Refeeding syndrome: a literature review. Gastroenterol Res Pract. 2011;2011:pii: 410971. [PMID: 20886063 PMCID: PMC2945646 DOI: 10.1155/2011/410971]

Medical Considerations and Consequences of Eating Disorders

Eating disorders may result in medical complications that affect every body system with both acute and chronic consequences. Although some medical complications may require acute medical hospitalization to manage, other complications, such as low bone mineral density, may not present until malnutrition has become chronic. It is critical for team members to be aware of the early clinical signs of malnutrition and disordered eating behaviors, as well as longer-term complications that may affect their patients. When identifying eating disorder concerns, appropriate colleagues from the medical, nutrition, and psychiatric fields can be engaged in order to collaborate on stabilizing and improving the health of patients.

Potentially Lethal But Rarely Considered. Risk of Developing Refeeding Syndrome in Primary Oral Squamous Cell Carcinoma

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.

Multiple micronutrient deficiencies as a long-term complication of bariatric surgery

Micronutrient deficiencies may develop as a long-term complication of bariatric surgery due to alteration of gut anatomy and disruption of normal gut absorption. Inadequate repletion of essential vitamin and mineral deficiencies can lead to multisystem dysfunction. We present a case of a woman in her 50s, with a history of Roux-en-Y gastric bypass over 10 years ago, who presented with generalised weakness and a diffuse desquamating rash. A punch biopsy performed was compatible with nutritional deficiency. Labs revealed low levels of micronutrients A, B1, B6, C, E, zinc and copper. The patient received intravenous micronutrients and an oral regimen, which improved her symptoms. Unfortunately, the patient died from cardiac arrest secondary to pulmonary oedema. This report highlights the importance of high suspicion of micronutrient deficiency in patients with a history of bariatric surgery and maintaining lifelong nutritional follow-up.

Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review

Refeeding syndrome (RS) is characterized by electrolyte imbalances that can occur in malnourished and abruptly refed patients. Typical features of RS are hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency. It is a potentially life-threatening condition that can affect both adults and children, although there is scarce evidence in the pediatric literature. The sudden increase in food intake causes a shift in the body's metabolism and electrolyte balance, leading to symptoms such as weakness, seizures, and even heart failure. A proper management with progressive increase in nutrients is essential to prevent the onset of this condition and ensure the best possible outcomes. Moreover, an estimated incidence of up to 7.4% has been observed in pediatric intensive care unit patients receiving nutritional support, alone or as an adjunct. To prevent RS, it is important to carefully monitor feeding resumption, particularly in severely malnourished individuals. A proper strategy should start with small amounts of low-calorie fluids and gradually increasing the calorie content and amount of food over several days. Close monitoring of electrolyte levels is critical and prophylactic use of dietary supplements such as thiamine may be required to correct any imbalances that may occur. In this narrative review, we aim to provide a comprehensive understanding of RS in pediatric clinical practice and provide a possible management algorithm.

Prediction of postoperative hypokalemia in patients with oral cancer undergoing en bloc cancer resection: a retrospective cohort study

BACKGROUND

The factors associated with postoperative hypokalemia in patients with oral cancer remain unclear. We determined the preoperative factors associated with postoperative hypokalemia in patients with oral cancer following en bloc cancer resection and established a nomogram for postoperative hypokalemia prediction.

METHODS

Data from 381 patients with oral cancer who underwent en bloc cancer resection were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the risk factors for postoperative hypokalemia. We used receiver operating characteristic (ROC) curves to quantify the factors' effectiveness. A nomogram was created to show each predictor's relative weight and the likelihood of postoperative hypokalemia development. The multinomial regression model's effectiveness was also evaluated.

RESULTS

Preoperative factors, including sex, preoperative serum potassium level, and preoperative platelet-to-lymphocyte ratio (PLR), were significantly associated with postoperative hypokalemia. Based on the ROC curve, the preoperative serum potassium and PLR cut-off levels were 3.98 mmol/L and 117, respectively. Further multivariate analysis indicated that female sex, preoperative serum potassium level < 3.98 mmol/L, and preoperative PLR ≥ 117 were independently associated with postoperative hypokalemia. We constructed a predictive nomogram with all these factors for the risk of postoperative hypokalemia with good discrimination and internal validation.

CONCLUSIONS

The predictive nomogram for postoperative hypokalemia risk constructed with these factors had good discrimination and internal validation. The developed nomogram will add value to these independent risk factors that can be identified at admission in order to predict postoperative hypokalemia.

A case of life-threatening, early postoperative refeeding syndrome in an obese young female undergoing laparoscopic sleeve gastrectomy

Early complications after a laparoscopic sleeve gastrectomy (LSG) include bleeding, leaks, strictures and bowel obstructions. Patients post-LSG experience rapid but intended weight loss and may be on a restricted diet before and following surgery. Thus, many of these patients are in a malnourished state, placing them at a risk of developing potentially life-threatening refeeding syndrome (RFS). We describe the case of an 18-year-old female who developed RFS 2 weeks after LSG. We examine potential causes, review literature and discuss RFS pathophysiology as well as the guidelines that could help prevent RFS in bariatric surgery. Currently, not much is known about the risk of RFS in bariatric surgery and to our knowledge, this is the first report of RFS occurring in the early postoperative phase after LSG. A globally accepted definition of RFS should be established for guidelines to encompass wider patient groups.

Refeeding Syndrome Awareness among Physicians of King Abdullah Medical City in Makkah, Saudi Arabia

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.

Diurnal Fasting During Ramadan Leading to Superior Mesenteric Artery Syndrome

Superior mesenteric artery (SMA) syndrome is a favorite of anatomists and clinicians because it results from extrinsic compression of the duodenum by the 2 vascular structures forming the aortomesenteric angle (the descending abdominal aorta and the SMA). Although it is an uncommon cause of upper gastrointestinal obstruction, SMA syndrome can cause significant morbidity. It is more common in younger people. Historically, it has been associated with weight loss and eating disorders, but there are several other risk factors that should be considered in the workup. Cases of SMA syndrome are typically managed conservatively, but surgical referral and intervention may be considered in situations that fail conservative management. We present a case of this rare syndrome in a young man with no medical or psychiatric history during diurnal voluntary fasting in the month of Ramadan.

