espen congress copenhagen 2016 · espen congress copenhagen 2016 refeeding syndrome. zeno stanga,...

NUTRITION THERAPY IN THE PATIENT WITH REFEEDING SYNDROME: PRACTICAL GUIDANCE

Z. Stanga (CH)

ESPEN Congress Copenhagen 2016REFEEDING SYNDROME

Zeno Stanga, MD

Division of Nutritional Medicine

NUTRITION THERAPY IN THE PATIENT WITH

REFEEDING SYNDROME: practical guidance

Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism

University Hospital of Bern, Switzerland

Refeeding Syndrome - Nutrition Therapy

Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University Hospital, Bern, Switzerland – Zeno Stanga – ESPEN 2016

Learning objektives

• To rise awareness regarding RFS management

• To identify patients who are at risk of RFS

• To understand how safe nutrition therapy is started

in patients with different levels of risk of RFS

• To know how can RFS be prevented

• To know how to treat RFS


Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University Hospital, Bern, Switzerland – Zeno Stanga – ESPEN 2016Reference Initial energy/day Proteins Fluids/day Vitamins (before/during)

Solomon et al.

JPEN 1990 20 kcal/kg 1.2-1.5g _ _

Dewar et al.

Clinical Nutrition 2001 20 kcal/kg _ _thiamine

IV or PO for 2 d

Crook et al.

Nutrition 2001 / 2010

Nutrition 2014

10 kcal/kg

high risk: 5 kcal/kg

50-60% CHO, 15-25% fat

20-30%

1.2-1.5g

20-30 ml/kg,

0 fluid balance

Thiamine 300 mg IV , than 100 mg daily during refeeding. In addition Vit B12, Vit B6 and folate

Kraft et al.

Nutr Clin Pract 2005 7.5 kcal/kg _ <1 L/dthiamine 50-100 mg IV or 100 mg PO for 5-7 d & multivitamin

NICE Guidelines

200610 kcal/kg


_ 0 fluid

balance

200-300 mg thiamine PO for 10 d & multivitamin for 10 days

Stanga et al.

Eur J Clin Nutr 2008


10-15 kcal/kg


50-60% CHO, 30-40% fat

15-20% 20-30 ml/kg,

0 fluid balance

200-300 mg thiamine IV or PO for 3 d & multivitamin for 10 days

Stroud et al.

Gut 2003 10-20 kcal/kg _ _thiamine and B vitamins IV for 3 days

Royal College of

Psychiatrists 200510-20 kcal/kg _ _ _

MARSIPAN (RCP)

201415-20 kcal/kg

high risk: 5-10 kcal/kg_ max. 30-35 ml/kg thiamine PO 4x/d for 7-10 days

Mehanna et al.

BMJ 200810 kcal/kg

high risk: 5 kcal/kg_

carefully fluid repletion


ESPEN Blue Book

201210-15 kcal/kg


50-60% CHO, 30-40% fat

15-20%20-30 ml/kg,

0 fluid balance




Solomon et al.

JPEN 1990 20 kcal/kg 1.2-1.5g _ _

Dewar et al.


IV or PO for 2 d

Crook et al.


Nutrition 2014

10 kcal/kg


50-60% CHO, 15-25% fat

20-30%

1.2-1.5g

20-30 ml/kg,

0 fluid balance

thiamine 300 mg IV , than 100 mg daily during refeeding. In addition Vit B12, Vit B6 and folate

Kraft et al.


NICE Guidelines

200610 kcal/kg


_ 0 fluid

balance


Stanga et al.



10-15 kcal/kg


50-60% CHO, 30-40% fat

15-20% 20-30 ml/kg,

0 fluid balance


Stroud et al.


Royal College of


MARSIPAN (RCP)

201415-20 kcal/kg


Mehanna et al.

BMJ 200810 kcal/kg




ESPEN Blue Book

201210-15 kcal/kg


50-60% CHO, 30-40% fat

15-20%20-30 ml/kg,

0 fluid balance




Solomon et al.

