Case Study
Enteral feeding for patient at risk of
refeeding syndrome
Date Presented:
April 11th, 2024
Medical History
3/18 first encounter
NRS for difficulty chewing/swallowing and Nutrition assessment
3/20 Second encounter
PEG tube placed for Failure to thrive in adulthood; Nutrition consult
for dietary to manage TF
3/22 third encounter
Patient electrolytes decreasing
3/25 Final encounter
Patient diet upgraded and ready for discharge
1st
Encounter
Nutrition Assessment
Assessment
Current Diagnosis
Acute Renal Failure, unspecified type
Gastrointestinal hemorrhage, unspecified type
Septic Shock
Past Medical History
Hypothermia
NSTEMI
ST-elevation myocardial infarction
Primary Hypertension
Mixed conductive and sensorineural
hearing loss of both ears
Hx of CABG
Dementia
CVA
Weight history
Height: 5' 4'’
Current weight: 106 lbs 8 oz
BMI: 22.31 kg/m^2*
Wt previously estimated at 130 lbs
Requested wt from RN
Weight loss of 23 lbs (17.7% BWL)
over past month
Clinically significant
SLP
Moderate-severe oropharyngeal dysphagia
Tried to see pt x2 for trials
-unable to do so d/t lethargy and concern for GI
bleed
Diet History
Visited room x2
Patient asleep both times
Diet history obtained via EMR
Patient NPOx4
Receiving 306 kcal/day from D5%
Per Case Management Note
Patient was feeder at NH
Generally only eats around
20% of meals
Suspected intake less than 50% over
past 5 days d/t:
NPOx4
Pt requiring feeding assistance
generally eats 20% meals at LTC facility
Nutrition Impact Symptoms
Pain affecting Chewing/ Food
PO Intakes Swallowing Allergies
NPO NPO None per EMR
Per EMR:
GI Bowel incontinence
symptoms
Last BM 3/17
Per EMR, blanchable redness on
Skin coccyx
Labs
3/18/24
BUN 18
Sodium 147 (H)
Creatinine 0.74
Potassium 3.2 (L)
eGFR above 60
Chloride 112 (H)
BUN/Creatinine ratio 24 (H)
Medications
Apixaban
Atorvastatin
Azithromycin
Ceftriaxone
D5%
Potassium chloride
Estimated Nutrition Needs
(based on 48.3 kg)
Calorie goal: 1449 kcal (30 kcal/kg)
Protein: 75-94 grams (1.0-1.2 grams/kg)
Fluids: 1500 ml (minimum fluid
requirement)
Diagnosis
A.S.P.E.N Criteria
Clinical Assessment Criteria/Location
Suspected intake less than 50% needs
Energy Intake Inadequate
over past 5 days
Weight Loss Significant 23 lbs (17.7% BWL) over past month
Subcutaneous Fat Loss Mild Buccal, Orbital
Muscle Loss Mild Temporal
Fluid Accumulation Mild 2+ Left hand
These characteristics indicative of:
These characteristics indicative of
Severe Malnutrition in the context of
chronic illness
Nutrition Diagnosis
Severe malnutrition in the context of chronic illness related to
decreased ability to consume sufficient nutrition as evidenced by
suspected intake less than 50% estimated needs over past 5 or
more days, weight loss of 23 lbs (17.7% BWL)over past month, mild
muscle/fat wasting, and mild fluid accumulation
Inadequate oral intake related to decreased ability to consume
sufficient nutrition as evidenced by NPOx4 and PTA reuiring feeding
assistance and eating around 20% of meals per case management
note
Intervention
Nutrition Prescription
Continue NPO;
Advance diet per medical plan of care
1. Messaged RN to request weight
2. Messaged MD to ask about nutrition
Interventions plan of care
3. Notify MD of malnutrition diagnosis;
recommend MVI
Goals
01
Patient to advance diet by next follow up date
02
Monitoring and Evaluation
PO intake GI symptoms
Weight Medical plan
of care
Labs
High Nutrition Risk Level
RD to follow up in 2-4 days (F 3/20-3/22)
2nd
Encounter
Tube Feeding Consult
3/21: Nutrition consult
received for dietary to
manage TF
Per surgeon note:
PEG tube placed that afternoon d/t
failure to thrive dx
Patient NPOx6
Receiving 306 kcal/day from D5%
Refeeding Syndrome
Definition and history
“a range of metabolic and electrolyte alterations occurring as a result of the
reintroduction and/or increased provision of calories after a period of
decreased or absent caloric intake” (1)
First described in medical literature after World War II
Earlier historic accounts also seem to describe
Rodulfus Glaber, 1033 during the Burgundy famine (2)
“even when they received food, they became distended and died
immediately”
Refeeding Syndrome
Challenges to research
high-quality scientific evidence regarding the clinical
syndrome is lacking
Research Challenges include:
reliance on retrospective, observational data
lack of a standard definition
Refeeding Syndrome
Diagnositc criteria
ASPEN Consensus Criteria (1)
A decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or
magnesium levels by 10%–20% (mild RS), 20%–30% (moderate RS), or
>30% and/or organ dysfunction resulting from a decrease in any of
these and/or due to thiamin deficiency (severe RS).
