Enteral nutrition and refeeding syndrome in a patient with anorexia nervosa and COVID-19

Introduction: the evidence on the health problem-related prevalence of COVID-19 is an emergency. Case report: we present the case of a 28-year-old woman who had had a behavioral eating disorder (BED) since age 12. Her body mass index (BMI) was 13.6 kg/m2. She was hospitalized for a respiratory condition (bronchospasm) due to COVID-19, with supplementary oxygen at two liters. During her stay, she refused food and was started on standard enteral nutrition via a naso-gastric tube. She developed refeeding syndrome (RFS), which was managed with electrolytes, and her enteral diet was changed to a low-carbohydrate high-protein diet. She received psychological therapy through video calls, recovered, and was discharged to home. Discussion: refeeding complications increase when a high caloric rate is begun. The standard enteral formula has 54% carbohydrates, which contributes to the risk of developing RFS. The consequences of BED and COVID-19 are unknown, and it is likely to become more evident over time. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2626).

Prevalência de hipofosfatemia e risco de síndrome de realimentação em idosos internados em uma unidade de terapia intensiva / Prevalence of hypophosphatemia and risk of refeeding syndrome in elderly patients admitted to an intensive care unit

Introdução: A presença de hipofosfatemia é fortemente relacionada à ocorrência de síndrome de realimentação em pacientes críticos, na qual um dos principais grupos de risco é a população idosa. Objetivos: Avaliar a prevalência de hipofosfatemia e o risco de síndrome de realimentação em idosos internados em uma unidade de terapia intensiva. Métodos: Estudo observacional prospectivo, realizado numa unidade de terapia intensiva com pacientes idosos de ambos os sexos e em uso de terapia nutricional enteral. Foram coletados dados demográficos, clínicos e exames bioquímicos, e realizadas triagem e avaliação nutricional. As necessidades nutricionais foram calculadas e adotou-se o ponto de corte de 90% para estabelecer a adequação da oferta calórica. Para avaliar o risco e a ocorrência de síndrome de realimentação, foram utilizados os critérios propostos pelo grupo NICE. A análise estatística foi realizada com o auxílio do programa SPSS 13.0, com um intervalo de confiança (IC) de 95%. Resultados: Foram estudados 44 pacientes, dos quais 34,1% estavam em magreza; 86,4% dos pacientes iniciaram a terapia nutricional enteral em até 48 horas, com 43,2% de adequação calórica em até 72 horas. A hipofosfatemia foi encontrada em 9,1% dos pacientes na admissão e em 29,5% após o início da dieta. Com isso, 88,6% dos pacientes apresentaram algum risco para desenvolver síndrome de realimentação e 40,9% deles manifestaram a síndrome. Conclusão: Foi identificada elevada prevalência de hipofosfatemia após o início da terapia nutricional. Além disso, o risco de desenvolver síndrome de realimentação foi elevado e sua manifestação se assemelha aos dados encontrados na literatura. (AU)

Introduction: The presence of hypophosphatemia is strongly related to the occurrence of refeeding syndrome in critically ill patients, in which one of the main risk groups is the elderly population. Objectives: To assess the prevalence of hypophosphatemia and the risk of refeeding syndrome in elderly patients admitted to an intensive care unit. Methods: Prospective observational study carried out in an intensive care unit with elderly patients of both genders using enteral nutritional therapy. Demographic, clinical and biochemical data were collected, and nutritional screening and assessment were performed. The energy and nutrient requirements were calculated and a cutoff point of 90% was adopted to establish the adequacy of the caloric supply. To assess the risk and occurrence of refeeding syndrome, the criteria proposed by the NICE group were used. Statistical analyses were performed using the SPSS 13.0 program, with a 95% confidence interval (CI). Results: 44 patients were studied, of which 34.1% were malnourished; 86.4% of patients started enteral nutritional therapy within 48 hours, with 43.2% of caloric adequacy within 72 hours. Hypophosphatemia was found in 9.1% of patients on admission and in 29.5% after starting the diet. Thus, 88.6% of patients had some risk of developing the refeeding syndrome and 40.9% of them manifested the syndrome. Conclusion: A high prevalence of hypophosphatemia was identified after starting nutritional therapy. In addition, the risk of developing refeeding syndrome was high and its manifestation is similar to data found in the literature. (AU)

