adult refeeding guidelines - nhs wales · hywel dda local health board database no: 209 page 3 of...

HYWEL DDA LOCAL HEALTH BOARD

ADULT REFEEDING GUIDELINES Managing patients at risk and preventing refeeding syndrome

Policy Number: 209 Supercedes: Standards For

Healthcare Services No/s

Standard 14

Version No: Date Of Review:

Reviewer Name:

Completed Action:

Approved by:

Date Approved:

New Review Date:

1 Nov 2011 Rachel Lewis

Actions as recommended by the CPRG 20

th May 2011

November

2013

Brief Summary of Document:

Guidance to support the safe recognition and management of refeeding syndrome in adults

To be read in conjunction

with:

National Institute of Clinical Excellence (NICE) nutrition support in adults – Clinical guideline 32 – 2006. Best practice advice on the care of adults who are malnourished or at nutritional risk. Oral Feeding Difficulties and Dilemmas – report of a working party. Royal College Physicians January 2010 Management of really sick patients with Anorexia Nervosa (MARSIPAN) – College report CR162. Royal college of Psychiatrists and Royal college of Physicians, October 2010.

Classification: Clinical Category: Guideline Freedom Of Information Status

Closed

Authorised by: Kathryn Davies

Job Title

Dir of Therapies, and Health Sciences

A signed copy of this policy is held within Corporate Services.


Database No: 209 of 32 Version 1

Adult Refeeding Guidelines

Responsible Officer/Author:

Rachel Lewis Job

Title: Clinical Lead – Acute nutrition support

Contact Details: Dept

Nutrition and Dietetics

Base Glangwili hospital

Tel No 01267 227067 E-mail: [email protected]

Scope ORGANISATION

WIDE DIRECTORATE

DEPARTMENT ONLY

COUNTY

ONLY

Staff Group

Administrative/ Estates

Allied Health Professionals

Ancillary Maintenance

Medical & Dental Nursing Scientific &

Professional Other

CONSULTATION

Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained.

Individual(s)

Rachel Lewis Dr R Canavan Dr N Haboubi Peter Johnson Sue Beach

Date(s) August 2010

Group(s) Acute Dietetic Nutrition Clinical Practice group Virtual Nutrition group

Date(s) August 2010

Committee(s) Hywel Dda nutrition steering group

Date(s) Dec 2010

RATIFYING AUTHORITY (in accordance with the Schedule of Delegation)

KEY

COMMENTS/ POINTS TO NOTE

NAME OF COMMITTEE

A = Approval Required

Date Approval Obtained FR = Final

Ratification

Clinical Policy Review Group FR Jan 2012

Date Equality Impact Assessment

Undertaken June 2011

Group completing

Equality impact assessment

Jackie Hooper Rachel Lewis

Please enter any keywords to be used in the policy search

system to enable staff to locate this policy

Refeeding, enteral, parenteral, nutritional risk




Document Implementation Plan

How Will This Policy Be Implemented?

Through usual guideline distribution channels, see detail below.

Who Should Use The Document?

All clinical staff should be aware of the guideline

What (if any) Training/Financial Implications are Associated with this document?

Training / awareness for all medical staff and secondary care pharmacy teams delivered by Dietetics. Plan rolling programme for learning session through learning and development and post grad.

What are the Action Plan/Timescales for implementing this policy?

Action By Whom By When

Approved guideline sent for signing Rachel Lewis Jan 2012

Signed guideline made active on intranet

Policy Coordinator

Jan 2012

Active guideline advertised via global e-mail

Dietetics Jan 2012

Awareness sessions across the health board

Dietetics Jan 2012

Cascade of guideline through locality nutrition groups

Dietetics Jan 2012

Post graduate teaching sessions in each locality

Dietetics Jan-Feb 2012

Promotion of guideline via nutrition steering groups

Dietetics March 2012




CONTENTS

1. INTRODUCTION………………………………………………………………………..……5 2. GUIDELINE STATEMENT…………………………………………………………………..5 3. SCOPE………………………………………………………………………………………...5 4. AIM…………………………………………………………………………………………..…5 5. OBJECTIVES……………………………………………………………………………..…..5 6. DEFINITION OF REFEEDING SYNDROME……………………………………..……….6 7. IDENTIFICATION OF PATIENTS AT RISK OF REFEEDING SYNDROME………..…7 8. STARTING NUTRITION ON PATIENTS WITH AN IDENTIFIED RISK OF REFEEDING SYNDROME………………………………………………………………....8 9. MONITORING………………………………………………………………………..……....9 10. GUIDELINES FOR THE PROVISION OF ELECTROLYTES, THIAMINE

OTHER VITAMINS…………………………………………………………………………10 11. RESPONSIBILITY…………………………………………………………………….…….12 12. TRAINING………………………………...…………………………………………………12 13. IMPLEMENTATION AND MONITORING………………………………………...………13 14. CLINICAL POLICIES – REFERENCES…………………………………………...……..13 15. REVIEW………………………………………………………………………………...……13 16. APPENDIX

16.1. PATHOGENESIS OF REFEEDING SYNDROME……………………..………..14 16.2. CLINICAL SEQUELLAE OF ALTERED ELECTROLYTES…………….……....16 16.3. BMI CHART…………………………………………………………………..……...18 16.4. PERCENTAGE WEIGHT LOSS CHART……………………………………..…..19 16.5. NUTRITIONAL CONTENT OF VITAMIN AND MINERAL SUPPLEMENTS.…20 16.6. REFEEDING SYNDROME FLOW CHART – QUICK REFERENCE GUIDES.21




