Question

Case Study - Refeeding Syndrome A 29 year old white male on active duty in the US Marines is admitted to the emergency room with nausea, fatigue, confusion, hypothermia, and bradycardia. Two weeks prior to admission, he began feeling weaker and trailed behind other trainees during boot camp sessions. He recently spent three months in intense training as a newly recruited US marine. Three months prior to recruit training, he began a weight loss regimen in an effort to achieve his desired goal weight based on US Marine standards and lost 20 lbs. Patient went on a calorically-restrictive low carbohydrate and high protein diet of 1700 kcal/day while undergoing a progressive increase in exercise load in a hot and humid climate. Three months later, his training with the Marines was more physically demanding than his pre-marine training. As a result, patient lost an additional 33 lbs. He was administered IV fluids of normal saline on day 1. Due to his nutritionally depleted status and weight changes, the physician promptly ordered a non- restricted 2000-calorie diet. Patient complied with the orders and began experiencing cardiac, mental status, fluid, and electrolyte complications by Days 2 to 4 of hospital stay. Evaluate all parameters as you respond to each question below. Height: 6'1" Admission weight: 163 lb. UBW: 255.4 lb. HR: 40 bpm BP: 130/110 Temperature: 30 degrees C Day 4 143 3.2 100 26 86 Table L. Laboratory Results Day 1 Day 2 135 1 44 4.6 3.9 98 110 • 26 27 S6 88 1.7 1.7 8.2 7.6 4.5 1.8 6.2 6.2 3.8 3.7 1.1 1.6 32 32 13 14 40% 46% 90 Biochemistry Sodium Potassium Chloride Bicarbonate Glucose . Magnesium Calcium Phosphorus Total Protein Albumin Creatinine BUN Hemoglobin Hematocrit Mean Corpuscular Volume 1.3 7.2 6.3 3.7 1.6 22 14 46 90 90 What trends can you note in his laboratory indicators over the last four days? Is his albumin level a good indicator of his present nutritional status in this situation? Why or why not? Considering his history and current medical situation, what risk factors for refeeding syndrome has this patient been presenting? Construct at least two PES statements that would be appropriate for this case (Nutrition Diagnosis). What feeding adjustments should the RD make to aid in restoring his nutritional status and electrolyte balance and which members of the healthcare team does he or she need to consult with and communicate recommendations to intervention)? Based on the scoring system of the mini nutritional assessment, how would you define this patient's level of nutrition risk? What measurable indicators will you continue to monitor patient progress with and how frequent should you follow up until this patient has achieved stability (Monitoring and Evaluation)?

Answer 1

1. His blood sodium went from being on the lower limit of the normal range to a normal level. His potassium levels are falling down which is concerning. So are his calcium levels. His BUN levels have almost normalised. The glucose levels gradually reached the low-normal range.
2. Albumin levels usually fall down when the nutritional status of a person deteriorates. However, the albumin status by itself is not the sole indicator of nutritional status. It also varies in inflammatory conditions.
3. The patient has already developed risk factors of refeeding syndrome: hypomagnesemia, hypokalemia and hypophasphatemia.
4. A) deranged electrolyte profile related to hyperfeeding syndrome as evidenced by low phosphorus, magnesium and potassium.
5. Intravenous electrolytes can help in the case of refeeding syndrome. He or she can consult a nutritionist in this regard.
6. He/ she should continue to monitor the electrolytes every 24 hours.