Challenges in Nutrition Management of Patient at Risk of Refeeding Syndrome: A Case Study

Hui Wen, P., Jazlina, S., Zalina, A.Z.
Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia

Assessment: Background: Severely malnourished is the common risk factor for refeeding syndrome (RFS). This case presents the challenges in nutrition management of patient at high risk RFS with underlying retro virus (RVD) and pulmonary tuberculosis (PTB) positive. Client History: A 53 years old Malay male prisoner admitted due to fever and diagnosed with oral candidiasis, scabies with underlying RVD, PTB and Hepatitis C positive referred to start enteral feeding. Nutritional Assessment: Patient had body weight of 35kg (BMI: 13.7kg/m2) with weight loss 10% of body weight in 2 months. Presented with low total protein and electrolytes (K, Mg, PO4). He claimed having oral thrush and reduced intake for the past one month. Patient's lip was severely crusted with creamy white lesions. Reported 24-hour dietary intake was 165kcal/day (5kcal/kg/d) and10g of protein (0.29g/kg/d).

Diagnosis: Predicted suboptimal nutrient intake related to risk of refeeding secondary to reintroduction of nutrition as evidenced by severely underweight (BMI:13.7kg/m2), impaired electrolytes (K, Mg, PO4), having oral thrush for past one month, febrile and cachectic appearance, 24-hour dietary recall (energy: 5kcal/kg, protein: 0.29g/kg).

Intervention: Prescription: 132kcal/day (12kcal/kg/day). Goal: Slow and gradual increment of energy provision was aimed to prevent RFS. The energy was increased gradually to achieve the requirement by 4-7 days. The provision of thiamine, vitamin Bcomplex, multivitamin and correction of electrolytes were suggested.

Monitoring and Evaluation: Electrolytes regressed due to planned regime was interrupted in view of uncooperative patient who kept requesting food due to hunger. Electrolyte correction, supplementation of thiamine and multivitamin were only prescribed on day 3. Patient achieved 33kcal/kg/d of energy requirement (day 7) without any sign and symptoms of RFS. Learning point: RFS is poorly recognized. Proactive in communicating with other health care professionals is important in order to provide advice and education in its prevention, recognition, and treatment.