Best available evidence for managing the conditionguideline NICE 2006/ England • Cohort studies, case series, and consensus expert opinion How common? • The true incidence of RS is unknown • a study of 10 197 hospitalised patients: 0.43% severe hypophosphataemia (malnutrition : one of the strongest risk factors) • Not contain phosphorus TPN: 100% hypophosphataemia (vs 18% if P contain) • Cohort study in ICU: 34% HP soon after feeding was started (SD= 1.9 ±1.1 days) pathogenesis: prolonged fasting • preventing protein and muscle breakdown (use of ketone bodies and fatty acids as the main energy source, ↓ gluconeogenesis), • severely depleted intracellular minerals but normal serum concentrations • Reduction in renal excretion. pathogenesis: Refeeding • ↑ glycemia : ↑ insulin and ↓glucagon secretion • Insulin stimulates glycogen, fat, and protein synthesis.(requires P,Mg, cofactors such as thiamine) • absorption of potassium into the cells through the Na,K ATPase symporter ( transports glucose into the cells) • Water follows by osmosis Results • ↓ P: ↓ATP, change in O2 delivery to tissues, acid base buffer, cell membranes integrity. • ↓ K: derangements in the electrochemical membrane potentialarrhythmias and cardiac arrest. • ↓ Mg: cardiac dysfunction, neuromuscular complications • Vitamin deficiency: B1 Wernicke’s encephalopathy (ocular abnormalities, ataxia, confusional state, hypothermia, coma) or Korsakoff’s syndrome (retrograde and anterograde amnesia, confabulation) • Sodium, nitrogen, and fluid: rapid ↓ in renal excretion of sodium and water cardiac failure, pulmonary oedema, and cardiac arrhythmia if try to maintain a normal urine output Prevention: high risk patients Criteria from the guidelines of the National Institute for Health and Clinical Excellence for identifying patients at high risk of refeeding problems (level D recommendations) *Either the patient has one or more of the following: • Body mass index (kg/m2) <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 feeding * Or the patient has 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 alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics NICE guidelines recommendation • Refeeding is started at no more than 50% of energy requirements • Increased to meet or exceed full needs over 4-7 days • High risk patients: tailored to each patient Very malnourished patient: cardiac monitoring • Correcting electrolyte and fluid imbalances before feeding is not necessary and that this should be done along with feeding. NICE guidelines recommendation • Vitamin supplementation should also be started with refeeding and continued for at least 10 days • Circulatory volume should also be restored. • Oral, enteral, or intravenous supplements of K, P,Ca, Mg should be given unless blood levels are high before refeeding P, Mg supplementation Treatment of the Malnourished child • Essential features of the initial feeding are – Frequent small feeds of low osmolality and low in lactose – Oral or nasogastric feeds (never IV feeds) – 100 kcal/kg/day – Protein 1-1.5 gm/kg/day – Liquid: 130 ml/kg/day (100 if child has severe edema) – Continue with breastfeeding but give scheduled amounts of formula first Treatment of the Malnourished child • Clinical status must be monitored carefully • Child should be fed every 2 hours for 1st day or 2, then every 3 hours until day 6 • If child’s intake does not reach 80 kcal/kg/day despite frequent feeds, coaxing and re-offering, the remaining feed should be given by nasogastric tube Treatment of the Malnourished child • Return of the appetite is the sign for entering the rehabilitation phase – Usually about 1 week after admission • During this phase very high intakes are encouraged to support a weight gain of > 10 g/kg/day – Must be alert to avoid heart failure (rapid pulse and fast breathing) if intake is high suddently) • Modified porridges or complementary foods can be used if comparable in energy an pro Treatment of the Malnourished child • Increase each feed by 10 ml until some remains uneaten – Likely to occur when intakes reach about 200 ml/kg/day • After a gradual transition, give – Frequent feed, unlimited amounts – 150-220 kcal/kg/day – 4-6 g/kg/day of protein REFERENCE: SOURCES AND SELECTION CRITERIA • search the databases Medline,Embase, PubMed, Cochrane, CINAHL, and AMED (Allied and ComplementaryMedicine Database), as well as cross checking with reference lists, textbooks, and personal reference lists • assessed the quality of evidence in original articles according to guidelines published on the Evidence-Based On-Call website • Downloaded from bmj.com on 22 October 2008 • Clinical review: Refeeding syndrome: what it is, and how to prevent and treat it Hisham M Mehanna,Jamil Moledina,Jane Travis REFERENCE 1. Refeeding Syndrome in a Severely Malnourished Child www.medscape.com/viewarticle/489090_4 2. Refeeding syndrome Is underdiagnosed and undertreated, but treatable Stephen D Hearing, consultant gastroenterologist Department of Gastroenterology, Staffordshire General Hospital, Weston Road, Stafford 3. Refeeding syndrome: life-threatening, underdiagnosed, but treatable qjmed.oxfordjournals.org/cgi/content/full/98/4/318-a THANKS FOR YOUR ATTENTION!
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