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Kittrell HD, Shaikh A, Adintori PA, McCarthy P, Kohli-Seth R, Nadkarni GN, Sakhuja A. Role of artificial intelligence in critical care nutrition support and research. Nutr Clin Pract 2024; 39:1069-1080. [PMID: 39073166 DOI: 10.1002/ncp.11194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 06/06/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Nutrition plays a key role in the comprehensive care of critically ill patients. Determining optimal nutrition strategy, however, remains a subject of intense debate. Artificial intelligence (AI) applications are becoming increasingly common in medicine, and specifically in critical care, driven by the data-rich environment of intensive care units. In this review, we will examine the evidence regarding the application of AI in critical care nutrition. As of now, the use of AI in critical care nutrition is relatively limited, with its primary emphasis on malnutrition screening and tolerance of enteral nutrition. Despite the current scarcity of evidence, the potential for AI for more personalized nutrition management for critically ill patients is substantial. This stems from the ability of AI to integrate multiple data streams reflecting patients' changing needs while addressing inherent heterogeneity. The application of AI in critical care nutrition holds promise for optimizing patient outcomes through tailored and adaptive nutrition interventions. A successful implementation of AI, however, necessitates a multidisciplinary approach, coupled with careful consideration of challenges related to data management, financial aspects, and patient privacy.
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Affiliation(s)
- Hannah D Kittrell
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Clinical Intelligence Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ahmed Shaikh
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter A Adintori
- Food and Nutrition Services Department, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Program in Rehabilitation Sciences, New York University Steinhardt, New York, New York, USA
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, Division of Cardiovascular Critical Care, West Virginia University, Morgantown, West Virginia, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Girish N Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Clinical Intelligence Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ankit Sakhuja
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Jaxa-Kwiatkowski A, Łysenko L, Gara-Rucińska M, Leszczyszyn A, Gerber H, Kubiak M. Potentially Lethal But Rarely Considered. Risk of Developing Refeeding Syndrome in Primary Oral Squamous Cell Carcinoma. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101742. [PMID: 38141827 DOI: 10.1016/j.jormas.2023.101742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/14/2023] [Indexed: 12/25/2023]
Abstract
Presurgical preparation and postoperative care are cornerstones of all surgical procedures. Surgeons should be especially vigilant with malnourished cancer patients. Refeeding syn-drome (RFS) is a serious, potentially fatal complication of initiating appropriate nutrition in malnourished patients or after a period of starvation, although no standard precise definition has been proposed. The rarity of its une-quivocally life-threatening course means that its risk may be underestimated in clinical practice. The study's main goal was to assess the degree of malnutrition and the risk of RFS in the presurgical status of patients with oral cavity cancer and to identify risk factors for the occurrence of RFS. This single-center prospective observational study included patients diagnosed with oral squamous cell carcinoma. We investigated the relationship of RFS with age, BMI, features of the malignant tumor process selected internal medicine comorbidities, inflam-matory markers, renal and hepatic parameters, plasma levels of diverse electrolytes, and microelements were assessed. In the work, we utilized the National Institute for Health and Clinical Excellence (NICE) criteria. The study included 90 patients: 35 women and 55 men, aged 64.2±10.5. A robust statistical correlation at a significance level of p < 0.05 was demonstrated between advanced age, lower BMI, lymph node metastases, and a relatively low LDH as positive predictors of the onset of RFS and confirmed the high predictive value of the NRS-2002 scale. This paper seeks to call attention to RFS and identify critical issues that may be useful for its prevention.
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Affiliation(s)
| | - Lidia Łysenko
- Department of Anesthesiology and Intensive Therapy, Medical University Wroclaw, Poland
| | | | - Anna Leszczyszyn
- Oral Surgery outpatient Clinic, 4th Military Hospital,Weigla 5 Street Wroclaw
| | - Hanna Gerber
- Department of Maxillofacial Surgery, Medical University Wroclaw, Poland
| | - Marcin Kubiak
- Department of Maxillofacial Surgery, Medical University Wroclaw, Poland
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Statlender L, Raphaeli O, Shochat T, Robinson E, Hellerman Itzhaki M, Bendavid I, Fishman G, Singer P, Kagan I. Contributing factors to hypophosphatemia development in critically Ill ventilated patients: a retrospective cohort study. Sci Rep 2024; 14:19771. [PMID: 39187535 PMCID: PMC11347557 DOI: 10.1038/s41598-024-68688-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/25/2024] [Indexed: 08/28/2024] Open
Abstract
Hypophosphatemia (serum phosphate < 2.5 mg/dL) is a major concern when initiating nutritional support. We evaluated which factors contribute to hypophosphatemia development in critically ill patients, as well as the association between hypophosphatemia and mortality. A retrospective cohort study of patients who were ventilated for at least 2 days in a 16-bed mixed ICU. Data collected includes demographics, Acute Physiology & Chronic Health Evaluation 2 (APACHE2) admission score, Sequential Organ Failure Assessment score at 24 h (SOFA24), hourly energy delivery, plasma phosphate levels during the first 2 weeks of admission, ICU length of stay (LOS), length of ventilation (LOV), and mortality (ICU and 90 days). For the hypophosphatemia development model, we considered mortality as a competing risk. For mortality analysis, we used the Cox proportional hazards model considering hypophosphatemia development as a time-varying covariate. 462 patients were used in the analysis. 59.52% of the patients developed hypophosphatemia. Several factors were associated with a decreased risk of hypophosphatemia: age, BMI, pre-admission diabetes diagnosis, APACHE2, SOFA24, first kidney SOFA score, hospital admission time before ICU admission, and admission after liver transplantation. Admission due to trauma was associated with an increased risk of hypophosphatemia. Survival analysis with hypophosphatemia as a time-varying covariate showed a protective effect of hypophosphatemia from mortality (HR 0.447, 95% CI 0.281, 0.712). Age, APACHE2, and SOFA24 score were found to be significantly associated with ICU mortality. Fasting duration in the ICU before nutritional support initiation was not found to be significantly associated with hypophosphatemia. We examined several fasting intervals (12 h, 24 h, 36 h, 48 h, 60 h, 72 h). In each fast interval, we compared the prevalence of hypophosphatemia among patients who fasted the specified length of time, with those who did not fast for the same length of time. In each fasting interval, hypophosphatemia prevalence was lower in the fasting group compared to the non-fasting group. However, this difference was insignificant. BMI, APACHE2, and hospital LOS before ICU admission were inversely associated with hypophosphatemia development. Fasting for up to 72 h in the ICU before starting nutritional support did not affect hypophosphatemia occurrence. Hypophosphatemia was associated with lower mortality.
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Affiliation(s)
- Liran Statlender
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel.
- School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Orit Raphaeli
- Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel
- Industrial Engineering and Management, Ariel University, Ari'el, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Centre, Petah Tikva, Israel
| | - Eyal Robinson
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
| | - Moran Hellerman Itzhaki
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
- Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itai Bendavid
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Fishman
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pierre Singer
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
- Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilya Kagan
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
- Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zheng P, Chen Y, Chen F, Zhou M, Xie C. Risk factors for the development of refeeding syndrome in adults: A systematic review. Nutr Clin Pract 2024. [PMID: 39187889 DOI: 10.1002/ncp.11203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 07/18/2024] [Accepted: 08/01/2024] [Indexed: 08/28/2024] Open
Abstract
Identifying patients with a particularly high risk of refeeding syndrome (RFS) is essential for taking preventive measures. To guide the development of clinical decision-making and risk prediction models or other screening tools for RFS, increased knowledge of risk factors is needed. Therefore, we conducted a systematic review to identify risk factors for the development of RFS. PubMed, EMBASE, Cochrane Library, and Web of Science were searched from January 1990 until March 2023. Studies investigating demographic, clinical, drug use, laboratory, and/or nutrition factors for RFS were considered. The Newcastle-Ottawa Scale was used to appraise the methodological quality of included studies. Of 1589 identified records, 30 studies were included. Thirty-three factors associated with increased risk of RFS after multivariable adjustments were identified. The following factors were reported by two or more studies, with 0-1 study reporting null findings: a previous history of alcohol misuse, cancer, comorbid hypertension, high Acute Physiology and Chronic Health Evaluation II score, high Sequential Organ Failure Assessment score, low Glasgow coma scale score, the use of diuretics before refeeding, low baseline serum prealbumin level, high baseline level of creatinine, and enteral nutrition. The majority of the studies (20, 66.7%) were of high methodological quality. In conclusion, this systematic review informs on several risk factors for RFS in patients. To improve risk stratification and guide development of risk prediction models or other screening tools, further confirmation is needed because there were a small number of studies and a low number of high-quality studies on each factor.
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Affiliation(s)
- Ping Zheng
- Department of Nursing, PengZhou People's Hospital, Chengdu, Sichuan, China
| | - Yilin Chen
- Department of Nursing, ChengFei Hospital, Chengdu, Sichuan, China
| | - Feng Chen
- Department of Oncology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Min Zhou
- Department of Urology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Caixia Xie
- Department of Nursing, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Alencar LDO, Neto JEF, Beserra EA, Mendes JFR. Nutritional therapy in intensive care unit inpatients at risk for refeeding syndrome: A systematic review. Nutrition 2024; 128:112562. [PMID: 39317131 DOI: 10.1016/j.nut.2024.112562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/20/2024] [Accepted: 07/25/2024] [Indexed: 09/26/2024]
Abstract
The profiles of intensive care cnit (ICU) critically ill inpatients differ from those of other hospitalized patients, since organ dysfunction is a factor that increases the risk for Refeeding Syndrome (RS) development. It is important to understand the influence of feeding methods and caloric intake on mortality and RS incidence among critically ill adult inpatients. A systematic search, following PRISMA guidelines and protocol for systematic reviews, was conducted for interventional and experimental studies analyzing RS occurrence in adults admitted to ICUs. Pubmed, Scielo, Lilacs, Google Scholar, Scopus and Web of Science were the databases searched, and the Scottish Intercollegiate Guidelines Network (SIGN) tool was used to assess methodological quality of selected articles. Out of 945 abstracts screened, 32 articles were read in full and 20 were included for data extraction. Considerable heterogeneity was found between all studies reviewed. Enteral feeding was the most used method, and, in general, progression of caloric intake did not follow the American Society of Parenteral and Enteral Nutrition (ASPEN) or National Institute of Health and Care (NICE) recommendations for RS. In majority, data collection period of studies was less than 7 days; RS was observed in up to 52.5% of patients, and related mortality varied between 15.6 and 83.3%. Due to weak level of evidence and high heterogeneity found within reviewed studies, it is not possible to determine a robust recommendation as to what would be the best and safest feeding method and caloric progression protocol for patients at risk for developing RS.