JPEN 1990 20 kcal/kg 1.2-1.5g _ _

Dewar et al.


IV or PO for 2 d

Crook et al.


Nutrition 2014

10 kcal/kg


50-60% CHO, 15-25% fat

20-30%

1.2-1.5g

20-30 ml/kg,

0 fluid balance

Thiamine 300 mg IV , than 100 mg daily during refeeding. In addition Vit B12, Vit B6 and folate

Kraft et al.


NICE Guidelines

200610 kcal/kg


_ 0 fluid

balance


Stanga et al.



10-15 kcal/kg


50-60% CHO, 30-40% fat

15-20% 20-30 ml/kg,

0 fluid balance


Stroud et al.


Royal College of


MARSIPAN (RCP)

201415-20 kcal/kg


Mehanna et al.

BMJ 200810 kcal/kg




ESPEN Blue Book

201210-15 kcal/kg


50-60% CHO, 30-40% fat

15-20%20-30 ml/kg,

0 fluid balance




NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS

Screening for nutritional risk & screening for the risk of RFS

Stratification of the risk of RFS according to risk factors

Assess hydration status & check electrolytes (K, Mg, PO4, Na, Ca)



MAJOR RISK FACTORS (A) MINOR RISK FACTORS (B)

BMI <16 kg/m2 BMI <18.5 kg/m2

Unintentional weight loss >15%

in the preceding 3 - 6 months


in the preceding 3 -6 months

Very little or no nutritional intake for

>10days


>5 days

Low levels of serum Mg, PO4 or K

prior to feedHistory of alcool or drug abuse

Criteria for determination of patients at risk of RFS

NICE: National Institute for Health and Clinical Excellence. 2006



MAJOR RISK FACTORS (A) MINOR RISK FACTORS (B)

BMI <16 kg/m2 BMI <18.5 kg/m2


in the preceding 3 - 6 months


in the preceding 3 -6 months


>10days


>5 days

Low levels of serum Mg, PO4 or K

prior to feedHistory of alcool or drug abuse

Criteria for determination of patients at risk of RFS

RISK BY PATIENT’S CATEGORY

• Hunger strike, eating disorders, chronic severe dieting

• After bariatric surgery, short bowel syndrome

• Oncology patients and fraily elderly (chronic debilitating disease)

NICE: National Institute for Health and Clinical Excellence. 2006



NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS




Correct the existing deficit of dehydrationand replace previous or ongoing abnormal fluid losses

NICE. Clin. Guid. 2006 / Crook MA. Nutrition 2014 / Stanga Z et al. Eur J Clin Nutr 2008



Fluid replacement

1• Correct the existing deficit of dehydration

2

• Replace losses: the most appropriate fluid to use

is that which most closely matches any previous

or ongoing losses

3

• Maintenance prescriptions should aim to provide

sufficient water and electrolytes to maintain

normal status of body fluid compartments

CONSIDER 3 ASPECTS OF REPLACEMENT



FEATURE

MILD

DEHYDRATION

<5%

MODERATE

DEHYDRATION

5-10%

SEVERE

DEHYDRATION

>10%

Pulse

ratenormal

slight

increasedrapid, weak

>90 bpm

Respiratory

ratenormal

slightly

increasedrapid

>20 breaths/min

Systolic

bpnormal

normal/

orthostatichypotension<100 mmHg

Mucosa

membraneslightly dry very dry parched

Urine

outputdecreased

oliguria<500 ml/d

anuria<50 ml/d

Clinical signs of dehydration

NICE Guidelines. May 2013



Fluid replacement


2



or ongoing losses

3







Cristalloid solutions for fluid replacement

INFUSION

(1000 ml)

Na

(mmol)

Cl

(mmol)

K

(mmol)

Glucose

(g)

Lactate

(mmol)