1. INTRODUCTION There is an identified need for clinical guidance for initiating oral, enteral or parenteral feeding in adult patients who are at risk of refeeding syndrome. These guidelines have been produced to provide guidance for staff within Hywel Dda Health Board about the requirements and processes for re-feeding syndrome. Nutrition is a fundamental element of care. Evidence suggests that 1 in 3 adults admitted to hospital are at risk of malnutrition (British Association of Parenteral and Enteral Nutrition (BAPEN), 2010). A percentage of these patients will have chronic poor nutrition or due to their acute illness have a period of significant poor nutrition that may predispose them to refeeding syndrome and associated complications. This risk must be recognised and managed appropriately to avoid consequences of refeeding syndrome. All adult patients admitted to secondary care must be nutritionally screened and re-screened weekly as a minimum throughout their hospital stay (NICE, 2006). Screening is undertaken by the nursing staff at ward level and provides a means of identifying patients at high nutritional risk. The nutritional screening tool indicates potential refeeding risk and prompts the nurse to consider the patients risk of refeeding and highlight at risk patients to the doctor. 2. CONSENT TO TREATMENT All patients with a poor nutritional status should be actively involved in decision making regarding their feeding plan and the management of potential refeeding risk. The Royal College of Physicians (2010) state ‘Those with intact cognitive function who are unable to eat or drink must be involved in decision making as their perception of the process resulting from absence of food will be different from those with absent cognitive function’. If there is a doubt about the patient’s mental capacity to consent to refeeding, the person providing the treatment should undertake a formal assessment of capacity in line with the Mental Capacity Act 2005. If the patient is found to lack capacity to make the decision for themselves treatment may proceed in their best interests. 3. PATIENTS WITH EATING DISORDERS Patients with eating disorders are at significant risk of refeeding syndrome and may be being admitted for ‘safe refeeding’ (although this may not be the only reason for an admission). Some patients with an eating disorder may lack capacity to make a decision around treatment because of an inability to understand or retain relevant information, or an inability to communicate their decision. Moreover, the nature of eating disorders may increase the likelihood that patients are unable to ‘use or weigh’ relevant information. Whilst the patient may understand information about the consequences of not eating, their compulsion not to eat might be too strong for them to ignore (MCA Code of Practice paragraph 4.22) and they would then not have the capacity to decide whether or not to accept treatment. If the case is complex and there is uncertainty about the patient’s capacity, then it may be helpful to obtain a second opinion from a psychiatrist or psychologist. If a patient with an eating disorder is found to lack capacity then treatment may proceed in their best interests. However, if a patient who lacks capacity indicates that they object to receiving the treatment then the only way forward is to consider detention under the Mental Health Act 1983, which allows for compulsory treatment of patients with eating disorders (including in-patient admission for re-feeding). An objection might be expressed verbally or be apparent from the patient’s behaviour.




Because an eating disorder is considered a mental disorder in terms of the Mental Health Act 1983, patients with capacity who refuse treatment for their eating disorder can be detained under the Mental Health Act and treated against their will as a life saving measure, although this should rarely be required (MARSIPAN, 2010).

4. POLICY STATEMENT To establish consensus within the Health Board on the management of re-feeding syndrome

5. SCOPE This clinical guideline is for use with all patients at risk of refeeding syndrome and can be used out of hours, at weekend and bank holidays and when a dietitian is not immediately available, to avoid a delay in initiating nutrition. These guidelines must be used by dietitians, registered nursing staff, biochemists, pharmacists, doctors, allied health professionals (AHPs) and students alike within the scope of the individual’s clinical competence. 6. AIM To minimise clinical risk and promote the safe introduction of oral nutritional supplements, enteral tube feeding and parenteral nutrition to all patients. 7. OBJECTIVE • To define re-feeding Syndrome • To provide guidance on identifying ‘at risk’ patients • To recommend best practice for the prevention and treatment of refeeding syndrome




8. DEFINITION OF REFEEDING SYNDROME The definition of refeeding syndrome is severe fluid and electrolyte shifts associated with initiating nutritional support in malnourished patients and the metabolic implications, which occur as a result of this (Solomon and Kirby 1990). 8.1. Potential consequences of refeeding syndrome

Cardiac failure, pulmonary oedema and dysrhythmias

Acute circulatory fluid overload or circulatory fluid depletion

Hypophosphataemia

Hypokalaemia

Hypomagnesaemia and occasionally hypocalcaemia

Hyperglycaemia (NICE 2006) 8.2. Pathogenesis of refeeding syndrome During starvation adaptations take place to reduce cellular activity and organ function in order to save energy. The changes include down regulation of metabolic pumping and synthetic activities with consequences that include:

Decreased insulin and increased glucagon secretion, with a switch from glucose towards ketone bodies as a source of energy

Deficiency of vitamins and trace elements

Whole body depletion of potassium, magnesium and phosphate

Increased intracellular and whole body sodium and water

Impaired cardiac, intestinal and renal reserve, leading to reduced ability to excrete excess sodium and water

Abnormal liver function During refeeding:

Increased insulin release leads to increased uptake of glucose, phosphate and potassium into the cells.

Reactivation of the sodium / potassium membrane pump leads to further movement of potassium into cells with a simultaneous movement of sodium and fluid out of the cells.

Reduced phosphate is associated with increased urinary magnesium excretion.

Stimulation of protein synthesis leads to increased anabolic tissue growth which in turn leads to increased cellular demand for phosphate, potassium, glucose and water

Reduced sodium and water excretion

Increased cellular thiamine utilisation due to its role as a co-factor for carbohydrate (Parenteral and enteral nutrition group (PENG), 2007)

(Further information available in Appendix 1 & 2)




9. IDENTIFICATION OF PATIENTS AT RISK OF REFEEDING SYNDROME

9.1. At Risk Those who have one or more of the following: Very little or no food intake for more than 5 days especially if already undernourished BMI < 20kg/m2 * Unintentional weight loss > 5% within the last 3-6 months* 9.2. High Risk Patient has one or more of the following: BMI < 16kg/m2* Unintentional weight loss > 15% within the previous 3-6 months* Very little or no nutritional intake for > 10 days Low levels of potassium, phosphate or magnesium prior to feeding

Or patient has two or more of the following: BMI < 18.5kg/m2* Unintentional weight loss > 10% within the previous 3-6 months* Those with very little or no intake for > 5 days A history of alcohol or drug abuse or some drugs including insulin, antacids or diuretics and patients on chemotherapy. 9.3. Extremely high risk Patient has one or more of the following: BMI < 14kg/m2* Negligible intake for > 15 days Pre-feeding hypokalemia, hypophosphataemia or hypomagnesaemia (NICE, 2006) 9.4. Other considerations Refeeding syndrome can occur in patients receiving oral, enteral or parenteral nutrition. It is

less likely to occur in those fed orally (although it is possible) since starvation is usually accompanied by a reduction in appetite

There have been reported cases of re-feeding syndrome occurring in patients with chronic vomiting (hyperemesis gravidarum), prolonged diarrhoea, gastrointestinal obstruction, malabsorption diseases, and poorly controlled diabetes

Refeeding problems can also occur in overweight patients who have eaten nothing for prolonged periods. Particular caution needed in bariatric surgical patients who have developed complications resulting in a significant period of starvation.

