Refeeding syndrome relevance for critically ill patients

48

Central European Journal of Clinical ResearchVolume 2, Issue 1, Pages 48-50DOI: 10.2478/cejcr-2019-0007

REVIEW

Refeeding syndrome relevance for critically ill patients

María Bermúdez López1

1 Servicio Anestesiología, Reanimación y Terapéutica del Dolor. Hospital Universitario Lucus Augusti. Lugo. 27003. España.

Correspondence to:María Bermúdez López, Servicio Anestesiología, Reanimación y Terapéutica del Dolor. Hospital Universitario Lucus Augusti.E-mail:[email protected]

Conflicts of interestsNothing to declare

AcknowledgmentNone

Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for profit sectors.

Keywords: refeeding syndrome, hypophosphatemia, thiamine, nutritional support, malnutrition.

These authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Central Eur J Clin Res 2019;2(1):48-50_____________________________________________________________________________Received: 05.03.2019, Accepted: 30.03.2019, Published: 10.04.2019

Copyright © 2018 Central European Journal of Clinical Research. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Refeeding Syndrome (RFS) is a poten-tial life-threatening complication of the nutrition-al therapy in the replenishment phase after peri-od of starvation. This not very known syndrome may be a life-threatening metabolic condition due to rapid, inadequate nutritional support in malnourished catabolic patients. The intake of food and therefore the switch from a catabolic to an anabolic metabolism is most considered etiological mechanism. The main biochemical feature of RFS is hypophosphatemia and low levels of potassium and magnesium. Lack of vitamins, especially vitamin B1 or thiamine is often present and involves severe clinical com-plications.

It is essential to know that the high morbidity and mortality can be reduced by ear-ly diagnosis and taking appropriate measures. Therefore, to be aware of this metabolic con-dition in critically ill patients is necessary for its prevention, recognition, and treatment. Despite many pathophysiological aspects of RFS re-main unclear it is highly relevant to identify in-dividuals at risk and avoid the development of RFS in the ICU. We insist on the need of elec-trolyte monitoring especially during the first 72 hours of initiation of nutritional support. Patients at risk may benefit from hypocaloric or restricted caloric intake for at least 48h resulting in lower long-term mortality.

RFS is common among critically ill pa-tients. But the potential risk of RFS is poorly known. Future quality studies may help to as-

49

sessment of RFS risk and optimize and stan-dardize the RFS management.

Refeeding syndrome (RFS) is a poten-tially fatal acute metabolic derangement that can result in morbidity and mortality [1]. RFS is a po-tential life-threatening complication of the nutri-tional therapy in the replenishment phase after period of starvation [2]. From a pathophysiolog-ical point of view, the intake of food and there-fore the switch from a catabolic to an anabolic metabolism is the main etiological mechanism.

By the start of the nutritional therapy, the concentration of glucose increases causing hy-perglycemia and stimulates anabolic processes [2]. The increased insulin secretion causes the intracellular uptake of phosphate. In fact, the main biochemical feature of RFS is hypophos-phatemia; and this abnormality is commonly en-countered during critical illness [3](4). Most com-monly used definitions are based on hypophos-phatemia [1]. The hypophosphatemia is usually accompanied by low concentrations of serum magnesium and potassium [1][2][5]. Rio et al. used a so-called three-facet criteria design to confirm the diagnosis of RFS unequivocally [6]. These criteria comprised disturbed electrolyte balances, acute peripheral edema or circulatory fluid overload combined with disturbances in or-gan function. Despite the exact pathophysiology of RFS remains unclear, mostly occurs because of the intracellular shift of glucose and electro-lytes (phosphate, potassium, magnesium) oc-cur, and their blood levels may drop severely provoking severe complications [7][8].

