Coma irreversível em paciente portadora de esquizofrenia paranóide: encefalopatia de Wernicke após síndrome de realimentação: um relato de caso / Irreversible coma in a patient with paranoid schizophrenia: Wernicke encephalopathy after refeeding syndrome: a case report

Encefalopatia de Wernicke (EW) e síndrome de realimentação (SR) são duas condições frequentemente coexistentes, subdiagnosticadas e que podem implicar prognóstico reservado após sua instalação. Sua identificação precoce representa um desafio para os intensivistas, haja vista a falta de sensibilidade e especificidade das manifestações clínicas. Apresenta-se um relato de caso de uma paciente portadora de esquizofrenia paranoide, sem histórico de abuso de álcool, que desenvolveu quadro de coma irreversível após greve de fome, sendo feito diagnóstico tardio de EW associada a SR. Descreve-se a evolução clínica e neuropsiquiátrica com o intuito de enfatizar a necessidade crucial de alta suspeição diagnóstica, com reposição vitamínica imediata, vigilância de distúrbios eletrolíticos e progressão parcimoniosa do aporte nutricional. (AU)

Wernicke encephalopathy (WE) and refeeding syndrome (RFS) are two often coexisting, underdiagnosed conditions that may involve a poor prognosis after their onset. Early identification represents a challenge for intensivists, given the lack of sensitivity and specificity of clinical manifestations. We report a case of a patient with paranoid schizophrenia, without a history of alcohol abuse, who developed irreversible coma after a hunger strike, with a late diagnosis of WE associated with RFS. The clinical and neuropsychiatric outcomes are described herein in order to emphasize the crucial need for a high diagnostic suspicion, with immediate vitamin replacement, monitoring of electrolyte disorders, and gradual progression of nutritional support. (AU)

Hypophosphatemia in a Malnourished Child: When Renal Fanconi Syndrome Does Not Stand for Refeeding Syndrome.

Refeeding syndrome is diagnosed based on the onset of multiple laboratory abnormalities (most commonly hypophosphatemia) and clinical signs in the setting of nutrition rehabilitation of malnourished patients. Because definitions are not uniform, a broad differential diagnosis should always include renal tubular dysfunction. Our report details a 3 year-old child with undiagnosed renal tubular dysfunction who presented with the clinical picture of refeeding syndrome with refractory electrolyte abnormalities. A diagnosis of renal Fanconi syndrome was made after urinalysis that revealed glucosuria and urine electrolyte losses. Thus, urinalysis can aid in making a positive diagnosis of refeeding syndrome.

Malnutrition and refeeding syndrome prevention in head and neck cancer patients: from theory to clinical application.

PURPOSE: The goal of this review is to raise awareness about refeeding syndrome (RFS) and to give a comprehensive presentation of recent guidelines and latest scientific data about nutritional management among head and neck cancer (HNC) patients while focusing on RFS prevention. METHODS: A review of literature for nutritional assessment and RFS management was conducted. Electronic searches of Medline, Cochrane, PubMed and Embase databases for articles published in peer-reviewed journals were conducted from February to September 2017 using the keywords: "nutrition assessment", "head and neck cancer", "refeeding syndrome" and "guidelines". Articles, reviews, book references as well as national and international guidelines in English and French were included. RESULTS: The prevalence of malnutrition is high in HNC patients and a large number of them will need artificial nutritional support or refeeding intervention. RFS is characterized by fluid and electrolyte imbalance associated with clinical manifestations induced by rapid refeeding after a period of malnutrition or starvation. Regarding risk factors for malnutrition and RFS, HNC patients are particularly vulnerable. However, RFS remains unrecognized among head and neck surgeons and medical teams. Practical data are summarized to help organizing nutritional assessment and refeeding interventions. It also summarizes preventive measures to reduce RFS incidence and morbidity in HNC population. CONCLUSION: Nutritional assessment and early refeeding interventions are crucial for HNC patients care. As prevention is the key for RFS management, early identification of patients with high risks is crucial and successful nutritional management requires a multidisciplinary approach.

Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm.

