Refeeding Syndrome Policy Page 1 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Group arrangements: Salford Royal Care Organisation
Refeeding Syndrome Policy
Lead Author: Gavin Leahy, Pharmacy Operational Services Manager and Kirstine Farrer, Consultant Dietitian Intestinal Failure Additional author(s) On behalf of the Nutrition Steering Group Division/ Department:: Pharmacy/Dietetics Applies to: Salford Royal Care Organisation Date approved: June 2019 Expiry date: June 2022 Contents Contents
What is this policy about? ...... 3 Where will this document be used? ...... 3 Why is this document important? ...... 4 What is new in this version? ...... 4 Policy ...... 5 1. Definition of refeeding syndrome ...... 5 2. Consent to Treatment ...... 5 3. Patients with Eating Disorders ...... 5 4. Pathogenesis of starvation and the refeeding syndrome ...... 7 5. Consequences of the refeeding syndrome ...... 7 6. Clinical Sequelae of Altered Electrolytes in Refeeding Syndrome ...... 9 7. Identification of patients at risk of refeeding syndrome ...... 10 8. Initiation of oral or enteral tube feeding in patients at risk of developing refeeding syndrome.... 10 9. Initiation of parenteral nutrition in patients at risk of developing refeeding syndrome ...... 14 Roles and responsibilities ...... 155 Monitoring document effectiveness ...... 166 Abbreviations and definitions ...... 177 References and Supporting Documents ...... 188 Document Control Information ...... 199 Equality Impact Assessment (EqIA) screening tool...... 20
Appendices ...... 22
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Refeeding Syndrome Policy Page 2 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Appendix 1 - Vitamin Supplementation ...... 22 Appendix 2 - Refeeding Syndrome Decision Tree ...... 23 Appendix 3 - Electrolyte Replacement Therapy in Patients at Risk Of Refeeding Syndrome 244 Appendix 4 - Examples of Meal Plans...... 266
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Refeeding Syndrome Policy Page 3 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Group arrangements: Salford RoyalDocument Care Organisation Summary Sheet
What is this policy about?
The NICE Guideline 32 (2006) - Nutrition Support in Adults1 highlighted the risks of refeeding syndrome and produced guidance on the treatment of refeeding syndrome. Guidance has also been produced by the Parenteral and Enteral Group of the British Dietetic Association on refeeding syndrome.
The SRFT policy on Refeeding Syndrome is consistent with guidance from the above two organisations.
While the SRFT policy follows the above two organisations' recommendation not to delay feeding in order to correct mild electrolyte derangements, the SRFT policy also recommends correction of severe degrees of electrolyte derangement prior to starting refeeding in addition to during refeeding. Severely deranged electrolyte levels are defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L.
The rationale for this is that:
the levels are so extreme as to constitute a hazard for any patient, regardless of whether they are refeeding or not.
there is a high risk that the derangements would be aggravated further, even with the cautious refeeding recommended in these and the above two organisations' guidelines.
Where will this document be used?
This policy applies to all clinical staff employed by Salford Royal Hospital NHS Foundation Trust.
This policy applies to all adult patients admitted to Salford Royal Hospital and patients reviewed in outpatient clinics at Salford Royal Hospital.
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Refeeding Syndrome Policy Page 4 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Why is this document important?
Due to homeostatic mechanisms it is not uncommon for serum levels of potassium, magnesium and phosphate to be within normal parameters prior to feeding.
The aim of the policy is to:
Assist in the identification of patients at risk of refeeding syndrome.
Provide evidence-based guidance for the management of patients at risk of refeeding syndrome.
What is new in this version?
. Updated to the new NCA template
. Removal of low levels of potassium, magnesium or phosphate prior to feeding as criteria for identification of patients at extremely high risk of refeeding syndrome (as is already criteria for identification of patients at high risk of refeeding syndrome).
. Potassium requirements reduced to 1-2mmol/kg/day from 2-4mmol/kg/day
. Clarification that feeding should not be started for patients with severely deranged electrolytes until appropriate correction has taken place.
. Addition of reference to the Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and maintenance for patients requiring additional intravenous fluids.
. Addition of reference to Salford Royal Care Organisation Parenteral Nutrition (PN) Referral and Administration policy.