Glucose 5% - - - 50 -

Glucosaline 1:1 77 7 - 25 -

Glucosaline 2:1 55 55 - 33 -

Glucosaline 4:1 31 31 - 40 -

Saline 0.9% 154 154 - - -

Ringer’s lactate 130 109 4 - 28

Hartmann’s 131 111 5 - 29

LOBO DN et al. 2013, ISBN 978-3-89556-058-3

http://www.bbraun.ph/service-layer-core/res/public/thumbnail/BPG000000000000000100001989000000/49C3CFD59D0C0231E1008000D400106F49C3CFD79D0C0231E1008000D400106F?vc=CW_EN_PH&s=65b91c4eac7a8f6b9b421c7cd00f9da5&max=400




Fluid replacement


2



or ongoing losses

3







NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS





Nutritional support

and fluids

maintenance

according to the

standard of care




NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS





Preventive measures: electrolytes repletion,

thiamine substitution (at least 30 min. before refeeding) Nutritional support

and fluids

maintenance

according to the

standard of care



Preventive measures

Supplement electrolytes prophylactically (unless pre-feeding plasma levels

are high) in very high risk patients. Amounts depend on patient size and

plasma concentrations, but usual daily requirements (man of 70 kg) are:

→ K 1.0-1.5 mmol/kg/d

→ Mg 0.2-0.4 mmol/kg/d

→ PO4 0.3-0.6 mmol/kg/d

CORRECT ELECTROLYTES LEVELS AND

EVALUATE EMPIRICAL SUPPLEMENTATION

BEFORE FEEDING IS INITIATED




Predictors of RFS

Rio A et al. BMJ Open 2013

• Prospective cohort study

• 243 patients starting EE oder PE

• 133 at risk of RFS

• Predictors of RFS (sensitivity 67%, specificity 80%)

Poor intake for >10 days

Weight loss of >15%

Low plasma magnesium (<0.7 mmol/L; p=0.021)

• STARVATION is the most reliable predictor



Preventive measures

Supplement electrolytes prophylactically (unless pre-feeding plasma levels

are high) in very high risk patients. Amounts depend on patient size and

plasma concentrations, but usual daily requirements (man of 70 kg) are:

→ K 1.0-1.5 mmol/kg/d

→ Mg 0.2-0.4 mmol/kg/d

→ PO4 0.3-0.6 mmol/kg/d

CORRECT ELECTROLYTES LEVELS AND

EVALUATE EMPIRICAL SUPPLEMENTATION

BEFORE FEEDING IS INITIATED

GIVE 200-300 mg THIAMINE I.V. OR

ORALLY BEFORE FEEDING




NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS





Nutritional support

and fluids

maintenance

according to the

standard of care


thiamine substitution (at least 30 min. before refeeding)

Nutritional support

Fluids maintenace

Give micronutrients

Nutritional support

Fluids maintenance

Give micronutrients

Nutritional support

Fluids maintenace

Give micronutrients




LOW RISK

of RFS DAYSNUTRITIONAL SUPPORT

by all routes

1-3 15-25 kcal/kg/d

4 30 kcal/kg/d

≥ 5 full requirements

I suggest to use

individually clinical

judgement in decision

how slow / fast

nutrition support should

proceed to full target in the

refeeding period

*

FLUID AND SODIUM BALANCE

Fluids to maintain zero balance,approx. 30-35 ml/kg/d

No restriction in salt intake

Nutritional & fluid management

*



LOW RISK


by all routes

1-3 15-25 kcal/kg/d

4 30 kcal/kg/d


I suggest to use



how slow / fast



refeeding period

*

*FLUID AND SODIUM BALANCE

Fluids to maintain zero balance,approx. 30-35 ml/kg/d

No restriction in salt intake




NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS





Nutritional support

and fluids

maintenance

according to the

standard of care



Nutritional support

Fluids maintenace

Give micronutrients

Nutritional support

Fluids maintenance

Give micronutrients

Nutritional support

Fluids maintenace

Give micronutrients





HIGH RISK


by all routes

1-3 10-15 kcal/kg/d

4-5 15-25 kcal/kg/d

6 30 kcal/kg/d


I suggest to use



how slow / fast



refeeding period

*


Fluids to maintain zero balance,D1-3 25-30 ml/kg/d, > D4 30-35 ml/kg/d

Salt: restrict Na to <1mmol/kg/d →D1-7

*



Intracellular volume (ICV)