Occurring within 5 days of reinitiating or substantially increasing
energy provision.
Refeeding Syndrome
Medical conditions/situations potentially increasing risk of RS (1)
Anorexia nervosa Child abuse
Mental health disorders Military recruits
Alcohol and substance-abuse Athletes
disorders Renal failure/hemodialysis
Bariatric surgery/bowel resection Critically ill
Malabsorption malignancy
Starvation Pt in emergency departments
At least 1 of the following
BMI <16
Unintentional weight loss >15% BW within last 3-6 months
Little or no nutritional intake for >10 days
Low levels of potassium, phosphate, or magnesium before
Identifying feeding
Patient’s OR
at Risk (3) 2 or more of the following
BMI <18
Unintentional weight loss >10% BW within last 3-6 months
Little or no nutritional intake for >5 days
At least 1 of the following
BMI <16
Unintentional weight loss >15% BW within last 3-6 months
Little or no nutritional intake for >10 days
Low levels of potassium, phosphate, or magnesium before
Identifying feeding
Patient’s OR
at Risk (3) 2 or more of the following
BMI <18
Unintentional weight loss >10% BW within last 3-6 months
Little or no nutritional intake for >5 days
Mechanism
↑ Glycogenesis* Inter- to
intracellular
shift in
↑ Insulin ↑ Lipogenesis* electrolytes
Secretion
Serum levels
↑ Protein synthesis* P drop
Mg
*requires magnesium, phosphorus, and thiamin
Mechanism
Lower availability
↑ Anabolic Requires more of ATP and
Processes ATP ↓ serum
phosphorus
Kidneys have Increased
increased sodium risk of fluid
+ fluid retention overload
Potential complications/signs/symptoms
Neurological Neuropathy Cardiac
Paresthesias Dementia Arythmias
Weakness Wernicke's syndrome Contraction changes
Delirium Korsakoff psychosis Cardiac decompensation
Disorientation Wet and dry beriberi Hypotension
Encephalopathy Shock
Pulmonary
Areflexic paralysis Decreased stroke volume
Diaphragmatic weakness
Seizures Decreased arterial pressure
Respiratory failure
Coma Increased wedge pressure
Dyspnea
Tetany
Hematologic Gastrointestinal
Tremor
Hemolysis Anorexia
Muscle twitching
Thrombocytopenia Nausea
Changed mental status
Leukocyte dysfunction Vomiting
Convulsions
Paralysis Constipation
Seizures
Pulmonary edema Rhabdomyolysis
Lactic acidosis
Cardiac Arrhythmias Muscle necrosis
Nystagmus
Contraction changes
Refeeding Syndrome
Clinical outcomes for patients that experience RS
Study by Friedli et al.: 967 patients with malnutrition with
RFS confirmed in 141 (14.6%) patients. (4)
Compared to pt with no evidence for RFS, pts with confirmed RFS had
significantly increased:
180-days mortality rates
(29.8% vs 21.9%) (P < .05)
increased risk for ICU admission
(4.3% vs 1.6%) (P < .05)
longer avg length of hospital stays
(10.5 ± 6.9 vs 9.0 ± 6.6 days) (P = .01)
Refeeding Syndrome
Guidelines for refeeding
Lack of evidence and standardized guidelines for feeding patient at risk of RS
Research looking at more aggressive feeding mostly studies patients with
anorexia nervosa
Research around conservative approaches mostly studies older patients with
multiple comorbidities
Currently no universal guidelines for refeeding
Many existing recomendations are general and vague
most recommend increasing feedings at slow rates over 3-7 days (1)
Refeeding Syndrome
Guidelines for refeeding (3)
Initiate nutrition support at max of 10 kcal/kg/day increase slowly to meet needs by
4-7 days
Restore circulatory volume and monitor fluid balance and clinical status closely
Provide before or during first 10 days of feeding
Oral thiamin 200-300 mg daily
Vit B compound: 1-2 tablets, 3x day
MVI
Provide supplements in following likely requirements unless prefeeding levels are
high. Correction PT feeding unnecessary
Potassium: 2-4 mEq/dL/day
Phosphorus: 0.3-0.6 mmol/kg
Magnesium: 0.2 mmol/kg/day IV or 0.4 mmol/kg/day orally
Nutrition Prescription
Initiate Jevity 1.2 at 10 mL/hr with 130 mL
flushes q6h. Increase EN by 10 mL/hr q12h
until reach goal rate of 55 mL/hr.