. Addition of reference to Salford Royal Care Organisation QRGs for hypokalaemia, hypomagnesaemia, hypocalcaemia and hypophosphataemia.
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Refeeding Syndrome Policy Page 5 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Policy
1. Definition of Refeeding Syndrome
The refeeding syndrome occurs as a result of severe fluid and electrolyte shifts (phosphate, potassium, magnesium), vitamin deficiency and related metabolic implications including sodium retention in malnourished patients undergoing refeeding orally, enterally, or parenterally2,3. The limitation of the term “refeeding syndrome” only to patients receiving parenteral nutrition is not justified, since these changes in metabolism have also been found in orally fed patients after long-term starvation.
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”4.
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 20054. 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 up’ relevant information. Whilst the patient may understand information about the consequences of not eating, their compulsion not to eat
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might be too strong for them to ignore 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 the patient should be referred to a psychiatrist5.
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 guidelines, 2014)5.
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Refeeding Syndrome Policy Page 7 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
4. Pathogenesis of Starvation and the Refeeding Syndrome6
Starvation / Malnutrition ↓ Gluconeogenesis Protein catabolism, e.g. muscles Negative protein balance ↓ Weight loss ↓ Water, vitamin and mineral depletion (N.B. serum concentrations of electrolytes may be normal because stores and hence depletion may be largely intracellular) ↓ Refeeding (oral, enteral or parenteral route) ↓ Conversion to glucose as major energy source ↓ Release of Insulin ↓ ↑ cellular glucose uptake ↑ protein synthesis (anabolic) ↓ Intracellular shifts and extracellular depletion of phosphate, potassium and magnesium ↓ ↑utilisation of thiamine that may already be low, may result in deficiency ↓ Clinical features of Refeeding Syndrome
5. Consequences of the Refeeding Syndrome2
Cardiac failure, pulmonary oedema and dysrhythmias Acute circulatory fluid overload or circulatory fluid depletion Hypophosphataemia Hypokalaemia Hypomagnesaemia and occasionally hypocalcaemia Hyperglycaemia
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.
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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 or vomiting.
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.
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Refeeding Syndrome Policy Page 9 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
6. Clinical Sequelae of Altered Electrolytes in Refeeding Syndrome6
Electrolytes Cardiac Respiratory Hepatic Renal GI Neuromuscular Haematological Low Altered Acute Liver - - Lethargy, Haemolytic Phosphate myocardial ventilatory dysfunction weakness, anaemia, WBC function. failure seizures, dysfunction, Arrhythmia confusion, coma, thrombocytopenia, Congestive paralysis, haemorrhage heart failure rhabdomyolysis Low Arrhythmia, Respiratory Exacerbation of Decreased Constipation, Paralysis - Potassium cardiac depression hepatic urinary Ileus Rhabdomyolysis arrest encephalopathy concentrating Weakness ability. Polyuria and polydipsia. Decreased GFR Low Arrhythmia, - - Potassium Abdominal Fits, ataxia, - Magnesium tachycardia loss pain, confusion, anorexia, muscle tremors, diarrhoea, weakness, tetany constipation
Low magnesium also leads to decreased PTH secretion and effect, which leads to hypocalcaemia.
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7. Identification of Patients at Risk of Refeeding Syndrome1
7.1. Patients will be considered to be at high risk of refeeding syndrome if they have one or more of the following:
Body Mass Index less than 16kg/m2 Unintentional weight loss of greater than 15% within the last 3-6 months Little or no nutritional intake for more than 10 days Low levels of potassium, magnesium or phosphate prior to feeding
Or two or more of the following: Body Mass Index of less than 18.5kg/m2 Unintentional weight loss greater than 10% within the last 3-6 months Little or no nutritional intake for more than 5 days History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics(4)
7.2. Patients will be considered to be at extremely high risk of refeeding syndrome if they have one or more of the following: BMI less than 14kg/m2 Little or no nutritional intake for more than 15 days
8. Initiation of Oral or Enteral Tube Feeding in Patients at Risk of Developing Refeeding Syndrome
In patients who are at risk of refeeding syndrome, oral feeding and enteral tube feeds should be introduced slowly and the amount of food or the volume of feed should be increased gradually over several days until nutritional requirements are met. In most cases, a tailored regimen will be written by the ward Dietitian.