Beware of very malnourished, dehydrated patients with renal impairment and consequently normal or high potassium and phosphate levels. The combined effect of rehydration and refeeding can cause significant changes in biochemistry within hours to very low levels.

(PENG, 2011) *Refer to tables in appendix 3 and 4 re calculation of BMI and percentage weight loss




10. STARTING NUTRITION FOR PATIENTS AT RISK OF REFEEDING SYNDROME

10.1. At risk patients Introduce feeding at a maximum 50% of total energy requirements for the first 2 days before

increasing to full requirements if clinical and biochemical monitoring reveals no abnormalities.

Meet full requirements for fluid, electrolytes, vitamins, minerals and trace elements from day 1 of feeding

10.2. High risk patients Start nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet full

needs by 4-7 days. Any increase in feed should be dependent on trends in biochemistry. Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate

and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment). Pre-feeding correction of low plasma levels is unnecessary

Provide immediately before and during the first 10 days of feeding: oral thiamine, vitamin B- co strong (or full dose daily intravenous vitamin B preparation if necessary)

Provide a balanced multivitamin/trace element supplement once a day 10.3. Extremely high Risk Start nutrition support at a maximum of 5kcal/kg/day increasing levels slowly to meet full

needs by 4-7 days. Any increase in feed should be dependent on trends in biochemistry. This level will be safe even with pre-existing low plasma electrolytes, yet will encourage intra-cellular up take of the phosphate and electrolyte supplementation that must be started at the same time.

Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment). Pre-feeding correction of low plasma levels is unnecessary

Providing immediately before and during the first 10 days of feeding: oral thiamine, vitamin B co strong (or full dose daily intravenous vitamin B preparation if necessary)

Provide a balanced multivitamin/trace element supplement once a day Where ECG available, monitoring of cardiac rhythm in this group and any others who have

or develop cardiac arrhythmias is recommended (NICE, 2006) See section 10.0: detailed guidance for provision of electrolytes, thiamine and multi-vitamins 10.4. Patients requiring additional fluids Circulatory volumes should be replaced but care should be taken not to overload patients. Consideration should be given to sodium and carbohydrate content of the fluid used - 1L 5% dextrose contains 200Kcal.




11. MONITORING

Due to homeostatic mechanisms it is not uncommon for serum levels of potassium, magnesium and phosphate to be within normal parameters prior to feeding

Pre feeding correction of low plasma levels is unnecessary Monitor appropriate biochemistry including potassium, phosphate and magnesium. Refer to

table below for detail As a guide glucose should be monitored 4 hourly initially and daily once stable. Diabetic

patients may differ. Please check with the diabetes team, however, the overall decision will lie with the medical/surgical team caring for the patient

Restore circulatory volume and monitor fluid balance and overall clinical status closely Monitor cardiac rhythm continuously in patients identified as at extreme high risk of

refeeding and any others who already have or develop any cardiac arrhythmias

Parameter Frequency

Sodium, Potassium, Urea, Creatinine

Baseline

Daily until stable

Then 1 or 2 times a week

Glucose Baseline

4 hourly initially

Daily once stable

Magnesium, Phosphate Baseline

Daily until stable

Then weekly

Liver function tests Baseline

Twice weekly until stable

Then weekly

Calcium, albumin Baseline

Then weekly

C-reactive protein Baseline

Then 2 or 3 times a week until stable

Fluid balance

Daily

Weight Daily to support fluid balance monitoring




12. GUIDELINES FOR PROVISION OF ELECTROLYTES, THIAMINE AND OTHER VITAMINS

12.1. Electrolytes Below are possible electrolyte supplements available, please discuss with your Pharmacist for further information

Intravenous Oral / Enteral Likely Requirement (NICE, 2006)

Phosphate Addiphos, polyfusor phosphate

Phosphate sandoz, potassium acid phosphate

0.3-0.6 mmol/kg/day

Potassium Potassium chloride Sando K, Slow K, Kay-Cee-L

2-4 mmol/kg/day

Magnesium Magnesium Sulphate Magnaspartate sachets, Magnesium oxide or glycerophosphate

0.2 mmol/kg/day intravenous 0.4 mmol/kg/day oral

12.2. Thiamine

High risk of refeeding

Very high risk of refeeding (extreme cases)

Patient on intravenous therapy only

High strength vitamins B & C (Pabrinex) injection 5mls of Ampoule 1 plus 5 mls of ampoule 2 in suitable infusion solution Once daily for five doses only

Patient able to tolerate oral therapy

Oral thiamine 200-300mg, daily for 10 days Vitamin B co strong 1-2 tablets tds daily for 10days

High strength vitamins B & C (Pabrinex) injection as documented above

If administration via an enteral feeding tube:

Enteral thiamine 200-300mg, daily for 10 days (50mg QDS) Disperse tablets in 10ml of water, leave for 10 minutes before administration Vitamin B co strong: Use Vigranon B syrup 5ml tds




12.3. Vitamin and Mineral supplementation Patients at risk of refeeding syndrome or those with prolonged poor nutritional intake may require additional vitamin supplementation, as sub clinical deficiency is likely. Avoid single micronutrient supplementation unless proven deficiency is established. If deficiency is suspected, liaise with the dietitian or pharmacist to establish recommended repletion levels.