The hormonal and metabolic changes that occur in this syndrome are complex and may cause serious clinical complications [4]. Proteins, lipid and glucose metabolisms are dis-turbed, and a lack of vitamins, especially vita-min B1 (thiamine) occurs [2]. Thiamine deficien-cy thus may lead to Wernicke’s encephalopathy or cardiovascular disorders with water retention [9]. Symptoms such as heart failure, peripheral edema, respiratory insufficiency, fluid imbalance and neurologic disorders can occur [2][10]. If not treated, these disturbances can lead to severe negative effects, from multiorganic dysfunction to death [7][8].

RFS can be defined as the biochemi-cal abnormalities and physical sings that occurs when a patient with vitamin and protein-energy malnutrition is incaustiously fed (whether enter-ally or parenterally) [11]. The lack of a proper uniform definition complicates diagnosis and re-search of RFS. Besides this, there is no clear correlations between risk factors proposed by international guidelines and the occurrence of RFS in ICU patients [3]. For this reason RFS and

its relevance in critical illness remains unclear.Recent literature shows that RFS is

common among critically ill patients [1][3]. But, whereas the awareness of malnutrition in the UCI is well established, the potential risk of RFS is much less known. Screening for RFS risk is not commonly done. Even when malnutrition is present, the risk of RFS is usually neglected or overlooked among hospitalized patients [2][12].

Concerning hospital stay and death the heterogeneous results in the different studies makes it difficult to establish a direct correlation between RFS and long-term outcomes [13][14]. However, there is evidence that early diagno-sis and adequate treatment may lead to better overall survival [1]. For this reason, it is highly relevant to identify individuals at risk and avoid the development of RFS in the ICU.

According to the guidelines of the Na-tional Institute for Health and Care Excellence the risk factors for RFS are: low BMI and/or un-intentional weight loss within the last 6 months, a negligible food intake for more than 5 days, low electrolyte (phosphate, potassium, mag-nesium) levels prior to nutritional support, poor absorptive capacity, catabolism and chronic al-coholism [15]. Friedli N. et al. describe other risk factors as age (>70 years), low (pre)albumin or insulin-like growth factor, overfeeding, intrave-nous glucose infusion before nutritional support, or scoring at least 3 points on the nutritional risk screening [10].

However, as common risk factors fail to identify RFS patients, regular phosphate and other electrolyte monitoring can be recommend-ed at least once daily, in particular during the first 72h after the initiation of nutritional support [1]. In the review of Boot R. et al. it is recommended that if occurs a marked drop of phosphate lev-els (>0.16 mmol/l) from normal levels within 72h of commencement of feeding, that feature may select patients that benefit from hypocaloric or restricted caloric intake for at least 48h result-ing in lower long-term mortality [1]. Friedli N. et al. suggests an interesting and detailed recom-mendations for the nutritional management ac-cording to all risk categories ( minor, high and very high risk) of developing RFS, including to-tal caloric intake, fluid therapy, sodium restric-tion, thiamine and multivitamin supplement [10]. Given the small number of randomized studies the evidence is low; however, caloric restriction for several days and gradual increase of caloric intake over days is recommendable [3].

Whereas if the RFS is yet established and diagnosed Boot R. et al. recommend as treatment strategy: electrolyte supplementation (phosphate, magnesium, potassium); glucose


50

monitoring to prevent hypoglycemia and hyper-glycemia; intravenous insulin administration in case of hyperglycemia; correction of fluid over-load if necessary; thiamine supplementation at a minimum dose of 100 mg daily, for at least 7–10 days; restriction of total caloric intake to a maximum of 500kcal/24h during the first 48h after the diagnosis of refeeding hypophospha-temia and refeeding syndrome; gradually ad-vance feeding after 48h of caloric restriction in daily steps of 25% of the target until the nutrition target is reached [1].

It is essential to include the amount of non nutritional calories from propofol, citrate (re-nal replacement therapy) and intravenous car-bohydrate solutions in total caloric intake calcu-lations, because these may be even higher than the proposed cutoff for caloric restriction [16].

