Sarah Joyner Aramark Distance Dietetic Internship March 9, 2014 Greater Baltimore Medical Center

CASE REPORT: CLINICAL NUTRITION

MANAGEMENT OF POTENTIAL REFEEDING

SYNDROME

¡  History: First discovered after World War II prisoners were refed and subsequently died.

¡  Studies attempted to determine why this occurs and ultimately found the following as monitoring of bodily function during refeeding occurred. §  During starvation the body begins using protein and fats instead of

carbohydrates for energy. §  Decreased intake severely depletes serum levels of minerals

including phosphate, magnesium, calcium, thiamine and potassium. § When energy is reintroduced, increasing blood glucose leads to an

increase in insulin, subsequently using minerals within the body and severely depleting serum levels of these nutrients as the cells are refed.

DISEASE DESCRIPTION

¡ Risk Factors: ¡ Any person who does not

consume adequate nutrition

¡ Many complex life altering conditions can lead to risk for refeeding syndrome

¡ Comorbidities § Anorexia nervosa § Oncology patients § Malnutrition § Stroke §  Inflammatory Bowel Disease

(IBD) § Chronic Pancreatitis § Diabetes Mellitus (DM) § Hunger strikes § Malabsorption diseases § Poor oral intake for greater

than 7 days § Acquired Immunodeficiency

Syndrome (AIDS) §  Institutionalized.

DISEASE DESCRIPTION CONT.

¡ Two research articles were used to support and determine evidenced-based research for the treatment of potential refeeding syndrome

¡ One original peer-reviewed article

¡ One systematic review article

EVIDENCED BASED NUTRITION RECOMMENDATIONS

Courtesy of BrandonSigma www.freedigitalphotos.net

¡  Occurrence of refeeding syndrome in adults started on artif icial nutrition support: prospective cohort study by Rio et. al

¡  133 participants qualified ¡  Must have been started on nutrition support for the first time

during admission ¡  Must also have one of the following risk factors

§  BMI less than or equal to 18.5 kg/m2 §  Unintentional weight loss of greater than 15% in past 3-6 months §  Little to no intake x 10 days prior to admission §  Alcohol or drug abuse, presently or history of abuse §  Low baseline levels of serum potassium, phosphate, or magnesium

¡  Split into two groups §  Group 1 received less than 800 kcal/day §  Group 2 received greater than 800 kcal/day

ORIGINAL PEER REVIEW

Rio A, Whelan K, Goff L, et al. Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study. BMJ Open. 2013; 3: e002173. DOI: 10.1136/bmjopen-2012-002173.

¡  Of the 133 participants; three resulted in refeeding syndrome, no related deaths §  Two participants in group one §  One participant in group two

¡  Indicators for refeeding syndrome seen in these patients included §  Severe electrolyte shifts §  Fluid overload §  Disturbance to organ functions

¡  Indicators with the most sensitivity to predict potential refeeding syndrome- 66.7% §  Low serum magnesium § Weight loss of greater than 15% §  Poor intake for greater than 10 days prior to admission

RESULTS: ORIGINAL PEER REVIEW

Rio A, Whelan K, Goff L, et al. Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study. BMJ Open. 2013; 3: e002173. DOI: 10.1136/bmjopen-2012-002173.

¡  Refeeding Syndrome: Treatment considerations based on collective analysis of literature case reports by Boateng et al

¡  Search terms on MEDLINE included §  “refeeding syndrome” §  “RFS” §  “refeeding hypophosphatemia”

¡  Articles must address §  The biochemical and physiological changes during a malnourished

cachectic state § Metabolic process of reverting back to a well nourished fed state

SYSTEMATIC REVIEW

Boateng A A, Sriram K, Meguid M and Crook M. Refeeding syndrome: Treatment considerations based on collective analysis of literature case reports. Nutrition. 2010; 26 (2)156-167. DOI: 10.1016/j.nut.2009.11.017

¡  Review of articles indicated the most effective ways to prevent refeeding syndrome included: §  Identify all patients at risk §  Provide adequate electrolyte §  Vitamin and micronutrient supplementation §  Careful fluid replenishment §  Cautious energy restoration § Monitor laboratory indices at risk including electrolytes and glucose

¡  The five case studies evaluated included: §  Anorexia nervosa §  Hyperemesis gravidarum §  Death resulted from RFS status post ureteral obstruction removal § Wernicke’s encephalopathy §  RFS despite hypocaloric feeding

RESULTS OF SYSTEMATIC REVIEW

Boateng A A, Sriram K, Meguid M and Crook M. Refeeding syndrome: Treatment considerations based on collective analysis of literature case reports. Nutrition. 2010; 26 (2)156-167. DOI: 10.1016/j.nut.2009.11.017

¡ Monitoring of laboratory values ¡  Slow infusion of nutrients ¡ Monitoring the patient’s mental status ¡  Less risk with control from nutrition support

¡  These factors decreased risk of RFS and the related signs and symptoms associated with the disease

¡  Identify, monitor electrolytes, replete and monitor all micronutrients slowly, fluid holding and slow administration, non-aggressive caloric feedings.