OBJECTIVES: Refeeding syndrome (RFS) can be a life-threatening metabolic condition after nutritional replenishment if not recognized early and treated adequately. There is a lack of evidence-based treatment and monitoring algorithm for daily clinical practice. The aim of the study was to propose an expert consensus guideline for RFS for the medical inpatient (not including anorexic patients) regarding risk factors, diagnostic criteria, and preventive and therapeutic measures based on a previous systematic literature search. METHODS: Based on a recent qualitative systematic review on the topic, we developed clinically relevant recommendations as well as a treatment and monitoring algorithm for the clinical management of inpatients regarding RFS. With international experts, these recommendations were discussed and agreement with the recommendation was rated. RESULTS: Upon hospital admission, we recommend the use of specific screening criteria (i.e., low body mass index, large unintentional weight loss, little or no nutritional intake, history of alcohol or drug abuse) for risk assessment regarding the occurrence of RFS. According to the patient's individual risk for RFS, a careful start of nutritional therapy with a stepwise increase in energy and fluids goals and supplementation of electrolyte and vitamins, as well as close clinical monitoring, is recommended. We also propose criteria for the diagnosis of imminent and manifest RFS with practical treatment recommendations with adoption of the nutritional therapy. CONCLUSION: Based on the available evidence, we developed a practical algorithm for risk assessment, treatment, and monitoring of RFS in medical inpatients. In daily routine clinical care, this may help to optimize and standardize the management of this vulnerable patient population. We encourage future quality studies to further refine these recommendations.

Síndrome de realimentação em idosos: estudo de uma série de cinco casos / Refeeding syndrome in elderly individuals: evaluation of a series of five cases

Introdução: A subnutrição é um problema frequente em idosos e sua prevalência aumenta entre os mais frágeis, tornando prioritária uma adequada oferta nutricional diante de eventos agudos. Entretanto, tal oferta, em pacientes desnutridos ou com privação calórica subaguda, pode ocasionar alterações hidroeletrolíticas associadas a sintomas neurológicos, respiratórios e cardiológicos, incluindo falência cardíaca. Esses distúrbios ocorrem poucos dias após a introdução da dieta, o que caracteriza a síndrome de realimentação. Metodologia: Avaliou-se retrospectivamente cinco pacientes idosos internados por causa clínica e que desenvolveram síndrome de realimentação durante a internação hospitalar. Resultados: Todos os pacientes analisados eram desnutridos e frágeis, dos quais quatro eram do sexo feminino. A idade variou entre 82 e 85 anos e o tempo de privação alimentar entre 7 e 15 dias. Três pacientes eram portadores de demência grave e foram admitidos com delirium hipoativo. Hipofosfatemia ocorreu em 100% da amostra, seguida por hipocalemia (60%) e hipomagnesemia (40%). Quatro pacientes cursaram com edema periférico (80%), dois apresentaram íleo metabólico e três idosos (os que apresentaram menores níveis de fosfato) faleceram durante a internação. Conclusão: Todos os casos de síndrome de realimentação analisados cursaram com hipofosfatemia, com desfecho fatal naqueles com menores níveis deste íon. A associação com edema e íleo metabólico foi comum. Dada a escassez de dados disponíveis na literatura, novos estudos são de extrema importância. A avaliação eletrolítica antes e após o início de suporte nutricional é imprescindível em pacientes de risco, auxiliando no reconhecimento e no tratamento precoce dessa grave condição.

Introduction: Undernourishment is a common health problem among elderly individuals, and its prevalence grows among frail patients, which makes nutritional support a priority, especially in acute diseases. However, providing nutritional support to undernourished patients or to those under acute caloric deprivation may lead to electrolyte disturbances associated with neurological, respiratory, and cardiac symptoms, including cardiac arrest. These disturbances occur a few days after receiving nutritional support, and characterize the refeeding syndrome. Methodology: Five elderly patients hospitalized for clinical reasons and who developed refeeding syndrome during the duration of the stay, were retrospectively evaluated. Results: All patients analyzed were malnourished and frail, of whom four were women. The age group ranged between 82 and 85 years, and food deprivation time ranged between 7 to 15 days. Three patients had severe dementia and were admitted with hypoactive delirium. Hypophosphatemia occurred in 100% of the sample, followed by hypokalemia (60%) and hypomagnesemia (40%). Four patients developed peripheral edema, two developed metabolic ileus and three elderly persons (who had lower phosphorus values) died during the hospital stay. Conclusion: All refeeding syndrome patients developed hypophosphatemia, with fatal outcome among those whose phosphorus values were lower. The development of peripheral edema and metabolic ileus was frequent. Owing to the lack of data in literature, new researches on refeeding syndrome are extremely important. Electrolyte evaluation before and after nutritional support in patients at risk, is indispensable to facilitate recognition and treatment of this severe condition.