Refeeding Syndrome With Hyperemesis Gravidarum: A Case Report

Refeeding syndrome refers to a clinical condition whereby biochemical abnormalities such as hypokalemia, hypomagnesemia, and mainly hypophosphatemia occur upon recommencement of feeding, typically in malnourished catabolic patients. A 36-year-old female presented at 30 weeks gestation with hyperemesis gravidarum. During this admission, the patient developed transaminitis with low platelets prompting suspicion of hemolysis, elevated liver enzymes low platelets (HELLP) syndrome, but the concurrent findings of severe hypophosphatemia and rhabdomyolysis were not in favor of HELLP syndrome but that of refeeding syndrome. These clinical entities proved to be a diagnostic dilemma but, ultimately, the patient was managed under refeeding syndrome. The multidisciplinary approach amongst gastroenterology, internal medicine, obstetrics, hematology, and dietetics departments led to the slowing up of the titration of caloric feeds, which ultimately led to full recovery.

SIRT3-mediated mitochondrial autophagy in refeeding syndrome-related myocardial injury in sepsis rats

Background

Myocardial injury induced by refeeding syndrome (RFS) is one of the important causes of deterioration in critically ill patients. Sirtuin-3 (SIRT3) has been shown to regulate mitochondrial autophagy in myocardial ischemia/reperfusion injury; however, the role of mitochondrial autophagy on RFS-related myocardial injury in patients in critical condition has not been reported on.

Methods

Thirty Sprague-Dawley (SD) rats were divided into 3 groups (n=10 each group): the control group; the standard calorie refeeding (SCR) group; and the low calorie refeeding (LCR) group. The rats were weighed every third or four days from day 1 to day 14. On day 14, all rats were anesthetized and received an echocardiography test. Blood and bronchoalveolar lavage fluid (BALF) were collected and tested for arterial oxygen pressure (PaO₂), phosphorus (P), and calcium (Ca), creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), and cardiac troponin 1 (cTnI), myeloperoxidase (MPO), tumor necrosis factor α (TNF-α), interleukin-1β (IL-1β), and IL-6. The histopathological change of hearts and lungs were evaluated, and lung injury score was calculated. Mitochondrial autophagy related proteins (including Beclin1, LC3, mitofusin-2, Mfn2, PINK1, Parkin, and SIRT3) were analyzed using a Western blot. To evaluate the effect of SIRT3, 20 rats were divided into 2 groups (n=10 each group): The adeno-associated virus 9 (AAV9-Nc) group; and the AAV9-SIRT3 overexpression (AAV9-SIRT3) group. The protocols for rats were the same as the SCR group since day 22 after injection of AAV9. The protein expressions of PINK1, Parkin, and SIRT3 were compared between the AAV9-Nc group and AAV9-SIRT3 group.

Results

SCR caused significant decline in cardiac contractility and increased inflammatory cell infiltration in myocardial tissue. Meanwhile, Beclin1, LC3, PINK1, Parkin, and SIRT3 levels decreased, while Mfn2 showed no significant change. Furthermore, significant positive correlations were also found between SIRT3 and P, PINK1, and Parkin, and significant negative correlations were found between SIRT3 and CK-MB, LDH, and cTnI. Overexpression of SIRT3 activated the PINK1/Parkin mediated mitochondrial autophagy.

Conclusions

SIRT3 has an essential role in RFS-related myocardial injury during LPS induced chronic sepsis in rats, probably via regulating mitochondrial autophagy.

Electrolyte Derangements, Hyperlactatemia, and Cardiac Abnormalities Secondary to Refeeding in Three Dogs: Case Report

Three dogs that presented to the emergency service in severely emaciated body conditions were admitted to the hospital for monitoring and refeeding. During their hospitalization, all three dogs developed electrolyte derangements or required supplementation to prevent hypophosphatemia and hypomagnesemia. Additionally, all dogs developed hyperlactatemia, which was suspected to be secondary to thiamine deficiency. Two dogs were reported to have cardiac abnormalities, including cardiac arrhythmias, systolic dysfunction, and spontaneous echogenic contrast. These cases highlight the complexity of refeeding syndrome and its associated complications that extend beyond electrolyte deficiencies.

Timing of Psychopharmacological and Nutritional Interventions in the Inpatient Treatment of Anorexia Nervosa: An Observational Study

This study aims to investigate possible different outcomes in the inpatient treatment of anorexia nervosa (AN) related to different timings of psychopharmacological and nutritional interventions. A retrospective observational study was conducted, involving young patients hospitalized for AN, treated with naso-gastric tube feeding (NGT). Participants were divided into five groups according to early (0–7 days) or late (8+ days) introduction of atypical antipsychotics (AAP) and NGT: early AAP-early NGT (EE), early AAP-late NGT (EL), late AAP-early NGT (LE), late AAP-late NGT (LL) and a control group treated with NGT only (NGT). Concurrent clinical and treatment variables were analyzed. AN psychopathology was measured with the Eating Disorder Inventory-3 (EDI-3) EDRC score. Outcomes were assessed as admission-discharge body-mass index (BMI) improvement and length of hospital stay (LOS). Contributions of variables related to outcomes were assessed with multifactorial-analyses of variance (MANOVA). Seventy-nine patients were enrolled in the study. LOS was different among treatment groups (F (4, 75) = 5.993, p < 0.001), and EE patients showed lower LOS than LE (p < 0.001) and LL (p = 0.025) patients. BMI improvement was not significantly different among treatment groups but correlated negatively with age (F (1, 72) = 10.130, p = 0.002), and admission BMI (F (1, 72) = 14.681, p < 0.001). In conclusion, patients treated with early AAP and early NGT showed lower LOS than those treated with late AAP. Prognostic treatment variables should be investigated in wider samples.

