An unexpectedly high incidence of refeeding syndrome in patients with total parenteral nutrition in a reference university hospital

The Australasian Society of Parenteral and Enteral Nutrition: Consensus statements on refeeding syndrome

AIMS

This consensus statement document describes the recommendations of the Australasian Society of Parenteral and Enteral Nutrition regarding the identification and management of refeeding syndrome and refeeding syndrome risk.

METHODS

An expert working group completed a review of the literature to develop recommendations for the consensus statements. Review of the drafted consensus statements was undertaken by highly experienced clinicians.

RESULTS

The identification and management of refeeding syndrome requires a multidisciplinary approach. Actual refeeding syndrome is rare; however, all patients should be assessed for the risk of its development. Refeeding syndrome should only be diagnosed if the patient has had adequate nutrition intake (≥50% of estimated requirements), with electrolyte imbalances and clinical symptoms emerging after its commencement. Thiamin and multivitamin supplementation and regular electrolyte monitoring should be provided to all patients at risk of developing refeeding syndrome. There is no evidence that patients at risk of developing refeeding syndrome should be started at an initial lower enteral feeding rate than already recommended for checking tolerance to enteral feeds. Goal nutrition rates should be reached within 24-72 h for all routes of nutrition. Low electrolyte levels should be replaced as per local guidelines, with consideration given to the route of replacement.

CONCLUSION

These consensus statements are expected to provide guidance at a national level to improve the identification and management of refeeding syndrome and refeeding syndrome risk.

Risk factors for the development of refeeding syndrome in adults: A systematic review

Identifying patients with a particularly high risk of refeeding syndrome (RFS) is essential for taking preventive measures. To guide the development of clinical decision-making and risk prediction models or other screening tools for RFS, increased knowledge of risk factors is needed. Therefore, we conducted a systematic review to identify risk factors for the development of RFS. PubMed, EMBASE, Cochrane Library, and Web of Science were searched from January 1990 until March 2023. Studies investigating demographic, clinical, drug use, laboratory, and/or nutrition factors for RFS were considered. The Newcastle-Ottawa Scale was used to appraise the methodological quality of included studies. Of 1589 identified records, 30 studies were included. Thirty-three factors associated with increased risk of RFS after multivariable adjustments were identified. The following factors were reported by two or more studies, with 0-1 study reporting null findings: a previous history of alcohol misuse, cancer, comorbid hypertension, high Acute Physiology and Chronic Health Evaluation II score, high Sequential Organ Failure Assessment score, low Glasgow coma scale score, the use of diuretics before refeeding, low baseline serum prealbumin level, high baseline level of creatinine, and enteral nutrition. The majority of the studies (20, 66.7%) were of high methodological quality. In conclusion, this systematic review informs on several risk factors for RFS in patients. To improve risk stratification and guide development of risk prediction models or other screening tools, further confirmation is needed because there were a small number of studies and a low number of high-quality studies on each factor.

Association between energy delivery from parenteral nutrition and refeeding syndrome in hospitalized adults: A retrospective cohort study

BACKGROUND

Patients receiving parenteral nutrition (PN) may develop refeeding syndrome (RFS). This study determined RFS prevalence in hospitalized adults on PN and evaluated whether higher energy delivered by PN on day 1 of PN initiation was associated with RFS development.

METHODS

We reviewed the medical records of adult patients receiving PN at a Thai quaternary hospital from June 2019 to May 2022. RFS was defined based on the Nutrition Management Clinical Practice Recommendation by the Society of Parenteral and Enteral Nutrition of Thailand. The association between PN energy delivery and RFS development was determined using a generalized estimating equation for multiple logistic regression analysis adjusted for NICE guideline risk factors.

RESULTS

A total of 547 patients was included (mean age 59.8 ± 17.2 years, mean body mass index 20.7 ± 4.8 ). The prevalence of RFS was 45%. Factors associated with RFS included energy from PN on the first day of PN initiation (adjusted odds ratio [aOR] 1.17; 95% CI 1.04-1.33; for every 5 kcal/kg/day increase), starvation >5 days prior to PN (aOR 1.54; 95% CI 1.04-2.26), concomitant diuretic use (aOR 1.81; 95% CI 1.25-2.64), low baseline potassium level (aOR 1.79; 95% CI 1.19-2.70), and individual compounding PN (aOR 1.61; 95% CI 1.04-2.51).