If a Dietitian is unavailable, an emergency tube feeding regimen can be used - these are found in the appendix of the nasogastric feeding policy, nasojejunal feeding policy, gastrostomy tube feeding policy and jejunal feeding policy.
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8.1. ‘ High risk’ patients
. Urgent biochemistry bloods to be checked. Request the TPN blood profile on the electronic patient record (EPR).
. Where possible the hospital guidance of the management of refeeding needs to be followed in the community (patient’s own homes or nursing/ residential homes). However it is accepted that on occasions the acute protocol and management of refeeding syndrome may not be clinically appropriate in this setting. A request to the GP/lead clinician must include magnesium, potassium, calcium and phosphate at the time nutritional support is commenced. Any abnormal levels should be corrected and bloods repeated as indicated by the GP/lead clinician. Any severely deranged levels defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L should result in the patient being admitted for correction of electrolytes. If bloods are within the normal range, the patient should have daily bloods for 3 consecutive days and repeated as indicated by the GP/lead clinician.
. Refer to the nutrition and dietetic department. Commence oral diet or 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.
. This level will be safe unless severely deficient with pre-existing low plasma electrolytes.
. Patients who have severely deranged biochemistry (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should not start feeding until they have received the appropriate electrolyte replacement (see Appendix 2 and 3).
. When feeding patients you must 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). The following recommendations have been adapted from NICE Guidelines: Nutrition support in adults1 and the Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and maintenance7:
. Potassium: 1-2mmol/kg/day orally, enterally or intravenously
. Phosphate: 0.3-0.6mmol/kg/day orally, enterally or intravenously
. Magnesium: 0.4mmol/kg/day orally or 0.2mmol/kg/day intravenously.
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. Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1
8.2. ‘Extremely high’ risk patients
. Where possible the hospital guidance of the management of refeeding needs to be followed in the community (patient’s own homes or nursing/ residential homes). However it is accepted that on occasions the acute protocol and management of refeeding syndrome may not be clinically appropriate in this setting. A request to the GP/lead clinician must include magnesium, potassium, calcium and phosphate at the time nutritional support is commenced. Any abnormal levels should be corrected and repeated as indicated by lead clinician / GP. Any severely deranged levels defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L should result in the patient being admitted for correction of electrolytes. If bloods are within the normal range, the patient should have daily bloods for 3 consecutive days and repeated as indicated by the GP/lead clinician.
. For hospital inpatients urgent biochemistry bloods need to be checked. Request the TPN blood profile on the EPR.
. Refer to the nutrition and dietetic department. Start oral or nutrition support at a maximum of 5kcal/kg/day increasing levels slowly to meet full needs by 4-7 days. Any increase in feeding should be dependent on trends in biochemistry. Monitor glucose levels (BM’s) several times per day.
. This level will be safe unless severely deficient with pre-existing low plasma electrolytes.
. Patients who have severely deranged biochemistry (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should not start feeding until they have received the appropriate electrolyte replacement (see Appendix 2 and 3).
. When feeding patients, you must 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). The following recommendations have
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been adapted from NICE Guidelines: Nutrition support in adults1 and the Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and maintenance7:
. Potassium: 1-2mmol/kg/day orally, enterally or intravenously
. Phosphate: 0.3-0.6mmol/kg/day orally, enterally or intravenously
. Magnesium: 0.4mmol/kg/day orally or 0.2mmol/kg/day intravenously.
. Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1
. Where ECG monitoring is available, monitoring of cardiac rhythm in this group who have or may develop cardiac arrhythmias is recommended1. If the patient has significant comorbidity e.g. infection, cardiac failure, abnormal ECG consider escalating to MHDU bed.
Patients requiring additional fluids
Circulatory volumes should be replaced but care should be taken not to overload patients. Refer to the Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and maintenance7. However, consideration must be given to the fact that, on commencement of feeding, renal sodium losses stop, leading to both sodium and water retention. Therefore, aim for fluid replacement of 20-30ml/kg/day and restrict sodium to <1mmol/kg/day. Consideration should be given to sodium and carbohydrate content of the fluid used e.g. 1L 5% dextrose contains 200Kcal.
