Would love to have more detail on his electrolytes prior to initiation of enteral nutrition, and if any electrolyte replacement was required before starting. Did he develop refeeding syndrome?Thanks for a great video.
Thank you for your question! Mr. X’s basic chemistry, phosphorus and magnesium lab levels were drawn daily since admission. The day his feeding tube was cleared for use his phosphorus was slightly low at 2.3 (reference range 2.5-4.3 mg/dL), potassium was within normal limits at 3.5 (reference range 3.3-5.1 mmol/L) and magnesium was within normal limits at 2.0 (reference range 1.6-2.6 mg/dL). Due to Mr. X’s mild hypophosphatemia, we recommended IV phosphorus supplementation. IV electrolyte supplementation should always be discussed with the primary team. It was decided Mr. X would receive a one-time dose of 30 mmol IV potassium phosphate. Per the ASPEN Refeeding Syndrome Consensus recommendations, we created a plan to monitor his basic chemistry, phosphorus and magnesium levels every 12 hours for 3 days while initiating his tube feeding. Given Mr. X’s phosphorus was only slightly low and he received IV supplementation, the dietitian felt it was appropriate to begin a slow initiation of tube feeding with Mr. X. Mr. X’s next set of labs 12 hours later revealed a phosphorus of 2.1, potassium of 3.2 and magnesium of 1.7. With the downtrend in electrolytes, Mr. X may have been experiencing mild refeeding syndrome. At that time the tube feeding was held at the current rate of 20 mL/hr and electrolytes were supplemented. If Mr. X had a dramatic decline in his electrolyte levels the ASPEN recommendations suggest decreasing the calories provided by 50% and advancing by 33% of the goal calories every 1 to 2 days. The next set of labs 12 hours later demonstrated Mr. X’s phosphorus had improved to 2.4, potassium to 3.4 and magnesium to 1.9. Given improvement in Mr. X’s labs his tube feeding advancement was resumed and his further labs draws were unremarkable. Reference: da Silva J, Seres D, Sabino K, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract.2020;35(2):178-195.
Thank you so much for this instructive case.What I don't understand is, is there a bag amount that varies depending on the hospital when switching to bolus feeding? On what basis did we base 237 ml? I think I missed that.
Thanks for your question! In this particular case, when Mr. X is preparing to transition to bolus feeding, he is also nearing discharge home on enteral nutrition support. In hospital settings, enteral nutrition formulas often come in large 1000 mL containers. However when discharged to go home, individuals will typically have access to their enteral formulas in 8 oz cans (237 mL). To make it easier for the patient, we will give guidance for the number of feeds per day in approximate full or half can measurements, although we can use the 237mL/can to help us calculate what the actual provisions will be. Hope this helps!
Would love to have more detail on his electrolytes prior to initiation of enteral nutrition, and if any electrolyte replacement was required before starting. Did he develop refeeding syndrome?Thanks for a great video.
Thank you for your question!
Mr. X’s basic chemistry, phosphorus and magnesium lab levels were drawn daily since admission. The day his feeding tube was cleared for use his phosphorus was slightly low at 2.3 (reference range 2.5-4.3 mg/dL), potassium was within normal limits at 3.5 (reference range 3.3-5.1 mmol/L) and magnesium was within normal limits at 2.0 (reference range 1.6-2.6 mg/dL). Due to Mr. X’s mild hypophosphatemia, we recommended IV phosphorus supplementation. IV electrolyte supplementation should always be discussed with the primary team. It was decided Mr. X would receive a one-time dose of 30 mmol IV potassium phosphate. Per the ASPEN Refeeding Syndrome Consensus recommendations, we created a plan to monitor his basic chemistry, phosphorus and magnesium levels every 12 hours for 3 days while initiating his tube feeding. Given Mr. X’s phosphorus was only slightly low and he received IV supplementation, the dietitian felt it was appropriate to begin a slow initiation of tube feeding with Mr. X. Mr. X’s next set of labs 12 hours later revealed a phosphorus of 2.1, potassium of 3.2 and magnesium of 1.7. With the downtrend in electrolytes, Mr. X may have been experiencing mild refeeding syndrome. At that time the tube feeding was held at the current rate of 20 mL/hr and electrolytes were supplemented. If Mr. X had a dramatic decline in his electrolyte levels the ASPEN recommendations suggest decreasing the calories provided by 50% and advancing by 33% of the goal calories every 1 to 2 days. The next set of labs 12 hours later demonstrated Mr. X’s phosphorus had improved to 2.4, potassium to 3.4 and magnesium to 1.9. Given improvement in Mr. X’s labs his tube feeding advancement was resumed and his further labs draws were unremarkable.
Reference: da Silva J, Seres D, Sabino K, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract.2020;35(2):178-195.
Thank you so much for this instructive case.What I don't understand is, is there a bag amount that varies depending on the hospital when switching to bolus feeding? On what basis did we base 237 ml? I think I missed that.
Thanks for your question! In this particular case, when Mr. X is preparing to transition to bolus feeding, he is also nearing discharge home on enteral nutrition support. In hospital settings, enteral nutrition formulas often come in large 1000 mL containers. However when discharged to go home, individuals will typically have access to their enteral formulas in 8 oz cans (237 mL). To make it easier for the patient, we will give guidance for the number of feeds per day in approximate full or half can measurements, although we can use the 237mL/can to help us calculate what the actual provisions will be. Hope this helps!