Analysis on 17 refeeding syndrome cases based on literature review of case reports / 中华临床营养杂志

Objective:To discuss the onset and development pattern and characteristics of refeeding syndrome (RFS) induced by nutrition support and to provide reference for rational drug use in parenteral nutrition management.Methods:Case reports of RFS from CNKI, Wanfang, VIP database and Pubmed from 2000 to 2020 were retrieved. The clinical data were collected and statistically analyzed.Results:A total of 17 reports, including 17 cases, were included in the analysis. Patients were 6 males(35.29%) and 11 females (64.71%). The distribution of age was from 29 weeks in a premature neonate to 87 years old. 12 cases (70.59%) of RFS occurred within 3 days after starting the nutrition support. The most common clinical manifestation were cardiovascular system symptoms (88.23%), with dyspnea as the most reported symptom (41.17%). 15 patients (88.23%) recovered after appropriate intervention and 2 patients died(11.76%).Conclusions:Refeeding syndrome is a potentially fatal condition. The risk of RFS should be assessed before initiating nutrition support. Patients at risk of RFS must be monitored closely at the early stage of nutritional support.

Research progress on risk predictors of refeeding syndrome in intensive care unit patients / 中华危重病急救医学

Refeeding syndrome (RFS) is a potentially fatal complication of clinical nutritional therapy. Patients in intensive care unit (ICU) consuming nutrients under high stress and high metabolism are more likely to develop RFS, which is closely related to the poor prognosis and higher mortality. However, due to the lack of characteristic clinical manifestations of RFS and the incomplete evaluation of risk factors, there are few reports on the related research of RFS risk prediction model, and it is easily ignored by clinicians. The key to prevention and treatment is to clarify the risk factors of RFS in ICU patients, early identify high-risk patients and initiate intervention. In this paper, the diagnostic criteria, current domestic and abroad situation, risk prediction indexes and preventive therapy of RFS are reviewed. It provides a reference for constructing an RFS risk prediction model that is in line with our national conditions, in order to improve the ability of medical staff to early identify RFS and improve the survival rate of ICU patients.

Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy

Summary OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

RESUMO OBJETIVO: Determinar a frequência de hipofosfatemia como marcador da síndrome de realimentação (SR) antes e após o início da TN em pacientes críticos. MÉTODOS: Coorte retrospectiva realizada com 917 pacientes adultos de um hospital terciário em Cuiabá-MT. Foi determinada a frequência de hipofosfatemia (fósforo <2,5 mg/dl) como marcador de risco de SR, para valores de fósforo sérico da admissão (P1) e após o início da TN (P2). RESULTADOS: Foi observado um aumento significativo (36,3%) da hipofosfatemia entre P1 e P2 e, consequentemente, do risco de SR (25,6% vs 34,9%; p<0,001) com o início da TN. Após o início da TN, pacientes desnutridos apresentaram maior queda do fósforo sérico. Os pacientes com TN apresentaram aproximadamente 1,5 vez mais chance de desenvolver hipofosfatemia e risco de SR (OR=1,44 IC95% 1,10-1,89; p=0,01) quando comparado aos com dieta oral. Nutrição parenteral foi mais associada à hipofosfatemia versus nutrição enteral (p=0,001) e nutrição enteral suplementada com parenteral (p=0,002). CONCLUSÃO: A frequência de pacientes críticos com hipofosfatemia e em risco de SR é alta e esse risco aumenta após o início da TN, especialmente nos desnutridos e naqueles recebendo nutrição parenteral.

Coma irreversível em paciente portadora de esquizofrenia paranóide: encefalopatia de Wernicke após síndrome de realimentação: um relato de caso / Irreversible coma in a patient with paranoid schizophrenia: Wernicke encephalopathy after refeeding syndrome: a case report

Encefalopatia de Wernicke (EW) e síndrome de realimentação (SR) são duas condições frequentemente coexistentes, subdiagnosticadas e que podem implicar prognóstico reservado após sua instalação. Sua identificação precoce representa um desafio para os intensivistas, haja vista a falta de sensibilidade e especificidade das manifestações clínicas. Apresenta-se um relato de caso de uma paciente portadora de esquizofrenia paranoide, sem histórico de abuso de álcool, que desenvolveu quadro de coma irreversível após greve de fome, sendo feito diagnóstico tardio de EW associada a SR. Descreve-se a evolução clínica e neuropsiquiátrica com o intuito de enfatizar a necessidade crucial de alta suspeição diagnóstica, com reposição vitamínica imediata, vigilância de distúrbios eletrolíticos e progressão parcimoniosa do aporte nutricional. (AU)

