Portsmouth Hospitals NHS Trust Formulary and Medicines Group Drug Therapy Guideline No: 46.00 Issued: 10.10.

07 Refeeding Syndrome Guideline

NHS

GUIDELINES FOR THE PREVENTION AND TREATMENT OF ADULT PATIENTS AT RISK OF DEVELOPING REFEEDING SYNDROME
Introduction These guidelines have been written to provide guidance for medical and nursing staff managing patients with severe malnutrition and/or at risk of refeeding syndrome when specialist nutritional support is unavailable, ie out-of-hours and weekends. The guidelines do not replace specialist nutritional support by the dietitians, clinical nutrition nurses, or nutrition support team when available and patients should be referred as soon as possible to the appropriate individual during normal working hours. The following guidelines are consistent with guidance from the Parenteral and Enteral Nutrition Group of the British Dietetic Association1 and National Institute for Health and Clinical Excellence17. Aims of the guidelines 1) To assist in the identification of patients at risk of refeeding syndrome. 2) Provide evidence-based guidance for the management of patients at risk of refeeding syndrome. This guideline applies to all adult patients under the care of practitioners working for the NHS Trust/ Primary Care Trusts listed below. Definitions The term refeeding syndrome describes a potentially fatal medical condition that may affect malnourished and/or ill patients in response to an inappropriately high protein-calorie intake. This commonly occurs following the institution of nutritional support, either parenteral (PN/TPN) or enteral (gastrically via NG/PEG or jejunally via NJ/PEJ/Surgical Jejunostomy etc) or unrestricted oral intake. The pathophysiology of refeeding syndrome relates to the rapid rise in insulin production following a carbohydrate or protein shock, when protein-calories are administered at a rate above which the patient can tolerate. This can occur in those receiving even moderate dietary intake depending on their underlying nutritional, metabolic or physical condition and may arise with administration of glucose alone. This insulin release, associated with possible increased insulin sensitivity, leads to increased cellular uptake of glucose, fluid and electrolytes with associated altered plasma availability of electrolytes. Refeeding syndrome can manifest as either metabolic changes (hypokalaemia, hypophosphataemia, hypomagnesaemia, altered glucose metabolism and fluid balance abnormalities) or physiological changes (ie arrhythmias, altered level of consciousness, seizures, cardiac or respiratory depression) and potentially death. Electrolyte Abnormalities Clinical Sequelae Hypophosphataemia Altered myocardial function, arrhythmias, congestive heart failure, acute ventilatory failure, liver dysfunction, lethargy, weakness, seizures, confusion, coma, paralysis, rhabdomyolysis, haematological disturbances Hypokalaemia Arrhythmias, cardiac arrest, respiratory depression, exacerbation of hepatic encephalopathy, decreased urinary concentrating ability, polyuria, dysuria, constipation, ileus, weakness, paralysis, rhabdomyolysis

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Portsmouth Hospitals NHS Trust Formulary and Medicines Group Drug Therapy Guideline No: 46.00 Issued: 10.10.07 Refeeding Syndrome Guideline

NHS

Hypomagnesaemia Arrhythmias, tachycardia, respiratory depression, abdominal pain, diarrhoea, constipation, ataxia, confusion, muscle tremors, weakness, tetany.

Algorithm 1: Initial assessment

ASSESS AND IDENTIFY PATIENTS AT RISK OF REFEEDING SYNDROME Your patient is at risk of refeeding syndrome if there is: History of chronic malnutrition Acute weight loss (inc. following weight loss surgery) of greater than 10% of pre-morbid body weight. Little or no nutritional intake of any form for greater than 7-10 days The risks of refeeding syndrome are higher in patients with: Significant co-morbidity, e.g. infection, surgery, pressure sores, cancer Evidence of physiological stress, e.g. post operatively or patients who require/required critical care input Prolonged fasting Anorexia nervosa Chronic alcoholism Electrolyte abnormalities (Potassium/Magnesium/Phosphate) The elderly (due to the increased risk of malnutrition in this patient group).

AT RISK Refer to Dietitian

NOT AT RISK Refer to Dietitian and feed as per normal ward procedures

HISTORY & CLINICAL EXAMINATION

Nutritional Assessment: 1. Weight 2. Rate of weight loss 3. Dietary intake 4. Reasons for malnutrition - physiological impediment to oral or enteral intake, swallowing difficulties, impaired intestinal function etc.

Monitor: 1. Heart rate, pulse rate, blood pressure, respiratory rate and level of consciousness 6 hourly for first 72 hours. 2. Daily temperature. 3. ECG if patient has: a. Irregular pulse b. Abnormal heart rate c. Serum potassium or phosphate level below normal range. If evidence of cardiac abnormalities on assessment or during refeeding, patient will require cardiac monitoring. If necessary, transfer to appropriate ward.