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9. Initiation of Parenteral Nutrition
In patients required to start parenteral feeding (regardless of whether they are identified as being at risk of refeeding syndrome or not) the following steps must be followed:
Referral to the Trust Nutrition hospital Team via EPR or, if outside normal working hours, the on-call pharmacist via switchboard. Refer to the Parenteral Nutrition (PN) Referral and Administration policy8.
Urgent biochemistry bloods to be checked. Request the TPN blood profile on the EPR Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1
Patients who have severely deranged biochemistry (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should not start feeding until they have received the appropriate electrolyte replacement. See appendix 2 and 3.
Parenteral nutrition should not be commenced outside normal working hours and a referral should be made to the Nutrition Support Team for the patient to be reviewed on the next working day. Commencing parenteral nutrition using a standard bag without additional electrolytes may put a patient at risk of refeeding syndrome and result in greater risk of complications.
It is very rare that a patient needs to start parenteral nutrition outside normal working hours8. Following authorisation from the on-call pharmacist, patients will be started on 1.2L out of 2.4L of the parenteral nutrition stock bag which contains 750kcals and 5gN. The patient must be urgently referred to the Trust Nutrition Support Team on the next working day via EPR.
To correct electrolytes patients may require additional intravenous fluids with supplemented electrolytes. See appendix 2 and 3.
Patients at high risk or extremely high risk of refeeding syndrome should have their biochemistry (TPN profile) checked daily until they are stable, when the frequency of biochemical monitoring can be reduced. This would include frequent and close monitoring of potassium, calcium, magnesium and phosphate.
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Roles and Responsibilities
All clinical staff have responsibility for ensuring that the principles outlined within this document are universally applied.
Director of nursing Executive responsibility for nutrition in the organisation.
The Trust Medicines Management Group The Trust Medicines Management Group is responsible for approving the pharmaceutical aspects of the Refeeding Policy.
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.
Prescribers Recognise and manage patients at risk of refeeding syndrome, including monitoring blood biochemistry and prescribing replacement electrolytes. Referral to the Dietitian must be made to support ongoing nutritional care.
Nursing staff Through the nutritional screening process highlight to the consulting team patients at risk of refeeding syndrome, follow prescribed feeding and electrolyte replacement regimens, highlighting any problems on a day to day level.
Dietitians Educate and train staff on refeeding syndrome, highlight patients at risk of refeeding syndrome, support consulting team through provision of expert advice, feeding regimens and monitoring nutritional status. Dietitians are able to recommend initiation of vitamin supplementation and advise on doses, providing that the advice is consistent with the Trust refeeding policy. Dietitians will not advise on the correction of electrolytes intravenously.
Pharmacists
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Provision and advice on electrolyte and micronutrient prescriptions.
Biochemists Advise on interpretation of test results and appropriate further investigations.
Other Allied Health Professionals Highlight any patients at risk of refeeding syndrome to appropriate team members.
Training Training / awareness sessions for medical staff and secondary care pharmacy teams will be led by the hospital nutrition team, and dietetics. This will be implemented through a rolling education programme in collaboration with learning and development and postgraduate department.
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
Monitoring document effectiveness
The following standards will form the basis of the annual audit of the Trust Refeeding Policy carried out by the Trust Nutrition Steering Group:
All patients will be nutritionally screened using the ‘MUST’ within 6 hours of admission and if identified at risk of malnutrition considered for nutrition support.
Patients identified as at risk of malnutrition should be assessed for risk of refeeding syndrome.
All patients identified as at risk of refeeding syndrome will have the appropriate monitoring and treatment, which will be documented on the EPR.
Monitoring and Review
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The Refeeding syndrome policy will be audited on an annual basis by the Nutrition Steering Group and the results reported to the Clinical Effectiveness Committee
Policy Implementation Plan Kirstine Farrer, Consultant Dietitian, as Chair of the Nutrition Steering Group, will be responsible for implementing this policy and the Nutrition Steering Group will keep the detailed implementation plan and review progress.
The policy will be implemented via communication with senior nurse managers, matrons and practice educators in the organisation.
Practice educators will ensure competence in this area.
Results of the implementation plan and review process will be reported to the Clinical Effectiveness Committee on an annual basis.
For Pharmacy Staff, the Refeeding Policy will be incorporated into the Local Pharmacy Induction Programme by the Principal Clinical Pharmacist.