All patients at Risk of refeeding

Patient on intravenous therapy only

Solivito, Additrace and Vitlipid (or equivalent as discussed with Pharmacy) 1 vial of each in 100mL – 500ml 0.9% sodium chloride infused over 4 hours once daily

Patient able to tolerate oral If administration via an enteral feeding tube:

Forceval / Sanatogen A-Z complete / Centrum OD (or equivalent, please discuss with pharmacy) Consider Sanatogen A-Z complete/Centrum prepared appropriately as agreed with pharmacy

(Further information available in appendix 5)

12.4. Guideline for the replacement of electrolytes It is not necessary to correct electrolyte levels before starting feeding, but bloods should be monitored daily and aggressively corrected as feeding continues. Electrolyte replacement therapy needs to be based on the clinical judgement of the doctor and pharmacist and considered on an individual patient basis. 13. RESPONSIBILITY All clinical staff have responsibility for ensuring that the principles outlined within this document are universally applied. 13.1. Director of nursing Executive responsibility for nutrition in the organisation. 13.2. Nutrition Steering Group Development of operational policy. Sub-groups of the Nutrition Steering Group are established when necessary to examine and address specific issues relating to nutrition. Reporting on compliance against this guideline is via the Nutrition Steering Group. 13.3. Doctors Recognise and manage patients at risk of refeeding syndrome, including monitor blood biochemistry and organise prescription of replacement electrolytes. Referral to the dietitian must be made to support ongoing nutritional care. 13.4. Nursing staff Through the nutritional screening process highlight to the consulting team patients at risk of refeeding Syndrome, follow prescribed feeding and electrolyte replacement regimes, highlighting any problems on a day to day level.




13.5. Dietitian Educate and train staff on refeeding syndrome, highlight patients at risk of refeeding syndrome, support consulting team through provision of expert advice, feeding regimes and monitoring nutritional status. 13.6. Pharmacist Provision and advice on electrolyte and micronutrient prescriptions. 13.7. Biochemist Advise on treatment of altered blood biochemistry and appropriate investigations. 13.8. Other Allied Health Professional Highlight any patients at risk of refeeding syndrome to appropriate team members. 14. TRAINING Training / awareness sessions for medical staff and secondary care pharmacy teams will be led by Dietetics implemented through a rolling education programme in collaboration with learning and development and postgraduate department. A log of all staff trained / made aware of the guideline will be kept within each locality of the health board. 15. IMPLEMENTATION AND MONITORING The guideline will be cascaded to relevant medical staff through the Nutrition steering and locality nutrition groups. Monitoring of this guideline will be through clinical audit. 16. CLINICAL POLICIES - REFERENCES

A Guide to Clinical Nutrition. PENG, 2007 and 2011

Alloju, M., Ehrinprieis, M. (1997) Shortage of intravenous multivitamin solution in the United States (correspondence). The New England Journal of Medicine. 337(1), 54-55

Russell, C. A., Elia M (2010) Nutrition screening survey in the Uk and Republic of Ireland. BAPEN

Brooks, MJ., Melnick, G. (1995) The refeeding syndrome: an approach to understanding its complications and preventing its occurrence. Pharmacotherapy. 15, 713-26

Champe, PC & Harvey, RA. (1994) Lippincott’s Illustrated Reviews Biochemistry 2nd Edition. J.B. Lippincott Company

Crook, M., Panteli, J., Horn, V. (2002) Guidelines for the prevention and management of the refeeding syndrome. University Hospital Lewisham NHS Trust 2002

Klein, C.J., Stanek, GS., Wiles, CE. (1998) Overfeeding macronutrients to critically ill adults: metabolic complications. J. American Dietetic Association 98, 795-806

NICE National Institute for Health and Clinical Excellence. Nutrition Support in Adults. Clinical Guideline 32(2006)

Reuler, J., Girard, D., Cooney,T. (1985) Current concepts: Wernicke's encepalopathy.

The New England Journal of Medicine. 312(16), 1035-1039

Royal college of Physicians (2010) Oral feeding difficulties and dilemmas – Report of a working party.

Royal college of Psychiatrists and Royal College odf physicians (2010) Management of really sick patients with Anorexia Nervosa – College report CR162.

Solomon,S.M., and Kirby, D.F. (1990) The Refeeding Syndrome: a review.

J. Parenteral and Enteral Nutrition 14, 90-97 17. REVIEW This guideline will be reviewed in two years time. Earlier review may be required in response to any relevant changes in national guidance.




18. APPENDIX 1 PATHOGENESIS OF REFEEDING SYNDROME (Taken from Oxford Radcliffe guidelines 2003) In starvation, synthesis of insulin is reduced and glucagon levels rise. As a consequence, glycogen stores are rapidly converted to glucose and gluconeogenesis is activated resulting in glucose synthesis from protein and lipid breakdown products. Adipose tissue lipase is activated releasing large amounts of fatty acids and glycerol. Free fatty acids and ketone bodies replace glucose as the major energy source in starvation. Patients in the starved state break down lean body mass and become depleted in water and minerals (Nightingale, 2001). During refeeding, there is a switch in metabolism from fat to carbohydrate and consequently insulin is released, which is stimulated by the glucose load. With increased carbohydrate load and increased insulin production there is an increased uptake of glucose, phosphorus, potassium and water into cells; and a stimulation of anabolic protein synthesis (Champe and Harvey 1994). The combined effect of depleted total body phosphorus during catabolic starvation and the movement of phosphorus into cells during refeeding leads to severe extracellular hypophosphataemia often in association with hypokalaemia and hypomagnesaemia (Solomon and Kirby 1990, Brooks and Melnick 1995). Thiamine (Vitamin B1) is an essential co-enzyme in carbohydrate metabolism and feeding without sufficient body stores can lead to Wernicke’s encephalopathy. In spite of total body depletion the serum concentration of electrolytes can appear normal in the starved state, due to alterations in renal rates of excretion. It is therefore essential to monitor electrolyte levels during the early stages of instigating enteral or parenteral nutrition, as it is during this time that biochemical shifts will occur (Solomon and Kirby 1990, Brooks and Melnick 1995).

* Insulin release stimulates the sodium potassium adenosinetriphosphatase sodium/potassium (ATPase) pump (which requires magnesium as a cofactor). This drives the potassium into the cells and sodium moves out. Carbohydrate load and insulin release stimulate phosphate shifts into the cells and phosphate depletion is associated with increased urinary magnesium excretion. This leads to low extracellular phosphate, magnesium and potassium, and may precipitate the symptoms of refeeding syndrome (Solomon and Kirby 1990, Brooks and Melnick 1995).

