Malnutrition And Refeeding Syndrome

Question 1

Unspecified protein energy malabsorption

Answer 1

Weight loss of at least 5%
Evidence of suboptimal intake
Resulting in subcutaneous fat loss and or muscle wasting

Question 2

Starvation related malnutrition

Answer 2

Pure chronic starvation, anorexia nervosa
Unintentional weight loss of <20 in 1 year, >10 in 6 months, >7.5 in 3 months or >5 in 1 month
Moderate- severe subcutaneous fat loss
Moderate- severe muscle loss
Severe localised or generalised fluid oedema

Severe estimated energy intake <50% requirements for >1 month
Moderate estimated energy intake <75% for >3 months
Client history of limited access to food, genetic or acquired conditions such as CP, failure to thrive or feeding difficult

Question 3

Chronic disease related malnutrition

Answer 3

Organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity
Unintentional weight loss of <20 in 1 year, >10 in 6 months, >7.5 in 3 months or >5 in 1 month
Moderate- severe subcutaneous fat loss
Moderate- severe muscle loss
Organ failure, malignancies, GI disease etc

Question 4

Acute disease or injury related malnutrition

Answer 4

Major infection, burns, trauma, closed head injury
Unintentional weight loss 1-2% in 1 week, >5% in 1 month or >7.5 in 3 months
Moderate- severe subcutaneous fat loss
Moderate- severe muscle loss
Severe localised or generalised fluid oedema
Severe estimated energy intake <50% requirements for >5 days
Moderate estimated energy intake <75% for >7 days

Question 5

Subjective global assessment

Answer 5

Section 1: medical history
Weight change 
Dietary intake 
GI symptoms 
Functional impairment 

Section 2: physical

Question 6

Refeeding syndrome

Answer 6

Life threatening acute micronutrient deficiencies, fluid and electrolyte imbalance, and disturbances of organ function and metabolic regulation that may result from over rapid or unbalanced nutrition support

Can occur in any severely malnourished individuals but are particularly common in those who have had very little or no food intake, even including overweight patients

Question 7

Metabolism in starvation

Answer 7

6-12 hours of starvation: glycogen from liver and muscles, gluconeogenesis and protein catabolism
>6-12 hours, protein, fat, mineral, electrolyte and vitamin depletion- salt and water intolerance
Refeeding (switch to anabolism)
Fluid, salt, nutrients
Insulin secretion
Increased protein and glycogen synthesis
Hypokalaemia, hypomagnesaemia, hypophosphataemia, thiamine deficiency, salt and water retention (oedema)

Question 8

Wernickes encephalopathy

Answer 8

Thiamine stores are already depleted
Half life 9-18 days
Reintroduction of CHO and increase use of thiamine as a cofactors for oxidation
High risk of thiamine deficiency - therefore coadministration of thiamine during refeeding is critical
Supplementation: 300mg IV daily for 3/7, then 100mg orally daily for 4-7 days (continue if other indications). First 3 days 500mg for severe alcoholism etc

Question 9

Other micronutrients

Answer 9

Likely to be inadequate so a complete multivitamin with adequate grace elements is recommended on commencement of nutrition support

Question 10

Identification of refeeding risk

Answer 10

• Patient has one or more of the following
  BLI <16
  Unintentional weight loss >15% 3-6/12
  Little or no nutritional intake >10 days
  Low levels of potassium phosphate or magnesium prior to feeding
  Elderly, oncology, malabsorption, eating disorder, food insecurity, post surgery, hospital fasting etc
• patient has two of more of the following
  BMI <16
  Unintentional weight loss >10% in 3-6/12
  Little or no nutrition intake >5 days
  Alcohol abuse of drugs including insulin, chemo, antacids or diuretics

Question 11

Biochem

Answer 11

Electrolyte abnormalities occur within 1-3 days of reintroduction of nutrition, but may develop up to 5 days later
Baseline blood tests required before nutrition support
Baseline bloods may be normal - this does not indicate they are at risk of refeeding
Serum levels of phosphate, potassium, magnesium, calcium, urea and creatinine checked
If severe electrolyte abnormalities, electrolyte correction should be made prior to commencement of nutrition support
High risk patients- prophylactic supplementation- regular supplements before refeeding to try and stop them from going below normal range
Monitoring- if supplementation is inadequate, this can further delay nutritional restoration. In high risk patients bloods b.d or tds, daily monitorhing for ithernpatients

Question 12

Fluid

Answer 12

High risk of fluid accumulation in the ECF
Reintroduction of CHO reduced renal excretion of sodium and water
Consider limiting fluids to 1-1.5L combined oral enteral and IV

Recommend 2nd daily weights and monitoring fluid balance to decrease risk of fluid overload

Question 13

Management

Answer 13

Slow reintroduction of nutrition support with regular, electrolyte and metabolic monitoring
Start at 10kcal (42)kg/ d providing no more than 50% of EER for first 2 days
Increasing slowly to meet goal rate between 4-7 days
In extreme cases, this may be as low as 5kcak/kg/ d eg very low BMI or cardiac arrhythmia s already present
For obese patients, would use ideal body weight
If electrolytes are imbalanced after two days, withhold increasing nutrition support until electrolytes are more stable. Commence prophylactic electrolyte supplementation,
Plus stat supplementation. May increase frequency of bloods to ensure timely nutrition restoration

Question 14

Meal plan

Answer 14

Restriction:

• fruit: concentrated sugar
• high salt foods: fluid retention
• dairy: conscious, malabsoptgionngenerally ok
• sports drinks etc with electrolytes and high GI foods
• fluids to 1.5L

Free foods with good macro nutrition distribution and slightly more protein