Abbreviations and definitions
Any acronyms or technical terms that require explanation or definition should be listed here if they have not been described elsewhere within the document.
PTH: Parathyroid Hormone
PN: Parenteral Nutrition
TPN: Total Parenteral Nutrition
MUST: Malnutrition Universal Screening Tool
EPR: Electronic Patient Record
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References and Supporting Documents
1. NICE Guidelines: Nutrition support in adults, Clinical Guideline 32, February 2006
2. Crook MA, Hally V, Panteli JV. The importance of the Refeeding Syndrome. Nutrition 2001 17:632-637
3. Solomon SM and Kirby DF. The refeeding syndrome: A review. JPEN. 1990: 14:90-97.
4. Royal College of Physicians and British Society of Gastroenterology. (2010) Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life. London: Royal College of Physicians.
5. The Royal Colleges of Psychiatrists, Physicians and Pathologists (2014) MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa, 2nd Edition
6. Dewar H, Horvath R. Refeeding Syndrome Guidelines. Oxford: Department of Nutrition and Dietetics, Oxford Radcliffe Hospital, 2000.
7. Salford Royal Care Organisation Intravenous fluid guideline for resuscitation and maintenance (2018)
8. Salford Royal Care Organisation Parenteral Nutrition (PN) Referral and Administration Policy (2019)
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Document Control Information
It is the author’s responsibility to ensure that all sections below are completed in relation to this version of the document prior to submission for upload.
Nominated Lead Gavin Leahy Pharmacy Operational Services Manager author: Lead author 0161 206 4308 [email protected] contact details: Lead Author’s Lindsay Harper Director of Pharmacy Manager:
Applies to: Salford CO
Document Nutrition Steering Group, Nutrition and Dietetic Department, Pharmacy Department, developed in Intestinal Failure Clinical Director, Medicines Management Group. consultation with: Keywords/ Refeeding, Nutrition, Parenteral, Enteral, Pabrinex phrases: Communication To be cascaded through nursing, clinicians, dietetic and pharmacy communication plan: channels Document review This document will be reviewed by the author, or a nominated person, at least once arrangements: every three years or earlier should a change in legislation, best practice or other change in circumstance dictate. Approval: Add name of Committee and Chairpersons name and role: Nutrition Steering Group – Kirstine Farrer, Consultant Dietician Medicines Management Group – Dr Richard Cooper, Consultant Anaesthetist Clinical Effectiveness Committee – Dr Pete Turkington, Medical Director
June 2019
How approved: Chair’s actions Formal Committee decision X
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Equality Impact Assessment (EqIA) screening tool
Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.
1a) Have you undertaken any consultation/ Yes involvement with service users, staff or other groups Consulting with medical, dietetic, in relation to this document? If yes, specify what. biochemistry, pharmacy and nursing colleagues. 1b) Have any amendments been made as a result? If Yes yes, specify what. Definition of severe electrolyte deficiency
2) Does this policy have the potential to affect any of the groups listed below differently? This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list. Protected Group Yes No Unsure Age (e.g. are specific age groups excluded? Would the same process affect X age groups in different ways?) Sex (e.g. is gender neutral language used in the way the policy or X information leaflet is written?) Race (e.g. any specific needs identified for certain groups such as dress, X diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?) Religion & Belief (e.g. Jehovah Witness stance on blood transfusions; X dietary needs that may conflict with medication offered.) Sexual orientation (e.g. is inclusive language used? Are there different X access/prevalence rates?) Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or X breastfeeding women?) Marital status/civil partnership (e.g. would there be any difference X because the individual is/is not married/in a civil partnership?) Gender Reassignment (e.g. are there particular tests related to gender? Is X confidentiality of the patient or staff member maintained?) Human Rights (e.g. does it uphold the principles of Fairness, Respect, X Equality, Dignity and Autonomy?) Carers (e.g. is sufficient notice built in so can take time off work to attend X appointment?) Socio/economic (e.g. would there be any requirement or expectation that X may not be able to be met by those on low or limited income, such as costs incurred?) Disability (e.g. are information/questionnaires/consent forms available in X different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.
