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Jeon TJ, Lee KJ, Woo HS, Kim EJ, Kim YS, Park JY, Cho JH. Refeeding Syndrome as a Possible Cause of Very Early Mortality in Acute Pancreatitis. Gut Liver 2019; 13:576-581. [PMID: 30970437 PMCID: PMC6743809 DOI: 10.5009/gnl18458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/21/2018] [Accepted: 12/10/2018] [Indexed: 01/17/2023] Open
Abstract
Background/Aims Refeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP). Methods Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals. Results Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support. Conclusions The findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.
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Affiliation(s)
- Tae Joo Jeon
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kyong Joo Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Sun Woo
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Eui Joo Kim
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Yeon Suk Kim
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Ji Young Park
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Korea
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Olthof LE, Koekkoek WK, van Setten C, Kars JC, van Blokland D, van Zanten AR. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: A retrospective study. Clin Nutr 2018; 37:1609-1617. [DOI: 10.1016/j.clnu.2017.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/08/2017] [Accepted: 08/03/2017] [Indexed: 12/15/2022]
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Bustos Lozano G, Soriano-Ramos M, Pinilla Martín MT, Chumillas Calzada S, García Soria CE, Pallás-Alonso CR. Early Hypophosphatemia in High-Risk Preterm Infants: Efficacy and Safety of Sodium Glycerophosphate From First Day on Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2018; 43:419-425. [PMID: 30070716 DOI: 10.1002/jpen.1426] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/25/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Early hypophosphatemia is common in premature infants ≤1250 g. The aim of this study was to assess the frequency and severity of hypophosphatemia after sodium glycerophosphate supplementation from first day of life in parenteral nutrition and to address the safety of this practice. METHODS Prospective cohort study of infants ≤1250 g birth weight born in a tertiary-care level neonatal intensive care unit and supplied with sodium glycerophosphate from the first day of life. Primary outcome was the presence of hypophosphatemia (<4 mg/dL) on the first week. Data were compared with our 2014 prospective subcohort of infants ≤1250 g receiving phosphate after 48 hours of life and morbidity with that of our 2016 retrospective cohort of ≤1250 g. RESULTS Fifty-four neonates were included. The frequency of hypophosphatemia was 29.6%. Only 1 patient presented hypophosphatemia <2 mg/dL. Mild hypokalemia was found in 8 patients (50%). No cases of hypernatremia were observed. Patients with hypophosphatemia had significantly lower gestational age (27.4 vs 28.8 weeks, P = .032) and lower z-score birth weight (-1.68 vs -0.47; P = .001). When compared with the 2014 subcohort, we found a lower frequency of hypophosphatemia (29.6% vs 69.2%; P = .008) and a lower rate of samples with hypophosphatemia (20.4% vs 51.4%; P = .0002) and critical hypophosphatemia (0.68% vs 11.4%, P = .0005). No differences were found in morbidity or mortality. CONCLUSIONS Sodium glycerophosphate supplementation in parenteral nutrition from the first day of life significantly decreased the frequency of hypophosphatemia. No adverse events were reported.
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Affiliation(s)
- Gerardo Bustos Lozano
- Division of Neonatology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Spanish Collaborative Maternal and Child Health Research Network, Complutense University of Madrid, Research Institute I+12, Madrid, Spain
| | - María Soriano-Ramos
- Division of Neonatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Carmen Rosa Pallás-Alonso
- Division of Neonatology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Spanish Collaborative Maternal and Child Health Research Network, Complutense University of Madrid, Research Institute I+12, Madrid, Spain
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López A, Varela JJ, Cid MM, Couñago M, Gago N. Hydroelectrolytic and infectious complications in one year of parenteral nutrition in critical care. ACTA ACUST UNITED AC 2018; 65:373-379. [PMID: 29680333 DOI: 10.1016/j.redar.2018.03.002] [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: 12/14/2017] [Revised: 02/13/2018] [Accepted: 03/04/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Parenteral nutrition consists of the intravenous administration of macronutrients, micronutrients and electrolytes. Our objectives were to evaluate the biochemical alterations during the first ten days of initiation and to quantify the bacteremia related to the central venous catheter during the administration of parenteral nutrition. MATERIAL AND METHODS Retrospective study of incidence and prevalence. We included 51 patients who started intravenous nutritional support therapy at Critical Care. We intend to know the infectious complications of the central line associated with parenteral nutrition, to evaluate the most frequent hydroelectrolytic complications of parenteral nutrition, and to identify minimum control points in the detection of hydroelectrolytic alterations. RESULTS Statistically significant daily variations were found for glucose, magnesium, potassium and creatinine, and bordering on the statistical significance for albumin and phosphate, the alterations occurring between the second and third days fundamentally. Hypoalbuminemia and hypocalcemia were very frequent. GGT was the liver enzyme that increased more frequently. The infection rate was 14.86 per 1,000 days of central venous catheter. CONCLUSIONS We found daily variations in glucose, potassium and magnesium, as well as a decrease in creatinine. We emphasize the frequency of hypoalbuminemia, hypocalcemia and elevation of GGT. The most important variations occurred between the second and third day, highlighting the precocity of potassium alteration and the peak of glycemia. The rate of infection related to the central venous catheter in patients with parenteral nutrition was high.