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Affiliation(s)
- Larissa de Oliveira Alencar
- Programa de Residência Multiprofissional em Rede: Terapia Intensiva, Escola Superior de Ciências da Saúde, Brasília, Brazil..
| | - Jorge Ery Farias Neto
- Programa de Residência Multiprofissional em Rede: Terapia Intensiva, Escola Superior de Ciências da Saúde, Brasília, Brazil
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Asfour SS, Alshaikh B, Mathew M, Fouda DI, Al-Mouqdad MM. Incidence and Risk Factors of Refeeding Syndrome in Preterm Infants. Nutrients 2024; 16:2557. [PMID: 39125435 PMCID: PMC11313990 DOI: 10.3390/nu16152557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024] Open
Abstract
This study aimed to evaluate the incidence and risk factors associated with refeeding syndrome (RFS) in preterm infants (≤32 weeks gestational age) during their first week of life. Infants (gestational age ≤ 32 weeks; birth weight < 1500 g) who were admitted to the neonatal intensive care unit (NICU), level III, and received parenteral nutrition between January 2015 and April 2024 were retrospectively evaluated. Modified log-Poisson regression with generalized linear models and a robust variance estimator was applied to adjust the relative risk of risk factors. Of the 760 infants identified, 289 (38%) developed RFS. In the multivariable regression analysis, male, intraventricular hemorrhage (IVH), and sodium phosphate significantly affected RFS. Male infants had significantly increased RFS risk (aRR1.31; 95% CI 1.08-1.59). The RFS risk was significantly higher in infants with IVH (aRR 1.71; 95% CI 1.27-2.13). However, infants who received higher sodium phosphate in their first week of life had significantly lower RFS risk (aRR 0.67; 95% 0.47-0.98). This study revealed a notable incidence of RFS among preterm infants aged ≤32 gestational weeks, with sex, IVH, and low sodium phosphate as significant risk factors. Refined RFS diagnostic criteria and targeted interventions are needed for optimal management.
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Affiliation(s)
- Suzan S. Asfour
- Clinical Pharmacy Department, Pharmaceutical Care Services, King Saud Medical City, Riyadh 12746, Saudi Arabia; (S.S.A.)
| | - Belal Alshaikh
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Maya Mathew
- Clinical Pharmacy Department, Pharmaceutical Care Services, King Saud Medical City, Riyadh 12746, Saudi Arabia; (S.S.A.)
| | - Dina I. Fouda
- Clinical Pharmacy Department, Pharmaceutical Care Services, King Saud Medical City, Riyadh 12746, Saudi Arabia; (S.S.A.)
| | - Mountasser M. Al-Mouqdad
- Neonatal Intensive Care, Hospital of Pediatrics, King Saud Medical City, Riyadh 12746, Saudi Arabia
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Xu Y, Qian Y, Liang P, Liu N, Dong D, Gu Q, Tang J. Refeeding hypophosphatemia is a common cause of delirium in critically ill patients: A retrospective study. Am J Med Sci 2024:S0002-9629(24)01362-4. [PMID: 39033818 DOI: 10.1016/j.amjms.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 07/10/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The purpose was to explore the correlation between refeeding hypophosphatemia and delirium and analyze the related factors in critically ill patients. METHODS We conducted a retrospective review of critically ill patients admitted to Nanjing Drum Tower Hospital between September 2019 and March 2021. The patients were divided into delirium and nondelirium groups. Demographic data, underlying diseases, laboratory findings, comorbidities, nutritional intake and overall prognosis were collected and analyzed. RESULTS In total, 162 patients were included and divided into delirium (n=54) and nondelirium (n=108) groups. Serum phosphorus levels in the two groups decreased significantly in the first three days (P1, P2, P3) after nutrient intake compared with baseline before nutrient intake (Ppre). P1 and P2 were significantly lower in the delirium group compared to the nondelirium group. The maximum blood phosphorus reduction (Pmax) in the first three days after nutrient intake was significantly higher in the delirium group than in the nondelirium group. The time of Pmax in the delirium group was on the first day after nutrient intake. Multivariable logistic regression analysis identified starting route of nutrition and P1< 0.845 mmol/L as the independent predictors of delirium development in critically ill patients. CONCLUSION The incidence of delirium in critically ill patients is high and associated with refeeding hypophosphatemia. Delirium may occur with serum phosphorus levels less than 0.845 mmol/L on the first day.
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Affiliation(s)
- Ying Xu
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Yajun Qian
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Pei Liang
- Pharmacy Department, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Ning Liu
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Danjiang Dong
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Qin Gu
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Jian Tang
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China.
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Yang CJ, Chang CM, Chang GP, Tsai HT, Yu TY, Han YY. Unveiling the heightened susceptibility: Exploring early hypophosphatemia in critically ill trauma patients. J Formos Med Assoc 2024:S0929-6646(24)00286-9. [PMID: 38880709 DOI: 10.1016/j.jfma.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Phosphorus is a vital mineral crucial for various physiological functions. Critically ill trauma patients frequently experience hypophosphatemia during the immediate post-traumatic phase, potentially impacting outcomes. This study aims to investigate the incidence of early hypophosphatemia in critically major trauma patients. METHODS In this prospective observational study, trauma patients admitted to the intensive care unit (ICU) within one day were enrolled. These patients were categorized into Hypo-P groups and Non-hypo groups based on the development of new-onset hypophosphatemia within 72 h after feeding. The primary outcome assessed was the incidence of new-onset hypophosphatemia. The secondary outcomes included ICU and hospital stay, ventilation duration, and mortality. RESULTS 76.1% of patients developed a new onset of hypophosphatemia within 72 h after feeding. The Hypo-P group had significantly longer ICU stays (8.1 days ± 5.5 vs. 4.4 days ± 3.1; p = 0.0251) and trends towards extended hospital stay, ventilation duration, and higher mortality. Additionally, they demonstrated significantly higher urine fractional excretion of phosphate (FEPO4) on the first ICU day (29.2% ± 14.23 vs. 19.5% ± 8.39; p = 0.0242). CONCLUSION Critically ill trauma patients exhibited a significantly higher incidence of early hypophosphatemia than typical ICU rates, indicating their heightened vulnerability. The significantly high urine FEPO4 underscores the crucial role of renal loss in disrupting phosphate metabolism in this early acute phase after trauma. A significant correlation was observed between hypophosphatemia and longer ICU stays. Monitoring and managing phosphate levels may influence outcomes, warranting further investigation.
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Affiliation(s)
- Chi-Ju Yang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ming Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environment and Occupational Health Sciences, National Taiwan University, Taipei, Taiwan
| | - Gyu-Ping Chang
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Huei-Ting Tsai
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ting-Yu Yu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yin-Yi Han
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan; Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
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Olsen SU, Tazmini K, Aas AM, Ranhoff AH, Pripp AH, Hesseberg K, Sunde S, Bye A. The incidence and mortality of refeeding syndrome in older hospitalized patients, based on three different diagnostic criteria: A longitudinal study. Clin Nutr ESPEN 2024; 61:101-107. [PMID: 38777421 DOI: 10.1016/j.clnesp.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND & AIMS Refeeding syndrome (RFS) lacks both a global definition and diagnostic criteria. Different diagnostic criteria are used; serum phosphate (traditional criterion (TC)), the Friedli consensus recommendations, and the ASPEN. We investigated the incidence of RFS in older hospitalized patients and the mortality rates in patients with or without RFS using these three different diagnostic criteria. METHODS This is a longitudinal study with data originating from a randomized controlled trial conducted between March 2017 and August 2019. A total of 85 malnourished hospitalized patients at risk of RFS according to the National Institute for Health and Clinical Excellence tool for detecting patients at risk of RFS, were included. All patients were provided with enteral tube feeding, and electrolytes were measured daily during the intervention period. Friedli and ASPEN included phosphate, magnesium, and potassium in their definitions, but used different cut-off values. Incidences were recorded, and Kaplan-Meier estimates were used to determine whether mortality was more prevalent in patients with RFS. Regression analysis was used to test for confounders regarding the association between RFS and death, and Kappa was used to test for agreement between the three diagnostic criteria. RESULTS The mean (SD) age of the patients was 79.8 (7.4) years, and the mean (SD) BMI was 18.5 (3.4) kg/m2. The mean (SD) kcal/kg/day was 19 (11) on day one and 26 (15) on day seven. The incidences of RFS differed with the criteria used; 12.9% (TC), 31.8% (Friedli), and 65.9% (ASPEN). Mortality was high, with 36.5% (n = 31) and 56.5% (n = 48) of patients dead at three-month and one-year follow-up, respectively. In the TC, 8/11 (72.7%) with RFS vs. 40/74 (54.1%) without RFS died within one-year, in Friedli 15/27 (55.5%) with RFS vs. 33/58 (56.9%) without RFS died, and in ASPEN 32/56 (65.9%) with RFS, vs. 16/29 (55.2%) without RFS died within one-year. There was no statistically significant difference in mortality between patients with or without RFS regardless of which criteria were used. Age was the only variable associated with death at one-year. The Kappa analysis showed very low agreement between the categories. CONCLUSION Our results show that using different diagnostic criteria significantly impacts incidence rates. However, regardless of criteria used, the mortality was not significantly higher in the group of patients with RFS compared to the patients without RFS. Furthermore, none of the criteria showed a significant association with death at one-year. This supports the need for a global unified diagnostic criterion for RFS. This study was registered in ClinicalTrials.gov (identifier NCT03141489).
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Affiliation(s)
- Sissel Urke Olsen
- Diakonhjemmet Hospital, Department of Clinical Dietetics, Postboks 19, N-0319 Vinderen, Oslo, Norway.
| | - Kiarash Tazmini
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Faculty of Medicine, Oslo University Hospital, 0424 Oslo, Norway.
| | - Anne-Marie Aas
- University of Oslo, Faculty of Medicine, Institute of Clinical Medicine, 0424 Oslo, Oslo University Hospital, Division of Medicine, Department of Clinical Services, Section of Clinical Nutrition, Norway.
| | - Anette Hylen Ranhoff
- University of Bergen, Department of Clinical Science, 7804 Bergen, Norway; Diakonhjemmet Hospital, Medical Department, N-0319 Oslo, Norway.
| | - Are Hugo Pripp
- Oslo Metropolitan University (OsloMet), Faculty of Health Sciences, 1152 Oslo, Norway.
| | - Karin Hesseberg
- Diakonhjemmet Hospital, Department of Physiotherapy, Postboks 19N-0319 Oslo, Norway.
| | - Sylvia Sunde
- Diakonhjemmet Hospital, Department of Physiotherapy, Postboks 19N-0319 Oslo, Norway.
| | - Asta Bye
- Oslo Metropolitan University, Department of Nursing and Health Promotion, Faculty of Health Sciences, 1152 Oslo, Norway; European Palliative Care Research Centre (PRC), Dept. of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway.