Expanding the differential diagnosis for transaminitis in patients with anorexia nervosa.

Aminotransferase elevations have been described in patients with anorexia nervosa. Hypothesized etiologies have included ischemic hepatitis, refeeding-induced transaminitis, and the process of autophagy. Supervised enteral nutrition is the mainstay of treatment for severe anorexia, but an increase in aminotransferase levels after initiation of enteral feeding presents clinicians with a diagnostic dilemma. We present a 31-year-old woman with anorexia nervosa (body mass index [BMI] of 13.5 kg/m2) who experienced a worsening of aminotransferase elevations even after the initiation of enteral feeding. Despite nutritional supplementation, the patient's weight continued to fall for 6 days. Peak aminotransferase concentrations correlated with the patient's lowest weight and improved only after an increase in BMI was eventually achieved. Secondary causes of severe transaminitis were investigated, and after no cause was found, a liver biopsy was performed. Pathology was consistent with liver injury secondary to severe malnutrition rather than from refeeding syndrome. This case highlights malnutrition as an important cause of aminotransferase elevations and underscores the need for judicious early weight restoration in patients with anorexia and abnormal liver chemistry.

Febrile neutropenia and refeeding syndrome.

We describe the management of a 4-year-old child with acute lymphoblastic leukaemia (ALL) who presented with febrile neutropenia, Cryptosporidium and subsequently developed refeeding syndrome. Febrile neutropenia is common and can be life-threatening and we highlight the identification of well low-risk neutropenic children with resolved febrile illnesses suitable for early discharge. We also discuss the potential management strategies for Cryptosporidium Refeeding syndrome is not common, but should be considered as a cause of acute inpatient deterioration and is a significant risk, with potential morbidity, in children who have undergone a period of catabolism. This article reviews the current literature and provides useful guidance on these issues.

Refeeding syndrome in Southeastern Taiwan: our experience with 11 cases.

AIM: To present our experience with refeeding syndrome in southeastern Taiwan. METHODS: We conducted a retrospective study during a 2-year period at the Mackay Memorial Hospital, Taitung Branch. We enrolled patients with very little or no nutrition intake for more than 10 d, a high risk group of refeeding syndrome, including those suffering from alcohol abuse, cancerous cachexia, chronic malnutrition, and prolonged starvation. RESULTS: A total of 11 patients (7 males, 4 females) with nasogastric feeding were included as having refeeding syndrome. Most of them had the symptoms of diarrhea, lethargy, and leg edema. The initial nutritional supplement was found to be relatively high in calories (1355.1 ± 296.2 kcal/d), high in protein (47.3 ± 10.4 gm/d), low in vitamin B1 (2.0 ± 0.5 mg/d), low in potassium (1260.4 ± 297.7 mg/d), and low in phosphorus (660.1 ± 151.8 mg/d). Furthermore, hypophosphatemia (2.4 ± 0.9 mg/dL) was noted during follow-up. Based on the suggestions of a dietician and a gastroenterologist, the clinical disorders of diarrhea, malaise and leg edema were significantly improved. The level of phosphate was also increased (3.3 ± 0.6 mg/dL). CONCLUSION: Refeeding syndrome is an overlooked and risky disorder that has some potentially fatal complications. Nasogastric feeding in nursing homes is an important risk factor for patients and deserves greater attention based on the initial results of this study.

Acute thiamine deficiency and refeeding syndrome: Similar findings but different pathogenesis.

