Article

Complications of emergency refeeding in anorexia nervosa: Case series and review

Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK.
Acute medicine 01/2011; 10(2):69-76.
Source: PubMed

ABSTRACT

The refeeding syndrome is common among patients with anorexia nervosa. It may be lethal and has many manifestations. We report a case series of 14 anorexic patients admitted for feeding to a single British centre. There was a high prevalence of the refeeding syndrome, with three cases requiring higher dependency unit support and one death. We present a review of the refeeding syndrome in anorectics and highlight our impression that infection among such patients may be serious and under-recognised.

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Available from: Gwilym J Webb, May 10, 2014
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    ABSTRACT: Anorexia nervosa exhibits one of the highest death rates among psychiatric patients and a relevant fraction of it is derived from undernutrition. Nutritional and medical treatment of extreme undernutrition present two very complex and conflicting tasks: (1) to avoid "refeeding syndrome" caused by a too fast correction of malnutrition; and (2) to avoid "underfeeding" caused by a too cautious refeeding. To obtain optimal treatment results, the caloric intake should be planned starting with indirect calorimetry measurements and electrolyte abnormalities accurately controlled and treated. This article reports the case of an anorexia nervosa young female affected by extreme undernutrition (BMI 9.6 kg/m(2)) who doubled her admission body weight (from 22.5 kg to 44 kg) in a reasonable time with the use of enteral tube feeding for gradual correction of undernutrition. Refeeding syndrome was avoided through a specialized and flexible program according to clinical, laboratory, and physiological findings.
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    ABSTRACT: Refeeding syndrome (RFS) broadly encompasses a severe electrolyte disturbance (principally low serum concentrations of intracellular ions such as phosphate, magnesium and potassium) and metabolic abnormalities in under-nourished patients undergoing refeeding whether orally, enterally, or parenterally; RFS reflects the change from catabolic to anabolic metabolism. The RFS sometimes is undiagnosed and unfortunately some clinicians remain oblivious to its presence. This is particularly concerning as RFS is a life threatening condition although it need not be so and early recognition reduces morbidity and mortality. Careful patient monitoring and multi-discipline nutrition team management may help to achieve this goal. The diagnosis of RFS is not facilitated by the fact that there is no universal agreement as to its definition. The presence of hypophosphataemia alone does not necessarily mean that the RFS is present as there are many other causes for this as I discuss later in this article. The RFS is increasingly being recognised in neonates and children. An optimal refeeding regime for RFS is not universally agreed due to paucity of randomised controlled trials in the field.
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    ABSTRACT: Anorexia nervosa is a serious psychiatric potentially life–threatening illness with high morbidity and severe medical complications.Actually AN shows the highest mortality of any psychiatric disorder (Hoek HW, Van Hoeken D. Int J Eat Disord 34:383–96, 2003). According to a meta-analysis from 35 studies on 12.808 AN patients, the overall annual mortality rate was 5.1 deaths per 1,000 person-year (95 % CI,3.99–6.14). Out of them, 1.3 were explicitly associated to suicide; that could leave 4.2 cases to other, nonpsychiatric or so-called medical causes (Arcelus J et al. Arch Gen Psychiatry 68:724–31, 2011). Severe AN patients should be admitted tospecialized units and cared for in a specialist eating disorder unit, and they should be managed by a multidisciplinary team including physicians better if trained in clinical nutrition, psychiatrists, dietitians, and nursing staff (National Institute for Health and Clinical Excellence. In: Nutrition Support in Adults: full guideline (CG32). http://www.nice.org.uk/nicemedia/live/10978/29978/29978.pdf. Accessed Feb 2006; Practice guideline for the treatment of patients with eating disorders.American Psychiatric Association Work Group on Eating Disorders, 2006). In high-risk patients, critical care management may be required, but medical management should be undertaken beside psychiatric treatment.The goals of nutritional rehabilitation for severe underweight patients are gradually to restore body weight, correct biological and psychological consequence of malnutrition, normalize eating patterns, and achieve normal perceptions of hunger and satiety. First of all, the patients should change from a catabolic to an anabolic state. The refeeding of severely malnourished patients represents two very complex and conflicting tasks Avoid refeeding syndrome caused by a too fast correction of malnutrition.Avoid underfeeding caused by a too cautions of refeeding (O’Connor G, Nicholls D.Nutr Clin Pract 28:358-64, 2013; Marpisan Group. Marpisan: management of really sick patients with anorexia nervosa. College report CR162 Royal College of Physicians, pp 1-58, 2010).To avoid these two dangerous risks, the caloric intake should be planned starting with indirect calorimetric measurements, because resting energy expenditure is the main component of daily expenditure particularly in severely undernourished bed rest patients. In inpatient setting, weight gain should be set at 0.5-1 kg perweek. We should consider the high individual variability;weight gain may be slow, but weight must be progressively restored. Coming to the kinds and routes of feeding, nutritional rehabilitation should be regarded as a process developing through different levels which are not to be considered mutually exclusive: (a) Improving energy and nutrient intake from ordinary food (b) Oral nutritional support (c) Artificial nutrition choosing enteral nutrition as preferred route of feeding if there is a functional accessible gastrointestinal tract EN must be closely monitored and regulatedvia an electronically operated pump.
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