Hyperemesis gravidarum induced refeeding syndrome causes blood cell destruction: a case report and literature review

Background

Hyperemesis gravidarum (HG) is a common complication during pregnancy, however, HG associated simultaneous onset of blood cell destruction due to electrolyte abnormalities is rare. In this case, a woman with refeeding syndrome (RFS) secondary to electrolyte abnormalities caused by severe HG was diagnosed and managed in our hospital.

Case presentation

A 29-year old woman was sent to the local hospitals because of severe HG with appetite loss, weight reduction, general fatigue, and she was identified to have severe electrolyte abnormalities. However, the electrolyte abnormalities were not corrected promptly, and then she had the symptoms of stillbirth, altered mental status, visual hallucination, hemolytic anemia and thrombocytopenia. After transferred to our hospital, we continued to correct the electrolyte abnormalities and the labor induction was performed as soon as possible. The symptoms of blood cell destruction were relieved obviously, and the patient discharged four days later. The electrolyte disturbances and physio-metabolic abnormalities caused by HG helped us diagnose this case as RFS.

Conclusions

This case emphasizes that patients with RFS should be diagnosed appropriately and intervened promptly in order to prevent electrolyte imbalance induced blood cell destruction.

Refeeding syndrome after radical cystoprostatectomy: A case report

Described as a potentially lethal condition that occurs in undernourished patients, refeeding syndrome (RFD) is a severe electrolyte disturbance that includes low intracellular serum concentrations of phosphor, magnesium and potassium in patients undergoing inappropriate oral or parenteral renutrition. We report a case of RFD in a 50-year-old male patient that occurs 22 days after a radical cystoprostatectomy. The patient was anorexic after the surgery, the body mass index decreased to 12,36 kg/m². The concentrations of albumin, magnesium, phosphor, and calcium were low. The Patient was admitted into the intensive care unit for severe cachexia and poor general condition 24 after introduction of parenteral nutrition (1500 Kcal/day). The evolution was lethal with multiple organ failure.

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The refeeding syndrome (SRI) is a complication occurring in malnourished patients during the reintroduction of enteral or parenteral energy intake.

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The clinical presentation can lead to a multiple organ failure.

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Earlier detection of patients at high risk of developing RFD is the main prevention.

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Prevention by substituting electrolytes and vitamins before initiating adequate support refeeding is crucial.

Perioperative peripheral parenteral nutrition to support major gastrointestinal surgery: Expert opinion on treating the right patients at the right time

BACKGROUND & AIMS

Patients undergoing major gastrointestinal surgery may be in particular need of nutritional therapy due to potential pre-existing disease-related malnutrition and the impact of surgical procedures. Peripheral parenteral nutrition (PPN), delivered via a peripheral catheter, is aligned with the Enhanced Recovery After Surgery (ERAS) concept of minimally invasive interventions where possible. However, uncertainties regarding perioperative PPN for patients undergoing major gastrointestinal surgery arise, in part, due to lack of clinical guidelines. This paper aims to provide practical guidance on perioperative PPN, within the framework of ERAS.

METHODS

A panel of surgeons and nurses convened to identify knowledge gaps and share their best practice experience regarding PPN provision for patients undergoing major gastrointestinal surgery. Clinical needs were identified and addressed based on the panel's experience and a narrative review.

RESULTS

Key topics addressed include how PPN can support ERAS nutritional recommendations, identifying gastrointestinal surgery patient subgroups who are likely to benefit from PPN, perioperative timepoints when PPN may be required, and optimizing the delivery of PPN. An algorithm to support the identification and management of patients' perioperative nutritional needs was developed.

CONCLUSIONS

This paper aims to assist healthcare providers by addressing best practice questions related to the use of PPN during the critical perioperative period within the ERAS concept. This may facilitate timely nutritional intervention to help improve postoperative clinical outcomes and quality of life for patients undergoing major gastrointestinal surgery.

Differential Diagnosis of Cachexia and Refractory Cachexia and the Impact of Appropriate Nutritional Intervention for Cachexia on Survival in Terminal Cancer Patients

Cancer cachexia subsequently shifts to refractory cachexia, however, it is not easy to properly differentiate them in clinical settings. Patients considered refractory cachexia may include cachectic patients with starvation. This study aimed to identify these cachectic patients and to evaluate the effect of nutritional intervention for them. Study subjects were terminal cancer patients admitted for palliative care and were judged refractory cachexia in the last five years. We retrospectively examined to find useful indices for identifying such cachectic patients and for evaluating the effect of nutritional intervention. Out of 223 patients in refractory cachexia, 26 were diagnosed cachexia with starvation after symptom management. Comparing before and one week after this management, Palliative Performance Scale (PPS) and transthyretin significantly improved (p < 0.0001, p = 0.0002, respectively) Then, we started nutritional intervention for these cachectic patients and divided into effective group (n = 17) and non-effective group (n = 9) using the criteria for cachexia. Comparing between the two groups, PPS significantly improved2 weeks after intervention in effective group (p = 0.006). Survival time was significantly longer in effective group (p = 0.008). PPS and transthyretin were useful for differential diagnosis of cachexia and refractory cachexia. PPS was useful for evaluating nutritional intervention for cachectic patients. Appropriate nutritional intervention improved survival.

Electrolyte disorders during the initiation of nutrition therapy in the ICU

PURPOSE OF REVIEW

To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition.

RECENT FINDINGS

Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome.

SUMMARY

Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.