OBJECTIVE: Refeeding syndrome can occur in several contexts of relative malnutrition in which an overaggressive nutritional support is started. The consequences are life threatening with multiorgan impairment, and severe electrolyte imbalances. During refeeding, glucose-involved insulin secretion causes abrupt reverse of lipolysis and a switch from catabolism to anabolism. This creates a sudden cellular demand for electrolytes (phosphate, potassium, and magnesium) necessary for synthesis of adenosine triphosphate, glucose transport, and other synthesis reactions, resulting in decreased serum levels. Laboratory findings and multiorgan impairment similar to refeeding syndrome also are observed in acute thiamine deficiency. The aim of this study was to determine whether thiamine deficiency was responsible for the electrolyte imbalance caused by tubular electrolyte losses. METHODS: We describe two patients with leukemia who developed acute thiamine deficiency with an electrolyte pattern suggestive of refeeding syndrome, severe lactic acidosis, and evidence of proximal renal tubular dysfunction. RESULTS: A single thiamine administration led to rapid resolution of the tubular dysfunction and normalization of acidosis and electrolyte imbalance. This demonstrated that thiamine deficiency was responsible for the electrolyte imbalance, caused by tubular electrolyte losses. CONCLUSIONS: Our study indicates that, despite sharing many laboratory similarities, refeeding syndrome and acute thiamine deficiency should be viewed as separate entities in which the electrolyte abnormalities reported in cases of refeeding syndrome with thiamine deficiency and refractory lactic acidosis may be due to renal tubular losses instead of a shifting from extracellular to intracellular compartments. In oncologic and malnourished patients, individuals at particular risk for developing refeeding syndrome, in the presence of these biochemical abnormalities, acute thiamine deficiency should be suspected and treated because it promptly responds to thiamine administration.

Refeeding Syndrome: Nursing Implications / Síndrome de Realimentação: Implicações de Enfermagem / Síndrome de Realimentación: Implicaciones de la Enfermería

Objective: To identify the etiological and physiological aspects on RS and describe the main nursing approaches aimed at preventing and reducing injuries from RS. Method: Exploratory bibliographic research, of literature and from an online database: Biblioteca Virtual de Saúde (BVS). Results: RS is characterized by manifestations that are directly related to an electrolyte disorder. Its tems from the reintroduction of nutritional support in malnourished patients, which can cause lethal damages. Conclusion: The studied scientific production reveals sparse theoretical production on nursing care towards RS, and that is related to the process of nutrition al repletion associated with enteral and parenteral nutrition therapy in which the nurse must be aware to know provide adequate care.

Objetivo: Identificar os aspectos etiológicos e fisiológicos acerca da SR, descrever as principais condutas do (a)enfermeiro(a),visando a prevenção e redução de agravos oriundos da SR. Método: Pesquisa bibliográfica,com caráter exploratório,realizada através de consulta em livros e banco de dados: Biblioteca Virtual de Saúde (BVS). Resultados: A SR é caracterizada por manifestações que estão diretamente relacionadas por uma disfunção eletrolítica. Decorre a partir da reintrodução do aporte nutricional em pacientes mal nutridos, que pode desencadear danos letais ao paciente. Conclusão: A produção científica estudada aponta uma escassa produção teórica acerca dos cuidados de enfermagem frente à SR e que está se relaciona ao processo de repleção nutricional associado à terapia nutricional enteral e parenteral em que o(a) enfermeiro (a) deve estar ciente para saber prestar uma adequada assistência.

Objetivos: Identificar los aspectos etiológicos y fisiológicos sobre el SR, describir los principales conductas de las enfermeras, destinadas a prevenir y reducir las lesiones por el síndrome de realimentación. Método: Se trata una búsqueda bibliográfica, con un carácter exploratorio, realizada por los libros de consulta y base de datos: Biblioteca Virtual en Salud (BSV). Resultados: El SR se caracteriza por las manifestaciones que están directamente relacionadas con un trastorno electrolítico. Se desprende de la reintroducción de la nutrición em los pacientes desnutridos, lo que puede causar daños letal es para el paciente. Conclusión: La producción científica demuestra uma señala un escasa producción teórica sobre los cuidados de la enfermería con el SR y que este proceso está relacionado con la repleción nutricional asociadas con la terapia de la nutrición enteral y parenteral donde la enfermeira debe conocer para proporcionar una atención adecuada.