REFEEDING

Conversion to glucose as major energy source

Insulin release*

cellular glucose uptake, protein synthesis

Intracellular shifts and extracellular depletion of phosphate, potassium and magnesium

Clinical symptoms of refeeding syndrome




Thiamine Deficiency Thiamine is an essential cofactor for a variety of enzyme activities involved in carbohydrate metabolism. If commencing feeding in a thiamine depleted patient, further depletion will occur and could result in clinical presentation of deficiency, this being Wernicke’s encephalopathy and Korsakov’s Syndrome (Drenick et al 1966, Reuler et al 1985, Brooks and Melnik 1995). Wernike-Korsakoff syndrome is an acute neurological abnormality characterised by one or more of the following (NICE 2006):

Apathy and disorientation

Nystagmus, opthalmoplegia or other eye movement disorders

Ataxia

Severe impairment of short term memory often with confabulation

It is frequently seen in alcoholics who may have low liver stores of thiamine, and in patients with chronic vomiting. Symptoms of sub-clinical deficiency include headaches, tiredness, anorexia and muscle wasting. Regular daily intake of less than 0.2mg/1000kcal results in clinical deficiency. A physiological deficiency is likely in 21 days of no dietary intake (Drenick et al 1966, Reuler et al 1985 and Alloju 1997).

Glucose and lipid metabolism Administering glucose/carbohydrate to a starved patient is initially beneficial because it reverses the negative nitrogen balance caused by starvation via suppression of gluconeogenesis and reduced amino acid usage. However, giving too much can lead to hyperglycaemia, hyper osmolar hyperglycaemic non-ketotic coma, metabolic acidosis, osmotic diuresis, dehydration or hypotension. Giving excessive amounts could also lead to conversion of glucose to fat predisposing to fatty liver and increased respiratory workload via increased carbon dioxide production (Brooks and Melnik 1995, Klein et al 1998 & Crock et al 2002). Body fluid homeostasis Refeeding can cause disturbances of the body’s fluid distribution. The result of this could be dehydration or fluid overload, which could then lead to: - cardiac failure - hypotension - pre-renal failure - sudden death Carbohydrate refeeding can lead to reduced sodium and water excretion. This along with movement of sodium from the intracellular space to the extracellular space with increased ATP production will expand the extracellular fluid compartment and precipitate weight gain (oedema/ascites) particularly if sodium intake is increased (Crook et al 2002, Klein et al 1998).




19. APPENDIX 2: CLINICAL SEQUELLAE OF ALTERED ELECTROLYTES IN REFEEDING SYNDROME (Solomon and Kirby 1990, Brooks and Melnik 1995)

Electrolytes Cardiac Respiratory Hepatic Renal GI Neuromuscular Haematological

Low phosphate

Altered myocardial function Arrhythmia Congestive heart failure

Acute ventilatory failure

Liver dysfunction

Acute renal failure Bicarbonate and glucose wasting

Anorexia Nausea

Lethargy, weakness, seizures, confusion, coma, paralysis, Diaphragm wasting

Haemolytic anaemia, WBC dysfunction thrombocytopenia, Haemorrhage, Red cell 2,3 diphosphoglycerate deficiency

Low potassium

Arrhythmia Cardiac arrest ECG changes

Respiratory depression

Exacerbation of hepatic encephalopathy

Decreased urinary concentrating Ability, Polyuria and polydipsia Decreased GFR

Constipation Ileus

Paralysis Rhabdomyolysis Weakness

Low magnesium

Arrhythmia Tachycardia

Respiratory depression

Increased potassium loss

Abdominal pain, Anorexia, Diarrhoea, Constipation

Ataxia Confusion Muscle tremors Weakness Tetany




WHY MAKE THESE RECOMMENDATIONS? Why do we measure electrolytes? Potassium, magnesium and phosphate are mainly intracellular ions and are affected by shifts across compartments, renal excretion and changes in acid-base status of the patient. Serum electrolyte concentrations are a poor reflection of total body stores, particularly in nutritionally depleted patients. When one electrolyte level is low there is an increased chance of other electrolyte abnormalities (Whang et al. 1984). Each electrolyte has essential roles and specific consequences in nutritional replacement. Sodium is the principal extracellular cation and maintains extracellular fluid balance. It is functional in acid-base balance and maintaining osmotic pressure. Sodium, calcium and potassium help maintain the electrical potential of membranes involved in neuromuscular transmission. Measurement of sodium is used to evaluate fluid-electrolyte balance, acid-base balance, and in the investigation of renal, adrenal and neuromuscular diseases. Water deficit can cause hypernatraemia and water overload can result in hyponatraemia. Potassium is the principal intracellular cation and primary intracellular buffer. It maintains the neuromuscular electrical potential and is important in acid-base balance (with hydrogen ions) and osmotic pressure (with sodium). Potassium is essential for the function of the Na-K-ATPase which uptakes solutes into the cell, including glucose. Abnormalities of potassium concentration affect cardiac excitability and hypo- or hyperkalaemia can lead to arrhythmias. Magnesium is primarily an intracellular electrolyte critical in metabolic processes. It is a cofactor for many enzymes including ATP-dependent cation transport (calcium and sodium). It interacts with calcium to affect the neuromuscular excitability and membrane potentials. Hypomagnesaemia is associated with other electrolyte deficiencies, particularly hypokalaemia and hypophosphataemia (Whang et al 1984). Phosphorus is present in the body mainly as phosphates or esters. It is an essential component of DNA, RNA and vitamins and is crucial in glycolysis and oxidative phosphorylation. Phosphate concentration is controlled by calcium concentration, parathyroid hormone, vitamin D and renal function. Nutritionally depleted patients have a higher phosphate requirement and are at risk of clinically significant hypophosphataemia (Marshall et al 1987). Calcium is the most abundant mineral in the body and 99% is within the skeleton. Serum calcium can be bound to proteins, complexes with other ions or remain as free ions. The functions of calcium include the structural role in bones, regulation of membrane potentials, and as a co-factor for coagulation. Hypercalcaemia is recognised in patients receiving parenteral nutrition. The most likely causes are metabolic bone disease and abnormal vitamin D metabolism, although other causes should be considered (Marshall et al 1987).