Refeeding syndrome in a woman with pancreatitis: a case report

Refeeding syndrome can occur in malnourished patients with acute pancreatitis who have electrolyte imbalances. Refeeding syndrome is characterized by severe electrolyte imbalances (mainly hypophosphatemia, hypomagnesemia, and hypokalemia), vitamin deficiency (mainly thiamine deficiency), fluid overload, and salt retention resulting in organ dysfunction and cardiac arrhythmias. We herein report a case involving a patient with severe pancreatitis and gallbladder stones who developed refeeding syndrome with shock and loss of consciousness. The patient was treated by opportune vitamin and electrolyte supplementation therapy and showed substantial improvement after 2 weeks of hospitalization, gaining the ability to eat small bites of solid food orally. Early diagnosis and treatment of refeeding syndrome may reduce morbidity and mortality in patients with acute pancreatitis. Patients should be fasted only if alimentation is contraindicated, and electrolyte values must be closely monitored.

Outcomes of a higher calorie inpatient refeeding protocol in Asian adolescents with anorexia nervosa

OBJECTIVE

This study aims to compare the outcomes of higher calorie refeeding (HCR) and a lower calorie refeeding (LCR) methods among a diverse sample of young Asian adolescents admitted to a tertiary institution in Asia for management of anorexia nervosa (AN).

METHOD

This is a retrospective case control study of Asian adolescents who were managed using an inpatient HCR protocol (2016-2017) and an LCR protocol (2010-2014). Baseline characteristics, daily change in percent median body mass index (%mBMI), and rates of refeeding hypophosphatemia were analyzed between groups.

RESULTS

A total of 125 adolescents with AN were analyzed with 61 (52%) patients in the HCR group. Mean age was 14.0 years (SD =1.5) and mean presenting %mBMI was 73.2 (SD =6.9) with mean length of stay of 11.9 days (SD = 6.6). Patients in the HCR group had significantly increased rate of change of %mBMI (M = 0.39, SD = 0.31) than patients in the LCR group (M = 0.12, SD = 0.43) (p < .001). There was an increased rate of mild hypophosphatemia in the HCR group (HCR: 46%, LCR: 22%, p = .007) but no difference in rates of moderate hypophosphatemia and no cases of severe hypophosphataemia. Lower presenting %mBMI significantly predicted the phosphate levels (p = .004).

DISCUSSION

In a sample of Asian adolescents with AN, use of an HCR protocol was associated with improved rate of inpatient weight gain. There was increased risk of mild hypophosphataemia, but not moderate to severe hypophosphataemia, suggesting that an HCR protocol can be used safely with close monitoring of phosphate levels.

The Refeeding Syndrome: a neglected but potentially serious condition for inpatients. A narrative review

The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe undernourishment. RFS derives from an abnormal electrolyte and fluid shifts leading to many organ dysfunctions. Symptoms generally appear within 2-5 days of re-feeding and may be absent/mild or severe and life threating, depending on the pre-existing degree of malnutrition and comorbidities. The lack of a standard definition and the nonspecificity of the symptoms make both incidence estimate and diagnosis difficult. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) proposed a unifying definition for the RFS and its severity classification. The awareness of the condition is crucial for identifying patients at risk, preventing its occurrence, and improving the management. The objectives of this narrative review were to summarize the current knowledge and recommendations about the RFS and to provide useful tips to help physicians to recognize and prevent the syndrome.

Incidence of Refeeding Syndrome in Children With Failure to Thrive

OBJECTIVES

To determine the incidence of refeeding syndrome in otherwise healthy children <3 years of age admitted for failure to thrive (FTT).

METHODS

A multicenter retrospective cohort study was performed on patients aged ≤36 months admitted with a primary diagnosis of FTT from January 1, 2011, to December 31, 2016. The primary outcome measure was the percentage of patients with laboratory evidence of refeeding syndrome. Exclusion criteria included admission to an ICU, parenteral nutrition, history of prematurity, gastrostomy tube feeds, and any complex chronic conditions.

RESULTS

Of the 179 patients meeting inclusion criteria, none had laboratory evidence of refeeding syndrome. Of these, 145 (81%) had laboratory work done at the time of admission, and 69 (39%) had laboratory work repeated after admission. A small percentage (6%) of included patients experienced an adverse event due to repeat laboratory draw.

CONCLUSIONS

In otherwise healthy hospitalized patients <3 years of age with a primary diagnosis of FTT, routine laboratory monitoring for electrolyte derangements did not reveal any cases of refeeding syndrome. More robust studies are needed to determine the safety and feasibility of applying low-risk guidelines to this patient population to reduce practice variability and eliminate unnecessary laboratory evaluation and monitoring.

Hepatic ballooning degeneration: a new feature of the refeeding syndrome in rats

AIM OF THE STUDY

Hepatic changes have been described during the refeeding syndrome due to increase in enzymes and hepatomegaly; however, they have not been properly described. Thus, the objective of this study was to investigate the hepatic histological characteristics and biochemical markers of hepatic steatosis in Wistar rats with refeeding syndrome.

MATERIAL AND METHODS

Thirty male Wistar rats were allocated to one of three groups: C, F or R. The animals from group C received an AIN-93 diet for 96 hours, and were then sacrificed. Animals allocated to group F were fasted for 48 hours and sacrificed. Animals from group R were also fasted for 48 hours, but were refed for another 48 hours, with AIN-93. The liver, blood and epididymal and retroperitoneal fats were collected.

RESULTS

Data obtained in groups F and R show the changes observed in refeeding syndrome, during starvation and refeeding. The serum glucose, magnesium, potassium and phosphorus, in group F, decreased. There was no evidence of hepatic steatosis. Hypophosphatemia, hypomagnesemia and hypokalemia were also observed in group R, confirming refeeding syndrome. The main histological characteristic, in this group, was the extensive presence of ballooning degeneration. This is the first article that has detected such change in liver structure, due to refeeding syndrome. The possible causes are: retention of sodium, causing whole body edema; and/or dysfunction of the sodium/potassium pump of the hepatocytes, as a result of hypophosphatemia.

CONCLUSIONS

This is the first description of an animal model of hepatic severe ballooning degeneration induced due to refeeding syndrome.