CONCLUSION

RFS was common among hospitalized patients receiving PN. The amount of energy delivered on the first day of PN was independently associated with RFS, raising a concern regarding initiation of PN with higher energy.

Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding

Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.

Evaluation of non-infectious complications in children receiving parenteral nutrition

BACKGROUND

Parenteral nutrition may lead to inevitable complications.

AIMS

To determine the indications, metabolic and mechanical complications of parenteral nutrition in children.

METHODS

One hundred fifty-eight children (91 males; 57.8%) who received 179 episodes of individualized parenteral nutrition for ≥ 5 days within 2 years were analyzed. Indications and duration of parenteral nutrition, effect on growth, and metabolic and central venous catheter-related non-infectious complications were evaluated.

RESULTS

Parenteral nutrition was administered in 179 different episodes (109 males; 60.9%), and the median age during these episodes was 64.0 (14.0-129.0) months. The most common indications were hematological malignancies, gastrointestinal surgery, and hematopoietic stem cell transplantation. Most of the electrolyte imbalances occurred in the first 3 days. Hypophosphatemia (44.7%), hypomagnesemia (43.0%), hypokalemia (43.0%), hyponatremia (40.8%), and hypertriglyceridemia (38.2%) were the most common metabolic complications. Liver transaminases elevated in 32/145 (22.1%) episodes and bilirubin in 30/149 (21.0%). Ursodeoxycholic acid treatment was added to 25 patients with hypertransaminasemia and/or hyperbilirubinemia. Transaminase levels improved in 16 (64%) and bilirubin levels in 15 (60%) patients receiving ursodeoxycholic acid. Catheter thrombosis was seen in 4.5% of the episodes. The targeted energy could be given more efficiently via central catheters rather than peripheral venous accesses. Patients' bodyweights increased in 39.1% of the episodes.

CONCLUSIONS

Close monitoring of electrolyte levels, especially in the first 3 days, is crucial to prevent complications of parenteral nutrition. When individualized PN preparations are used for metabolically unstable patients, it can be easier to maintain the blood glucose, lipids, and electrolyte levels within the normal range.

Parenteral Nutrition Overview

Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.

Incidence and Impact of Refeeding Syndrome in an Internal Medicine and Gastroenterology Ward of an Italian Tertiary Referral Center: A Prospective Cohort Study

Background: Refeeding syndrome (RS) is a neglected, potentially fatal syndrome that occurs in malnourished patients undergoing rapid nutritional replenishment after a period of fasting. The American Society for Parenteral and Enteral Nutrition (ASPEN) recently released new criteria for RS risk and diagnosis. Real-life data on its incidence are still limited. Methods: We consecutively enrolled patients admitted to the Internal Medicine and Gastroenterology Unit of our center. The RS risk prevalence and incidence of RS were evaluated according to ASPEN. The length of stay (LOS), mortality, and re-admission rate within 30 days were assessed. Results: Among 203 admitted patients, 98 (48.3%) were at risk of RS; RS occurred in 38 patients (18.7% of the entire cohort). Patients diagnosed with RS had a higher mean LOS (12.5 days ± 7.9) than those who were not diagnosed with RS (7.1 ± 4.2) (p < 0.0001). Nine patients (4.4%) died. Body mass index (OR 0.82; 95% CI 0.69−0.97), RS diagnosis (OR 10.1; 95% CI 2.4−42.6), and medical nutritional support within 48 h (OR 0.12; 95% CI 0.02−0.56) were associated with mortality. Conclusions: RS incidence is high among clinical wards, influencing clinical outcomes. Awareness among clinicians is necessary to identify patients at risk and to support those developing this syndrome.

[Refeeding Syndrome: Where Do We Stand in 2022?]

Refeeding Syndrome: Where Do We Stand in 2022? Abstract. The refeeding syndrome is a potentially life-threatening condition that can occur when refeeding malnourished patients. In recent years, two consensus manuscripts were published by the major clinical nutrition societies ESPEN and ASPEN. Pathophysiological aspects, clinical manifestations, prevention measures and criteria for diagnosis and management have been described in detail. The aim of this mini-review is to provide an evidence-based overview on the refeeding syndrome. For this purpose, the systematic literature search by Friedli et al. 2015 was updated. Evidence that the refeeding syndrome is associated with a negative clinical outcome exists. Many questions about management aspects remain unanswered. A robust randomized controlled trial is urgently needed to answer all these questions in an evidence-based manner and to elicit reliable evidence about independent predictors and an estimate of metabolic risk.