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Are there any adjustments that need to be made to ensure that X people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)
3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? (what action has been taken or will be taken, who is responsible for taking a future action, and when it will be completed by – may include adjustment to wording of policy or leaflet to mitigate) N/A
4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? (what action has been taken or will be taken, who is responsible for taking a future action, and when it will be completed by – may include adjustment to wording of policy or leaflet) N/A
Will this policy require a full impact assessment? No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or if you believe there is a potential for it to affect a group differently and do not know how to mitigate against this - Please contact the Inclusion and Equality team for advice on [email protected])
Author: Type/sign: Gavin Leahy Date: 04.07.2019
Sign off from Equality Champion: Date: 04.07.2019
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Appendices
Appendix 1 - Vitamin Supplementation
Patients with refeeding syndrome can suffer severe neurological and cardiac problems from thiamine (vitamin B1) deficiency.
Before feeding is started a dose of appropriate vitamins should be given and continued as indicated below.
For patients fed via the oral route/enteral tube feeding route
. Thiamine tablets – 50mg four times a day for 10 days and
. Vitamin B Compound Strong tablets - 2 tablets three times a day for 10 days
For patients fed via an enteral feeding tube, Thiamine and Vitamin B Compound Strong tablets may be crushed and dispersed in water before administration down the tube. However, for patients with a fine bore feeding tube, a decision should be made on an individual patient basis on whether to administer medication via this route (due to the risk of blocking the tube).
. Forceval (or Forceval soluble) 1 tablet daily should be given from initiation of the refeeding regimen for 10 days.
For patients on Parenteral Nutrition (or for those who an oral/enteral tube feeding route is inappropriate):
. Pabrinex, 1 pair of vials, IV once daily for 3 days
. Note – Forceval is not needed for patients on parenteral nutrition.
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Appendix 2 – Refeeding Syndrome Decision Tree
Establish the likelihood of refeeding syndrome risk:
High risk – see section 7.1 Extremely high risk – see section 7.2
Establish the route the patient or resident will be fed – Oral, tube feeding or Parenteral Nutrition
Measure electrolytes. Do not start feeding if severely deranged electrolytes (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L). When starting feeding, replace potassium, phosphate and magnesium. Only withhold supplementation if levels are high. Monitor glucose (BMs) several times per day, and observe potassium, calcium, magnesium, phosphate and sodium closely. Keep fluid input low, but enough to maintain renal function. Restrict sodium replacement.
Seek assistance from hospital nutrition team, pharmacists or dietitians. Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1
Is patient to be fed orally/enterally?
Yes No
Refer to suggested meal plans in Appendix 4 of the policy or Commence parenteral nutrition via starter regimens in nasogastric, gastrostomy or jejunostomy appropriate venous access. policies. Patients at high risk should commence nutrition at a maximum of 10kcal/kg/day increasing to meet needs by 7 days. Refer to the Parenteral Nutrition (PN) Referral and Administration Extremely high risk patients are those with BMI<14kg/m² or policy prolonged poor intake of >15 days and should commence at a maximum of 5kcal/kg/day. The more rapidly calories are Repeat nutrition profile of bloods delivered and the rate increased, the greater the demand on daily. circulating electrolytes; thus there will be an increased risk of re- feeding syndrome.
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Refeeding Syndrome Policy Page 24 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Appendix 3 - Electrolyte Replacement Therapy in Patients at Risk Of Refeeding Syndrome
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).
Hyperammonemia can be prevented by increasing energy supply slowly during re-feeding. During prolonged starvation a reduction in protein degradation in muscle and other tissues is the consequence of adaptive metabolic mechanisms. The activity of enzymes of amino-acid metabolism is reduced, which can lead to an increased plasma concentration of amino acids
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Refeeding Syndrome Policy Page 25 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
during refeeding. The concentration of amino acids in blood can exceed the capacity of the urea cycle and thus, hyperammonemia may occur. The death of patients with severe malnutrition refed with a protein-rich diet has been attributed to this metabolic derangement.