Nutraceuticals and Exercise against Muscle Wasting during Cancer Cachexia

Cancer cachexia (CC) is a debilitating multifactorial syndrome, involving progressive deterioration and functional impairment of skeletal muscles. It affects about 80% of patients with advanced cancer and causes premature death. No causal therapy is available against CC. In the last few decades, our understanding of the mechanisms contributing to muscle wasting during cancer has markedly increased. Both inflammation and oxidative stress (OS) alter anabolic and catabolic signaling pathways mostly culminating with muscle depletion. Several preclinical studies have emphasized the beneficial roles of several classes of nutraceuticals and modes of physical exercise, but their efficacy in CC patients remains scant. The route of nutraceutical administration is critical to increase its bioavailability and achieve the desired anti-cachexia effects. Accumulating evidence suggests that a single therapy may not be enough, and a bimodal intervention (nutraceuticals plus exercise) may be a more effective treatment for CC. This review focuses on the current state of the field on the role of inflammation and OS in the pathogenesis of muscle atrophy during CC, and how nutraceuticals and physical activity may act synergistically to limit muscle wasting and dysfunction.

Case report: Nutrition therapy and side-effects monitoring in critically ill coronavirus disease 2019 patients

An outbreak of pneumonia proved to be infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), named Coronavirus Disease 2019 (COVID-19) by World Health Organization (WHO), has rapidly and widely spread to the whole world, affecting thousands of people. COVID-19 patients have poor gastrointestinal function and microecological disorders, which lead to the frequent occurrence of aspiration pneumonia, gastric retention, and diarrhea. In the meanwhile, it takes a certain period of time for nutrition therapy to reach the patient's physiological amount. Refeeding syndrome and hypoglycemia may occur during this period, causing the high risk of death in critical patients. Therefore, we reported the nutrition therapy and side-effects monitoring as well as the adjustment of the nutrition therapy of 2 critical COVID-19 patients, thus provide clinical evidence for nutrition therapy and prevention of the side effects.

Mortality associated with new risk classification of developing refeeding syndrome in critically ill patients: A cohort study

BACKGROUND & AIMS

Although refeeding syndrome (RFS) has been recognized as a potentially fatal metabolic complication, the definition of RFS has remained unclear. Recently, European researchers suggested an evidence-based and consensus-supported algorithm that consisted of a new RFS risk classification and treatment strategies for medical inpatients. The classification was based on the National Institute for Health and Clinical Excellence (NICE) criteria for patients at risk of developing RFS. In this study, we aimed to investigate the frequency of each applied new risk group and the association between the new classification and mortality in critically ill patients.

METHODS

This cohort study was conducted at a Japanese metropolitan tertiary-care university hospital from December 2016 to December 2018. We included critically ill adult patients who were admitted to the intensive care unit (ICU) via the emergency department and who stayed in the ICU for 24 h or longer. We applied the new risk classification based on the NICE RFS risk factors on ICU admission. The main exposure was risk classification of RFS: no risk, low risk, high risk, or very high risk. The primary outcome was in-hospital mortality censored at day 30 after ICU admission. We performed a multivariable analysis using Cox proportional hazard regression.

RESULTS

We analyzed 542 patients who met the eligibility criteria. The prevalence of the four RFS risk classification groups was 25.8% for no risk, 25.7% for low risk, 46.5% for high risk, and 2.0% for very high risk. The 30-day mortality was 5.0%, 7.2%, 16.3%, and 27.3%, respectively (log-rank trend test: p < 0.001). In the multivariable Cox regression, adjusted hazard ratios with no risk group as a reference were 1.28 (95% CI 0.48-3.38) for low risk, 2.81 (95% CI 1.24-6.35) for high risk, and 3.17 (95% CI 0.78-12.91) for very high risk.

CONCLUSIONS

Approximately half the critically ill patients were categorized as high or very high risk based on the new risk classification. Furthermore, as the risk categories progressed, the 30-day in-hospital mortality increased. Early recognition of patients at risk of developing RFS may improve patient outcomes through timely and optimal nutritional treatment.

Refeeding syndrome in small ruminants receiving parenteral nutrition

Background

Small ruminants presented to tertiary care facilities commonly suffer from severe protein‐calorie malnutrition. Some of these patients require parenteral nutrition (PN; amino acids and dextrose with or without lipids) during hospitalization. Refeeding syndrome, a potentially fatal shift of electrolytes seen in malnourished patients during refeeding, may occur.

Objective

(a) To report the prevalence of refeeding syndrome in small ruminants receiving PN and (b) to determine risk factors for the development of refeeding syndrome.

Animals

Hospitalized small ruminants (n = 20) that received PN from 2010 to 2018 and that had serial (≥2) monitoring of serum electrolyte concentrations after initiation of PN.

Methods

Retrospective case series. Refeeding syndrome was defined as the presence of at least 2 of the following electrolyte abnormalities after initiation of PN: hypophosphatemia, hypokalemia, hypomagnesemia, or some combination of these. Data was analyzed using Fisher's exact test, followed by univariate logistic regression.

Results

Eleven of 20 (55%) animals met the definition of refeeding syndrome. Mean minimum serum phosphorus concentration in animals with refeeding syndrome was 1.96 ± 0.69 mg/dL (reference range, 4.2‐7.6 mg/dL). Eleven of 20 animals survived to discharge. Survival rate did not differ significantly between refeeding cases (4/11, 36.3%) and nonrefeeding cases (7/9, 77.8%; P = .09). Mean serum phosphorus concentration was significantly lower in nonsurvivors than in survivors (1.88 ± 0.10 mg/dL vs 4.32 ± 0.70 mg/dL, P = .006).

Conclusions and Clinical Importance

We report the prevalence of refeeding syndrome in small ruminants receiving PN. Clinicians should anticipate refeeding syndrome after initiation of PN and consider pre‐emptive supplementation with phosphorus, potassium, magnesium, or some combination of these.

Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies

Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.