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Colmenero M, Morón R, de Dios-Chacón I, Fernández-Morales P, Mañas-Vera MR, Manzano F. Incidence of hypophosphataemia after ICU admission in mechanically ventilated patients and its relationship with risk factors for refeeding syndrome. Med Intensiva 2024; 48:317-325. [PMID: 38388219 DOI: 10.1016/j.medine.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/02/2023] [Accepted: 12/13/2023] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To describe the incidence of hypophosphatemia in patients admitted to the ICU who have required mechanical ventilation. To analyze the presence of risk factors and its relationship with nutritional practice. DESIGN Prospective observational study. SETTING Polyvalent ICUs of 2 University Hospitals. PATIENTS OR PARTICIPANTS Patients on invasive mechanical ventilation ≥72 h with normal level of phosphorus at admission. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Electrolyte levels (phosphorus, magnesium, potassium) were determined on admission to the ICU and at 96 h. Risk categories on admission, caloric intake, insulin doses and acid-base status during the first 4 days of admission were recorded. Incidence was calculated as the number of patients who developed hypophosphataemia after admission. Univariate analysis was performed for between-group comparison and multivariate analysis of potential risk factors. RESULTS 89 patients were included. The incidence of hypophosphataemia was 32.6%. In these patients phosphorus decreased from 3.57 ± 1.02 mmol/l to 1.87 ± 0.65 mmol/l (52.3%). The mean kcal/kg/24 h provided in the first 4 days was 17.4 ± 4.1, with no difference between the group that developed hypophosphataemia and the group that did not. Significant risk factors were insulin doses administered and pH and PaCO2 values. CONCLUSIONS The incidence of hypophosphataemia at 96 h from admission in mechanically ventilated patients is high and unrelated to the risk category and hypocaloric nutritional practice used. Insulin dosis and acid-base status are the main determinants of its occurrence.
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Affiliation(s)
- Manuel Colmenero
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Cecilio, Granada, Spain; Instituto de Investigación Biosanitaria, Ibs.GRANADA, Granada, Spain.
| | - Rocío Morón
- Servicio de Farmacia Hospitalaria, Hospital Universitario Clínico San Cecilio, Granada, Spain; Instituto de Investigación Biosanitaria, Ibs.GRANADA, Granada, Spain
| | | | | | - María Reyes Mañas-Vera
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Manzano
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria, Ibs.GRANADA, Granada, Spain
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11
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Heydenrych N, De Maayer T, Nel M, van den Berg L. A retrospective cohort analysis of factors associated with the development of refeeding syndrome in children 0-59 months diagnosed with severe acute malnutrition in a South African setting. Heliyon 2024; 10:e30091. [PMID: 38694037 PMCID: PMC11061717 DOI: 10.1016/j.heliyon.2024.e30091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/07/2024] [Accepted: 04/19/2024] [Indexed: 05/03/2024] Open
Abstract
Background Refeeding syndrome (RFS) is a life-threatening, underdiagnosed, and under-researched complication in treating children with severe acute malnutrition (SAM). This study aimed to determine the incidence and onset of RFS and identify biochemical abnormalities, clinical signs, and complications associated with RFS development in children, 0-59 months, treated with SAM in a South African public hospital setting. Methods A retrospective cohort study was performed on hospital medical records of children aged 0-59 months, diagnosed with SAM at Rahima Moosa Mother and Child Hospital, Johannesburg, from 1/10/2014 to 31/12/2018. The onset of RFS among children included in the study was diagnosed based on published criteria for RFS. On admission, children who developed RFS and those who did not were compared concerning biochemistry and clinical signs and symptoms. Results A total of 148 medical records were retrieved from the hospital archives. The diagnosis of SAM based on the World Health Organization (WHO) definition was confirmed in 126 children who were then included in the study. The median age of the 126 children (63 % male) with confirmed SAM was 11.2 months (P25:7.0 months; P75:17.0 months). The in-hospital mortality rate was 18.2 %, of which 8.7 % were retrospectively diagnosed as having developed RFS during their recorded hospital stay, despite implementing the WHO treatment guidelines for SAM. A significantly higher percentage of the children who developed RFS presented on admission with hypophosphatemia (p = 0.015), hypokalemia (p = 0.001), hyponatremia (p = 0.001), an international normalized ratio (INR) of above 1.7 (p = 0.025), diarrhea (p = 0.042), dehydration (p = 0.029) and urinary tract infection (UTI) (p = 0.041), than those who did not. Children who developed RFS stayed in hospital significantly longer than those who did not (18 vs. 12 days with a p-value of 0.003). Conclusion In this population of children with SAM treated in a South African public hospital setting, the presence on hospital admission of low levels of electrolytes, elevated INR, dehydration, diarrhea, and UTI was significantly associated with developing RFS. Recognizing these as possible red flags for developing RFS in children admitted with SAM might contribute to improved outcomes and needs further investigation.
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Affiliation(s)
- Natalie Heydenrych
- Department of Nutrition and Dietetics, School of Health and Rehabilitation Sciences Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
- Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa
| | - Tim De Maayer
- Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa
- Clinical Unit, General Paediatrics, University of the Witwatersrand, South Africa
| | - Mariette Nel
- Department of Biostatistics, School of Biomedical Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Louise van den Berg
- Department of Nutrition and Dietetics, School of Health and Rehabilitation Sciences Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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12
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Chen S, Cai D, Lai Y, Zhang Y, He J, Zhou L, Sun H. Risk factors and outcomes for refeeding syndrome in acute ischaemic stroke patients. Nutr Diet 2024. [PMID: 38738826 DOI: 10.1111/1747-0080.12872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/24/2023] [Accepted: 03/04/2024] [Indexed: 05/14/2024]
Abstract
AIM Patients with acute ischaemic stroke are more likely to develop refeeding syndrome due to increased need for nutritional support when suffering alterations of consciousness and impairment of swallowing. This study aimed to evaluate the incidence, risk factors and outcomes of refeeding syndrome in stroke patients. METHODS This was a retrospective observational study, using the prospective stroke database from hospital, included all consecutive acute ischaemic stroke patients who received enteral nutrition for more than 72 h from 1 January 2020 and 31 December 2022. Refeeding syndrome was defined as occurrence of new-onset hypophosphataemia within 72 h after enteral feeding. Multiple logistic regression analysis was conducted to evaluate risk factors and relationships between refeeding syndrome and stroke outcomes. RESULTS 338 patients were included in the study. 50 patients (14.8%) developed refeeding syndrome. Higher scores on National Institutes of Health Stroke Scale and Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were risk factors for refeeding syndrome. Moreover, refeeding syndrome was independently associated with a 3-month modified Rankin Scale score of >2 and 6-month mortality. CONCLUSIONS Refeeding syndrome was common in stroke patients and higher baseline National Institutes of Health Stroke Scale, higher Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were independent risk factors of refeeding syndrome. Occurrence of refeeding syndrome was significantly associated with higher 3-month modified Rankin Scale and 6-month mortality.
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Affiliation(s)
- Shumin Chen
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Dongchun Cai
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Yuzheng Lai
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Yongfang Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianfeng He
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Liang Zhou
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao Sun
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
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13
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Biolato M, Terranova R, Policola C, Pontecorvi A, Gasbarrini A, Grieco A. Starvation hepatitis and refeeding-induced hepatitis: mechanism, diagnosis, and treatment. Gastroenterol Rep (Oxf) 2024; 12:goae034. [PMID: 38708095 PMCID: PMC11069106 DOI: 10.1093/gastro/goae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/27/2024] [Accepted: 03/19/2024] [Indexed: 05/07/2024] Open
Abstract
Anorexia nervosa (AN) is one of the most common psychiatric disorders among young adults and is associated with a substantial risk of death from suicide and medical complications. Transaminase elevations are common in patients with AN at the time of hospital admission and have been associated with longer lengths of hospital stay. Multiple types of hepatitis may occur in these patients, including two types that occur only in patients with AN: starvation hepatitis and refeeding-induced hepatitis. Starvation hepatitis is characterized by severe transaminase elevation in patients in the advanced phase of protein-energy deprivation and is associated with complications of severe starvation, such as hypoglycaemia, hypothermia, and hypotension. Refeeding-induced hepatitis is characterized by a milder increase in transaminases that occurs in the early refeeding phase and is associated with hypophosphatemia, hypokalemia, and hypomagnesaemia. Among the most common forms of hepatitis, drug-induced liver injury is particularly relevant in this patient cohort, given the frequent use and abuse of methamphetamines, laxatives, antidepressants, and antipsychotics. In this review, we provided an overview of the different forms of anorexic-associated hepatitis, a diagnostic approach that can help the clinician to correctly frame the problem, and indications on their management and treatment.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Rosy Terranova
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Caterina Policola
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
- Unit of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
- Unit of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
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14
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Hemstreet DES, Weisz GM. One Page in the History of Starvation and Refeeding. Rambam Maimonides Med J 2024; 15:RMMJ.10524. [PMID: 38717179 PMCID: PMC11065092 DOI: 10.5041/rmmj.10524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
There is a long history of starvation, including reports dated back to antiquity. Despite exceptional scientific developments, starvation still exists today. The medical aspects of starvation were well established in the twentieth century, particularly following studies related to the 1943-1944 Bengal famine in India and starved prisoners of war and survivors of World War 2. The refeeding of the starved victims provided disappointing results. Nevertheless, those studies eventually led to the development of a new branch of research in medicine and to the definition of what is now known as refeeding syndrome. This paper briefly reviews the history and groundwork that led to today's understanding of starvation and refeeding, with a particular emphasis on the observations from studies on starved Holocaust survivors and prisoners of war after World War 2. The relevance of these studies for modern times is briefly discussed.
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Affiliation(s)
- Deborah E.-S. Hemstreet
- English Communications Coordinator, Rambam Health Care Campus, Haifa, Israel
- Editorial Assistant, Rambam Maimonides Medical Journal, Haifa, Israel
| | - George M. Weisz
- School of Humanities, University of New South Wales, Sydney, Australia
- School of Humanities, University of New England, Armidale, Australia
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15
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Budka-Chrzęszczyk A, Szlagatys-Sidorkiewicz A, Bień E, Irga-Jaworska N, Borkowska A, Krawczyk MA, Popińska K, Romanowska H, Toporowska-Kowalska E, Świder M, Styczyński J, Szczepański T, Książyk J. Managing Undernutrition in Pediatric Oncology: A Consensus Statement Developed Using the Delphi Method by the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology. Nutrients 2024; 16:1327. [PMID: 38732574 PMCID: PMC11085082 DOI: 10.3390/nu16091327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
"Managing Undernutrition in Pediatric Oncology" is a collaborative consensus statement of the Polish Society for Clinical Nutrition of Children and the Polish Society of Pediatric Oncology and Hematology. The early identification and accurate management of malnutrition in children receiving anticancer treatment are crucial components to integrate into comprehensive medical care. Given the scarcity of high-quality literature on this topic, a consensus statement process was chosen over other approaches, such as guidelines, to provide comprehensive recommendations. Nevertheless, an extensive literature review using the PubMed database was conducted. The following terms, namely pediatric, childhood, cancer, pediatric oncology, malnutrition, undernutrition, refeeding syndrome, nutritional support, and nutrition, were used. The consensus was reached through the Delphi method. Comprehensive recommendations aim to identify malnutrition early in children with cancer and optimize nutritional interventions in this group. The statement underscores the importance of baseline and ongoing assessments of nutritional status and the identification of the risk factors for malnutrition development, and it presents tools that can be used to achieve these goals. This consensus statement establishes a standardized approach to nutritional support, aiming to optimize outcomes in pediatric cancer patients.