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Portsmouth Hospitals NHS Trust Formulary and Medicines Group Drug Therapy Guideline No: 46.00 Issued: 10.10.07 Refeeding Syndrome Guideline

NHS

Algorithm 2: Initial management

INITIAL MANAGEMENT OF REFEEDING SYNDROME

1.

Identification and treatment of sepsis: May not be clinically apparent but may explain an acute deterioration. Low threshold for septic screen Low threshold for broad-spectrum antibiotics (orally or via NG tube if possible).

2. Fluid resuscitation and monitoring fluid balance. Assess and carefully restore circulatory volume, monitor pulse rate, fluid intake and output. Malnourished patients have a reduced tolerance of intravenous fluids in moderate to high intakes (ie more than 2 litres per 24 hours) that can lead to heart failure. Administration of intravenous fluids may be necessary in the initial 72 hours until sufficient oral intake is achieved. If evidence of dehydration, for careful rehydration ie 1-2 litres in the first 24 hours depending on response. Greater volumes only if severely dehydrated. Total fluid intake (including intravenous, enteral and oral) should aim for a maximum of 30ml/kg per day (ie commonly 1.5 litre or less). At least 6-hourly monitoring of blood pressure, pulse and respiratory rate is necessary to detect evidence of heart failure or inadequate intra vascular volume.

3. Correction of electrolyte abnormalities Ensure recent (last 48 hours) electrolyte levels are available. These should include: urea and electrolytes, phosphate, calcium, magnesium (add to standard blood profile), liver function tests, full blood count. If electrolytes are deranged consider and treat possible causes. Perform ECG if: Potassium is less than 3.5mmol/l or Phosphate is less than 0.80mmol/l. Organise supplementation if: Phosphate is less than 0.8mmol/l, Potassium is less than 3.5 mmol/l, Magnesium is less than 0.5mmol/l or adjusted Calcium is less than 2.0mmol/l. Caution should be used in renal patients due to the reduced excretion of these electrolytes. If very low plasma electrolyte values are demonstrated, eg Phosphate is less than 0.32mmol/l, Potassium is less than 2.5mmol/l, Magnesium is less than 0.5mmol/l, then the institution of feeding or nutritional support may result in a further drop of these electrolytes to possibly critical levels. Electrolyte correction with oral or intravenous supplementation is required to achieve levels above these thresholds before the institution of feeding.

4. Correction of Hypoglycaemia/Blood Sugar Control: Monitor blood glucose once to twice daily unless more frequent tests are indicated (ie for those patients with know diabetes or IGT). If hypoglycaemic replace intravenous fluids with 5% glucose.

5. Management of hypothermia Monitor body, and if necessary core, temperature at least daily. Hypothermia is commonly associated with malnutrition. Its correction should be simultaneous with fluid rehydration and can include provision of heated drinks and blankets.

6. Correction/Prevention of micronutrient deficiencies Administer Thiamine 100mg orally or crushed via feeding tube three times daily for 10 days or until recommended feeding rate reached with the first dose being administered at least 30 minutes before instituting feeding. If enteral route not available, patient has anorexia nervosa or has chronic alcoholism; administer Pabrinex IVHP * - 1 pair of ampoules 30 minutes before instituting feeding and then daily until recommended feeding rate reached. Administer vitamin B compound strong (one tablet three times daily) and Sanatogen Gold (one tablet daily) orally or crushed via feeding tube Page 3 of 5 Control date: 25/03/2008

Portsmouth Hospitals NHS Trust Formulary and Medicines Group Drug Therapy Guideline No: 46.00 Issued: 10.10.07 Refeeding Syndrome Guideline

NHS

*Administration of Pabrinex IVHP Two pairs of ampoules may be diluted in 50ml to 100ml of sodium chloride 0.9% or 5% glucose. Infuse over 30 minutes. Note small risk of anaphylaxis. Facilities to manage anaphylaxis must be available

Algorithm 3: Commencing feeding in patients at risk of refeeding syndrome

COMMENCE FEEDING SLOWLY
Weekdays
Commencement of feeding should be according to a planned regime in association with the dietitian/ nutrition nurse Feeding must be within the context of appropriate electrolyte supplementation.