Refeeding syndrome: multimodal monitoring and clinical manifestation of an internal severe neurotrauma

Refeeding syndrome (RFS) is a rare, potentially life-threatening, condition seen in malnourished patients starting refeeding. RFS may provoke seizures and acute encephalopathy and can be considered an internal severe neurotrauma in need of specific treatment. The objective was to describe course of disease, treatment and, for the first time, multimodal monitoring output in a comatose patient suffering RFS. After gastric-banding and severe weight loss, the patient initiated self-starving and was transferred to our intensive care unit (ICU) following rapid refeeding. At arrival, seizures, decrease in consciousness (GCS 7) and suspected acute encephalitis was presented. Serum albumin was 8 g/l. Intracranial pressure (ICP), invasive blood pressure and electrocardiography (ECG) were monitored. Pressure reactivity (PR_x) and compliance (RAP) were calculated. The patient developed congestive heart failure, anuria and general oedema despite maximal neuro- and general ICU treatment. Global cerebral oedema and hypoperfusion areas with established ischemia were seen. ECG revealed massive cardiac arrhythmia and disturbed autonomic regulation. PR_x indicated intact autoregulation (-0.06 ± 0.18, mean ± SD) and relatively normal compliance (RAP = 0.23 ± 0.13). After 15 days the clinical state was improved, and the patient returned to the primary hospital. RFS was associated with serious deviations in homeostasis, high ICP levels, ECG abnormalities, kidney and lung affections. It is of utmost importance to recognize this rare syndrome and to treat appropriately. Despite the severe clinical state, cerebral autoregulation and compensatory reserve were generally normal, questioning the applicability of indirect measurements such as PR_x and RAP during neuro-intensive care treatment of RFS patients with cerebral engagement.

Systemic lupus erythematosus gastrointestinal involvement: a computed tomography-based assessment

Systemic lupus erythematosus (SLE) gastrointestinal (GI) complication is characterized by multi-segment and multi-compartment involvement. The aim of this study is to develop a computed tomography (CT) image-based system for disease evaluation. SLE patients with GI involvement from two independent cohorts were retrospectively included. Baseline abdominal CT scan with intravenous and oral contrast was obtained from each individual. A CT scoring system incorporating the extent of GI tract involvement and intestinal wall thickness, along with extra-GI compartment involvement, was developed and validated. The outcome measurement was the time to GI functional recovery, defined as the time to tolerable per os (PO) intake ≥50% of ideal calories (PO50). A total of 54 and 37 patients with SLE GI involvement were enrolled in the derivation and validation cohorts, respectively. The CT scores for SLE GI involvement were positively correlated with patients' time to PO50 (r = 0.57, p < 0.0001, derivation cohort; r = 0.42, p = 0.0093, validation cohort). Patients with a CT score ≤ 3 had a shorter time to PO50 (median time of 0 day) in pooled cohort, whereas those with a CT score > 3 incurred a significantly prolonged recovery with a median time to PO50 of 13 days (p < 0.0001). The CT-based scoring system may facilitate more accurate assessment and individualized management of SLE patients with GI involvement.

Refeeding syndrome in hematological cancer patients - current approach

Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.

Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician's Guide

PURPOSE OF REVIEW

To provide an overview of current methods of diagnosis and management of refeeding syndrome in the critically ill patient population.

RECENT FINDINGS

Despite recent publications indicating refeeding syndrome (RFS) is an ongoing problem in critically ill patients, there is no standard for the diagnosis and management of this life-threatening condition. There is not a "gold standard" nutrition assessment tool for the critically ill. Currently, the National Institute for Health and Clinical Excellence criteria represent the best clinical assessment tool for RFS. Diagnosis and management with the help of a multidisciplinary metabolic team can decrease morbidity and mortality. Although a universal definition of RFS has yet to be defined, the diagnosis is made in patients with moderate to severe malnutrition who develop electrolyte imbalance after beginning nutritional support. The imbalances potentially can lead to cardiac, pulmonary, and gastrointestinal complications and failure. Standardizing a multidisciplinary nutrition care plan and formulating a protocol for critically ill patients who develop RFS can potentially decrease complication rates and overall mortality.

Acute Respiratory Failure after Administration of Hydrogen Peroxide as an Emetic in a Cat

OBJECTIVE AND CASE SUMMARY

This case report describes a 5-year-old domestic short-haired cat that was orally administered with 4 mL of 3% hydrogen peroxide by the owner after suspecting ingestion of a foreign body by the cat. Shortly after the administration, the cat developed severe respiratory distress. Thoracic radiography showed an interstitial-to-alveolar pulmonary pattern, while echocardiography and heart injury markers ruled out a cardiac origin. Intensive management with oxygen, diuretics, bronchodilators, and sedation resulted in survival of the cat without further respiratory complications.

NEW AND UNIQUE INFORMATION PROVIDED

To the best of our knowledge, this is the first report of a lung injury and acute respiratory failure after administration of hydrogen peroxide in a cat with successful management.

Refeeding Syndrome as a Possible Cause of Very Early Mortality in Acute Pancreatitis

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.

Hypophosphatemia before endoscopic gastrostomy predicts higher mortality during the first week and first month post-gastrostomy: a risk marker of refeeding syndrome in gastrostomy-fed patients

Introduction

Introduction: starvation is usual in patients referred for endoscopic gastrostomy (PEG). A high risk of refeeding syndrome (RS) may contribute to poor prognosis. Objectives: this study aims to: a) evaluate serum phosphorus and magnesium when patients underwent PEG; b) determine the mortality rate during the first week and first month of enteral nutrition; and c) assess if hypophosphatemia or hypomagnesemia are associated with early mortality. Material and methods: retrospective study with patients followed in the Artificial Nutrition Clinic and died under PEG feeding. General nutritional assessment included NRS 2002, anthropometry and serum proteins. Serum phosphorus and magnesium were measured immediately before gastrostomy. Survival was recorded and compared to electrolyte and nutritional status. Results: one hundred and ninety-seven patients (137 men/60 women) aged 26-100 years. Most underwent PEG due to neurologic disorders (60.9%) and were malnourished according to body mass index (BMI) and serum proteins. Low phosphorus and magnesium were found in 6.6% and 4.6%, respectively. Hypophosphatemia was associated with malnutrition (p < 0.05). Mean survival was 13.7 ± 15.4 months. Mortality was 4.6% in the first week and 13.2% in the first month post-gastrostomy. Overall survival was shorter in malnourished patients but malnutrition did not directly influence early mortality (p > 0.05). Hypophosphatemia was associated with mortality during the first week (p = 0.02) and the first month of PEG feeding (p = 0.02). Conclusions: hypophosphatemia was uncommon but predicted early mortality after PEG. Although RS may be less frequent than expected, hypophosphatemia may be used as a RS marker and RS is the probable cause of increase early mortality in hypophosphatemic PEG-fed patients.