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Affiliation(s)
- Agnieszka Budka-Chrzęszczyk
- Department of Pediatrics, Pediatric Gastroenterology, Allergology and Nutrition, Medical University of Gdansk, 80-210 Gdansk, Poland; (A.S.-S.)
| | - Agnieszka Szlagatys-Sidorkiewicz
- Department of Pediatrics, Pediatric Gastroenterology, Allergology and Nutrition, Medical University of Gdansk, 80-210 Gdansk, Poland; (A.S.-S.)
| | - Ewa Bień
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Anna Borkowska
- Department of Pediatrics, Pediatric Gastroenterology, Allergology and Nutrition, Medical University of Gdansk, 80-210 Gdansk, Poland; (A.S.-S.)
| | - Małgorzata Anna Krawczyk
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Katarzyna Popińska
- Department of Pediatrics, Nutrition and Metabolic Diseases, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Hanna Romanowska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Ewa Toporowska-Kowalska
- Department of Pediatric Allergology, Gastroenterology and Nutrition, Medical University of Lodz, 91-738 Lodz, Poland
| | - Magdalena Świder
- Department of Anesthesiology and Critical Care Medicine, Clinical Provincial Hospital No. 2 in Rzeszow, 35-301 Rzeszow, Poland
| | - Jan Styczyński
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, 85-000 Bydgoszcz, Poland
| | - Tomasz Szczepański
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, 40-752 Katowice, Poland
| | - Janusz Książyk
- Department of Pediatrics, Nutrition and Metabolic Diseases, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
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16
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Apiromruck N, Kano H, Taemkaew K, Ingviya T, Intusoma U, Churuangsuk C. Association between energy delivery from parenteral nutrition and refeeding syndrome in hospitalized adults: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:318-328. [PMID: 38341682 DOI: 10.1002/jpen.2605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 12/27/2023] [Accepted: 01/19/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Patients receiving parenteral nutrition (PN) may develop refeeding syndrome (RFS). This study determined RFS prevalence in hospitalized adults on PN and evaluated whether higher energy delivered by PN on day 1 of PN initiation was associated with RFS development. METHODS We reviewed the medical records of adult patients receiving PN at a Thai quaternary hospital from June 2019 to May 2022. RFS was defined based on the Nutrition Management Clinical Practice Recommendation by the Society of Parenteral and Enteral Nutrition of Thailand. The association between PN energy delivery and RFS development was determined using a generalized estimating equation for multiple logistic regression analysis adjusted for NICE guideline risk factors. RESULTS A total of 547 patients was included (mean age 59.8 ± 17.2 years, mean body mass index 20.7 ± 4.8 ). The prevalence of RFS was 45%. Factors associated with RFS included energy from PN on the first day of PN initiation (adjusted odds ratio [aOR] 1.17; 95% CI 1.04-1.33; for every 5 kcal/kg/day increase), starvation >5 days prior to PN (aOR 1.54; 95% CI 1.04-2.26), concomitant diuretic use (aOR 1.81; 95% CI 1.25-2.64), low baseline potassium level (aOR 1.79; 95% CI 1.19-2.70), and individual compounding PN (aOR 1.61; 95% CI 1.04-2.51). CONCLUSION RFS was common among hospitalized patients receiving PN. The amount of energy delivered on the first day of PN was independently associated with RFS, raising a concern regarding initiation of PN with higher energy.
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Affiliation(s)
- Nichakarn Apiromruck
- School of Pharmacy, Walailak University, Thasala, Nakhon Si Thammarat, Thailand
- Clinical Nutrition and Obesity Medicine Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Hasma Kano
- Clinical Nutrition and Obesity Medicine Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kittithat Taemkaew
- Clinical Nutrition and Obesity Medicine Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thammasin Ingviya
- Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Hat Yai, Thailand
| | - Utcharee Intusoma
- Department of Pediatrics, Faculty of Medicine, Prince of Songkhla University, Hat Yai, Songkla, Thailand
| | - Chaitong Churuangsuk
- Clinical Nutrition and Obesity Medicine Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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17
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Nunes G, Guimarães M, Coelho H, Carregosa R, Oliveira C, Pereira SS, Alves de Matos A, Fonseca J. Prolonged Fasting Induces Histological and Ultrastructural Changes in the Intestinal Mucosa That May Reduce Absorption and Revert after Enteral Refeeding. Nutrients 2023; 16:128. [PMID: 38201958 PMCID: PMC10780540 DOI: 10.3390/nu16010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Malnutrition is usual in patients referred for endoscopic gastrostomy (PEG). Refeeding syndrome is rarely observed in PEG-fed patients, which could possibly be associated with reduced absorption induced by prolonged starvation. Objective: In patients submitted to PEG after a significant period of fasting, the present study aims to: 1. evaluate the histological/ultrastructural initial changes in the intestinal mucosa, potentially associated with reduced absorption, and 2. assess if these changes could reverse with enteral refeeding. Methods: The present study is an observational, prospective, controlled study. Adult patients with ingestion below 50% of daily needs for at least one month and/or diagnosis of malnutrition were enrolled. Duodenal biopsies were taken at baseline and after 3-6 months of PEG feeding, which then underwent histological/ultrastructural analysis. Random healthy individuals were used as controls. Results: A total of 30 patients (16 men/14 women) aged 67.1 ± 13.5 years were included. Malnutrition was found in 40% of patients. Approximately 14 patients completed follow-up during both periods (46.7%). At baseline: duodenal mucosal atrophy was evident in three patients (10%); the median villi length (MVL) was 0.4 mm (0.25-0.6 mm), with it being shorter than the controls, which was 0.6 mm (0.4-0.7 mm) (p = 0.006); ultrastructural changes included focal shortening, bending, and disruption of enterocyte microvilli, the presence of citoplasmatic autophagic vacuoles, dilation and vesiculation of the smooth endoplasmic reticulum, and the presence of dilated intercellular spaces with basement membrane detachment. After refeeding, most patients displayed normal histology (92.9%) and increase MVL (p < 0.001), ultrastructural changes disappeared, and enterocytes resumed a normal appearance, although retaining scarce, small, dense bodies in apical regions from the evolution of previous autophagy. Conclusions: Prolonged fasting induces histological and ultrastructural changes in the intestinal mucosa that may reflect impaired absorption in the early post-PEG period. These changes were reverted after refeeding with enteral nutrition.
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Affiliation(s)
- Gonçalo Nunes
- Gastroenterology Department, GENE—Artificial Feeding Team, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- ICBAS-UP—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
- PaMNEC—Grupo de Patologia Médica, Nutrição e Estudos Clínicos, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, 2829-511 Almada, Portugal
| | - Marta Guimarães
- UMIB—Unit for Multidisciplinary Research in Biomedicine, ICBAS—School of Medicine and Biomedical Sciences, Universidade do Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
- ITR—Laboratory of Integrative and Translocation Research in Population Health, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - Hélder Coelho
- Pathology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Ricardo Carregosa
- Cmicros—Centro de Microscopia Eletrónica e Histopatologia, CiiEM—Centro de Investigação Interdisciplinar Egas Moniz, 2829-511 Almada, Portugal
| | - Cátia Oliveira
- Gastroenterology Department, GENE—Artificial Feeding Team, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Sofia S. Pereira
- UMIB—Unit for Multidisciplinary Research in Biomedicine, ICBAS—School of Medicine and Biomedical Sciences, Universidade do Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
- ITR—Laboratory of Integrative and Translocation Research in Population Health, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - António Alves de Matos
- Cmicros—Centro de Microscopia Eletrónica e Histopatologia, CiiEM—Centro de Investigação Interdisciplinar Egas Moniz, 2829-511 Almada, Portugal
| | - Jorge Fonseca
- Gastroenterology Department, GENE—Artificial Feeding Team, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- ICBAS-UP—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
- PaMNEC—Grupo de Patologia Médica, Nutrição e Estudos Clínicos, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, 2829-511 Almada, Portugal
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Dunbar EMP, Pribble C, Cueto J, Goldschmidt AB, Tortolani C, Donaldson AA. Multi-electrolyte disturbance and supplementation in severely malnourished hospitalized adolescents with restrictive eating disorders. J Eat Disord 2023; 11:202. [PMID: 37968751 PMCID: PMC10647075 DOI: 10.1186/s40337-023-00919-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/27/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND This study describes the prevalence of hypophosphatemia, hypokalemia, and/or hypomagnesemia and resulting electrolyte supplementation during refeeding in severely malnourished youths hospitalized for restrictive eating disorders. METHODS Hospitalized patients between 11-26y (N = 81) at < 75% treatment goal weight (TGW) were assessed through retrospective chart review. Outcomes were compared between participants < 70% TGW and those 70-75% TGW. Nutritional rehabilitation started at 1750 kcals/day and advanced by 500 kcal every other day until target intake was achieved. Associations between %TGW on admission; hypophosphatemia, hypokalemia, and/or hypomagnesemia; and electrolyte supplementation were examined. RESULTS Of the 24 (29.6%) participants with hypophosphatemia, hypokalemia, and/or hypomagnesemia, 7 (8.6%) received supplementation; the remainder corrected without supplementation. Participants < 70% TGW did not differ from those 70-75% TGW on rates of these conditions or need for supplementation. CONCLUSIONS Hospital-based nutritional rehabilitation did not confer increased rates of hypophosphatemia, hypokalemia, and/or hypomagnesemia or need for electrolyte supplementation in patients < 70% TGW compared to those 70-75% TGW. While additional research is needed to establish clinical practice guidelines on electrolyte management in this population, our findings suggest that nutritional rehabilitation may be reasonably undertaken without prophylactic electrolyte supplementation, even in patients < 70% TGW.
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Affiliation(s)
- Eva-Molly Petitto Dunbar
- University of California San Diego Eating Disorders Center for Treatment and Research, San Diego, CA, 92121, USA.
| | - Chase Pribble
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
| | - Jennifer Cueto
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
- Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Andrea B Goldschmidt
- University of Pittsburgh School of Medicine, 3711 O'Hara St., Pittsburgh, PA, 15213, USA
| | - Christina Tortolani
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
- Rhode Island College, 600 Mount Pleasant Ave., Providence, RI, 02908, USA
| | - Abigail A Donaldson
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
- Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
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Naik NM, Li J, Seres D, Freedberg DE. Assessment of refeeding syndrome definitions and 30-day mortality in critically ill adults: A comparison study. JPEN J Parenter Enteral Nutr 2023; 47:993-1002. [PMID: 37689982 DOI: 10.1002/jpen.2560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/18/2023] [Accepted: 09/06/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Patients in the intensive care unit (ICU) are at high risk for refeeding syndrome (RFS), yet there is uncertainty regarding how RFS should be operationalized in the ICU. We evaluated different definitions for RFS and tested how they associated with patient-centered outcomes in the ICU. METHODS This was a retrospective comparison study. Patients age ≥18 years were eligible if they were newly initiated on enteral feeding while hospitalized in the ICU. Eight definitions for RFS were operationalized, including that from the American Society for Parenteral and Enteral Nutrition (ASPEN), all based on electrolyte levels from immediately before until up to 5 days after the initiation of enteral nutrition. Patients were followed for death or for ICU-free days, a measure of healthcare utilization. RESULTS In all, 2123 patients were identified, including 406 (19.1%) who died within 30 days of ICU admission and 1717 (80.9%) who did not. Prevalence of RFS varied from 1.5% to 88% (ASPEN definition) depending on the RFS definition used. The excess risk for death associated with RFS varied from 33% to 92% across definitions. The development of RFS based on the ASPEN definition was associated with a greater decrease in ICU-free days compared with other definitions, but the relationship was not statistically significant. CONCLUSION Eight definitions for RFS were evaluated, none of which showed strong associations with death or ICU-free days. It may be challenging to achieve a standardized definition for RFS that is based on electrolyte values and predicts mortality or ICU-free days.