Wernicke encephalopathy (WE) and refeeding syndrome (RFS) are two often coexisting, underdiagnosed conditions that may involve a poor prognosis after their onset. Early identification represents a challenge for intensivists, given the lack of sensitivity and specificity of clinical manifestations. We report a case of a patient with paranoid schizophrenia, without a history of alcohol abuse, who developed irreversible coma after a hunger strike, with a late diagnosis of WE associated with RFS. The clinical and neuropsychiatric outcomes are described herein in order to emphasize the crucial need for a high diagnostic suspicion, with immediate vitamin replacement, monitoring of electrolyte disorders, and gradual progression of nutritional support. (AU)

Risk of refeeding syndrome. case report

ABSTRACT Introduction: Refeeding syndrome (RS) is an acute metabolic disorder that occurs during nutritional repletion. Although it has been known for years, the early detection of risk factors for its onset and the implementation of measures to prevent it are not common in nutritional care. Case presentation: 48-year-old male patient, in critical care for 6 days, with suspected Wernicke-Korsakoff encephalopathy and high risk of refeeding syndrome according to criteria of the United Kingdom National Institute of Health and Clinical Excellence. The subject received enteral nutrition with 14 kcal/kg for the first 3 days, with subsequent increases aiming to achieve a nutritional goal of 25 kcal/kg on day 5. He also received daily supplementation of thiamine 600mg, folic acid 5mg and pyridoxine 50mg. Blood phosphorus decreased from 3 mg/dL to 2 mg/dL the day after initiating the nutritional plan and normalized by day 3. Discussion: The patient did not present severe hypophosphatemia or clinical manifestations of refeeding syndrome. Hypophosphatemia was resolved by maintaining a stable caloric restriction during the first days. Some professionals consider this restriction as very conservative, and others think that it may lead to achieve significant improvements in mortality reduction. Conclusions: The strategy for assessing the risk of refeeding syndrome, nutritional management and implemented follow-up were successful in preventing the patient from developing a refeeding syndrome.

RESUMEN Introducción. El síndrome de realimentación (SR) es un trastorno metabólico agudo que ocurre durante la repleción nutricional. Aunque ha sido conocido por años, la detección precoz de factores de riesgo para su desarrollo y la instauración de medidas para prevenirlo no son una práctica habitual en la atención nutricional. Presentación del caso. Paciente masculino de 48 años en cuidado crítico por 6 días, con sospecha de encefalopatía de Wernicke-Korsakoff y riesgo alto de SR según criterios del Instituto Nacional de Salud y Excelencia Clínica del Reino Unido. El sujeto recibió nutrición enteral con 14 kcal/kg los 3 primeros días, con aumentos posteriores que pretendían una meta de 25 kcal/kg al día 5 y suplementación diaria de tiamina 600mg, ácido fólico 5mg y piridoxina 50mg. El fósforo en sangre disminuyó de 3 mg/dL a 2 mg/dL al día siguiente del inicio de la nutrición y se normalizó para el día 3. Discusión. El paciente no presentó manifestaciones clínicas de SR ni hipofosfatemia severa; esta última se resolvió manteniendo estable la restricción calórica los primeros días. Para algunos profesionales dicha restricción puede ser muy conservadora; sin embargo, para otros puede llevar a mejoras significativas en la reducción de la mortalidad. Conclusiones. La estrategia para valorar el riesgo de SR, el manejo nutricional y el seguimiento implementado fueron acertados para evitar que el paciente desarrollara el síndrome.

Refeeding Syndrome as a Possible Cause of Very Early Mortality in Acute Pancreatitis

BACKGROUND/AIMS: Refeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP). METHODS: Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals. RESULTS: Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support. CONCLUSIONS: The findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.