Distribution of infused solutions

40 % 15 % 5 %

Colloids

0.9% NaCl

Interstitial Intravascular

fluid fluid

5% Glucose

Extracellular volume (ECV)

LOBO DN et al. 2013, ISBN 978-3-89556-058-3



Cristalloid solutions for fluid maintenance

INFUSION

(1000 ml)

Na

(mmol)

Cl

(mmol)

K

(mmol)

Glucose

(g)

Lactate

(mmol)

Glocose 5% - - - 50 -

Glucosaline 1:1 77 7 - 25 -

Glucosaline 2:1 55 55 - 33 -

Glucosaline 4:1 31 31 - 40 -

Saline 0.9% 154 154 - - -

Ringer’s lactate 130 109 4 - 28

Hartmann’s 131 111 5 - 29

9g NaCl

6g NaCl

6g NaCl

4.5g NaCl

3g NaCl

1.8g NaCl

0g NaCl

LOBO DN et al. 2013, ISBN 978-3-89556-058-3






HIGH RISK


by all routes

1-3 10-15 kcal/kg/d

4-5 15-25 kcal/kg/d

6 30 kcal/kg/d


I suggest to use



how slow / fast



refeeding period

*


Fluids to maintain zero balance,D1-3 25-30 ml/kg/d, > D4 30-35 ml/kg/d


*



NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS



Assess hydration status & Check electrolytes (K, Mg, PO4, Na, Ca)


Nutritional support

and fluids

maintenance

according to the

standard of care



Nutritional support

Fluids maintenace

Give micronutrients

Nutritional support

Fluids maintenance

Give micronutrients

Nutritional support

Fluids maintenace

Give micronutrients




VERY HIGH

RISK of RFS DAYSNUTRITIONAL SUPPORT

by all routes

1-3 5-10 kcal/kg/d

4-6 10-20 kcal/kg/d

7-9 20-30 kcal/kg/d


I suggest to use



how slow / fast



refeeding period

*


Fluids to maintain zero balance,D1-3 20-25 ml/kg/d, D4-6 25-30 ml/kg/d, > D7 25-35 ml/kg/d



*



NO risk

of RFSLOW RISK

of RFS

HIGH RISK

of RFS

VERY HIGH

RISK of RFS





Nutritional support

and fluids

maintenance

according to the

standard of care



Nutritional support

Fluids maintenace

Give micronutrients

Nutritional support

Fluids maintenance

Give micronutrients

Nutritional support

Fluids maintenace

Give micronutrients

Clinical and laboratory monitoring, management of complications




Monitoring

• Body weight (or fluid balance)

• Vital signs

→ blood pressure, pulse rate, respiratory rate, oxygen sat.

• Clinical examination

→ hydration state, oedema, cardiopulmonary state

• Lab serum-parameters

→ PO4, K, Mg, Na, Ca, glucose, urea, creatinine

DAY 1-3

monitor

daily

DAY 4-6

monitor

every 2nd day

DAY 7-10

monitor

1-2x wkly

Crook MA. Nutrition 2009 / Stanga Z et al. Eur J Clin Nutr 2008



Monitoring

• Body weight (or fluid balance)

• Vital signs

→ blood pressure, pulse rate, respiratory rate, oxygen sat.