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Affiliation(s)
| | - Jianhua Li
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - David Seres
- Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
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20
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Lopes HCB, Mazzolani BC, Koritar P, Cordás TA. Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review. Gen Hosp Psychiatry 2023; 85:43-54. [PMID: 37778285 DOI: 10.1016/j.genhosppsych.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN). METHODS This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS). RESULTS Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies. CONCLUSION All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.
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Affiliation(s)
- Helen Cristina Bittencourt Lopes
- Nutrition and Dietetics Service and Interdisciplinary Project for Care, Teaching, and Research on Eating Disorders in Childhood and Adolescence (PROTAD), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
| | - Bruna Caruso Mazzolani
- Applied Physiology & Nutrition Research Group and Laboratory of Assessment and Conditioning in Rhematology, University of São Paulo, São Paulo, Brazil.
| | - Priscila Koritar
- Nutrition and Dietetics Service, Barueri City Hall, São Paulo, SP, Brazil
| | - Táki Athanássios Cordás
- AMBULIM - Eating Disorders Program, Institute and Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
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21
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Terlisten K, Wirth R, Daubert D, Pourhassan M. Refeeding Syndrome in Older Hospitalized Patients: Incidence, Management, and Outcomes. Nutrients 2023; 15:4084. [PMID: 37764866 PMCID: PMC10535909 DOI: 10.3390/nu15184084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Refeeding syndrome (RFS) is a serious metabolic disturbance that manifests after reintroducing nutrition to severely malnourished individuals. Especially susceptible are older patients, due to higher malnutrition rates, although the incidence remains uncertain. Our study aimed to assess the occurrence and management of RFS in malnourished older hospitalized patients. This prospective study included 156 malnourished older patients, with malnutrition identified using the Mini Nutritional Assessment-Short Form. We evaluated critical biochemical parameters at admission and for ten days after starting nutritional therapy. Using the consensus evidence-based approach, we managed and evaluated RFS. We also tracked mortality and unexpected hospital readmissions for six months after discharge. The average patient age was 82.3 ± 7.5 years, with 69% female. Patients showed hypophosphatemia (23%), hypomagnesemia (31%), and hypokalemia (6%) on admission. Prior to nutritional replenishment, patients were classified as being at low (64%), high (30%), or very high risk (6%) for RFS. After nutritional therapy, 14% and 5% developed imminent and manifest RFS, respectively. There were no significant differences in six-month post-discharge mortality rates or unexpected hospital readmissions between patients with or without RFS. Despite adherence to guideline-recommended management, RFS can persist. No elevated mortality was noted in RFS patients, potentially due to early diagnosis and treatment.
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Affiliation(s)
| | | | | | - Maryam Pourhassan
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-Universität Bochum, 44625 Herne, Germany; (K.T.); (R.W.); (D.D.)
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22
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Stoody VB, Garber AK, Miller CA, Bravender T. Advancements in Inpatient Medical Management of Malnutrition in Children and Adolescents with Restrictive Eating Disorders. J Pediatr 2023; 260:113482. [PMID: 37196778 DOI: 10.1016/j.jpeds.2023.113482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/10/2023] [Accepted: 04/30/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Vishvanie Bernadene Stoody
- Division of Adolescent/Young Adult and Sports Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.
| | - Andrea Kay Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, CA
| | - Catherine Anne Miller
- Division of Adolescent/Young Adult and Sports Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Terrill Bravender
- Division of Adolescent/Young Adult and Sports Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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Puga FM, Baptista P, Oliveira A, França M. Refeeding syndrome: What to expect when you're not expecting. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 3:71-73. [PMID: 37640475 DOI: 10.1016/j.endien.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/20/2022] [Indexed: 08/31/2023]
Affiliation(s)
| | - Patrícia Baptista
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Oliveira
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Margarida França
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
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24
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Heuft L, Voigt J, Selig L, Schmidt M, Eckelt F, Steinbach D, Federbusch M, Stumvoll M, Schlögl H, Isermann B, Kaiser T. Development, Design and Utilization of a CDSS for Refeeding Syndrome in Real Life Inpatient Care-A Feasibility Study. Nutrients 2023; 15:3712. [PMID: 37686744 PMCID: PMC10490138 DOI: 10.3390/nu15173712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The refeeding syndrome (RFS) is an oftentimes-unrecognized complication of reintroducing nutrition in malnourished patients that can lead to fatal cardiovascular failure. We hypothesized that a clinical decision support system (CDSS) can improve RFS recognition and management. METHODS We developed an algorithm from current diagnostic criteria for RFS detection, tested the algorithm on a retrospective dataset and combined the final algorithm with therapy and referral recommendations in a knowledge-based CDSS. The CDSS integration into clinical practice was prospectively investigated for six months. RESULTS The utilization of the RFS-CDSS lead to RFS diagnosis in 13 out of 21 detected cases (62%). It improved patient-related care and documentation, e.g., RFS-specific coding (E87.7), increased from once coded in 30 month in the retrospective cohort to four times in six months in the prospective cohort and doubled the rate of nutrition referrals in true positive patients (retrospective referrals in true positive patients 33% vs. prospective referrals in true positive patients 71%). CONCLUSION CDSS-facilitated RFS diagnosis is possible and improves RFS recognition. This effect and its impact on patient-related outcomes needs to be further investigated in a large randomized-controlled trial.
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Affiliation(s)
- Lara Heuft
- Institute of Human Genetics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Jenny Voigt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Lars Selig
- Department of Endocrinology, Nephrology and Rheumatology, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Maria Schmidt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Felix Eckelt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Daniel Steinbach
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Martin Federbusch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Michael Stumvoll
- Department of Endocrinology, Nephrology and Rheumatology, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Haiko Schlögl
- Department of Endocrinology, Nephrology and Rheumatology, University Medical Center Leipzig, 04103 Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Zentrum München at University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Berend Isermann
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
- Institute for Laboratory Medicine, Microbiology and Pathobiochemistry, Medical School and University Medical Center OWL, Hospital Lippe, Bielefeld University, 32756 Bielefeld, Germany
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25
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Inayat-Hussain A, Falck H, Oorschot S, Picardo S, So K. Peripheral parenteral nutrition: An evaluation of its use, safety and cost implications in a tertiary hospital setting. Clin Nutr ESPEN 2023; 56:215-221. [PMID: 37344076 DOI: 10.1016/j.clnesp.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND AND AIMS Malnutrition is a common challenge among hospitalised patients and its associatiation with poor patient health-related outcomes places a significant financial burden on the healthcare system. Total parenteral nutrition (TPN) is the primary means for providing nutrition to individuals in whom enteral feeding is not possible but is costly and requires invasive central venous access. Peripheral parenteral nutrition (PPN) provides a suitable option for early nutrition provision in select patients; however, its routine use has been limited by safety and tolerability concerns, with high rates of phlebitis reported in previous studies. The objectives of this study were to review the use, safety, and costs of PPN in an Australian tertiary hospital. METHODS A single-site, prospective observational study was conducted over 15 months in a tertiary hospital. 139 participants (87 male and 52 female) were enrolled in the study. Data collected assessed the indication for PPN initiation, compliance with the hospital's protocols for PPN, total fasting days, the proportion of the patient's total energy and protein requirements provided by PPN, the incidence of phlebitis and potential cost implications associated with the use of PPN. RESULTS 139 patients (62.6% male), median age 62 years (IQR (interquartile range) 48-74) were enrolled. Most patients had an emergency admission (80.6%) under a general surgical team (84.2%). Forty-eight patients (34.5%) were malnourished, as assessed by the Subjective Global Assessment tool (SGA). Patients fasted for a median of 3 days (IQR 2-5) before PPN commencement, with a median duration of PPN use of 3 days (IQR 2-4). PPN provided an average of 61.6% of the patients' required caloric intake and 46.4% of protein requirements. Progression to TPN was observed in 34.5% of patients. There were low rates of complications with phlebitis observed in 3.7%, extravasation in 1.1%, and no patients developed septicaemia, despite suboptimal compliance with the recommended cannula management guidelines for PPN (66.4% compliant). The cost of PPN was estimated to be AUD$187 per patient day. CONCLUSION PPN is an effective short-term nutrient delivery solution to facilitate early feeding with small numbers of patients requiring transition to TPN. PPN was safe with low rates of cannula complications. Costs were favourable, with potentially significant cost savings as compared with TPN.
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Affiliation(s)
| | - Heather Falck
- Department of Dietetics and Nutrition, Royal Perth Hospital, Perth, WA, Australia.
| | - Sarah Oorschot
- Department of Pharmacy, Royal Perth Hospital, Perth, WA, Australia.
| | - Sherman Picardo
- Department of Gastroenterology, Royal Perth Hospital, Perth, WA, Australia.
| | - Kenji So
- Department of Gastroenterology, Royal Perth Hospital, Perth, WA, Australia.
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26
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Lima W, Calderaro DC, Passos R, Côrte M, Leal JA, Mayrink MO, Ferreira G. Lower mean phosphate independently predicts mortality in critically ill patients: Results from a prospective cohort study. J Crit Care 2023; 75:154273. [PMID: 36739201 DOI: 10.1016/j.jcrc.2023.154273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate lower mean phosphate as a prognostic tool in critically ill patients. METHODS This is a prospective single-center cohort study including adult patients (> 18 years) with a length of intensive care unit (ICU) stay of at least 24 h. Phosphatemia was evaluated within 1 h of ICU admission and once daily. Mean phosphate, calculated by the simple arithmetic mean of daily phosphate measurements, was proposed and tested. Standard severity scores were applied. Multivariate and survival analyses were performed. RESULTS A total of 317 patients were included, of whom 111 (35%) presented hypophosphatemia. Hypophosphatemia associated with surgical conditions, nutritional therapy, hypovitaminosis D, hyperparathyroidism, mechanical ventilation (need and duration), and ICU and hospital length of stay were evaluated. Admission APACHE II and SOFA (ICU days 1, 3, and 7) scores and ICU and in-hospital mortality were greater in the hypophosphatemia group than control group. Higher APACHE II (RR: 1.1; 95%CI: 1.01-1.2; p = 0.045) and lower mean phosphate (RR: 0.02; 95%CI: 0.001-0.09; p = 0.044) independently predicted ICU and in-hospital mortality. CONCLUSIONS Hypophosphatemia is frequent in the ICU, and was associated with unfavorable outcomes. This study introduces the importance of longitudinal monitoring of phosphate levels, since lower mean phosphate is an independent predictor of mortality in critically ill patients.