Síndrome de realimentação em idosos: estudo de uma série de cinco casos / Refeeding syndrome in elderly individuals: evaluation of a series of five cases

Introdução: A subnutrição é um problema frequente em idosos e sua prevalência aumenta entre os mais frágeis, tornando prioritária uma adequada oferta nutricional diante de eventos agudos. Entretanto, tal oferta, em pacientes desnutridos ou com privação calórica subaguda, pode ocasionar alterações hidroeletrolíticas associadas a sintomas neurológicos, respiratórios e cardiológicos, incluindo falência cardíaca. Esses distúrbios ocorrem poucos dias após a introdução da dieta, o que caracteriza a síndrome de realimentação. Metodologia: Avaliou-se retrospectivamente cinco pacientes idosos internados por causa clínica e que desenvolveram síndrome de realimentação durante a internação hospitalar. Resultados: Todos os pacientes analisados eram desnutridos e frágeis, dos quais quatro eram do sexo feminino. A idade variou entre 82 e 85 anos e o tempo de privação alimentar entre 7 e 15 dias. Três pacientes eram portadores de demência grave e foram admitidos com delirium hipoativo. Hipofosfatemia ocorreu em 100% da amostra, seguida por hipocalemia (60%) e hipomagnesemia (40%). Quatro pacientes cursaram com edema periférico (80%), dois apresentaram íleo metabólico e três idosos (os que apresentaram menores níveis de fosfato) faleceram durante a internação. Conclusão: Todos os casos de síndrome de realimentação analisados cursaram com hipofosfatemia, com desfecho fatal naqueles com menores níveis deste íon. A associação com edema e íleo metabólico foi comum. Dada a escassez de dados disponíveis na literatura, novos estudos são de extrema importância. A avaliação eletrolítica antes e após o início de suporte nutricional é imprescindível em pacientes de risco, auxiliando no reconhecimento e no tratamento precoce dessa grave condição.

Introduction: Undernourishment is a common health problem among elderly individuals, and its prevalence grows among frail patients, which makes nutritional support a priority, especially in acute diseases. However, providing nutritional support to undernourished patients or to those under acute caloric deprivation may lead to electrolyte disturbances associated with neurological, respiratory, and cardiac symptoms, including cardiac arrest. These disturbances occur a few days after receiving nutritional support, and characterize the refeeding syndrome. Methodology: Five elderly patients hospitalized for clinical reasons and who developed refeeding syndrome during the duration of the stay, were retrospectively evaluated. Results: All patients analyzed were malnourished and frail, of whom four were women. The age group ranged between 82 and 85 years, and food deprivation time ranged between 7 to 15 days. Three patients had severe dementia and were admitted with hypoactive delirium. Hypophosphatemia occurred in 100% of the sample, followed by hypokalemia (60%) and hypomagnesemia (40%). Four patients developed peripheral edema, two developed metabolic ileus and three elderly persons (who had lower phosphorus values) died during the hospital stay. Conclusion: All refeeding syndrome patients developed hypophosphatemia, with fatal outcome among those whose phosphorus values were lower. The development of peripheral edema and metabolic ileus was frequent. Owing to the lack of data in literature, new researches on refeeding syndrome are extremely important. Electrolyte evaluation before and after nutritional support in patients at risk, is indispensable to facilitate recognition and treatment of this severe condition.

Falla multiorgánica asociada a síndrome de realimentación / Multiple organ failure refeeding syndrome associated / Falência de múltiplos órgãos associada à síndrome de realimentação

Resumen: El síndrome de realimentación es una entidad clínica subdiagnosticada, de no reconocerse puede causar desenlaces fatales. La literatura sobre la prevalencia de este trastorno es escasa. La presentación clínica es inespecífica y por tanto es de suma importancia la sospecha de esta entidad. Presentamos el caso de una paciente con múltiples factores de riesgo quien, posterior al inicio de nutrición parenteral hipercalórica, desarrolló disfunción orgánica múltiple manifestada con insuficiencia cardiaca aguda, edema agudo de pulmón, encefalopatía y oliguria. Mediante tratamiento de soporte hemodinámico, nutrición parenteral adecuada y corrección electrolítica se obtuvo un desenlace favorable.

Abstract: Refeeding syndrome is a commonly under diagnosed pathology, with potentially fatal outcomes when untreated. Nowadays few data exists about its prevalence. The clinical presentation is unspecific that is the reason why it is so important to recognize this disease. The case presented here is about a multiple risk factor patient who developed multiple organ failure with acute heart failure, acute lung edema, encephalopathy and diminishment of urine output after been treated with a hypercaloric parenteral nutrition. Treatment with hemodynamic support, an adequate parenteral nutrition and electrolyte correction, brought to a favorable clinical outcome.