Refer to the following Quick Reference Guides (QRGs) before prescribing electrolyte replacement:
1. Hypocalcaemia QRG
2. Hypokalaemia QRG
3. Hypomagnesaemia QRG
4. Hypophosphataemia QRG
In the case of complex patients with multiple deranged electrolytes, contact your ward pharmacist or, if out of hours, the on call pharmacist via switchboard
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Refeeding Syndrome Policy Page 26 of 33 Reference Number: TC22(09) Version Number: 4 Issue Date: 12/07/2019
Appendix 4 - Examples of Meal Plans
Examples of Meal Plans for Patients at high risk of refeeding syndrome
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 Provide half portions of all meals from menu Include 1 starter, 1 main and 1 dessert course
Day 2 Provide full meals from menu Include 1 starter, 1 main and 1 dessert course
Day 3 onwards 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
Oral diet regimen: Quick reference flow chart for patients at ‘High risk’ of refeeding syndrome
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 including insulin, antacids or diuretics and patients on chemotherapy.
Initial Management
1. Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding.
2. Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1
3. 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). Patients who have severely deranged biochemistry (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should
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not start feeding until they have received the appropriate electrolyte replacement. See appendix 2 and 3.
4. Introduce feeding at a maximum of 10kcal/kg/day, increasing slowly to meet full requirements by 4-7 days. (e.g. for a 50 kg patient – 10 x 50 = 500kcal/day).
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Sample meal plan - Based on 35kg Weight. Classified as ‘at high risk’ of refeeding syndrome.
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: BREAKFAST: BREAKFAST:
3 tbsp cereal or 1 weetabix with 100ml semi- 3 tbsp cereal or 1 weetabix with 100ml semi- 3 tbsp cereal with 100ml semi-skimmed milk, skimmed milk skimmed milk & 100mls fruit juice 100ml fruit juice & ½ slice bread / toast with margarine OR ½ slice bread or toast with margarine and OR 1 slice bread or toast with margarine and 1 pot diet yoghurt 100ml milk OR 2 Weetabix with 100mls semi-skimmed milk & 100ml fruit juice OR 100Kcals via Ensure Plus or Ensure OR 1 creamy yogurt and 100ml fruit juice Compact OR 250Kcals from Ensure Plus or Ensure OR 200Kcals Ensure Plus or Ensure Compact Compact
LUNCH: LUNCH: LUNCH:
1oz portion of meat / fish / poultry e.g. 1 small 2oz portion of meat / fish / poultry e.g. 1 small 3oz portion of meat / fish / poultry e.g. 1 slice slice ham / beef or ½ oz cheese OR 2 slice ham / beef or 1oz cheese OR 3 ham / beef or 1oz cheese Or 4 Tablespoons Tablespoons of vegetarian dish Tablespoons of vegetarian dish of vegetarian dish
Above served with either 1scoop mashed Above served with either 2 scoops mashed Above served with either 2 scoops mashed potato / ½ small jacket potato / 2 egg size potato / small jacket potato/ 4 egg size boiled potato / 1 small jacket potato / 4 egg size boiled potatoes served with 1 tbsp of potato served with 2 tbsp of vegetables or boiled potato served with 2 tbsp of vegetables vegetables or salad salad or salad
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OR 100Kcals via Ensure Plus or Ensure OR 200Kcals from Ensure Plus or Ensure and 1 Portion fruit e.g. Banana or fruit salad Compact Compact OR 300Kcals from Ensure Plus or Ensure Compact
EVENING MEAL EVENING MEAL EVENING MEAL
Sandwich – 1 slice of bread with meat / fish / Sandwich – 1 slice of bread with meat / fish / 1 Sandwich – 2 slices of bread with meat / fish cheese / egg filling cheese / egg filling and 1 portion fruit / cheese / egg filling and 1 portion fruit or small pot fruit salad OR ½ small jacket potato with ½ oz cheese or OR 1 slice toast with 1oz cheese or 2 tbsp 2 tbsp beans or 1oz tuna with mayonnaise / baked beans or 1 egg scrambled and 1 OR 2 slices toast with 1 oz cheese or 3 tbsp salad cream or 1 tbsp ‘hot filling’ when portion fruit of fruit salad baked beans or 1 egg scrambled And 1 available e.g. Curry portion fruit OR Small Jacket Potato with 1oz cheese or 2- OR 100Kcals from Ensure Plus or Ensure 3 tbsp beans or 2oz tuna or 2 tbsp ‘hot filling’ OR ½ medium jacket potato with 1 oz cheese Compact when available e.g. Curry or 2-3 tbsp beans or small pot tuna or 2 tbsp ‘hot filling’ when available eg. Curry and 1 OR 200Kcals from Ensure Plus or Ensure portion fruit Compact OR 300Kcal from Ensure Plus or Ensure Compact
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ADULT PATIENT IDENTIFIED AS EXTREMELY HIGH RISK OF REFEEDING SYNDROME
Oral diet regimen: Quick reference guide Severely Extremely High risk (Extreme cases) Patient has one or more of the following: BMI < 14kg/m² Negligible intake for > 15 days Initial management 1. Check Potassium, Calcium, Phosphate and Magnesium prior to commencing feeding. 2. Provide multivitamins and trace element supplementation immediately before and during the initial period of feeding. See appendix 1
3. Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate, calcium and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment)). Patients who have severely deranged biochemistry (defined as Phosphate <0.5mmol/L, Magnesium <0.5mmol/L, Calcium <2.0mmol/L and Potassium <3.0mmol/L) should not start feeding until they have received the appropriate electrolyte replacement. See appendix 2 and 3.