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Affiliation(s)
- Washington Lima
- Nutrition and Diet Service, Governador Israel Pinheiro Hospital - Instituto de Previdência Servidor do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Débora Cerqueira Calderaro
- Musculoskeletal System Department, Falculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Rogério Passos
- Intensive Care Unit, São Rafael Hospital, Salvador, Bahia, Brazil.
| | - Margaret Côrte
- Speech Therapy Nucleus, Governador Israel Pinheiro Hospital - Instituto de Previdência do Servidor do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Jose Adalberto Leal
- Nutrition and Diet Service, Governador Israel Pinheiro Hospital - Instituto de Previdência Servidor do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | | | - Gilda Ferreira
- Musculoskeletal System Department, Falculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Refeeding Syndrome Awareness among Physicians of King Abdullah Medical City in Makkah, Saudi Arabia. Healthcare (Basel) 2023; 11:healthcare11060794. [PMID: 36981452 PMCID: PMC10048025 DOI: 10.3390/healthcare11060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Background: Refeeding syndrome (RFS) is a lethal condition of metabolic disturbances that arise from the sudden switch of metabolism from a state of starvation to one of nourishment. Quick recognition would reduce health complications. Physicians who are unaware of the syndrome will not identify and treat it. As nutritional risk is associated with the risk of RFS, physicians should be aware of it. Aim: To determine whether the physicians of King Abdullah Medical City (KAMC) in Makkah know of RFS and, if so, have skills in diagnosis and managing the syndrome. Methods: One hundred and fifty-nine physicians of KAMC were recruited in a cross-sectional study. They were asked to complete a questionnaire by face-to-face interview. The questionnaire was designed to capture physicians’ knowledge and ability to manage RFS based on the awarding of certain scoring points. Results: The level of knowledge among physicians had a significant association between knowledge and age (p = 0.021) and medical specialty (p = 0.010). Additionally, the most knowledgeable physicians were those who work in critical care (21.4%). Around 18% of physicians were not able to manage RFS. Conclusions: Lacking knowledge of RFS and how to manage it leads to critical life-threatening complications. Physicians need nutritional education to help them diagnose RFS and consult dietitians to avoid its complications.
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Thiamine pharmaconutrition in sepsis: Monotherapy, combined therapy, or neither? Current evidence on safety and efficacy. Nutrition 2023; 109:112000. [PMID: 36913862 DOI: 10.1016/j.nut.2023.112000] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
Sepsis is a life-threatening condition characterized by multiorgan dysfunction due to an exaggerated host response to infection associated with a homeostatic failure. In sepsis, different interventions, aimed at improving clinical outcomes, have been tested over the past decades. Among these most recent strategies, intravenous high-dose micronutrients (vitamins and/or trace elements) have been investigated. According to current knowledge, sepsis is characterized by low thiamine levels, which are associated with illness severity, hyperlactatemia, and poor clinical outcomes. However, caution is needed about the clinical interpretation of thiamine blood concentration in critically ill patients, and the inflammatory status, based on C-reactive protein levels, should always be measured. In sepsis, parenteral thiamine has been administered as monotherapy or in combination with vitamin C and corticosteroids. Nevertheless, most of those trials failed to report clinical benefits with high-dose thiamine. The purpose of this review is to summarize the biological properties of thiamine and to examine current knowledge regarding the safety and efficacy of high-dose thiamine as pharmaconutrition strategy when administering singly or in combination with other micronutrients in critically ill adult patients with sepsis or septic shock. Our examination of the most up-to-date evidence concludes that Recommended Daily Allowance supplementation is relatively safe for thiamine-deficient patients. However, current evidence does not support pharmaconutrition with high-dose thiamine as a single therapy or as combination therapy aimed at improving clinical outcomes in critically ill septic patients. The best nutrient combination still needs to be determined, based on the antioxidant micronutrient network and the multiple interactions among different vitamins and trace elements. In addition, a better understanding of the pharmacokinetic and pharmacodynamic profiles of intravenous thiamine is needed. Future well-designed and powered clinical trials are urgently warranted before any specific recommendations can be made regarding supplementation in the critical care setting.
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Dock-Nascimento DB, Ribeiro AC, Silva Junior JM, de Aguilar-Nascimento JE. Impact of Nutritional Management on Survival of Critically Ill Malnourished Patients with Refeeding Hypophosphatemia. Arch Med Res 2023; 54:231-238. [PMID: 36805190 DOI: 10.1016/j.arcmed.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early nutritional therapy may aggravate hypophosphatemia in critically ill patients. AIM To investigate the influence of the type nutritional therapy on the survival of critically-ill malnourished patients at refeeding hypophosphatemia risk. METHODS Retrospective cohort study including malnourished, critically-ill adults, admitted from June 2014-December 2017 in an intensive care unit (ICU) at a tertiary hospital. Refeeding hypophosphatemia risk was defined as low serum phosphorus levels (<2.5 mg/dL) seen at two timepoints: before the initiation and at day 4 of the nutritional therapy. Patients receiving enteral nutrition (EN) were compared with those receiving supplemental parenteral nutrition (SPN-EN plus parenteral nutrition). Primary outcome was 60 d survival. Secondary endpoint was the incidence of refeeding hypophosphatemia risk. RESULTS We included 468-321 patients (68.6%) received EN and 147 (31.4%) received SPN. The mortality rate was 36.3% (n = 170). Refeeding hypophosphatemia risk was found in 116 (24.8%) patients before and in 177 (37.8%) at day 4 of nutritional therapy. The 60 d mean survival probability was greater for patients receiving SPN both before (42.4 vs. 22.4%, p = 0.005) and at day 4 (37.4 vs. 25.8%, p = 0.014) vs. patients receiving EN at the same timepoints. Cox regression showed a hazard ratio of 3.3 and 2.4 for patients at refeeding hypophosphatemia risk before and at day 4 of EN, respectively, compared to the SPN group at the same timepoints. CONCLUSION Refeeding hypophosphatemia risk was frequent in malnourished ICU patients and the survival for patients receiving SPN seemed associated with better survival than EN only.
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Affiliation(s)
| | - Amanda Coelho Ribeiro
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso Cuiabá, Brazil
| | - João Manoel Silva Junior
- Postgraduate Program in Anesthesiology of University of São Paulo, Brazil; Anesthesiology Department of Hospital do Servidor Publico Estadual, São Paulo, Brazil
| | - José Eduardo de Aguilar-Nascimento
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso Cuiabá, Brazil; University Center of Várzea Grande Medical School, Cuiabá, Brazil.
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Zhang W, Zhang SX, Chen SF, Yu T, Tang Y. Development and validation of risk prediction model for refeeding syndrome in neurocritical patients. Front Nutr 2023; 10:1083483. [PMID: 36875840 PMCID: PMC9975392 DOI: 10.3389/fnut.2023.1083483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023] Open
Abstract
Background The incidence of refeeding syndrome (RFS) in critically ill patients is high, which is detrimental to their prognoses. However, the current status and risk factors for the occurrence of RFS in neurocritical patients remain unclear. Elucidating these aspects may provide a theoretical basis for screening populations at high risk of RFS. Methods A total of 357 patients from January 2021 to May 2022 in a neurosurgery ICU of a tertiary hospital in China were included using convenience sampling. Patients were divided into RFS and non-RFS groups, based on the occurrence of refeeding-associated hypophosphatemia. Risk factors for RFS were determined using univariate and logistic regression analyses, and a risk prediction model for RFS in neurocritical patients was developed. The Hosmer-Lemeshow test was used to determine the goodness of fit of the model, and the receiver operator characteristic curve was used to examine its discriminant validity. Results The incidence of RFS in neurocritical patients receiving enteral nutrition was 28.57%. Logistic regression analyses showed that history of alcoholism, fasting hours, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores, low serum albumin, and low baseline serum potassium were risk factors of RFS in neurocritical patients (p < 0.05). The Hosmer-Lemeshow test showed p = 0.616, and the area under the ROC curve was 0.791 (95% confidence interval: 0.745-0.832). The optimal critical value was 0.299, the sensitivity was 74.4%, the specificity was 77.7%, and the Youden index was 0.492. Conclusion The incidence of RFS in neurocritical patients was high, and the risk factors were diverse. The risk prediction model in this study had good predictive effects and clinical utility, which may provide a reference for assessing and screening for RFS risk in neurocritical patients.
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Affiliation(s)
- Wei Zhang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Sheng-Xiang Zhang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Shu-Fan Chen
- Department of Nursing, Soochow University, Suzhou, China
| | - Tao Yu
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yun Tang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
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31
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Adika E, Jia R, Li J, Seres D, Freedberg DE. Evaluation of the ASPEN guidelines for refeeding syndrome among hospitalized patients receiving enteral nutrition: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2022; 46:1859-1866. [PMID: 35274317 PMCID: PMC9464262 DOI: 10.1002/jpen.2368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Until recently, refeeding syndrome (RFS) has lacked standardized diagnostic criteria. This study sought to (1) determine whether RFS, as operationalized in the 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline definition, is associated with adverse clinical outcomes and (2) identify key risk factors for RFS. METHODS In this retrospective cohort study, adults hospitalized from 2015 to 2019 were included if they were ordered for enteral feeding during hospitalization. Data were collected for up to 30 days, and RFS was operationalized as per the ASPEN 2020 guidelines as a ≥10% (corresponding to mild RFS), ≥25% (moderate), and ≥50% (severe) decline in prefeeding serum phosphorus, magnesium, or potassium. The mortality associated with RFS was assessed, and risk factors for RFS were identified using multivariable logistic regression modeling. RESULTS Of 3854 participants, 3480 (90%) developed mild RFS. Thirty-day mortality was higher in those without mild RFS (24%) than in those with mild RFS (18%) (P < 0.01). When RFS was reoperationalized as a 50% decline in electrolytes, 25% of patients developed RFS with a 20% 30-day mortality. Risk factors for development of RFS included renal failure, elevated creatinine, and low platelets; additionally, prefeeding serum phosphorus level was strongly associated with development of RFS (adjusted odds ratio, 6.09; 95% confidence interval, 4.95-7.49 for those in the highest tertile of prefeeding phosphorus compared with the lowest). CONCLUSION The ASPEN operationalization of RFS as a decline in baseline electrolyte values was not associated with death. Prefeeding serum phosphorus level strongly predicted severe RFS.
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Affiliation(s)
- Edem Adika
- City University Of New York School of Medicine, New York, New York, USA
| | - Rongqing Jia
- Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jianhua Li
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - David Seres
- Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
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Berlana D. Parenteral Nutrition Overview. Nutrients 2022; 14:4480. [PMID: 36364743 PMCID: PMC9659055 DOI: 10.3390/nu14214480] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/22/2022] [Indexed: 09/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.