Resumo: A síndrome de realimentação é uma entidade clínica subdiagnosticada, o seu não reconhecimento pode ser fatal. A literatura sobre a prevalência dessa difunção é escassa. A apresentação clínica é inespecífica e, portanto, é de suma importância suspeitar desta entidade. Relatamos o caso de uma paciente com múltiplos fatores de risco que, após o início da nutrição parenteral hipercalórica desenvolveu disfunção de múltiplos órgãos manifestado com insuficiência cardíaca aguda, edema agudo pulmonar, encefalopatia e oligúria. Obteve-se um resultado favorável no tratamento com o suporte hemodinâmico, nutrição parenteral adequada e correção electrolítica.

Refeeding Syndrome

Refeeding syndrome refers to a life-threatening shift of electrolytes and fluid with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. Clinical findings are fluid-balance abnormalities, abnormal glucose metabolism, hypophosphatemia, hypomagnesemia, hypokalemia and deficiencies of vitamin and trace element. Multiple organ systems including cardiac, respiratory, neurologic, renal, hematologic, and gastrointestinal can be affected. When recognized in a timely manner, these complications can be easily and successfully prevented and treated. Four factors appear fundamental: early identification of patients at risk, correction of abnormalities before refeeding, close monitoring during refeeding, and an appropriate feeding regimen.

Refeeding Syndrome: Nursing Implications / Síndrome de Realimentação: Implicações de Enfermagem / Síndrome de Realimentación: Implicaciones de la Enfermería

Objective: To identify the etiological and physiological aspects on RS and describe the main nursing approaches aimed at preventing and reducing injuries from RS. Method: Exploratory bibliographic research, of literature and from an online database: Biblioteca Virtual de Saúde (BVS). Results: RS is characterized by manifestations that are directly related to an electrolyte disorder. Its tems from the reintroduction of nutritional support in malnourished patients, which can cause lethal damages. Conclusion: The studied scientific production reveals sparse theoretical production on nursing care towards RS, and that is related to the process of nutrition al repletion associated with enteral and parenteral nutrition therapy in which the nurse must be aware to know provide adequate care.

Objetivo: Identificar os aspectos etiológicos e fisiológicos acerca da SR, descrever as principais condutas do (a)enfermeiro(a),visando a prevenção e redução de agravos oriundos da SR. Método: Pesquisa bibliográfica,com caráter exploratório,realizada através de consulta em livros e banco de dados: Biblioteca Virtual de Saúde (BVS). Resultados: A SR é caracterizada por manifestações que estão diretamente relacionadas por uma disfunção eletrolítica. Decorre a partir da reintrodução do aporte nutricional em pacientes mal nutridos, que pode desencadear danos letais ao paciente. Conclusão: A produção científica estudada aponta uma escassa produção teórica acerca dos cuidados de enfermagem frente à SR e que está se relaciona ao processo de repleção nutricional associado à terapia nutricional enteral e parenteral em que o(a) enfermeiro (a) deve estar ciente para saber prestar uma adequada assistência.

Objetivos: Identificar los aspectos etiológicos y fisiológicos sobre el SR, describir los principales conductas de las enfermeras, destinadas a prevenir y reducir las lesiones por el síndrome de realimentación. Método: Se trata una búsqueda bibliográfica, con un carácter exploratorio, realizada por los libros de consulta y base de datos: Biblioteca Virtual en Salud (BSV). Resultados: El SR se caracteriza por las manifestaciones que están directamente relacionadas con un trastorno electrolítico. Se desprende de la reintroducción de la nutrición em los pacientes desnutridos, lo que puede causar daños letal es para el paciente. Conclusión: La producción científica demuestra uma señala un escasa producción teórica sobre los cuidados de la enfermería con el SR y que este proceso está relacionado con la repleción nutricional asociadas con la terapia de la nutrición enteral y parenteral donde la enfermeira debe conocer para proporcionar una atención adecuada.

A review of literature on modern parenteral nutrition.