SYSTEMATIC REVIEW: “TAKE HOME MESSAGE”

Boateng A A, Sriram K, Meguid M and Crook M. Refeeding syndrome: Treatment considerations based on collective analysis of literature case reports. Nutrition. 2010; 26 (2)156-167. DOI: 10.1016/j.nut.2009.11.017

¡  American Society for Parenteral and Enteral Nutrition (ASPEN)

§ Monitoring and correcting electrolyte imbalances prior to initiation of feeding

§  Nutrition support should be initiated at 25% of goal rate §  Advance nutrition support over 3-5 days §  Serum electrolytes and vitals signs closely monitored during initiation

ASPEN GUIDELINES

¡  93 year old female with decreased mental status, non-communicative on admission

¡  The patient’s daughter was the primary caregiver ¡  Brought by family to Emergency Room for worsening mental

status and decreased interest in food, water ¡  Admitted to intensive care unit (ICU) and Diagnosed with:

§  pre-renal kidney injury, §  severe hypernatremia, §  SIRS/Sepsis, §  respiratory failure, §  infectious pneumonia, §  anemia, §  multiple unstageable pressure ulcers, §  malnutrition

¡  Consults from wound care, care management and palliative team were requested

¡  Nasogastric Tube placed on admission ¡  Plan to feed after patient stabilized

CASE PRESENTATION

¡  Client History §  Past Medical History

§  Breast Cancer status post mastectomy §  Hypothyroidism §  Recent hospitalizations for respiratory failure and sepsis §  Peripheral vascular disease §  Unstageable pressure ulcers §  Anemia §  Hypoalbuminemia §  History of intestinal ileus

§ Medications Discharged from previous hospitalization §  ASA, lovenox, prevacid §  Initiated on vancomycin, zosyn, pantoprazole

NUTRITION CARE PROCESS: ASSESSMENT- HISTORY

¡  Food/Nutrition History §  Poor intake x 2-3 weeks prior to admission § Multiple failed swallow evaluations at an outside hospital §  One ensure per day plus 1 bowl pureed food per day §  Bedbound for one month, unable to prepare meals

NUTRITION CARE PROCESS: ASSESSMENT- HISTORY

¡  Physical Findings §  No weight loss §  Appearance of muscle wasting §  Prominent collar bones and cheek bones §  Severely diminished mental capacity §  Positive bowel sounds §  Open sacral wound- unstageable § Multiple other wounds in variety of locations

NUTRITION CARE PROCESS: ASSESSMENT- PHYSICAL

¡  Usual body weight 145#-150# ¡  Bedscale weight on admission 145#

NUTRITION CARE PROCESS: ASSESSMENT- ANTHROPOMETRICS

Anthropometrics

Height Weight IBW BMI

60” (152.4 cm) 145# (65.9 kg) 100# (45.45 kg) 28.3 (overweight)

¡  Biochemical data, tests and procedures §  Placement of NG tube § Multiple chest x-rays- determination of pneumonia, placement of NG

tube, and questionable pulmonary embolism §  Patient family refused MRI, CT scans §  Scheduled for debridement of wounds – cancelled

NUTRITION CARE PROCESS: ASSESSMENT- CONT.

¡  Nutrient needs:

NUTRITION CARE PROCESS: ASSESSMENT- CONT.

Macronutrient Needs

Macronutrient Fluid REE-Mifflin St. Jeor- Kilocalories

Protein Needs

Equation utilized For greater than age 65 years of age = 25 mL/kg

(10x weight) + (6.25 x cm) – (5x age) – 161=

(65.9 kg x 10) + (6.25 x 152.4cm) – (5 x 93 YO)

-161= 986 kcal/day

1.3-1.5 g protein/kg/day

Formula/ Additonal Information

25 mL/kg x 65.9 kg Injury Factor of 1.2-1.4

986 kcal x 1.2-1.4= Total Estimated Needs

1.3 x 65.9 kg= 85 g/day

1.5 x 65.9 kg=98g/day

Determined Need 1647 mL fluid/day 1176-1375 kcal/day 85-98 g/protein/day

¡  Aramark Nutrition Status §  Severely Compromised

§  Total of 16 priority points awarded §  Follow-up occurred every 1-4 days

¡ Malnutrition Classification §  Severe malnutrition in the context of social or environmental

circumstances §  Consuming less than 50% of estimated energy needs §  Clavicle, shoulders, cheek bones prominence §  Limited to no grip strength §  Signs of inflammation and acute illness

§  Decreased intake due to age, dementia, and dysphagia resulted in severe malnutrition

ARAMARK NUTRITION STATUS CLASSIFICATION

Nutrition Diagnosis Terminology

Domain Problem or nutrition Diagnosis Label

Etiology Signs and/or Symptoms

Intake (NI 2.1) #1 Inadequate oral intake

Related to Lethargy, declining mental status

As evidenced by

Patient with history of failed swallow evaluations, need to remain NPO and risk for refeeding syndrome

Clinical (NC 1.1)

#2 Swallowing difficulty

Related to Altered mental status, lethargy

As evidenced by

Pt with history of failed swallowing evaluations, evidence of silent aspiration and maintaining NPO status.

