Does a patient with persistent emesis (vomiting) and total parenteral nutrition (TPN) intolerance, at risk for refeeding syndrome due to inadequate enteral nutrition (EN) infusion, require inpatient admission due to malnutrition?

From the Guidelines

I strongly recommend immediate inpatient admission for this patient who is experiencing continued emesis and tube feeding intolerance, as they are at high risk for refeeding syndrome due to inadequate enteral nutrition for weeks and meet criteria for malnutrition. The patient's condition necessitates close monitoring of electrolytes, cardiac function, and fluid status while carefully reintroducing nutrition. According to the most recent and highest quality study, initial feeding should start at approximately 25% of caloric needs (typically 5-10 kcal/kg/day) with gradual advancement over 3-5 days 1. Additionally, supplementing thiamine (100-300mg daily for 5-7 days) and correcting any electrolyte abnormalities before and during refeeding is crucial 1. This cautious approach is necessary because refeeding syndrome can cause potentially fatal shifts in fluids and electrolytes when nutrition is reintroduced too quickly in malnourished patients, leading to cardiac, neurological, and hematological complications that require immediate medical intervention.

Some key considerations for the patient's care include:

• Monitoring electrolytes, particularly phosphorus, magnesium, and potassium, and substituting them as necessary by the oral, enteral, or parenteral route 1
• Providing a balanced micronutrient mixture and vitamin B1 in daily doses of 200-300 mg 1
• Avoiding overfeeding and starting with a low calorie regimen, with progressive increase and tight evaluation of the patient's metabolism 1
• Being mindful of the potential pitfalls and complications of parenteral nutrition, such as catheter-related sepsis and hyperglycemia 1

Overall, the patient's condition requires careful management and close monitoring to prevent refeeding syndrome and ensure a safe and effective reintroduction of nutrition.

From the Research

Patient Assessment and Risk of Refeeding Syndrome

• The patient's continued endorsement of emesis/TF intolerance and inadequate EN infusion for weeks raises concerns about the risk of refeeding syndrome, as supported by studies 2, 3, 4.
• Refeeding syndrome is a metabolic complication that can occur in the initial phase of nutritional therapy, particularly in malnourished patients, and is characterized by severe electrolyte disturbances and metabolic abnormalities 3, 4.
• The patient's malnutrition status meets the criteria for refeeding syndrome risk, highlighting the need for careful monitoring and management to prevent this life-threatening condition 2, 3.

Importance of Electrolyte Evaluation and Monitoring

• Electrolyte evaluation is crucial in patients at risk of refeeding syndrome, with studies showing that hypophosphatemia, hypomagnesemia, and hypokalemia are common in these patients 2.
• The importance of registered dietitians in screening for refeeding syndrome risk and monitoring electrolyte levels is emphasized in the literature 2.
• Careful patient monitoring and multidiscipline nutrition team management can help reduce the risk of refeeding syndrome and its associated morbidity and mortality 3.

Inpatient Admission and Management

• Given the patient's high risk of refeeding syndrome and malnutrition, inpatient admission is strongly recommended to ensure close monitoring and management of their nutritional therapy 2, 3, 5.
• Inpatient admission will allow for careful monitoring of electrolyte levels, nutritional status, and overall health, reducing the risk of complications and improving patient outcomes 6, 5.