management and prevention of refeeding …...4/18/20 1 management and prevention of refeeding...
TRANSCRIPT
4/18/20
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Management and Prevention of Refeeding Syndrome in Patients with Restrictive Eating Disorders
Kendel Rose-Chojnacki
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Objectives
Provide an overview of refeeding
syndrome, what is known and unknown
1Bring awareness to patients at risk and current guidelines
2Challenge universal
best practice &
Evaluate safety of higher calorie feeding
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Personal Interest
• Experience working at a mental health facility
• Prolonged malnourishment • Hunger strike• Mental health diagnoses• religious preoccupation• hallucinations
• Alcohol and substance-use disorders• Eating disorders
• No standard protocol – further need to develop knowledge
Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.
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1OVERVIEW
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Introduction
• Refeeding Syndrome (RFS) is a rare, potentially deadly phenomenon• Often associated with critically ill patients started on tube feeding• Practices and protocols in place to prevent it • “Start low, go slow”
• New research - different ways to manage RFS for different cases?• ”Low and slow” may not be universal best practice
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Defining Refeeding Syndrome
ASPEN 2020 proposed consensus definition:
• Decrease in serum P, K and/or Mgand/or
• Resulting organ dysfunctionand/or
• Severe thiamine deficiency• Within 5 days of reintroducing calories
Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.
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PATHOLOGY OF REFEEDING SYNDROME
Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R. F., Shenkin, A., Allison, S. P., & Lobo, D. N. (2008). Retrieved from https://www.researchgate.net/figure/Pathogenesis-and-features-of-the-refeeding-syndrome_fig1_6138422
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Signs and Symptoms of RFS
• Hypophosphatemia• Hypomagnesemia• Hypokalemia• Hypoglycemia• Thiamin Deficiency• Edema
• Respiratory failure• Cardiac arrhythmias• Cardiac arrest• Seizures• Coma• Excess infections• Death
Crook, M ., Hally, V., & Panteli, J. (2001). The im portance of the refeeding syndrom e. Nutrition , 17(7-8), 632-637.
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2RISK FACTORS & GUIDELINES
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Risk Factors for RFS
One or more:
• BMI < 16 kg/m2
• Weight loss > 15% in 3-6 months• Little to no intake > 10 days• Low K, Mg, P before feeding
Two or more:
• BMI < 18.5 kg/m2
• Weight loss > 10% in 3-6 months• Little to no intake > 5 days• Hx of alcohol abuse or drugs
• Includes chemo, insulin, antacids, or diuretics
Pilling S. NICE guidelines. Ann Gen Psychiatry. 2010;9(Suppl 1):S53. Published 2010 Apr 22. doi:10.1186/1744-859X-9-S1-S53
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Populations at Risk
Bariatric Surgery and bowel resection
Malabsorption
Child abuse and starvation
Military recruits
Athletes
Renal failure/HD
Critically Ill
Starvation in protest
Cancer
Mental health disorders
Alcohol and substance-abuse
Anorexia nervosa Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.
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General Management of Refeeding for High Risk Individuals
Historical standard: “start
low, go slow”
Start at 5 kcal/kg/d
(severe) up to 20-25 kcal/kg/d
Slowly introduce calories 4-10 days
until goal met
Closely monitor electrolytes
(first 72 hours)
Thiamine supplementation
Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.
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3IS HIGHER CALORIE REFEEDING SAFE IN
CERTAIN POPULATIONS?
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Outcomes of an Inpatient Refeeding Protocol in Youth with Anorexia Nervosa: Rady Children’s
Hospital San Diego/University of California, San Diego
Study 1
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa:
Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Overview
PurposeTo evaluate the safety of a higher calorie refeeding protocol in adolescent patients with restrictive eating disorders
Design Observational Study – Retrospective Chart Review
Intervention Oral nutrition rehabilitation protocol using high or low starting calorie prescription
Primary Outcomes Electrolyte abnormalities and length of stay
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Participants
Inclusion Criteria• 8-20 years old• Dx AN, ARFID, or EDNOS• Met criteria for hospitalization• First or second hospital
admission
Exclusion Criteria• Dx Bulimia Nervosa• Left against medical advice• Transfer to different medical or
psychiatric facility• Admission to this hospital in last
30 days
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Methods
• Prescribed calorie level up to discretion of provider• Low calorie group = < 1500 kcal/d • Mean = 1185 kcal/d
• High calorie group = > 1500 kcal/d • Mean = 1781 kcal/d
• Aim for weight gain of 150-300 g/d• Calories increased in increments of 300 kcal/d
• Primarily oral feeding• Electrolytes & refeeding labs monitored daily
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Results
Low Calorie Group (n=21)
High Calorie Group (n=66)
P Value**
Hypophosphatemia* 57.1% 51.5% 0.65
Hypomagnesemia* 52.4% 51.5% 0.94
Hypokalemia* 19.1% 4.6% 0.03
Length of Stay 20.7 days 13.5 days <0.01
**P < 0.05 statistically significant
*frequency of development of in the first 72h of admission
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Results – Severely Malnourished Patients
Low Calorie Group High Calorie Group P Value **
Hypophosphatemia* 69% 60% 0.65
Hypomagnesemia* 6% 10% 0.72
Hypokalemia* 63% 50% 0.53
**P < 0.05 statistically significant
*frequency of development of in the first 72h of admission
• < 75% Expected Body Weight• n = 26
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Conclusions
Higher calorie refeeding may be supported in AN
Calories or rate not associated with electrolyte abnormalities
Degree of body depletion possibly better predictor of electrolyte abnormalities
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Overall EAL Rating: Negative
Strengths• Close monitoring of labs & vitals • Inclusion of severely
malnourished patients
Weaknesses• Observational study• Relatively small sample size• Calorie prescription based on
physician judgment• Rate of weight loss prior to
