Further evidence to throw caution to the wind: outcomes using an assertive approach to manage refeeding syndrome risk

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.

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.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study

OBJECTIVE

Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED.

METHOD

This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change.

RESULTS

Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission.

DISCUSSION

The incidence of severe RFS was low in this cohort and was associated with lower admission weight.

PUBLIC SIGNIFICANCE

This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

Use and safety of enteral nutrition protocols in acute care: A scoping review of literature and retrospective audit of practice

AIM

Standardised enteral nutrition protocols are recommended in critical care, however their use and safety are not well described in other inpatient populations. This mixed methods study reports on the use and safety of enteral nutrition protocols for non-critically ill adults.

METHODS

A scoping review of published literature was conducted. In addition a retrospective audit of practice at an Australian tertiary teaching hospital with an existing hospital-wide standardised enteral nutrition protocol was performed. Data on use, safety and adequacy of enteral nutrition prescription were collected from medical records for patients receiving enteral nutrition on acute wards (January-March 2020).

RESULTS

Screening of 9298 records yielded six primary research articles. Studies were generally low quality. Published literature suggested that protocols may reduce time to enteral nutrition initiation and goal rate, and improve adequacy of nutrition provision. No adverse outcomes were reported. From the local audit of practice (105 admissions, 98 patients), enteral nutrition commencement was timely (median 0 (IQR 0-1) days from request; goal rate: median 1 (IQR 0-2) days from commencement and adequate (nil underfeeding), without prior dietitian review in 82% of cases. Enteral nutrition was commenced per protocol in 61% of instances. No adverse events, including refeeding syndrome, were observed.

CONCLUSIONS

Most inpatients requiring enteral nutrition can be safely and adequately managed on enteral nutrition protocols. Evaluation of protocols outside of the critical care setting remains a gap in the literature. Standardised enteral nutrition protocols may improve delivery of nutrition to patients, whilst allowing dietitians to focus on those with specialised nutrition support needs.

[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.

The incidence of the refeeding syndrome. A systematic review and meta-analyses of literature

BACKGROUND & AIMS

The refeeding syndrome (RFS) has been recognized as a potentially life-threatening metabolic complication of re-nutrition, but the definition widely varies and, its incidence is unknown. The aim of this systematic review and meta-analyses was to estimate the incidence of RFS in adults by considering the definition used by the authors as well as the recent criteria proposed by the American Society of Parenteral and Enteral Nutrition (ASPEN) consensus. Furthermore, the incidence of refeeding hypophosphatemia (RH) was also assessed.

METHODS

Four databases were systematically searched until September 2020 for retrieving trials and observational studies. The incidences of RFS and RH were expressed as percentage and reported with 95% confidence intervals (CI).

RESULTS

Thirty-five observational studies were included in the analysis. The risk of bias was serious in 16 studies and moderate in the remaining 19. The incidence of RFS varied from 0% to 62% across the studies. No substantial change in the originally reported incidence of RFS was found by applying the ASPEN criteria. Similarly, the incidence of RH ranged between 7% and 62%. In the subgroup analyses, inpatients from Intensive Care Units (ICUs) and those initially fed with >20 kcal/kg/day seemed to have a higher incidence of both RFS (pooled incidence = 44%; 95% CI 36%-52%) and RH (pooled incidence = 27%; 95% CI 21%-34%). However, due to the high heterogeneity of data, summary incidence measures are meaningless.

CONCLUSION

The incidence rate of both RFS and RH greatly varied according to the definition used and the population analyzed, being higher in ICU inpatients and in those with increased initial caloric supply. Therefore, a universally accepted definition for RFS, taking different clinical contexts and groups of patients into account, is still needed to better characterize the syndrome and its approach.