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Affiliation(s)
- A López
- Grupo de Investigación en Anestesia y Cuidados Críticos, Instituto de Investigación Sanitaria Galicia SUR (ISS Galicia Sur). SERGAS-UVigo, Vigo, España; Servicio de Anestesia y Reanimación, Complexo Hospitalario Universitario de Ourense (CHUO), Sergas, Ourense, España.
| | - J J Varela
- Servicio de Farmacia, Complexo Hospitalario Universitario de Ourense (CHUO), Sergas, Ourense, España
| | - M M Cid
- Grupo de Investigación en Anestesia y Cuidados Críticos, Instituto de Investigación Sanitaria Galicia SUR (ISS Galicia Sur). SERGAS-UVigo, Vigo, España; Servicio de Anestesia y Reanimación, Complexo Hospitalario Universitario de Ourense (CHUO), Sergas, Ourense, España
| | - M Couñago
- Grupo de Investigación en Anestesia y Cuidados Críticos, Instituto de Investigación Sanitaria Galicia SUR (ISS Galicia Sur). SERGAS-UVigo, Vigo, España; Servicio de Anestesia y Reanimación, Complexo Hospitalario Universitario de Ourense (CHUO), Sergas, Ourense, España
| | - N Gago
- Grupo de Investigación en Anestesia y Cuidados Críticos, Instituto de Investigación Sanitaria Galicia SUR (ISS Galicia Sur). SERGAS-UVigo, Vigo, España; Servicio de Anestesia y Reanimación, Complexo Hospitalario Universitario de Ourense (CHUO), Sergas, Ourense, España
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Bustos Lozano G, Hidalgo Romero Á, Melgar Bonis A, Ureta Velasco N, Orbea Gallardo C, Pallás Alonso C. Early hypophosphataemia in at risk newborns. Frequency and magnitude. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Araujo Castro M, Vázquez Martínez C. The refeeding syndrome. Importance of phosphorus. Med Clin (Barc) 2018; 150:472-478. [PMID: 29448987 DOI: 10.1016/j.medcli.2017.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/25/2017] [Accepted: 12/02/2017] [Indexed: 11/29/2022]
Abstract
Refeeding syndrome (RS) is a complex disease that occurs when nutritional support is initiated after a period of starvation. The hallmark feature is the hypophosphataemia, however other biochemical abnormalities like hypokalaemia, hypomagnesaemia, thiamine deficiency and disorder of sodium and fluid balance are common. The incidence of RS is unknown as no universally accepted definition exists, but it is frequently underdiagnosed. RS is a potentially fatal, but preventable, disorder. The identification of patients at risk is crucial to improve their management. If RS is diagnosed, there is one guideline (NICE 2006) in place to help its treatment (but it is based on low quality of evidence). The aims of this review are: highlight the importance of this problem in malnourished patients, discuss the pathophysiology and clinical characteristics, with a final series of recommendations to reduce the risk of the syndrome and facilitate the treatment.
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Affiliation(s)
- Marta Araujo Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Rey Juan Carlos, Madrid, España.
| | - Clotilde Vázquez Martínez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
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Pourhassan M, Cuvelier I, Gehrke I, Marburger C, Modreker MK, Volkert D, Willschrei HP, Wirth R. Prevalence of Risk Factors for the Refeeding Syndrome in Older Hospitalized Patients. J Nutr Health Aging 2018; 22:321-327. [PMID: 29484344 DOI: 10.1007/s12603-017-0917-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The incidence of refeeding syndrome (RFS) in older patients is not well-known. The aim of the study was to determine the prevalence of known risk factors for RFS in older individuals during hospitalization at geriatric hospital departments. DESIGN AND SETTING 342 consecutive older participants (222 females) who admitted at acute geriatric hospital wards were included in a cross-sectional study. We applied the National Institute for Health and Clinical Excellence (NICE) criteria for determining patients at risk of RFS. In addition, Mini Nutritional Assessment Short Form (MNA®-SF) was used to identify patients at risk of malnutrition. Weight and height were assessed. The degree of weight loss was obtained by interview. Serum phosphate, magnesium, potassium, sodium, calcium, creatinine and urea were analyzed according to standard procedures. RESULTS Of 342 older participants included in the study (mean age 83.1 ± 6.8, BMI range of 14.7-43.6 kg/m2), 239 (69.9%) were considered to be at risk of RFS, in which 43.5% and 11.7% were at risk of malnutrition and malnourished, respectively, according to MNA-SF. Patients in the risk group had significantly higher weight loss, lower phosphate and magnesium levels. In a multivariate logistic regression analysis, low levels of phosphate and magnesium followed by weight loss were the major risk factors for fulfilling the NICE criteria. CONCLUSION The incidence of risk factors for RFS was relatively high in older individuals acutely admitted in geriatric hospital units, suggesting that, RFS maybe more frequent among older persons than we are aware of. Patients with low serum levels of phosphate and magnesium and higher weight loss are at increased risk of RFS. The clinical characteristics of the older participants at risk of RFS indicate that these patients had a relatively poor nutritional status which can help us better understand the potential scale of RFS on admission or during the hospital stay.