Refeeding in anorexia nervosa

Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/"underfeeding syndrome" and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients. What is Known: • Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice. • The risk of a refeeding syndrome is well known and well managed in severely malnourished patients ("conservative approaches"). What is New: • There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness. • The risks of "underfeeding syndrome" and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Graphical abstract.

Refeeding syndrome in the gastroenterology practice: how concerned should we be?

Clinical nutrition is emerging as a major area in gastroenterology practice. Most gastrointestinal disorders interfere with digestive physiology and compromise nutritional status. Refeeding syndrome (RS) may increase morbidity and mortality in gastroenterology patients. Literature search using the keywords "Refeeding Syndrome", "Hypophosphatemia", "Hypomagnesemia" and "Hypokalemia". Data regarding definition, pathophysiology, clinical manifestations, risk factors, management and prevention of RS were collected. Most evidence comes from case reports, narrative reviews and scarse observational trials. RS results from the potentially fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving nutritional therapy. No standard definition is established and epidemiologic data is lacking. RS is characterized by hypophosphatemia, hypomagnesemia, hypokalemia, vitamin deficiency and abnormal glucose metabolism. Oral, enteral and parenteral nutrition may precipitate RS. Awareness and risk stratification using NICE criteria is essential to prevent and manage malnourished patients. Nutritional support should be started using low energy replacement and thiamine supplementation. Correction of electrolytes and fluid imbalances must be started before feeding. Malnourished patients with inflammatory bowel disease, liver cirrhosis, chronic intestinal failure and patients referred for endoscopic gastrostomy due to prolonged dysphagia present high risk of RS, in the gastroenterology practice. RS should be considered before starting nutritional support. Preventive measures are crucial, including fluid and electrolyte replacement therapy, vitamin supplementation and use of hypocaloric regimens. Gastroenterology patients must be viewed as high risk patients but the impact of RS in the outcome is not clearly defined in current literature.

What a Trainee Surgeon Should Know About Refeeding Syndrome: A Literature Review

Refeeding syndrome (RFS) is potentially fatal, yet there is limited understanding regarding its management among general surgeons due in part to a lack of universally accepted guidelines for RFS diagnosis. The aim of this review is to equip general surgery trainees with the essentials of RFS including a review of the National Institute for Health and Care Excellence (NICE) best practice guidelines for RFS. We used the keywords "refeeding", "syndrome", and "hypophosphatemia" to search PubMed, Embase, and Medline databases. We reviewed approximately 130 indexed papers for relevance. Having profound knowledge of nutritional needs in critically ill patients will help trainee surgeons prevent illnesses in the spectrum of RFS, and, over time, this would immensely contribute to reducing the morbidity and mortality associated with RFS.

Malnutrition and refeeding syndrome prevention in head and neck cancer patients: from theory to clinical application

PURPOSE

The goal of this review is to raise awareness about refeeding syndrome (RFS) and to give a comprehensive presentation of recent guidelines and latest scientific data about nutritional management among head and neck cancer (HNC) patients while focusing on RFS prevention.

METHODS

A review of literature for nutritional assessment and RFS management was conducted. Electronic searches of Medline, Cochrane, PubMed and Embase databases for articles published in peer-reviewed journals were conducted from February to September 2017 using the keywords: "nutrition assessment", "head and neck cancer", "refeeding syndrome" and "guidelines". Articles, reviews, book references as well as national and international guidelines in English and French were included.

RESULTS

The prevalence of malnutrition is high in HNC patients and a large number of them will need artificial nutritional support or refeeding intervention. RFS is characterized by fluid and electrolyte imbalance associated with clinical manifestations induced by rapid refeeding after a period of malnutrition or starvation. Regarding risk factors for malnutrition and RFS, HNC patients are particularly vulnerable. However, RFS remains unrecognized among head and neck surgeons and medical teams. Practical data are summarized to help organizing nutritional assessment and refeeding interventions. It also summarizes preventive measures to reduce RFS incidence and morbidity in HNC population.

CONCLUSION

Nutritional assessment and early refeeding interventions are crucial for HNC patients care. As prevention is the key for RFS management, early identification of patients with high risks is crucial and successful nutritional management requires a multidisciplinary approach.

Parenteral Nutrition Electrolyte Abnormalities and Associated Factors Before and After Nutrition Support Team Initiation

BACKGROUND

Studied since the 1940s, refeeding syndrome still has no universal definition, thus making comparison of studies difficult. Negative outcomes (eg, metabolic abnormalities) may occur with the use of specialized nutrition, such as parenteral nutrition (PN). Less than half of medical institutions have a nutrition support team (NST) managing PN. Interdisciplinary team management of PN may reduce negative outcomes of PN. The objective of this study was to show the value of the NST by measuring differences in PN variables, especially electrolyte abnormalities (EAs), before and after NST initiation at a large medical center and to identify factors associated with EAs among adult subjects receiving PN.

MATERIALS AND METHODS

During this retrospective study, computerized medical charts (N = 735) from 2007-2010 were reviewed for electrolyte changes (particularly potassium, magnesium, and phosphorus) the first 3 days following PN initiation in hospitalized adults. Changes in EAs with other variables were compared before and after NST implementation. Equivalent samples sizes were collected to better evaluate the impact of the team.