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Affiliation(s)
- David Berlana
- Pharmacy Department, Vall Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain;
- Pharmacology, Toxicology and Therapeutic Chemistry Department, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
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Refeeding Hypophosphatemia in Hospitalized Adolescents With Anorexia Nervosa. J Adolesc Health 2022; 71:517-520. [PMID: 36123000 DOI: 10.1016/j.jadohealth.2022.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 10/14/2022]
Abstract
Refeeding hypophosphatemia in hospitalized adolescents with anorexia nervosa is correlated with degree of malnutrition, with a high index of suspicion for severely malnourished patients (<70% median body mass index). Weight history (greater magnitude or rate of weight loss prior to admission) regardless of presentation weight has also been associated with lower serum phosphate. Higher energy meal-based refeeding starting at 2,000 kcal has not been shown to be associated with higher rates of refeeding hypophosphatemia than the traditional standard of care, lower energy refeeding. Further research is needed to identify risk factors for refeeding hypophosphatemia and develop optimal delivery methods (oral vs. enteral), macronutrient content, and electrolyte replacement strategies to optimize weight gain without increasing the risk for refeeding hypophosphatemia.
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Liu N, Zhao XL, Xiong RQ, Chen QF, Wu YM, Lin ZZ, Wang SN, Wu T, Pan SY, Huang KB. The Performances of SNAQ, GLIM, mNICE, and ASPEN for Identification of Neurocritically Ill Patients at High Risk of Developing Refeeding Syndrome. Nutrients 2022; 14:nu14194032. [PMID: 36235685 PMCID: PMC9572145 DOI: 10.3390/nu14194032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
We previously found that neurocritically ill patients are prone to refeeding syndrome (RFS), a potentially life-threatening complication. However, there is no unified or validated consensus on the screening tool for RFS so far. We aimed to validate and compare the performance of four screening tools for RFS in neurocritically ill patients. We conducted a single-center, observational, retrospective cohort study among neurocritically ill adult patients who were admitted to the neurocritical care unit (NCU), and who received enteral nutrition for 72 h or longer. They were scored on the Short Nutritional Assessment Questionnaire (SNAQ), the Global Leadership Initiative on Malnutrition (GLIM), the modified criteria of the Britain’s National Institute for Health and Care Excellence (mNICE), and ASPEN Consensus Recommendations for Refeeding Syndrome (ASPEN) scales to predict RFS risk via admission data. The performance of each scale in predicting RFS was evaluated. Logistic regression analysis was used to identify the independent risk factors for RFS, and they were added to the above scales to strengthen the identification of RFS. Of the 478 patients included, 84 (17.57%) developed RFS. The sensitivity of the SNAQ and GLIM was only 20.2% (12.6–30.7%), although they had excellent specificities of 84.8% (80.8–88.1%) and 86.0% (82.1–89.2%), respectively; mNICE predicted RFS with a sensitivity of 48.8% (37.8–59.9%) and a specificity of 65.0% (60.0–69.9%); ASPEN had the highest Youden index, with a sensitivity and specificity of 53.6% (42.4–64.4%) and 64.7% (59.8–69.4%), respectively. The Area Under the receiver operating characteristic Curves (AUC) of SNAQ, GLIM, mNICE, and ASPEN to predict RFS were 0.516 (0.470–0.561), 0.533 (0.487–0.579), 0.568 (0.522–0.613), and 0.597 (0.551–0.641), respectively. We identified age, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Glasgow Coma Scale (GCS) score as independent risk factors of RFS, and the combination of GCS and age can improve the AUC of ASPEN to 0.664 (0.620–0.706) for predicting RFS. SNAQ, GLIM, mNICE, and ASPEN do not perform well in identifying neurocritically ill patients at high risk of RFS, although ASPEN appears to have relatively a good validity among them. Combining GCS and age with ASPEN slightly improves RFS recognition, but it still leaves a lot of room for improvement.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Su-Yue Pan
- Correspondence: (S.-Y.P.); (K.-B.H.); Tel.: +86-020-62787664 (S.-Y.P. & K.-B.H.)
| | - Kai-Bin Huang
- Correspondence: (S.-Y.P.); (K.-B.H.); Tel.: +86-020-62787664 (S.-Y.P. & K.-B.H.)
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Refeeding syndrome: What to expect when you’re not expecting. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Evaluation of refeeding hypophosphatemia frequency, risk factors, and nutritional status during stem cell transplantation in patients with hematologic malignancy. Clin Nutr ESPEN 2022; 51:385-390. [DOI: 10.1016/j.clnesp.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022]
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Refeeding Syndrome: A Critical Reality in Patients with Chronic Disease. Nutrients 2022; 14:nu14142859. [PMID: 35889815 PMCID: PMC9324596 DOI: 10.3390/nu14142859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 02/04/2023] Open
Abstract
Malnutrition is one of the most frequent metabolic challenges in the population of chronically ill patients. This results in increased administration of nutritional therapy in inpatient settings, which poses the risk of side effects, in particular, the development of refeeding syndrome. If not managed accordingly, it leads to a significant rise in morbidity and mortality. However, despite its importance, evidence-based recommendations on the management of refeeding syndrome are largely lacking, and only a few randomized controlled trials have been conducted. In light of this, the aim of this review is to raise awareness of refeeding syndrome in chronically ill patients by critically reviewing recent literature and providing a short overview as well as diagnosis and treatment algorithms of this underreported metabolic condition. In summary, recent findings suggest undergoing risk assessment and stratification for every patient receiving nutritional therapy. According to this, adaptation of energy and fluid support during the replenishment phase should be implemented in the nutritional therapy for patients at high risk. Additionally, continuous monitoring should take place, and appropriate actions should be initiated when necessary.
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Iacopelli M, Cereda E, Caccialanza R, Borgatti R, Mensi MM. Delayed appearance of refeeding syndrome in a patient with anorexia nervosa: a case report. Nutrition 2022; 103-104:111788. [DOI: 10.1016/j.nut.2022.111788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/09/2022] [Accepted: 06/25/2022] [Indexed: 10/31/2022]
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Liu P, Chen L, Zhong T, Zhang M, Ma T, Tian H. Impact of calorie intake and refeeding syndrome on the length of hospital stay of patients with malnutrition: a systematic review and meta-analysis. Clin Nutr 2022; 41:2003-2012. [DOI: 10.1016/j.clnu.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/04/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022]
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Incidence and Impact of Refeeding Syndrome in an Internal Medicine and Gastroenterology Ward of an Italian Tertiary Referral Center: A Prospective Cohort Study. Nutrients 2022; 14:nu14071343. [PMID: 35405956 PMCID: PMC9002385 DOI: 10.3390/nu14071343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Refeeding syndrome (RS) is a neglected, potentially fatal syndrome that occurs in malnourished patients undergoing rapid nutritional replenishment after a period of fasting. The American Society for Parenteral and Enteral Nutrition (ASPEN) recently released new criteria for RS risk and diagnosis. Real-life data on its incidence are still limited. Methods: We consecutively enrolled patients admitted to the Internal Medicine and Gastroenterology Unit of our center. The RS risk prevalence and incidence of RS were evaluated according to ASPEN. The length of stay (LOS), mortality, and re-admission rate within 30 days were assessed. Results: Among 203 admitted patients, 98 (48.3%) were at risk of RS; RS occurred in 38 patients (18.7% of the entire cohort). Patients diagnosed with RS had a higher mean LOS (12.5 days ± 7.9) than those who were not diagnosed with RS (7.1 ± 4.2) (p < 0.0001). Nine patients (4.4%) died. Body mass index (OR 0.82; 95% CI 0.69−0.97), RS diagnosis (OR 10.1; 95% CI 2.4−42.6), and medical nutritional support within 48 h (OR 0.12; 95% CI 0.02−0.56) were associated with mortality. Conclusions: RS incidence is high among clinical wards, influencing clinical outcomes. Awareness among clinicians is necessary to identify patients at risk and to support those developing this syndrome.
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41
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ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr 2022; 41:958-989. [DOI: 10.1016/j.clnu.2022.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/15/2022]
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42
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Santos DCD, Ataide CDG, Mota da Costa N, Oliveira Junior VPD, Egea MB. Blenderized formulations in home enteral nutrition: a narrative review about challenges in nutritional security and food safety. Nutr Rev 2022; 80:1580-1598. [PMID: 35026011 DOI: 10.1093/nutrit/nuab121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Blenderized formulations (BFs) are prepared by homogenization of food that is normally used in oral nutrition. BFs are mainly used in home enteral nutrition (HEN), although their use has also been reported by hospitals when commercial enteral formulas are not available. HEN is applied when the patient has been discharged from the hospital. This nutritional therapy promotes the patient's reintegration into the family nucleus and promotes humanized care, and decreases treatment costs. However, the patient should continue to receive health and nutritional care, ranging from periodic nutritional re-evaluation to adaptation of the dietary plan. HEN provides the patient a greater contact with the family, whereas BFs promote the adaptation of the diet with food, respecting the food diversity and culture, lower cost, and easier access to food. Disadvantages of BFs include more time spent by the professional to calculate the dietary plan, greater difficulty in adjusting daily needs, and less microbiological and chemical stability. In this review, the nutritional, food security, and safety aspects of BF used in HEN are discussed. Technological quality aspects that are essential knowledge in the preparation of the patient's dietary plan also are presented.
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Affiliation(s)
- Daiane Costa Dos Santos
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Carla Daniela Gomes Ataide
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Nair Mota da Costa
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Valtemir Paula de Oliveira Junior
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Mariana Buranelo Egea
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
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Sasegbon A, Hasan SS, Disney BR, Vasant DH. Rumination syndrome: pathophysiology, diagnosis and practical management. Frontline Gastroenterol 2022; 13:440-446. [PMID: 36046491 PMCID: PMC9380772 DOI: 10.1136/flgastro-2021-101856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Syed Shariq Hasan
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Benjamin R Disney
- Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Dipesh Harshvadan Vasant
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Proulx-Cabana S, Metras ME, Taddeo D, Jamoulle O, Frappier JY, Stheneur C. To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol. Nutrients 2022; 14:nu14010229. [PMID: 35011105 PMCID: PMC8747364 DOI: 10.3390/nu14010229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 02/05/2023] Open
Abstract
Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.
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Affiliation(s)
- Stephanie Proulx-Cabana
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
- Correspondence: (S.P.-C.); (C.S.)
| | - Marie-Elaine Metras
- Pharmacy Department, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada;
| | - Danielle Taddeo
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
| | - Olivier Jamoulle
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
| | - Jean-Yves Frappier
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
| | - Chantal Stheneur
- CESP, UVSQ, INSERM U 1178, Paris-Saclay University, 94805 Villejuif, France
- Clinique FSEF Varennes Jarcy, Fondation Sante des Etudiants de France, 91480 Varennes-Jarcy, France
- Simone Veil Health Science Training and Research Unit, Saint-Quentin-en-Yvelines University, 78180 Montigny-le-Bretonneux, France
- Correspondence: (S.P.-C.); (C.S.)