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Affiliation(s)
- M Pourhassan
- Maryam Pourhassan, Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Germany, Hölkeskampring 40, D- 44625 Herne, Germany,
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Bustos Lozano G, Hidalgo Romero Á, Melgar Bonis A, Ureta Velasco N, Orbea Gallardo C, Pallás Alonso C. [Early hypophosphataemia in at risk newborns. Frequency and magnitude]. An Pediatr (Barc) 2017; 88:216-222. [PMID: 28587906 DOI: 10.1016/j.anpedi.2017.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/22/2017] [Accepted: 04/24/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the frequency and magnitude of neonatal hypophosphataemia (<4mg/dL) in a neonatal Intensive Care Unit and to describe risk groups. PATIENTS AND METHODS Retrospective study of hospitalised newborns over a 44 month period (phase 1). Retrospective study of <1,500g/<32 weeks of gestation newborns over a 6 month period (phase 2). Prospective study of <1,500g or 1,550-2,000g, and intrauterine growth restriction (IUGR) newborns. Measurements were made on the 1st, 3rd, 7th, and 14th days of life (phase 3). RESULTS Phase 1: 34 (2.4%) of 1,394 patients had a diagnosis of hypophosphataemia, 76% of them ≤32 weeks of gestation and <1500 grams, and 24% >32 weeks with weight<P10. Phase 2: 12 (16.4%) of 73 patients had a diagnosis of hypophosphataemia, with <2mg/dL in 5 (6.8%). Eight (75%) of those with hypophosphataemia had IUGR, and 4 (25%) weighed <1,000g. Five cases had associated hypokalaemia, and three hypercalcaemia. Phase 3: 9 (45%) of 20 patients had hypophosphataemia, all of them <1,000g or<1,200g and weight percentile <10. Thirty-three percent of samples on days 1, 3, and 7 showed hypophosphataemia, four of them <2mg/dL. There was mild hypokalaemia in 5 (55%), and mild hypercalcaemia in 2 (22%) cases. Hypophosphataemia was associated with lower enteral nutrition and higher parenteral amino acid intake in the early days of life. CONCLUSIONS Hypophosphataemia is common, and can be severe, in the first week of life in premature infants <1,000 grams, and newborns<1,200g with foetal malnutrition and receiving amino acids in early parenteral nutrition.
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Affiliation(s)
- Gerardo Bustos Lozano
- Servicio de Neonatología, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Red SAMID del Instituto Carlos III, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, España.
| | | | - Ana Melgar Bonis
- Servicio de Neonatología, Hospital Universitario 12 de Octubre, Madrid, España
| | | | | | - Carmen Pallás Alonso
- Servicio de Neonatología, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Red SAMID del Instituto Carlos III, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, España
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Solà-Bonada N, Carcelero-San Martín E, Miana-Mena MT, López-Suñé E, Diego-Del Río E, Ribas-Sala J. [Drug treatment in surgical patients with electrolyte imbalances]. FARMACIA HOSPITALARIA 2011; 36:84-91. [PMID: 21798781 DOI: 10.1016/j.farma.2010.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 12/21/2010] [Accepted: 12/29/2010] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To qualitatively and quantitatively determine electrolyte imbalances (potassium, phosphorus, magnesium and calcium) in patients admitted for general and gastrointestinal surgery, the degree of these imbalances in percentage detected by medical staff, and the acceptance of the recommendations made by the Hospital Pharmacy Department. METHOD Seven-month prospective study. Any alteration detected was recorded on a data collection form (personal data, hospital ward, type of alteration, detection by medical staff, type of pharmaceutical intervention, form of notification, acceptance of the intervention, date of imbalance correction, patient receiving parenteral nutrition). RESULTS 100 imbalances were detected in 66 patients (231 analytical tests revised). A total of 78 interventions were carried out. Most changes were due to hypokalaemia and hypomagnesaemia, hypophosphataemia being the most frequent abnormality in patients receiving parenteral nutrition.The acceptance of pharmaceutical intervention was higher if the information was oral (100% vs. 35% written). Twice the number of analytical tests were performed after interventions (RR: 2.1, 95% CI: 1.11 to 3.94, P=.006). When pharmaceutical intervention was accepted there was a greater number of imbalance resolutions in comparison with those cases which did not accept (RR: 1.5, 95% CI: 1.01 to 2.24, P=.04). CONCLUSIONS This study shows that electrolyte imbalances are common in surgical patients and the level of detection and monitoring by medical staff is low. Therefore, the pharmacist could help in improving this aspect.
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Affiliation(s)
- N Solà-Bonada
- Servicio de Farmacia, Hospital Clínic de Barcelona, España.
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