RESULTS

Following the implementation of the NST, fewer EAs were seen in PN patients (53%; χ2  = 10.906, P = .004); significantly less potassium, phosphorus, and magnesium intravenous piggyback supplementation (88.8% vs 94%; χ2  = 5.05, P = .026) was used; and mortality within 30 days of PN cessation was significantly less (12.7% vs 10.6%, P = .012).

CONCLUSION

Our study complements existing research, finding that an NST was associated with a decreased occurrence of EAs and mortality in the hospitalized adult receiving PN.

Risk factors of refeeding syndrome in malnourished older hospitalized patients

BACKGROUND & AIMS

Despite the high prevalence of malnutrition among older hospitalized persons, it is unknown how many of these malnourished patients are at risk of developing the refeeding syndrome (RFS). In this study, we sought to compare the prevalence and severity of malnutrition among older hospitalized patients with prevalence of known risk factors of RFS.

METHODS

This cross-sectional multicenter-study investigated older participants who were consecutively admitted to the geriatric acute care ward. Malnutrition screening was conducted using Nutritional Risk Screening (NRS-2002), Malnutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment-Short Form (MNA-SF). The National Institute for Health and Clinical Excellence (NICE) criteria were applied for assessing patients at risk of RFS. Weight and height were measured. Degree of weight loss (WL) was obtained by interview. Serum phosphate, magnesium, potassium, sodium, calcium, creatinine and urea were analyzed according to standard procedures.

RESULTS

The study group comprised 342 participants (222 females) with a mean age of 83.1 ± 6.8 and BMI range of 14.7-43.6 kg/m². More participants were assessed at risk of malnutrition using NRS-2002 (n = 253, 74.0%) compared to MUST (n = 170, 49.7%) and MNA-SF (n = 191, 55.8%). Of total participants, 239 (69.9%; 157 females) were considered to be at risk of RFS. Based on NRS-2002, 75.9% (n = 192) of patients at risk of malnutrition are at risk of RFS whereas according to MUST and MNA-SF, 85.9% (n = 146) and 69.1% (n = 132) of patients at risk of malnutrition are exposed to high risk of RFS, respectively. In addition, the prevalence of risk of RFS is significantly increased with higher score of NRS-2002 and MUST and lower score of MNA-SF. In a stepwise multiple regression analysis, disease severity (38.2%), WL in 3 months (20.3%) and BMI (33.3%) mainly explained variance in NRS-2002, MUST and MNA-SF scores, respectively, in patients with risk of RFS.

CONCLUSION

Nearly three-quarters of geriatric hospitalized patients with risk of malnutrition demonstrated significant risk of RFS. Therefore, additional screening for risk of RFS in patients screened for malnutrition appears to be abdicable among this population.

Management of parenteral nutrition in critically ill patients

Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel “myths” about PN-related complications and show how prevention and monitoring are able to reach the goal of “near zero” PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting “near zero” catheter-related bloodstream infections. Adopting all these strategies, the goal of “near zero” PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.

Near-fatal Anorexia Nervosa in a Middle-aged Woman

Anorexia nervosa (AN) is a serious psychiatric disorder which typically occurs in young women; however, more and more cases in middle-aged women are being reported. The management of this complex disease requires a team approach, and full recovery occurs only in 50% of patients. Endocrine and metabolic complications are commonly observed, the latter of which may even be life-threatening, and require prompt and proper management. Infections, albeit reported, are not usually a major clinical problem in these patients. We herein report the case of a severely malnourished middle-aged woman with long-standing AN who was hospitalized with marked hypokalaemia (1.5 mEq/L) and rhabdomyolysis; during hospitalization she developed septic shock and acute respiratory distress syndrome, which required urgent admission to the intensive care unit. She underwent sedation and tracheal intubation for mechanical ventilation and was managed with combined therapies, which eventually led to a successful outcome. Life-threatening medical complications can occur not only in young women but in middle-aged women with AN as well and require a combined multidisciplinary approach.

Outcomes of an inpatient refeeding protocol in youth with Anorexia Nervosa and atypical Anorexia Nervosa at Children's Hospitals and Clinics of Minnesota

BACKGROUND

Historically, inpatient protocols have adopted relatively conservative approaches to refeeding in Anorexia Nervosa (AN) in order to reduce the risk of refeeding syndrome, a potentially fatal constellation of symptoms. However, increasing evidence suggests that patients with AN can tolerate higher caloric prescriptions during treatment, which may result in prevention of initial weight loss, shorter hospital stays, and less exposure to the effects of severe malnutrition. Therefore the present study sought to examine the effectiveness of a more accelerated refeeding protocol in an inpatient AN and atypical AN sample.

METHODS

Participants were youth (ages 10-22) with AN (n = 113) and atypical AN (n = 16) who were hospitalized for medical stabilization. A retrospective chart review was conducted to assess changes in calories, weight status (percentage of median BMI, %mBMI), and indicators of refeeding syndrome, specifically hypophosphatemia, during hospitalization. Weight was assessed again approximately 4 weeks after discharge.

RESULTS

No cases of refeeding syndrome were observed, though 47.3 % of participants evidenced hypophosphatemia during treatment. Phosphorous levels were monitored in all participants, and 77.5 % were prescribed supplemental phosphorous at the time of discharge. Higher rates of caloric changes were predictive of greater changes in %mBMI during hospitalization. Rates of caloric and weight change were not related to an increased likelihood of re-admission.

CONCLUSIONS

Results suggest that a more accelerated approach to inpatient refeeding in youth with AN and atypical AN can be safely implemented and is not associated with refeeding syndrome, provided there is close monitoring and correction of electrolytes. These findings suggest that this approach has the potential to decrease length of stay and burden associated with inpatient hospitalization, while supporting continued progress after hospitalization.