Has Refeeding Syndrome become more prevalent. It seems that more and more patients that are started on PN or enteral feeds, have marked electrolyte disturbances, especially critical care patients. Working at my small community hospital over the past 30 years, it seems as if we are observing perceptibly more patients with Refeeding Syndrome, or, are we just evaluating and monitoring for it more thoroughly. On one hand, I would observe, that we are feeding patients much more quickly than we have in the past, so you would assume that refeeding syndrome would not be as common place. On the other hand, it is quite possible that we are monitoring for it more closely now and are actually able to see it more plainly. Another thing to consider, is that quite probably, our patient population is becoming more sick, with chronic conditions, abuses of alcohol and drugs, etc, and they are living longer only to be less healthy and less nutritionally sound, so that when we are starting nutrition, their chronic state of malnutrition, brought on by constant states of inflammation, poor intake and overall decompensation become apparent.
One thing I have learned over the years, as far as nutrition goals, is to not cause problems with nutrition being provided. This means, not adding to the overall chaos that may be going on with the patient. Low and slow is usually a good approach. This means starting with a lower amount of calories and protein the first few days, allowing for glucose levels to be controlled and insulin regimens to be put into place. Patients can be rehydrated and extreme kidney failure can be avoided. Having a goal rate for enteral nutrition of less than overall estimated energy needs for the first few days has led to better patient outcomes, less stress for the patient and better tolerance to nutrition.
“When nutrition begins, insulin not only transports glucose but also moves potassium and phosphate into intracellular spaces. Glucose oxidation increased the demand for thiamine and phosphate, resulting in hypokalemia, hypophosphatemia, hypomagnesemia, and may lead to fatal arrthymias, muscle weakness, congestive heart failure, lactic acidosis, and acute abdominal symptoms. Prevention resides in a progressive delivery of feeding (whatever the route) and in the development of hypophosphatemia, to slow down the process by temporary reduction of feeding.” http://arly Feeding in Critical Care – Where Are We Now? Mette M. Berger, MD, PhDa [email protected] ∙ Annika Reintam Blaser, MD, PhDb,c ∙ Orit Raphaeli, PhDd ∙ Pierre Singer, MDe,f
This is the best definition of Refeeding Syndrome I have found. It also includes a recommendation for decreasing feedings when phosphorus levels decrease by 0.16 mol/L.
This is one of my go to guides I have found to be helpful when feeding patients that you think may be at risk for Refeeding Syndrome. I review it weekly and share with all interns. It is so helpful to have it for reference and makes you realize the importance that monitoring for Refeeding Syndrome has become. This is, of course, from “Dietitians on Demand” I would highly recommend following them and signing up for their email list. They have lots of up to date information, graphics and continuing educations for clinical dietitians of all years of experiences.
An area that my hospital has made strides in is monitoring our PN patients for Refeeding Syndrome. Electrolyte assessment and supplementation is on the standing orders when any PN is ordered so abnormalities are taken care of in a timely manner. We have moved into a multidisciplinary model, where the RD’s and pharmacists are consulted to order, monitor and supplement the PN as needed. We do this under the direction of the Primary Care Provider, but quite honestly, they depend on us and our expertise for most of the decision making.
An area where we need more evaluation is our enteral feeding initiation. If our patients are in the ICU, they generally are having labs ordered fairly regularly, but if enteral nutrition is initiated on an acute care floor, that is not always the case. Improvement may be needed. That will be for another day.
In conclusion, Refeeding Syndrome is a major complication we are seeing more and more of. Anytime nutrition is initiated, it should be assessed as a possible outcome prior to initiating and advancing nutrition to the goal rate. Electrolyte monitoring and supplementation is vital for all patients having enteral or parenteral nutrition initiated. Good communication with PCP is important so they are aware of some of the side effects and outcomes of feeding that may have to be addressed after it is started.