Weekends and Bank Holidays

Institution of feeding in at risk patients should be cautious and individualised. Feeding an at risk patient with 10kcals/kg/24 hours for the first 48 hours is safe in most clinical situations but slower rates may be indicated in those at greater risk. Feed should be delivered within the context of careful fluid balance with intravenous fluids being reduced or discontinued as required. Fluid balance should be carefully monitored. Ensure referred to dietitian for review as soon as possible

Enteral feeding regimen:

Feeding must be increased slowly, in accordance with the regimen below, following thiamine administration: Date/ Day No. Day 1 Day 2 Day 3 Feed Type Water Fresubin Original Water Fresubin Original Water Fresubin Original Rate (ml/hour) 30 15 30 20 30 25 Duration (hours) 4 20 4 20 4 20 Volume (ml) 120 300 120 400 120 500

Recommended rates are to guide but not contravene medical opinion. Do NOT recommend to start nutritional supplement drinks (e.g. Fresubin energy, etc) at the same time as starter regimen. DO NOT bolus feed

MONITORING minimum 72 hours

Monitor until levels in reference range or patient on stable feeding regimen: Serum urea & electrolytes, adjusted calcium, phosphate, liver function tests at least daily Serum Magnesium baseline, every 3 days and then weekly once stable Fluid balance daily Blood glucose once to twice daily unless more frequent tests are indicated. Temperature, pulse, respiration, heart rate; daily Blood pressure 6 hourly ECG if abnormal heart rate or pulse. If evidence of cardiac abnormalities on assessment or during refeeding patient will require cardiac monitoring. If necessary transfer to appropriate ward Clinical deterioration may reflect over rapid feeding, too little is always safer than too much, halve rate of feeding and observe. Page 4 of 5 Control date: 25/03/2008

Portsmouth Hospitals NHS Trust Formulary and Medicines Group Drug Therapy Guideline No: 46.00 Issued: 10.10.07 Refeeding Syndrome Guideline

NHS

Evidence Base The recommendations in this guideline are based on published evidence and national guidelines.
References: 1. Dewar, H., Horvath, R. for Parenteral and Enteral Nutrition Group of the British Dietetic Association. Refeeding Syndrome. 2001 p13.1-13.12. 2. Soloman, S. M. & Kirby D. F. The Refeeding Syndrome: A Review. J. Parenteral & Enteral Nutr.1990; 14: 90-7. 3. Crook. M. A., Hally. V., Panteli. J. V. The Importance of Refeeding Syndrome. Nutrition. 2001;17:632637. 4. Livingstone, C. Refeeding syndrome and nutrition support. Clinical Nutrition 2004. 4 (5): p36-38. 5. Drug Therapy Bulletin. Malnourished inpatients: overlooked and undertreated.1996 Aug;34(8):57-60. 6. British Dietetic Association. Professional standards for dietitians. 2004. 7. Weinsier. R. L., Krumdieck. C. L . Death resulting from overzealous total parenteral nutrition : the refeeding syndrome. The Am J Clinical Nutrition 1980; 34: 393-399. 8. Marik. P.E. & Bedigan. M. K.. Refeeding hypophosphatemia in critically ill patients in an intensive care unit a prospective study. Archives of surgery; 1996; 131 (10):1043-7. 9. Marinella. M.A The refeeding syndrome and hypophosphatemia. 2003; 62(9):320-323. 10. Maier-Dobersberger. T., Lochs. H. Enteral supplementation of phosphate does not prevent hypophosphatemia during refeeding of cachectic patients. Journal of parenteral and enteral nutrition; 1994; 18 (2) 182-184. th 11. BNF 49 Edition March 2005 ISBN: 0853696314 Pharmaceuticals Press, British Medical Association. 12. Portsmouth Hospitals NHS Trust. Drug Therapy Guidelines. 2005 Administration of Drugs to Adults with Feeding Tubes. 13. Altman, P. 2001Calcium and phosphate balance in renal failure: the disease. British Journal of Renal Medicine. P6-9. 14. Oxford Radcliffe Hospital nutrition Parenteral Nutrition Guideline, August 2004 th 15. Martindale the complete drug reference 34 edition. 2005. ISBN: 0853695504 Pharmaceutical Press. 16. Shulman, R. 1998. UCL Hospitals Injectable Drug Administration Guide 1998. Blackwell Science 17. National Institute for Health and Clinical Excellence. Nutrition Support in Adults. February 2006.

Tim Trebble, Consultant Gastroenterologist; Laura Purvis, Dietitian; Jacqueline Collett, Lead Clinical Nurse Specialist and Andrew Prowse, Divisional Pharmacist for Surgery manage this guideline. See Trust Policy for the Production of Drug Therapy Guidelines Approved by: Formulary and Medicines Group Ratified by: Professional Advisory Committee Review Date: October 2009 Date: September 2007 Date: October 2007

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