4. Introduce feeding at a maximum of 5kcal/kg/day, increasing slowly to meet full requirements by 4-7 days. (e.g. for a 50kg patient – 5 x 50 = 250kcal/day
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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. This is for patients at extremely high risk of refeeding syndrome
Day 1 – (approx) 200Kcals Day 2 – (approx) 350Kcals Day 3 – (approx) 500Kcals
BREAKFAST: BREAKFAST: BREAKFAST:
2 tablespoon cereal with 30mls semi-skimmed 3 tbsp cereal or 1 weetabix with 100ml semi- 3 tbsp cereal or 1 weetabix with 100ml semi- milk skimmed milk skimmed milk
OR ½ weetabix with 30mls semi-skimmed OR ½ slice bread or toast with margarine and OR ½ slice bread / toast with margarine and 1 milk 1 pot diet yoghurt / 100mls semi-skimmed pot diet yoghurt / 100ml semi-skimmed milk milk OR ½ Slice bread/toast with spread OR 100Kcals from Ensure Plus or Ensure OR 100Kcals from Ensure Plus or Ensure Compact OR 50Kcals from Ensure Plus or Ensure Compact Compact
LUNCH: LUNCH: LUNCH:
1 tablespoon of main meat / chicken / fish 1oz portion of meat / fish / poultry e.g. 1 small 2oz portion of meat / fish / poultry e.g. 1 small course slice ham / beef or ½ oz cheese slice ham / beef or 1oz cheese
OR 1 tablespoon vegetarian option (must OR 2 Tablespoons of vegetarian dish OR 3 Tablespoons of vegetarian dish contain cheese or egg Above served with either 1scoop mashed Above served with either 2 scoops mashed Above served with either ½ scoop mashed potato / ½ small jacket potato / 2 egg size potato / small jacket potato/ 4 egg size boiled boiled potatoes served with 1 tbsp of potato served with 2 tbsp of vegetables or
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potatoes / 1 boiled potato vegetables or salad salad
Served with 1 tablespoon vegetables OR 100Kcals from Ensure Plus or Ensure OR 200Kcals from Ensure Plus or Ensure Compact Compact OR 50Kcals from Ensure Plus or Ensure Compact
Evening meal: EVENING MEAL: EVENING MEAL:
1 tablespoon of main meat / chicken / fish Sandwich – 1 slice of bread with meat / fish / Sandwich – 1 slice of bread with meat / fish / course cheese / egg filling cheese / egg filling and 1 portion fruit
OR 1 tablespoon vegetarian option (must OR ½ small jacket potato with ½ oz cheese or OR 1 slice toast with 1oz cheese or 2 tbsp contain cheese or egg) 2 tbsp beans or 1oz tuna with mayonnaise / baked beans or 1 egg scrambled and 1 salad cream or 1 tbsp ‘hot filling’ when portion fruit of fruit salad Above served with either 1 scoop mashed available e.g. Curry potato / 2 boiled potatoes OR Small Jacket Potato with 1oz cheese or 2- OR 150Kcals from Ensure Plus or Ensure 3 tbsp beans or 2oz tuna or 2 tbsp ‘hot filling’ Served with 1 tablespoon vegetables Compact when available e.g. Curry
OR 100Kcals from Ensure Plus or Ensure OR 200Kcals from Ensure Plus or Ensure Compact Compact
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