Appropriate nutritional support is the standard of care for hospitalized patients. Total parenteral nutrition has evolved as a distinct therapeutic reality within the past decade for patients with appropriate indications including but not limited to non/dysfunction of the gastrointestinal tract. Starvation/malnutrition historically associated with prolonged hospital stay and protracted illness course can be somewhat addressed successfully. Though it is a well-established fact that current TPN techniques can be both safe and effective if used with due caution, the prevention and awareness of potential complications must be considered. Changes in technique are to be anticipated as advancement of knowledge and improvement and innovation in materials ensues. The current effectiveness and safety of TPN, particularly in comparison to enteral feeding and the clinical situations most appropriate for nutrition support have been the topic of ongoing discussion. Innovative strategies such as supplementation of TPN with medium-chain triglycerides, glutamine or branched-chain amino acids have been compared with standard treatments. Increasing efforts are being made to mitigate the adverse effects associated with TPN such as hyperglycaemia, central venous catheter infection, and hepatic dysfunction. This review focuses on these issues as addressed by the recent literature.

Analyses enteral nutrition some problems in children / 国际儿科学杂志

Enteral nutrition therapy is the first choice of clinical nutrition therapy method in children with disease.We should make full use of the gastrointestinal function and total nutritional therapy.The key is based on gastrointestinal function choose enteral nutrition infusion way,infusion pattern and prevention and treatment of refeeding syndrome.As following is introduction about a few problems.

Conduta nutricional no trauma para o clínico / Conduct in nutrition on trauma for clinical

JUSTIFICATIVA E OBJETIVOS: Trauma é um evento agudo que altera a homeostase do organismo, por desencadear reações neuroendócrinas e imunológicas que visam a manutenção da volemia, do débito cardíaco, da oxigenação tecidual e da oferta e utilização de substratos energéticos. Todas têm em comum um evento inicial agudo, alterando todo o equilíbrio do organismo e uma resposta fisiopatológica complexa. O objetivo deste estudo foi alertar sobre as necessidades energético-proteicas no trauma, consumo metabólico,formas mais seguras de administração da dieta e as possíveis complicações do suporte nutricional inadequado nessas situações. CONTEÚDO: A nutrição deve ser integrada no tratamento global do paciente criticamente doente a fim de minimizar as complicações de um tratamento mais prolongado. As prioridades imediatas após o trauma são: reanimação volêmica, oxigenação e a interrupção da hemorragia. Associados a esses fatores estão o estado hiperdinâmico da resposta ao trauma, bem como a dor, febre, exposição ao frio, acidose e hipovolemia, e possíveis infecções, aumentando a demanda metabólica. O suporte nutricional é parte essencial do tratamento metabólico desses pacientes. Ele deve ser instituído antes que haja perda significativa de peso, de preferência nas primeiras 24h da admissão no hospital, através de dietas orais ou enterais preferencialmente e parenterais, quando necessário. CONCLUSÃO: Uma dieta bem administrada é capaz de manter a massa celular corporal e a limitação da perda de peso a menos de 10% do peso na pré-lesão. O importante é o paciente ser constantemente reavaliado para ajuste da dieta de acordo com as necessidades diárias. Dentre as consequências de uma inadequada abordagem destes pacientes, tem-se a síndrome de realimentação, a cetose e a desnutrição.

BACKGROUND AND OBJECTIVES: Trauma is an acute event that alters the body's homeostasis, neuroendocrine and for triggering immune responses aimed at maintaining blood volume, cardiac output, tissue oxygenation and the supply and use of energy substrates. All have in common an acute initial event, changing the whole balance of the body and a complex pathophysiological response. The objective of this study was to make aware of the protein-energy needs in trauma, metabolic consumption, the bests ways of diet administration and the possible complications of inadequate nutritional support in these situations. CONTENTS: Nutrition must be integrated into the overal ltreatment of critically ill patients in order to minimize the complications of a longer treatment. The immediate priorities are thefollowing trauma fluid resuscitation, oxygenation and stopping the bleeding. These factors are associated with the state of a hyperdynamic response to trauma, as well as pain, fever, exposure to cold, acidosis and hypovolemia, and possible infections, increasing the metabolic demand. Nutritional support is an essential part of the metabolic treatment of these patients. It must be established before there is significant loss of weight, preferably within 24 hours of admission to the hospital, through diet or oral enteral and parenteral preferably when necessary. CONCLUSION: A well-managed diet is able to maintain body cell mass and limiting the weight loss to less than 10% weight inthe pre-injury. The important thing is to be constantly reassessed the patient to adjust the diet according to the daily needs. Among the consequences of an inadequate approach to these patients, are: Refeeding syndrome, ketosis, and malnutrition.