NUTRITION CARE PROCESS: DIAGNOSIS

1.  Vitamin and Mineral Supplements (ND 3.2.6) Recommend initiation of daily thiamine supplementation, usually depleted first in patients with malnutrition.

2.  Enteral and Parenteral Nutrition (ND 2.1) § Monitor Phosphorous, Magnesium and Potassium daily due to

patient’s risk of refeeding syndrome §  Initiate Promote at 15mL/hr via NGT §  Advance q8 hours due to risk for refeeding syndrome §  Add 1 prosource packet daily for additional 15 g protein and 60

kilocalories. §  Goal of Promote 55 mL/hour x 24 hours with 1 prosource packet to

provide 1380 kcal, 98 g protein, 1108 mL free water and 132% of the RDI.

NUTRITION CARE PROCESS: INTERVENTIONS

1.  Collaboration and Referral of Nutrition Care (RC 1.4) Recommend obtaining SLP evaluation prior to initiation of oral diet, secondary to patient’s history of dysphagia/ silent aspiration and failing swallowing evaluations at other outside hospitals.

2.  Meals and Snacks (ND 1.2) §  Advance diet as tolerated and medically appropriate to least

restrictive diet per SLP recommendations § Monitor need for oral nutrition supplements when diet initiated.

NUTRITION CARE PROCESS: INTERVENTIONS CONT.

¡  Patient never reached goal rate for enteral nutrition

¡  Patient exhibited no signs and symptoms of refeeding syndrome with close monitoring of electrolytes and vital signs as nutrition was initiated

¡  Nutrition initiated after medical stabilization

¡  Rate advanced every 4 hours, instead of recommended 8 hours

¡  No noted additional weight loss, stable weight prior to admission

¡  *Patient eventually placed on comfort care measures and expired after condition found likely not to improve.

NUTRITION CARE PROCESS: MONITORING AND EVALUATION

¡  Rio A, Whelan K, Goff L, et al. Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study. BMJ Open. 2013; 3: e002173. DOI: 10.1136/bmjopen-2012-002173.

¡  Mehanna HM. Moledina J, Travis J. Refeeding Syndrome: what is is, and how to prevent and treat it. BMJ. June 28, 2008; 336:1495-1498. DOI: 10.1136.bmj.a301

¡  Wagstaff G. Dietetic practice in refeeding syndrome. Journal of Human Nutrition and Dietetics. 2011; 24: 505-515. DOI: 10.1111/j.1365-277X.2011.01196.x

¡  Khan LUR, Ahmed J, Khan S, MacFie J. Review Article: Refeeding Syndrome: A Literature Review. Gastroenterology Research and Practice. August 2010; 2011. DOI: 10.1155/2011/410971.

¡  Boateng A A, Sriram K, Meguid M and Crook M. Refeeding syndrome: Treatment considerations based on collective analysis of literature case reports. Nutrition. 2010; 26 (2)156-167. DOI: 10.1016/j.nut.2009.11.017

¡  Bankhead R, Boullata J, Brantley S, Corkins M, et al. A.S.P.E.N. Enteral Nutrition Practice Recommendations. JPEN J Parenteral Enteral Nutrition. January 26, 2009; 33: 122. DOI: 10.1188/0148607108330314.

¡  Charney PhD, RD, Pamela, Malone MS, RD, CNSD, Ainsley. ADA Pocket Guide to Nutrition Assessment. Second Edition. Chicago, IL: Academy of Nutrition and Dietetics; 2009

¡  Pronsky Z M and Crowe SRJP. Food-Medication Interactions. Birchrunville, PA: Food-Medication interactions: Seventeenth Ed; 2012; second printing.

¡  MedicineNet.com. Individual Drugs. 2014. Available at http://www.medicinenet.com/medications/article.htm. Accessed February 2014.

¡  National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer treatment recommendations. Prevention and treatment of pressure ulcers: clinical practice guidelines. Washington DC; 2009: 51-120.

¡  Aramark Healthcare. Assessment and education policy #2: Nutrition status classification. Patient Food Services: Policies and Procedures, Volume IV; 2007, Updated 2010.

¡  White JV, Guenter P, Jensen G, Malone A, et. al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). Journal of Parenteral and Enteral Nutrition. Chicago. 2012; 36: 275. DOI: 10.1177/0148607112440285.

¡  Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago, IL: Academy of Nutrition and Dietetics; Fourth Edition; 2013.

¡  Author guidelines. J Am Diet Assoc. 2010;110:124-133.

REFERENCES