Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study.

BACKGROUND: Refeeding syndrome is a potentially life-threatening condition characterised by severe intracellular electrolyte shifts, acute circulatory fluid overload and organ failure. The initial symptoms are non-specific but early clinical features are severely low-serum electrolyte concentrations of potassium, phosphate or magnesium. Risk factors for the syndrome include starvation, chronic alcoholism, anorexia nervosa and surgical interventions that require lengthy periods of fasting. The causes of the refeeding syndrome are excess or unbalanced enteral, parenteral or oral nutritional intake. Prevention of the syndrome includes identification of individuals at risk, controlled hypocaloric nutritional intake and supplementary electrolyte replacement. OBJECTIVE: To determine the occurrence of refeeding syndrome in adults commenced on artificial nutrition support. DESIGN: Prospective cohort study. SETTING: Large, single site university teaching hospital. Recruitment period 2007-2009. PARTICIPANTS: 243 adults started on artificial nutrition support for the first time during that admission recruited from wards and intensive care. PRIMARY OUTCOME: occurrence of the refeeding syndrome. Secondary outcome: analysis of the risk factors which predict the refeeding syndrome. Tertiary outcome: mortality due to refeeding syndrome and all-cause mortality. RESULTS: 133 participants had one or more of the following risk factors: body mass index <16-18.5≥(kg/m(2)), unintentional weight loss >15% in the preceding 3-6 months, very little or no nutritional intake >10 days, history of alcohol or drug abuse and low baseline levels of serum potassium, phosphate or magnesium prior to recruitment. Poor nutritional intake for more than 10 days, weight loss >15% prior to recruitment and low-serum magnesium level at baseline predicted the refeeding syndrome with a sensitivity of 66.7%: specificity was >80% apart from weight loss of >15% which was 59.1%. Baseline low-serum magnesium was an independent predictor of the refeeding syndrome (p=0.021). Three participants (2% 3/243) developed severe electrolyte shifts, acute circulatory fluid overload and disturbance to organ function following artificial nutrition support and were diagnosed with refeeding syndrome. There were no deaths attributable to the refeeding syndrome, but (5.3% 13/243) participants died during the feeding period and (28% 68/243) died during hospital admission. Death of these participants was due to cerebrovascular accident, traumatic injury, respiratory failure, organ failure or end-of-life causes. CONCLUSIONS: Refeeding syndrome was a rare, survivable phenomenon that occurred during hypocaloric nutrition support in participants identified at risk. Independent predictors for refeeding syndrome were starvation and baseline low-serum magnesium concentration. Intravenous carbohydrate infusion prior to artificial nutrition support may have precipitated the onset of the syndrome.

Replacement of mushroom cage gastrostomy tube using a modified technique to allow percutaneous replacement with an endoscopic tube in patients with amyotrophic lateral sclerosis.

Radiologic inserted gastrostomy (RIG) is the preferred method in our institution for enteral feeding in amyotrophic lateral sclerosis (ALS). Skin-level primary-placed mushroom cage gastrostomy tubes become tight with weight gain. We describe a minimally invasive radiologic technique for replacing mushroom gastrostomy tubes with endoscopic mushroom cage tubes in ALS. All patients with ALS who underwent replacement of a RIG tube were included. Patients were selected for a modified replacement when the tube length of the primary placed RIG tube was insufficient to allow like-for-like replacement. Replacement was performed under local anesthetic and fluoroscopic guidance according to a preset technique, with modification of an endoscopic mushroom cage gastrostomy tube to allow percutaneous placement. Assessment of the success, safety, and durability of the modified technique was undertaken. Over a 60-month period, 104 primary placement mushroom cage tubes in ALS were performed. A total of 20 (19.2%) of 104 patients had a replacement tube positioned, 10 (9.6%) of 104 with the modified technique (male n = 4, female n = 6, mean age 65.5 years, range 48-85 years). All tubes were successfully replaced using this modified technique, with two minor complications (superficial wound infection and minor hemorrhage). The mean length of time of tube durability was 158.5 days (range 6-471 days), with all but one patient dying with a functional tube in place. We have devised a modification to allow percutaneous replacement of mushroom cage gastrostomy feeding tubes with minimal compromise to ALS patients. This technique allows tube replacement under local anesthetic, without the need for sedation, an important consideration in ALS.

Mushroom-cage gastrostomy tube placement in patients with amyotrophic lateral sclerosis: a 5-year experience in 104 patients in a single institution.