Goal rate provides 1584 kcal, 74 grams
Goal rate provides 1584 kcal, 74 grams protein,
protein, and 1585 mL free water
and 1585 mL free water daily daily
1. Recommend potassium replacement
to MD
2. RD to order labs for magnesium and
Interventions
phosphorous
3. Order IV thiamin for 5 days
4. Notify RN of nutrition prescription
3rd
Encounter
Pt electrolytes decreasing
Per Surgeon
Patient having some diarrhea
Wanting to start bolus feeds
Per Case Management
NH did not have Jevity,
requesting switch to Osmolite
NH to advance TF rate to goal
Patient receiving
Jevity 1.2 at 30 mL/hr
Receiving 306 kcal/day from D
Electrolyte status
Potassium Phosphorus
2.4 (L) 1.5 (L)
27% decrease from 11% decrease from
yesterday* yesterday*
*meets Aspen Criteria for RS
Electrolyte status
Thaimin given that AM
Pt received potassium replacements
No phosphorus replacements given
Recommended do not increase rate until
replacements are given and labs are within
normal range
Recommend do not initiate bolus feeds
To CM: recommended do not discharge until
labs WNL -CM agreed
Recommended contacting on-call
dietitian for discharge nutrition
prescription if pt to be discharged
with electrolytes and other labs
WNL over the weekend
1. Recommend phosphorus
replacement to MD
Interventions 2. RD to order labs for magnesium and
phosphorous through 3/25
3. On-call dietitian informed of situation
Nutrition Prescription
Hold Jevity 1.2 at 30 mL/hr with 130 mL
flushes q6h until labs have normalized then
can continue to ncrease EN by 10 mL/hr q12h
until reach goal rate of 55 mL/hr
3rd
Encounter
Pt to discharge
Pt upgraded to dysphagia III diet with
nextar thickened liquids
Case Management called RD:
inform pt ready for discharge
for Osmolite 1.2 formula change
Patient receiving
Jevity 1.2 at 50 mL/hr
Receiving 306 kcal/day from D
TF tolerance
No GI signs/symptoms of intolerance
No updated BM since 3/22
polyethelyne glcol given per MAR
Blood Glucose WNL
TF tolerance
Potassium and magnesium WNL
Phosphorus and sodium low
No phosphorus replacement noted
per MAR
Nutrition Prescription
Continue Osmolite 1.2 at 50 mL/hr with 130
mL flushes q6h. Increase EN by 5 ml/hr
q12huntil reaching goal rate of 55 mL/hr.
Goal rate provides 1584 kcal, 73 g protein,
and 1602 ml free water daily
References
1. oda Silva JS, Seres DS, Sabino K, et al. Aspen consensus recommendations for Refeeding
syndrome. Nutrition in Clinical Practice. 2020;35(2):178-195. doi:10.1002/ncp.10474
2. oRPF D. Refeeding syndrome in historical perspective: Its first description by Rodulfus Glaber
(1033). American Journal of Biomedical Science & Research. 2021;11(4):273-274.
doi:10.34297/ajbsr.2021.11.001643
3. Mullins A. Refeeding syndrome: CLinical Guidelines for Safe Prevention and Treatment. Support
Line. 2016;10(10).
4. oFriedli N, Baumann J, Hummel R, et al. Refeeding syndrome is associated with increased
mortality in malnourished medical inpatients. Medicine. 2020;99(1).
doi:10.1097/md.0000000000018506
5. Tsui C, Kim K, Spencer M. The diagnosis “failure to thrive” and its impact on the care of
hospitalized older adults: A matched case-control study. BMC Geriatrics. 2020;20(1).
doi:10.1186/s12877-020-1462-y
Thank you!