Nutrición parenteral: elementos traza, energía, complicaciones y monitorización / Parenteral nutrition: trace elements, energy, complications and monitoring

En el niño enfermo, una excelente alternativa en caso de no contar con nutrición enteral, es la nutrición parenteral (NP). Los requerimientos de los elementos traza, no están bien definidos. El síndrome de realimentación se puede presentar en niños con desnutrición moderada o grave, con desequilibrio metabólico y electrolítico. Las complicaciones pueden ser infecciosas, metabólicas, mecánicas, hepáticas, gastrointestinales, y psicológicas. En la práctica clínica la monitorización de los parámetros bioquímicos, mecánicos y antropométricos debe ser seguida. La nutrición domiciliaria, debe ser el objetivo fundamental en pacientes que dependen al 100% del apoyo por NP.

In the sick child, an excellent alternative if you do not have enteral nutrition is parenteral nutrition (PN). The requirements of trace elements are not well defined. The refeeding síndrome can occur in children with moderate or severe malnutrition, metabolic and electrolyte imbalance. Complications can be infectious, metabolic, mechannical, hepatic, gastrointestinal, and psychological. In clinical practice the monitoring of biochemical parameters and anthropometric mechanics must be followed. Home nutrition should be the primary goal in patients who dependo n the support 100% of the PN.

Refeeding syndrome in a cat with hepatic lipidosis.

Refeeding syndrome is characterized by severe hypophosphatemia occurring in patients given enteral or parenteral nutrition after severe weight loss. There are few veterinary reports that describe this syndrome but it is well documented in human medicine. This report describes a case of a domestic shorthair cat diagnosed with hepatic lipidosis following a 4-week history of decreased appetite and weight loss and in whom refeeding syndrome was documented after initiation of enteral nutrition. Clinical findings, blood work abnormalities and disease progression in this patient are described from the time of diagnosis through to recovery. A review of the current literature pertinent to this clinical syndrome is included.

Cachexia, malnutrition, the refeeding syndrome, and lessons from Goldilocks.

Cachexia has plagued clinicians for centuries. Although all cachexia is related to malnutrition, cachexia associated with malignant diseases differs from starvation cachexia in that it is more recalcitrant to nutritional therapy. All cachexia responds to judicious nutritional support; however, cancer cachexia worsens autonomously as the disease advances and cannot be arrested or reversed by any known form of nutrition, hormonal, or pharmacologic therapy. Cachexia must be treated cautiously to avoid overfeeding syndrome, which may result in serious or dangerous complications or death.

When the brakes came off: re-feeding oedema after deflation of a gastric band: a case report.

Bariatric surgery is now the treatment of choice for morbid obesity, but is not without risk. Patients are cared for in specialised centres, but complications can present to non-specialised centres. We describe life-threatening re-feeding oedema in a patient following routine deflation of a gastric band. Band deflation or removal may be required for various reasons, but rapid release of the band without additional supplementation of electrolytes may be dangerous due to re-feeding syndrome.

Refeeding syndrome--awareness, prevention and management.

BACKGROUND: Refeeding syndrome is an important, yet commonly overlooked condition affecting patients. It occurs when feeding is commenced after a period of starvation. Head and neck cancer patients are at particular risk owing to prolonged periods of poor nutritional intake. This may be from general effects such as cancer anorexia or from more specific problems of dysphagia associated with this group of patients. Awareness of the condition is crucial in identifying patients at risk and taking measures to prevent its occurrence. OBJECTIVES: The aims of this review are to: 1) Highlight the condition and stress the importance of its consideration when admitting head and neck cancer patients. 2) Discuss the pathophysiology behind refeeding syndrome. 3) Review the literature for the best available evidence and guidelines. 4) Highlight the need for further high quality research. CONCLUSION: Refeeding syndrome is potentially fatal, yet is preventable. Awareness and identification of at-risk patients is crucial to improving management. Refeeding syndrome is caused by rapid refeeding after a period of under-nutrition, characterised by hypophosphataemia, electrolyte shifts and has metabolic and clinical complications. High risk patients include the chronically under-nourished and those with little intake for greater than 10 days. Patients with dysphagia are at particular risk. Refeeding should commence at 10 kcal/kg per day in patients at risk, and increased slowly. Thiamine, vitamin B complex and multi-vitamin supplements should be started with refeeding. New NICE guidelines state that pre-feeding correction of electrolyte and fluid deficits is unnecessary, but should be done concurrently with re-feeding. More research in this field is needed as the evidence base is lacking.