To review our experience of placement of a mushroom-cage gastrostomy tube (Entristar, Tyco Healthcare, Mansfield, MA), using radiological guidance, in patients with amyotrophic lateral sclerosis (ALS). All procedures were performed under local anaesthesia without sedation. Complications were recorded as peri-procedural, early (<24 h), late (>24 h), major or minor. Deaths were recorded as related to the underlying ALS or secondary to radiological-inserted gastrostomy (RIG) placement. Replacement RIG tube rate was recorded. Over a 5-year period RIG tubes were placed in 104 patients with ALS (male n = 52, female n = 52), with a median age of 62 years (range 34-86 years). All procedures were technically successful. Of the RIG procedures, 21/104 (20.2%) were performed with respiratory support. The 30-day mortality rate was 7/104 (6.7%); no patient died as a result of the procedure. There were 23/104 (22.1%) complications overall; 20/104 (19.2%) were minor and 3/104 (2.9%) major, requiring surgery (n = 2) and radiological-guided abscess drainage (n = 1). A median interval between replacement RIG procedures in 20/104 (19.2%) patients was 141.5 days (range 43-537 days). A mushroom-cage RIG tube may be safely and effectively inserted in a 'one-step' radiological procedure and may replace endoscopic-inserted gastrostomy tubes in the nutritional management of ALS.

Survival of patients with ALS following institution of enteral feeding is related to pre-procedure oximetry: a retrospective review of 98 patients in a single centre.

A retrospective review was carried out on the influence of pre-procedure respiratory assessment on survival of patients with amyotrophic lateral sclerosis (ALS) requiring nutritional support with either a gastrostomy or a nasogastric feeding tube. Over a five-year period 98 patients (49 male, 49 female; median age 61 years, range 26-86 years) with ALS were referred for enteral feeding with either radiological inserted gastrostomy (RIG), percutaneous endoscopic gastrostomy (PEG) or nasogastric tube (NG). Case notes review was performed to record patient age, sex, pre-procedure respiratory assessment, method of enteral feeding and survival post-procedure. Kaplan-Meier survival curves were constructed for each group, with Cox regression analyses performed in order to establish the effect of each variable on outcome. Median survival (with 95% confidence intervals) following RIG, PEG and NG was 6.31 months (4.58-8.04 months), 7.13 months (4.81-9.45 months) and 0.95 months (0.00-2.77 months), respectively. The survival advantage between RIG and PEG was not statistically significant (p = 0.50), but for NG versus RIG and PEG groups combined, there was a significant difference (p = 0.03). For patients with normal overnight oximetry, median survival was 8.54 months (3.88-13.21 months), compared to 4.80 months (1.20-8.39 months) in the abnormal oximetry group (p = 0.03; relative risk 1.97). It is concluded that RIG and PEG are equivalent in terms of post-procedure survival. Abnormal oximetry prior to the procedure is a significant indicator of post-procedure survival.

Comparison of two percutaneous radiological gastrostomy tubes in the nutritional management of ALS patients.

Patient care and minimizing complications post gastrostomy have to date received little attention in ALS patients. We compare the complications associated with pigtail and mushroom type percutaneous radiological gastrostomy tubes in this patient group. Patients requiring PRG received either Wills-Oglesby or the skin level Entristar. Retrospective review of the clinical notes was performed capturing demographic data, peristomal infection, tube displacement, tube failure, nutritional status, site of disease onset, and survival. Thirty-five patients (Group 1) had the Wills-Oglesby tube of which 14 (40%) tubes required replacement. The Entristar tube was inserted in 29 patients (Group 2) where 8 (28%) required replacement (NS). The incidence of infection was significantly lower with the Entristar tube, (p<0.001). The mean time to tube removal in Group 2 was 223 days (SD 147; range 71-494 days) due to 'buried bumper syndrome'. We conclude that the Entristar skin level gastrostomy tube is associated with a reduction in peristomal infection, tube failure and blockage compared with the Wills-Oglesby tube.

Entristar skin-level gastrostomy tube: primary placement with radiologic guidance in patients with amyotrophic lateral sclerosis.

PURPOSE: To retrospectively review the authors' experience with a radiologic method of primary insertion of a skin-level gastrostomy tube (Entristar; Tyco Healthcare, Mansfield, Mass) in patients with amyotrophic lateral sclerosis (ALS). MATERIALS AND METHODS: Over a 12-month period (September 2002 through September 2003), 25 patients with ALS (mean age, 62.4 years; age range, 41-83 years; 15 men, 10 women) who had bulbar impairment and a body mass index of less than 20 kg/m(2) or weight loss of greater than 10% were selected for placement of an enteral feeding tube. Patients with overnight oxygen desaturation or respiratory acidosis were referred for placement of the Entristar tube with radiologic guidance. This procedure was performed with local anesthesia and without sedation by using a modified percutaneous lateral fluoroscopic technique that aided tube insertion in patients with elevation of the hemidiaphragm and a "high" stomach position. Technical success and immediate and delayed procedure complications were recorded. RESULTS: The Entristar tube was successfully inserted in all 25 patients. Pneumoperitoneum as an early complication was documented in one patient, and one patient developed a pelvic abscess that required drainage. Follow-up for a median of 112 days (range, 14-343 days) revealed superficial wound infections in four patients and weight gain in two patients; weight gain necessitated tube replacement in one patient. There were no procedure-related deaths. CONCLUSION: Radiologically guided insertion of the Entristar skin-level gastrostomy tube is a safe procedure in patients with ALS that allows the creation of a permanent feeding gastrostomy without the need for sedation or endoscopy.