* Remember patients with normal pre-feeding levels of potassium, magnesium and phosphate can still be at risk of refeeding syndrome. *




20. APPENDIX 3: BMI CHART




21. APPENDIX 4: PERCENTAGE WEIGHT LOSS CHART




22. APPENDIX 5: NUTRITIONAL CONTENT OF VITAMIN & MINERAL PREPARTAIONS

Drug name Additrace (per 10 ml vial)

Solivito (per 10ml vial)

Vitlipid (per 10ml vial)

Pabrinex (vial 1&2)

Forceval Capsules

Route Intra venous(IV) I.V I.V I.V Enteral

Contents

A - - 330units - 2,500iu

B1 Thiamine - 3.1mg - 250mg 1.2mg

B2 Riboflavine - 4.9mg - 4mg 1.6mg

B3 Niacin - - - 160mg 18mg

B5 Pantothenic acid

- 16.5mg - - 4mg

B6 Pyridoxine - 4.9mg - 50mg 2mg

B7 Biotin (Vitamin H)

- 60mcg - - 100mcg

B8 Inositol - - - - -

B9 Folic Acid - 400mcg - - 400mcg

B12 - 5mcg - - 3mcg

C - 100mg - 500mg 60mg

D - - 5mcg - 400iu (10mcg)

E - - 9.1mg - 10mg

K - - 150mcg - -

Zinc 100micromol - - - 15mg

Copper 20 micromol - - - 2mg

Selenium 0.4 micromol - - - 50mcg

Manganese 5 micromol - - - 3mg

Iron 20micromol - - - 12mg

Molybdenum 0.2 micromol - - - 250mcg

Chromium 0.2 micromol - - - 200mcg

Iodine 1 micromol - - - 140mcg

Fluoride 50 micromol - - - -

Calcium - - - - 100mg

Phosphorus - - - - 77mg

Magnesium - - - - 30mg

Potassium - - - - 4mg

23. REFEEDING SYNDROME FLOW CHARTS – QUICK REFERENCE GUIDES The quick reference guides below can be used to initiate nutrition support out side working hours, weekends and bank holidays. The ward dietitian must be informed on the next working day to devise an individual nutritional care plan.




23.1. ADULT PATIENT IDENTIFIED AS AT RISK OF REFEEDING SYNDROME

Quick reference flow chart: Enteral feeding regimen: Nasogastric tube (NGT) / Naso jejeunal (NJ) / Percutanous endoscopic gastrostomy (PEG) / Jejunostomy / Radiological inserted gastrostomy (RIG): At Risk Those who have one or more of the following:

Very little or no food intake for more than 5 days especially if already undernourished

BMI < 20kg/m2

Unintentional weight loss > 5% within the last 3-6 months Initial management

Introduce feeding at a maximum 50% of total energy requirements for the first 2 days before increasing to full requirements (If clinical biochemical monitoring reveals no abnormalities)

Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding

Meet full requirements for fluid, electrolytes, vitamins and minerals from day 1 of feeding

Commence feeding as per regimen on reverse




Recommended starter regimen if Dietitian is unavailable Suitable for patients more than 35Kg. This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual regimen can be developed.

Check placement of NGT using pH indicator paper as per NPSA guidance

Ensure patient is positioned as upright as possible throughout feeding to minimise risk of aspiration

Check feed label to ensure correct feed administered and do not hang feed for longer than 24hrs

Day No.

Feed

Rate (mls/hr)

Duration (hours)

Volume (mls)

Energy (Kcals)

Fluid (mls)

Day 1

Nutrison

21

24

500

500

500

Fluid flushes: 50mls before and after each feed

-

100

Day 2

Nutrison

31

24

750

750

750


-

100

Day 3

Nutrison

42

24

1000

1000

1000


-

100

Continue with feeding as per day 3 until assessment by Dietitian

Do not start nutritional sip supplements at the same time as the starter regimen

Restore circulatory volume and monitor fluid balance and overall clinical status closely

For patients who require additional IV fluids to meet fluid requirements saline or Hartmann’s

solution may be more appropriate compared with dextrose saline due to the calorie content

Recheck potassium, calcium, phosphate, and magnesium levels 12 hours after initiation of feeding. If electrolyte levels low then continue feeding as per regimen and discuss replacement with your pharmacist. Monitor daily until levels within normal ranges, then 3 times a week for 2 weeks. Glucose should be monitored 4 hourly initially, and daily once stable.




14.6.2 ADULT PATIENT IDENTIFIED AS HIGH RISK OF REFEEDING SYNDROME Quick reference flow chart: Enteral feeding regimen: Nasogastric tube (NGT) / Naso jejeunal (NJ) / Percutanous endoscopic gastrostomy (PEG) / Jejunostomy / Radiological inserted gastrostomy (RIG): High Risk Patient has one or more of the following:

BMI <16 Kg/m2

Unintentional weight loss > 15% within the previous 3-6 months

Very little or no nutritional intake for > 10 days

Low levels of potassium, phosphate or magnesium prior to feeding

Or patient has two or more of the following:

BMI < 18.5kg/m2


Those with very little or no intake for > 5 days

A history of alcohol or drug abuse including insulin, antacids or diuretics and patients on chemotherapy

Initial management

Introduce feeding at a maximum of 10 Kcal/kg/day, increasing slowly to meet full requirements by 4-7 days (e.g. for a 50 kg patient: 10 x 50 = 500 Kcal /day) Refer to regimen on reverse

Provide immediately before and during the first 10 days of feeding:

Oral thiamine 200-300mg per day and vitamin B co strong 1 - 2 tablets t.d.s OR a full dose daily intravenous vitamin B (Pabrinex - 5mls of Ampoule 1 plus 5 mls of ampoule 2 in suitable infusion solution. Once daily for two doses only)

A balanced multivitamin/trace element supplement once a day






Recommended starter regimen if Dietitian is unavailable Suitable for patients more than 35Kg. This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual regimen can be developed.




Day No.

Feed

Rate (mls/hr)

Duration (hours)

Volume (mls)

Energy (Kcals)

Fluid (mls)

Day 1

Nutrison

15

24

350

350

350


-

100

Day 2

Nutrison

25

24

600

600

600


-

100

Day 3

Nutrison

35

24

850

850

850


-

100



For patients who require additional IV fluids to meet fluid requirements saline or Hartmann’s

solution may be more appropriate compared with dextrose saline due to the calorie content

Recheck potassium, calcium, phosphate, and magnesium levels 12 hours after initiation of feeding. If electrolyte levels low then continue feeding as per regimen and discuss replacement with your pharmacist. Monitor daily until levels within normal ranges, then 3 times a week for 2 weeks. Glucose should be monitored 4 hourly initially, and daily once stable.




