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 It is your responsibility to check on the intranet that this printed copy is the latest version 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 It is your responsibility to check on the intranet that this printed copy is the latest version 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. It is your responsibility to check on the intranet that this printed copy is the latest version 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. It is your responsibility to check on the intranet that this printed copy is the latest version 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 It is your responsibility to check on the intranet that this printed copy is the latest version Refeeding Syndrome Policy Page 6 of 33 Reference Number: TC22(09) Version Number: 4 Issue