admission self reported
Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
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Higher Caloric Intake in Hospitalized Adolescents with Anorexia Nervosa is Associated with
Reduced Length of Stay and No Increased Rate of Refeeding Syndrome
Study 2
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced
Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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Overview
Purpose: Determine the impact of higher calorie intake on weight gain, length of stay, and markers of refeeding syndrome in AN patients
Design: Observational Study – Retrospective Chart Review
Intervention: Oral nutrition rehabilitation protocol using high or low starting calorie prescription
Primary Outcomes: Electrolyte abnormalities and length of stay
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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Participants
Inclusion Criteria
• 10– 21 years old• Dx AN• Mod/severe protein-calorie
malnutrition• Unstable vital signs• OR electrolyte disturbances
Exclusion Criteria
• Dx bulimia nervosa or EDNOS• Transferred after start of
nutrition intervention• Left AMA• Required NG feeding
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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Methods
• High calorie group vs. low calorie group• High = ≥ 1400 kcal/d• Low = < 1400 kcal/d
• Oral refeeding + high calorie oral supplement• NG if needed
• Increased ~200 kcal every 24-48 hours
• Weight gain goal 0.2-0.5 kg/d
• Serum chemistries monitored every 24-48 hours• Supplemental P, Mg, & K if needed
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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Results
P < 0.0001 statistically significant
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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Conclusion
Refeeding at > 1,550 kcal/d leads to reduced LOS
High cal refeeding not associated with signs of RFS
Degree of malnutrition better predictor of RFS
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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Overall EAL Rating: Neutral
Strengths• Large sample size• Severely malnourished patients
(n=49)• Specialized unit• Calorie intake and BMI assessed
prior to admission
Weaknesses• Retrospective study• Calorie level not randomized• Prophylactic P supplementation
Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
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A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients
with Eating DisordersStudy 3
Matthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse
Outcomes in Adult Patients with Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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Overview
Purpose Compare incidence of RFS between low-cal and higher-cal protocol in adults with EDs
Design Retrospective pre-test-post-test
Intervention Oral & NG refeeding protocol using different prescribed kcal levels
Primary Outcomes Prevalence of electrolyte disturbance, hypoglycemia, edema and RFS dx
M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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Participants
Inclusion Criteria
• ≥ 18 years• ED diagnosis• Admitted to specialized unit
Exclusion Criteria
• Admitted from psychiatric unit• Admitted to ICU during
admission• Renal conditions• Pregnancy • < 5-day admission
M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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Methods
• Low-calorie control group (n=26)• December 2010 – August 2013• 875-1,000 kcal/d first 4-7 days• Primarily oral feeding• Advanced 500 kcal/d every 3-4 days• Goal 3,000 kcal
• Vitals, electrolytes, P, Mg, LFT daily until goal
M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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Methods Continued
• High-calorie group (n=93)• September 2013– January 2017• 1,500 kcal/d• NG tube within 24 hours• Fluid restricted to 250 ml/d• Advanced 500 kcal/d every 48 hours• Goal 3,000 kcal • Transition to oral after 48 hours at goal
• Vitals, electrolytes, P, Mg, LFT daily until goal
M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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Results
P < 0.05 statistically significant
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Conclusion
Higher calorie refeeding protocol may be safe in adults with EDs
Fewer hypoglycemic events occurred with higher refeeding protocol
Level of starting calorie prescription did not influence incidence of electrolyte disturbances or RFS diagnosis
M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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Overall EAL Rating: Neutral
Strengths• Relatively large sample size• Detailed protocol in isolated
time frames• Several clinical outcomes
measured & analyzed• Corrected for differences in BMI
Weaknesses• Retrospective study • Calorie groups not randomly
assigned• Differences in admission criteria• Difference in sample sizes
M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.
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The Role of the RD
•Recognize types of patients who may be at risk for RFS•Consider all factors when initiating a refeeding protocol • Individualize approaches to refeeding •Remain up to date with current research
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Future Directions
Research in all areas, age groups
& populations
RCTs, Reviews, Meta-Analyses
RFS definition, criteria and treatment
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Thank you
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References• Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus
Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.• Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R. F., Shenkin, A., Allison, S. P., & Lobo, D. N. (2008). Retrieved
from https://www.researchgate.net/figure/Pathogenesis-and-features-of-the-refeeding-syndrome_fig1_6138422• Crook, M., Hally, V., & Panteli, J. (2001). The importance of the refeeding syndrome. Nutrition, 17(7-8), 632-637.• Pilling S. NICE guidelines. Ann Gen Psychiatry. 2010;9(Suppl 1):S53. Published 2010 Apr 22. doi:10.1186/1744-859X-
9-S1-S53• Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017).
Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.
• Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014
• Matthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463
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