14.6.3 ADULT PATIENT IDENTIFIED AS VERY HIGH RISK OF REFEEDING SYNDROME Quick reference flow chart: Enteral feeding regimen: Nasogastric tube (NGT) / Nasojejeunal (NJ) / Percutanous endoscopic gastrostomy (PEG) / Jejunostomy / Radiological inserted gastrostomy (RIG): Extremely high risk Patient has one or more of the following:

BMI < 14kg/m2

Negligible intake for > 15 days

Pre-feeding hypokalaemia, hypophosphataemia or hypermagnesaemia Initial management



Oral thiamine 200-300mg per day and vitamin B co strong 1 - 2 tablets t.d.s. OR a full dose daily intravenous vitamin B (Pabrinex - 5mls of Ampoule 1 plus 5 mls of ampoule 2 in suitable infusion solution. Once daily for two doses only)

A balanced multivitamin/trace element supplement once a day e.g. Forceval


Introduce feeding at a maximum of 5 Kcals/Kg/day, increasing slowly to meet full requirements by 4-7 days. (E.g. for a 50 kg patient – 5 x 50 = 250 Kcal /day). Refer to recommended starter regimen on reverse




Recommended starter regimen if Dietitian is unavailable: Suitable for patients over 35Kg: This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual regimen can be developed.




Day No.

Feed

Rate (mls/hr)

Duration (hours)

Volume (mls)

Energy (Kcals)

Fluid (mls)

Day 1

Nutrison

8

24

192

192

192


-

100

Day 2

Nutrison

15

24

350

350

350


-

100

Day 3

Nutrison

20

24

500

500

500


-

100



Monitor cardiac rhythm continually in these patients (NICE 2006)

For patients that require additional IV fluids to meet fluid requirements saline or Hartmann’s solution may be more appropriate compared with dextrose saline due to the calorie content

Recheck potassium, calcium, phosphate, and magnesium levels 12 hours after initiation of feeding. If electrolyte levels low continue feeding as per regimen and discuss replacement with your Pharmacist. Monitor daily until levels within normal ranges, then 3 times a week for 2 weeks. Glucose should be monitored 4 hourly initially, and daily once stable.




14.6.4 ADULT PATIENT IDENTIFIED AS AT RISK OF REFEEDING SYNDROME

Oral diet regimen: Quick reference flow chart At Risk Those who have one or more of the following:

Very little or no food intake for more than 5 days especially if already undernourished

BMI < 20kg/m2

Unintentional weight loss > 5% within the last 3-6 months Initial management


Meet full requirements for fluid, electrolytes, vitamins and minerals from day 1 of feeding

Introduce feeding at a maximum 50% of total energy requirements for the first 2 days before increasing to full requirements (If clinical biochemical monitoring reveals no abnormalities) Refer to meal plan on reverse




SAMPLE MEAL PLAN. Suitable for patients more than 35kg This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual meal plan can be developed

Day 1

Day 2

Day 3 onwards

Provide half portions of all meals from menu Include 1 starter, 1 main and 1 dessert course

Provide full meals from menu Include 1 starter, 1 main and 1 dessert course

Provide full meals from menu Include 1 starter, 1 main and 1 dessert course Consider nourishing fluids & snacks if additional calories required for weight gain




14.6.5 ADULT PATIENT IDENTIFIED AS HIGH RISK OF REFEEDING SYNDROME Oral diet regimen: Quick reference flow chart High Risk Patient has one or more of the following:

BMI <16Kg/m2


Very little or no nutritional intake for > 10 days

Low levels of potassium, phosphate or magnesium prior to feeding

Or patient has two or more of the following:

BMI < 18.5kg/m2


Those with very little or no intake for > 5 days

A history of alcohol or drug abuse including insulin, antacids or diuretics and patients on chemotherapy. Initial management

Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding.


oral thiamine 200-300mg per day and vitamin B co strong 1 - 2 tablets t.d.s.


Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment). Pre-feeding correction of low plasma levels is unnecessary.

Introduce feeding at a maximum of 10 Kcal/kg/day, increasing slowly to meet full requirements by 4-7 days. (e.g. for a 50 kg patient – 10 x 50 = 500 Kcal /day). Refer to meal plan on reverse

HYWEL DDA LOCAL HEALTH BOARD SAMPLE MEAL PLAN - Based on 35 Kg Weight This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual meal plan can be developed.

Day 1 – (approx) 300Kcals Day 2 – (approx) 600Kcals Day 3 – (approx) 850 Kcals

BREAKFAST: 3 tbsp cereal or 1 weetabix with 100ml semi-skimmed milk OR ½ slice bread or toast with margarine and 1 pot diet yoghurt OR 100Kcals via a nutritionally complete sip feed**

BREAKFAST: 3 tbsp cereal or 1 weetabix with 100ml semi-skimmed milk & 100mls fruit juice OR 1 slice bread or toast with margarine and 100ml milk OR 1 creamy yogurt and 100ml fruit juice OR 200Kcals via a nutritionally complete sip feed**

BREAKFAST: 3 tbsp cereal with 100ml semi-skimmed milk, 100ml fruit juice & ½ slice bread / toast with margarine OR 2 Weetabix with 100mls semi-skimmed milk & 100ml fruit juice OR 250Kcals via a nutritionally complete sip feed**

LUNCH: 1oz portion of meat / fish / poultry e.g. 1 small slice ham / beef or ½ oz cheese OR 2 Tablespoons of vegetarian dish Above served with either 1scoop mashed potato / ½ small jacket potato / 2 egg size boiled potatoes served with 1 tbsp of vegetables or salad OR 100Kcals via a nutritionally complete sip feed**

LUNCH: 2oz portion of meat / fish / poultry e.g. 1 small slice ham / beef or 1oz cheese OR 3 Tablespoons of vegetarian dish Above served with either 2 scoops mashed potato / small jacket potato/ 4 egg size boiled potato served with 2 tbsp of vegetables or salad OR 200Kcals via a nutritionally complete sip feed**