In regard to elderly patients it is known that aging is often linked to frailty and poor nutri-tional status. Aubry E. et al. alert about the high risk for RFS in that kind of patients and recom-mend an early identification of patients and risk and a refeeding start at a low level of energy re-placement [2]. As frailty is a reversible process and can be positively influenced by adequate nutritional support it is essential to optimize the nutritional therapy, especially in that population.

As conclusion, awareness of refeeding syndrome and identification of patients at risk is crucial as the condition is preventable and the metabolic complications are avoidable [4]. De-spite the paucity of published guidance on the practical details of how refeeding patients at risk, most of authors recommend start at 10 kcal/kg/day, increasing to full needs over a minimum of 4 days, with supplementation of thiamine, for at least 10 days, and regular phosphate and mag-nesium monitoring [11][15].

References

1. Boot R, Koekkoek KWAC, van Zanten ARH. Refeeding syndrome. Curr Opin Crit Care. 2018 Aug;24(4):235–40.

2. Aubry E, Friedli N, Schuetz P, Stanga Z. Refeeding syndrome in the frail elderly population: prevention, diagnosis and man-agement. Clin Exp Gastroenterol. 2018 Ju-l;Volume 11:255–64.

3. Koekkoek WAC, Van Zanten ARH. Is re-feeding syndrome relevant for critically ill patients? Curr Opin Clin Nutr Metab Care. 2018 Mar;21(2):130–7.

4. Mehanna HM, Moledina J, Travis J. Refeed-ing syndrome: what it is, and how to prevent and treat it. Bmj. 2008;336(7659):1495–8.

5. Schuetz P, Laviano A, Friedli N, Crook M, Stanga Z, Kressig RW, et al. Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm. Nutrition. 2017;47:13–20.

6. Rio A, Whelan K, Goff L, Reidlinger DP, Smeeton N. Occurrence of refeeding syn-drome in adults started on artificial nutrition support: prospective cohort study. BMJ Open. 2013 Jan 1;3(1):e002173.

7. Crook M., Hally V, Panteli J. The impor-tance of the refeeding syndrome. Nutrition. 2001 Jul 1;17(7–8):632–7.

8. Stanga Z, Brunner A, Leuenberger M, Grimble RF, Shenkin A, Allison SP, et al. Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr. 2008 Jun 15;62(6):687–94.

9. Boateng AA, Sriram K, Meguid MM, Crook M. Refeeding syndrome: Treatment con-siderations based on collective analysis of literature case reports. Nutrition. 2010 Feb;26(2):156–67.

10. Friedli N, Stanga Z, Sobotka L, Culkin A, Kondrup J, Laviano A, et al. Revisiting the refeeding syndrome: Results of a system-atic review. Nutrition. 2017 Mar;35:151–60.

11. Walmsley RS. Refeeding syndrome: Screening, incidence, and treatment during parenteral nutrition. J Gastroenterol Hepa-tol. 2013;28(S4):113–7.

12. Pourhassan M, Cuvelier I, Gehrke I, Mar-burger C, Modreker MK, Volkert D, et al. Risk factors of refeeding syndrome in mal-nourished older hospitalized patients. Clin Nutr. 2018 Aug 1;37(4):1354–9.

13. Olthof LE, Koekkoek WACK, van Setten C, Kars JCN, van Blokland D, van Zanten ARH. Impact of caloric intake in critically ill patients with, and without, refeeding syn-drome: A retrospective study. Clin Nutr. 2018 Oct 1;37(5):1609–17.

14. Coşkun R, Gündoğan K, Baldane S, Güven M, Sungur M. Refeeding hypophospha-temia: a potentially fatal danger in the intensive care unit. Turkish J Med Sci. 2014;44(3):369–74.

15. Overview | Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition | Guidance | NICE.

16. Bousie E, van Blokland D, Lammers HJW, van Zanten ARH. Relevance of non-nutri-tional calories in mechanically ventilated critically ill patients. Eur J Clin Nutr. 2016 Dec 14;70(12):1443–50.


Documents

Refeeding syndrome relevance for critically ill patients