Qual é a importância clínica e nutricional da síndrome de realimentação? / Refeeding syndrome: clinical and nutritional relevance

INTRODUÇÃO: A síndrome de realimentação caracteriza-se por alterações neurológicas, sintomas respiratórios, arritmias e falência cardíacas, poucos dias após a realimentação. Ocorre em consequência do suporte nutricional (oral, enteral ou parenteral) em pacientes severamente desnutridos. OBJETIVO: Avaliar de suas causas e a aplicação das medidas dietéticas profiláticas apropriadas visando a prevenção e diminuição da morbimortalidade desta condição. MÉTODOS: Foi realizado levantamento bibliográfico na SciELO, LILACS, Medline/Pubmed, Biblioteca Cochrane e sites governamentais nos idiomas português, inglês e espanhol. Os levantamentos foram sobre os últimos 15 anos, selecionando os descritores: síndrome de realimentação, desnutrição, hipofosfatemia, hipocalemia, hipomagnesemia. CONCLUSÃO: O acompanhamento de parâmetros metabólicos e de níveis de eletrólitos antes do início do suporte nutricional e periodicamente durante a alimentação deve ser baseado em protocolos, no estado da doença subjacente e na duração da terapia. Equipe multidisciplinar de terapia nutricional pode orientar e educar outros profissionais de saúde na prevenção, diagnóstico e tratamento dessa síndrome.

INTRODUCTION: Feedback syndrome is characterized clinically by neurological alterations, respiratory symptoms, arrhythmias and heart failure few days after refeeding. It happens due to severe electrolyte changes, such as hypophosphatemia, hypomagnesemia and hypokalemia associated with metabolic abnormalities that may occur as a result of nutritional support (oral, enteral or parenteral) in severely malnourished patients. OBJETIVE: To evaluate its causes and the preventive dietary measures aiming to reduce the morbimortality. METHODS: Was conducted literature review in SciELO, LILACS, Medline / Pubmed, Cochrane Library and government websites in Portuguese, English and Spanish. The survey was about the last 15 years, selecting the headings: refeeding syndrome, malnutrition, hypophosphatemia, hypokalemia, hypomagnesemia. CONCLUSION: The monitoring of metabolic parameters and electrolyte levels before starting nutritional support and periodically during feeding should be based on protocols and the duration of therapy. Patients at high risk and other metabolic complications should be followed closely, and depletion of minerals and electrolytes should be replaced before starting the diet. A multidisciplinary team of nutrition therapy can guide and educate other health professionals in prevention, diagnosis and treatment of the syndrome.

Revisión del tratamiento dietético-nutricional de la anorexia nerviosa / Review of nutritional and dietary management of anorexia nervosa

While numerous studies have highlighted the need to approach anorexia nervosa from a multidisciplinary perspective, the dietary and nutritional aspects of the disorder are rarely considered in depth. Basic guidelines to monitor food intake of patients, are available. A literature review was performed in Medline, searching for articles related to the dietary and nutritional management of anorexia nervosa and published over the last five years. Thefinal analysis focused on 102 articles. This review summarizes the different therapeutic contexts and objectives, nutritional support, the use of dietary supplements, the role of artificial nutrition, refeeding syndrome, involuntary treatment and nutritional education.

Orthorexia Nervosa with Hyponatremia, Subcutaneous Emphysema, Pneumomediastimum, Pneumothorax, and Pancytopenia

30-year-old male was admitted with general weakness and drowsy mental status. He had eaten only 3-4 spoons of brown rice and fresh vegetable without salt for 3 months to treat his tic disorder, and he had been in bed-ridden state. He has had weight loss of 14 kg in the last 3 months. We report a patient with orthorexia nervosa who developed hyponatremia, metabolic acidosis, subcutaneous emphysema, mediastinal emphysema, pneumothorax, and pancytopenia and we will review the literature. Also, we mention to prevent refeeding syndrome, and to start and maintain feeding in malnourished patients.