• Clinical examination

→ hydration state, oedema, cardiopulmonary state

• Lab serum-parameters

→ PO4, K, Mg, Na, Ca, glucose, urea, creatinine

DAY 1-3

monitor

daily

DAY 4-6

monitor

every 2nd day

DAY 7-10

monitor

1-2x weekly

Crook MA. Nutrition 2009 / Stanga Z et al. Eur J Clin Nutr 2008



Electrolyte deficiency and replacement

POTASSIUM REPLETION

S-POTASSIUM RECOMMENDATION FOR REPLETION

Mild deficit

3.1- 3.5 mmol/l

oral replacement with 20 mmol (as KCl or other

formularies) OR i.v. replacement with 20

mmol KCl over 4-8 h → check K levels the next day

Moderate deficit

2.5 - 3.0 mmol/l

i.v. replacement with 20-40 mmol KCl over 4-8 h

→ check K levels after 8 hours

→ if not normal levels, give further 20 mmol KCL

Severe deficit

<2.5 mmol/l

i.v. replacement with 40 mmol KCl over 4-8 h

→ check K levels after 8 hours

→ if not normal levels, give further 40 mmol KCL

Marinella MA et al. Int J Clin Pract 2008 / Stanga Z et al. Eur J Clin Nutr 2008

Gennari FJ. NEJM 1998 / Boateng AA et al. Nutrition 2010 / ESPEN Blue Book 2011



S-MAGNESIUM RECOMMENDATION FOR REPLETION

Mild to moderate

deficit

0.5 - 0.6 mmol/l

oral replacement with 10-15 mmol Mg-chlorid or

Mg-citrat or Mg-L-aspartat

→ oral Mg should be given in divided doses to

minimise diarrhoea (absorption process is

saturated at about 5-10 mmol Mg)

Severe deficit

<0.5 mmol/l

i.v. replacement with 20-24 mmol MgSO4 (4-6 g)

over 4-8 h → reassess every 8-12 h

MAGNESIUM REPLETION

Weisinger JR et al. Lancet 1998 / Stanga Z et al. Eur J Clin Nutr 2008

Brannan GB et al. J Clin Invest 1976 / Boateng AA et al. Nutrition 2010 / ESPEN Blue Book 2011




S-PHOSPHATE RECOMMENDATION FOR REPLETION

Mild deficit

0.61- 0.8 mmol/l

oral replacement with 0.3 mmol/kg/d PO4 (divided

doses to minimise diarrhoea) OR i.v. replacement

with 0.3 mmol/kg/d PO4 (as K3PO4 or Na3PO4) over

8-12 h → check PO4 levels next day

Moderate deficit

0.32 - 0.6 mmol/l

i.v. replacement with 0.6 mmol/kg/d PO4 (as K3PO4

or Na3PO4) over 8-12 h

→ check PO4 levels after 8-12h and repeat infusion

if necessary (max. of 50 mmol PO4 in 24 h).

Severe deficit

<0.32 mmol/l

same replacement therapy as above (moderate

deficit)

PHOSPHATE REPLETION


Thatte L et al. Am J Med 1995 / Crook MA. Nutrition 2009 / Stanga Z et al. Eur J Clin Nutr 2008


Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, University Hospital, Bern, Switzerland – Zeno Stanga – ESPEN 2016E

ne

rgy (

kc

al)

S-P

O4

(m

mo

l/l)

Enrollment: 72h after start feeding (EE/PE) & PO4↓, 1:1 rand., stratification by PO4 > 0.32 vs ≤ 0.32 mmol/l

and BMI < 18 vs ≤ 18 kg/m2 n = 170 Standard care n = 169 Hypocaloric management

PO4-substitution i.v. (mmol )

Energy intake/d (mean) Lowest daily s-phosphates

Days Days

(15 ICUs)

Doig GS et al. Lancet Respir Med 2015



Doig GS et al. Lancet Respir Med 2015

Su

rviv

al

(%

)

Overall survival time

Survival time (days )

p = 0.002

78%

91%



Culkin A. Copenhagen 2013



Pending questions

• To date only low quality evidence exists........

• Too cautious energy step up?

so far conflicting statements

possible start feeding higher energy/CHO in hospital?

• Build-up of full food intake within 3-4 days?

reduction of the catabolic phase

• Do we have to give electrolytes in a prophylactic way?

prevention is better than cure

• Reliable predictors?

• How important is the clinical examination?



The big challenge



Take home message



UNIVERSITY HOSPITAL BERN

espen congress copenhagen 2016 · espen congress copenhagen 2016 refeeding syndrome. zeno stanga,...

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