LUNCH: 3oz portion of meat / fish / poultry e.g. 1 slice ham / beef or 1oz cheese Or 4 Tablespoons of vegetarian dish Above served with either 2 scoops mashed potato / 1 small jacket potato / 4 egg size boiled potato served with 2 tbsp of vegetables or salad and 1 Portion fruit e.g. Banana or fruit salad OR 300Kcals via a nutritionally complete sip feed**

EVENING MEAL

Sandwich – 1 slice of bread with meat / fish / cheese / egg filling OR ½ small jacket potato with ½ oz cheese or 2 tbsp beans or 1oz tuna with mayonnaise / salad cream or 1 tbsp ‘hot filling’ when available e.g. Curry OR 100Kcals via a nutritionally complete sip feed**

EVENING MEAL Sandwich – 1 slice of bread with meat / fish / cheese / egg filling and 1 portion fruit OR 1 slice toast with 1oz cheese or 2 tbsp baked beans or 1 egg scrambled and 1 portion fruit of fruit salad OR Small Jacket Potato with 1oz cheese or 2-3 tbsp beans or 2oz tuna or 2 tbsp ‘hot filling’ when available e.g. Curry OR 200Kcals via a nutritionally complete sip feed**

EVENING MEAL 1 Sandwich – 2 slices of bread with meat / fish / cheese / egg filling and 1 portion fruit or small pot fruit salad OR 2 slices toast with 1 oz cheese or 3 tbsp baked beans or 1 egg scrambled And 1 portion fruit OR ½ medium jacket potato with 1 oz cheese or 2-3 tbsp beans or small pot tuna or 2 tbsp ‘hot filling’ when available eg. Curry and 1 portion fruit OR 300Kcals via a nutritionally complete sip feed**

** The volume provided will vary depending on the energy density of the oral sip feed – please refer to the label of each product




14.6.6 ADULT PATIENT IDENTIFIED AS VERY HIGH RISK OF REFEEDING SYNDROME Oral diet regimen: Quick reference flow chart Severely High risk (Extreme cases) Patient has one or more of the following:

BMI < 14kg/m2

Negligible intake for > 15 days

Pre-feeding hypokalaemia, hypophosphataemia or hypermagnesaemia Initial management

Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding.


Oral thiamine 200-300mg per day and vitamin B co strong 1 - 2 tablets t.d.s. OR a full dose daily intravenous vitamin B (Pabrinex - 5mls of Ampoule 1 plus 5mls

of ampoule 2 in suitable infusion solution. Once daily for two doses only)


Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment)). Pre-feeding correction of low plasma levels is unnecessary

Introduce feeding at a maximum of 5Kcals/Kg/day, increasing slowly to meet full requirements by 4-7 days. (e.g. for a 50 kg patient – 5 x 50 = 250 Kcal /day). Refer to recommended eating plan on the back.

HYWEL DDA LOCAL HEALTH BOARD SAMPLE MEAL PLAN - Based on 30 Kg: This is a guide only for short term use. Please inform the Dietitian on the next working day and an individual meal plan can be developed.

** The volume provided will vary depending on the energy density of the oral sip feed – please refer to the label of each product

Day 1 – (approx) 200Kcals Day 2 – (approx) 350Kcals Day 3 – (approx) 500Kcals BREAKFAST: 2 tablespoon cereal with 30mls semi-skimmed milk OR ½ weetabix with 30mls semi-skimmed milk OR ½ Slice bread/toast with spread OR 50Kcals via a nutritionally complete sip feed**

BREAKFAST: 3 tbsp cereal or 1 weetabix with 100ml semi-skimmed milk OR ½ slice bread or toast with margarine and 1 pot diet yoghurt / 100mls semi-skimmed milk OR 100Kcals via a nutritionally complete sip feed**

BREAKFAST: 3 tbsp cereal or 1 weetabix with 100ml semi-skimmed milk OR ½ slice bread / toast with margarine and 1 pot diet yoghurt / 100ml semi-skimmed milk OR 100Kcals via a nutritionally complete sip feed**

LUNCH: 1 tablespoon of main meat / chicken / fish course OR 1 tablespoon vegetarian option (must contain cheese or egg Above served with either ½ scoop mashed potatoes / 1 boiled potato Served with 1 tablespoon vegetables OR 50Kcals via a nutritionally complete sip feed**

LUNCH: 1oz portion of meat / fish / poultry e.g. 1 small slice ham / beef or ½ oz cheese OR 2 Tablespoons of vegetarian dish Above served with either 1scoop mashed potato / ½ small jacket potato / 2 egg size boiled potatoes served with 1 tbsp of vegetables or salad OR 100Kcals via a nutritionally complete sip feed**

LUNCH: 2oz portion of meat / fish / poultry e.g. 1 small slice ham / beef or 1oz cheese OR 3 Tablespoons of vegetarian dish Above served with either 2 scoops mashed potato / small jacket potato/ 4 egg size boiled potato served with 2 tbsp of vegetables or salad OR 200Kcals via a nutritionally complete sip feed**

Evening meal: 1 tablespoon of main meat / chicken / fish course OR 1 tablespoon vegetarian option (must contain cheese or egg) Above served with either 1 scoop mashed potato / 2 boiled potatoes Served with 1 tablespoon vegetables OR 100Kcals via a nutritionally complete sip feed**

EVENING MEAL: Sandwich – 1 slice of bread with meat / fish / cheese / egg filling OR ½ small jacket potato with ½ oz cheese or 2 tbsp beans or 1oz tuna with mayonnaise / salad cream or 1 tbsp ‘hot filling’ when available e.g. Curry OR 150Kcals via a nutritionally complete sip feed**

EVENING MEAL: Sandwich – 1 slice of bread with meat / fish / cheese / egg filling and 1 portion fruit OR 1 slice toast with 1oz cheese or 2 tbsp baked beans or 1 egg scrambled and 1 portion fruit of fruit salad OR Small Jacket Potato with 1oz cheese or 2-3 tbsp beans or 2oz tuna or 2 tbsp ‘hot filling’ when available e.g. Curry OR 200Kcals via a nutritionally complete sip feed**

adult refeeding guidelines - nhs wales · hywel dda local health board database no: 209 page 3 of...

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