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Eilinger L, Arifi T, Dziadova V, Schuetz P. [Clinical Nutrition for the Medical Patient: From Screening to Diagnosis and Start of Nutritional Therapy]. PRAXIS 2022; 111:367-373. [PMID: 35611485 DOI: 10.1024/1661-8157/a003862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Clinical Nutrition for the Medical Patient: From Screening to Diagnosis and Start of Nutritional Therapy Abstract. With the demographic increase of elderly, multimorbid patients, the number of those with disease-related malnutrition is also steadily increasing. We now know that malnutrition is a strong and independent risk factor for morbidity, mortality, and poor quality of life. Fortunately, however, several studies have shown that malnutrition screening followed by physiological nutritional therapy to meet individual nutritional goals has a positive impact on the clinical course of medical patients. In this context, Nutritional Risk Screening is suitable as a tool for assessing nutritive risk in hospitalized and ambulatory patients in family practice. Patients at risk for malnutrition should undergo an in-depth clinical assessment in an interdisciplinary team of nutritionists, nurses, and physicians to clarify the etiology of malnutrition and risk factors, and to examine the indication for nutritional therapy. Such nutrition therapy should be individually tailored to the patient's nutritional needs (calorie, protein, and micronutrient requirements), the underlying disease and the patient's preferences. Patients should be closely monitored, and the therapy should be adapted during the disease.
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Affiliation(s)
- Luca Eilinger
- Allgemeine Innere und Notfallmedizin, Kantonsspital Aarau, Aarau, Schweiz
| | - Teuta Arifi
- Allgemeine Innere und Notfallmedizin, Kantonsspital Aarau, Aarau, Schweiz
| | - Vera Dziadova
- Allgemeine Innere und Notfallmedizin, Kantonsspital Aarau, Aarau, Schweiz
| | - Philipp Schuetz
- Allgemeine Innere und Notfallmedizin, Kantonsspital Aarau, Aarau, Schweiz
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Schönenberger KA, Dürig C, Huwiler VV, Reber E, Stanga Z. [Refeeding Syndrome: Where Do We Stand in 2022?]. PRAXIS 2022; 111:381-387. [PMID: 35611483 DOI: 10.1024/1661-8157/a003863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Refeeding Syndrome: Where Do We Stand in 2022? Abstract. The refeeding syndrome is a potentially life-threatening condition that can occur when refeeding malnourished patients. In recent years, two consensus manuscripts were published by the major clinical nutrition societies ESPEN and ASPEN. Pathophysiological aspects, clinical manifestations, prevention measures and criteria for diagnosis and management have been described in detail. The aim of this mini-review is to provide an evidence-based overview on the refeeding syndrome. For this purpose, the systematic literature search by Friedli et al. 2015 was updated. Evidence that the refeeding syndrome is associated with a negative clinical outcome exists. Many questions about management aspects remain unanswered. A robust randomized controlled trial is urgently needed to answer all these questions in an evidence-based manner and to elicit reliable evidence about independent predictors and an estimate of metabolic risk.
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Affiliation(s)
- Katja A Schönenberger
- Departement für Diabetologie, Endokrinologie, Ernährungsmedizin und Metabolismus (UDEM), Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
- Klinische Pharmazie und Epidemiologie, Departement Pharmazeutische Wissenschaften, Universität Basel, Basel, Schweiz
| | - Christa Dürig
- Departement für Diabetologie, Endokrinologie, Ernährungsmedizin und Metabolismus (UDEM), Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Valentina V Huwiler
- Departement für Diabetologie, Endokrinologie, Ernährungsmedizin und Metabolismus (UDEM), Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
- Klinische Pharmazie und Epidemiologie, Departement Pharmazeutische Wissenschaften, Universität Basel, Basel, Schweiz
| | - Emilie Reber
- Departement für Diabetologie, Endokrinologie, Ernährungsmedizin und Metabolismus (UDEM), Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Zeno Stanga
- Departement für Diabetologie, Endokrinologie, Ernährungsmedizin und Metabolismus (UDEM), Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Blanc S, Vasileva T, Tume LN, Baudin F, Chessel Ford C, Chaparro Jotterand C, Valla FV. Incidence of Refeeding Syndrome in Critically Ill Children With Nutritional Support. Front Pediatr 2022; 10:932290. [PMID: 35799690 PMCID: PMC9253668 DOI: 10.3389/fped.2022.932290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Early enteral nutrition is recommended for critically ill children, potentially exposing those who are undernourished to the risk of refeeding syndrome. However, data on its incidence is lacking, and the heterogeneity of diagnostic criteria and frequent electrolyte disorders in this population make its diagnosis complex. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) developed consensus recommendations for identifying patients at risk and with refeeding syndrome. These state that undernourished children are considered at risk of refeeding syndrome; those who develop one significant electrolyte disorder (decrease ≥ 10% in phosphorus, potassium, and/or magnesium) within the first five days of nutritional support, combined with a significant increase in energy intake, are considered to have refeeding syndrome. The aim of this study was to determine the incidence of refeeding syndrome according to the ASPEN definition in critically ill children on nutritional support. MATERIALS AND METHODS A secondary analysis of two prospective cohorts conducted in a tertiary pediatric intensive care unit in France was undertaken, and additional data were retrospectively collected. Children included were those (0-18 years) admitted to the pediatric intensive care unit with a minimum of one phosphorus, potassium, and/or magnesium assay and who received exclusive or supplemental nutritional support. Undernourished children (body mass index z-score < -2 standard deviations) were considered at risk of refeeding syndrome. The ASPEN critiera were used to identify those with probable refeeding syndrome. RESULTS A total of 1,261 children were included in the study, with 199 children (15.8%) classified as undernourished, who were at risk of refeeding syndrome. Of these, 93 children were identified as having probable refeeding syndrome, giving an overall incidence of 7.4%. The incidence rate among at-risk children was 46.7%. Most patients (58.1%) were classified as having severe refeeding syndrome. CONCLUSION Refeeding syndrome remains difficult to diagnose in critically ill children, due to frequent confounding factors impacting electrolyte plasma levels. These findings suggest that refeeding syndrome incidence may be high in undernourished children, and that refeeding syndromes can be severe. Further prospective studies using the ASPEN definition and risk criteria are required.
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Affiliation(s)
- Stéphanie Blanc
- HES-SO Master, HES-SO University of Applied Sciences and Arts Western Switzerland, University of Lausanne, Lausanne, Switzerland
| | - Tajnja Vasileva
- HES-SO Master, HES-SO University of Applied Sciences and Arts Western Switzerland, University of Lausanne, Lausanne, Switzerland
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, United Kingdom
| | - Florent Baudin
- Pediatric Intensive Care, Hospices Civils de Lyon, Lyon, France
| | | | - Corinne Chaparro Jotterand
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Frederic V Valla
- School of Health and Society, University of Salford, Salford, United Kingdom.,Pediatric Intensive Care, Hospices Civils de Lyon, Lyon, France
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Parker EK, Flood V, Halaki M, Wearne C, Anderson G, Gomes L, Clarke S, Wilson F, Russell J, Frig E, Kohn M. A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial. J Eat Disord 2021; 9:160. [PMID: 34895344 PMCID: PMC8666027 DOI: 10.1186/s40337-021-00513-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 11/19/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat). METHODS Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds. RESULTS At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay. CONCLUSIONS The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations. TRIAL REGISTRATION ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.
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Affiliation(s)
- Elizabeth Kumiko Parker
- Department of Dietetics and Nutrition, Westmead Hospital, PO Box 533, Wentworthville, NSW, 2145, Australia. .,Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Victoria Flood
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.,Western Sydney Local Health District, Westmead, NSW, 2145, Australia
| | - Mark Halaki
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Christine Wearne
- Department of Medical Psychology, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Gail Anderson
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Linette Gomes
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Simon Clarke
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia.,Centre for Research Into AdolescentS' Health (CRASH), Westmead Hospital, Westmead, NSW, 2145, Australia.,Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Frances Wilson
- Department of Psychiatry, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Janice Russell
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.,NSW Statewide Eating Disorder Service, Peter Beumont Unit, Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Elizabeth Frig
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Michael Kohn
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia.,Centre for Research Into AdolescentS' Health (CRASH), Westmead Hospital, Westmead, NSW, 2145, Australia.,Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
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Is the risk of refeeding syndrome a problem in reaching nutritional requirements? A cohort of patients on enteral nutrition support. NUTR HOSP 2021; 39:12-19. [PMID: 34825568 DOI: 10.20960/nh.03767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND refeeding syndrome (RS) is a metabolic complication associated with nutritional support. The lack of management protocols for patients on nutritional support may lead to the development of RS or undernourishment. OBJECTIVE to evaluate adherence to the algorithm for total enteral nutritional support (ASNET), and the efficacy of reaching nutrient requirements in patients at risk of RS. METHODS a cohort study: screening and nutritional evaluation of patients and risk of RS were performed. Adults admitted to hospital for noncritical illness who received exclusively enteral nutrition (EN) were eligible. Patients with RS, intestinal failure or chronic diarrhea were excluded. Adherence to ASNET was evaluated along with the efficacy of nutritional support to reach the optimal protein and energy requirement (OPER) and any associated complications. Patient follow-up ended when the feeding route was changed or upon discharge. RESULTS a total of 73 patients were included (mean age, 62 ± 16 yrs; BMI, 18.5 ± 4.2 kg/m2), and 55 % were men. All had nutritional risk of developing RS (57, low; 15, high; 1, very high); 34 % had adequate adherence to ASNET, and 33 % managed to cover the total requirement between 4 and 6 days. OPER was reached by 38 % by the fourth day of EN, and adequate adherence to ASNET increased the probability of achieving it (RR, 2.2; 95 % CI, 1.6-3.2, p < 0.0001) without increasing the associated complications. Nonetheless, 36 % developed complications, of whom 96 % did not adhere to ASNET. CONCLUSION adherence to ASNET in patients at risk of RS allowed the achievement of OPER safely by day four with fewer associated complications.
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Schunemann MJ, Bertschinger M, Trachsel C, Bachli E. Severe refeeding syndrome after human chorionic gonadotropin diet: a potentially lethal complication. BMJ Case Rep 2021; 14:e244011. [PMID: 34789523 PMCID: PMC8601063 DOI: 10.1136/bcr-2021-244011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/04/2022] Open
Abstract
We present the case of a young male patient who presented with paralysing muscle weakness due to severe hypokalaemia and hypophosphataemia. The initial patient history evaluations could not establish the aetiology. Only after we reviewed the patient's history did he reveal that he had been following a severe calorie-restricted regime, the human chorionic gonadotropin diet, which had ended 2 days prior to developing symptoms. This information then allowed us to diagnose severe refeeding syndrome. As a further complication, the patient developed rhabdomyolysis. After correction of serum electrolytes, symptoms resolved completely. This case emphasises the potential harm of severely calorie-restricted diets, often recommended by online 'experts'. Furthermore, we underline the importance of thorough history taking.
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Affiliation(s)
- Max J Schunemann
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Martina Bertschinger
- Department of Oncology and Haematology, Kantonsspital Winterthur, Winterthur, Switzerland
| | | | - Esther Bachli
- Inflammation Research Unit, Department for Internal Medicine, University Hospital Zurich, Schlieren, Switzerland
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