Thursday, November 18, 2010

Praxis: Prepare for Refeeding Syndrome.

No one knows how bad things may get in this country in the future, nor how a future regime might use food as a weapon. Depending upon the scenario, it is possible that we will see widespread starvation in this country. If so, we need to be cognizant of something called "Refeeding Syndrome."

Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Renourishment is the process of avoiding refeeding syndrome. . .

Refeeding syndrome usually occurs within four days of starting to feed. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. Most effects result from a sudden shift from fat to carbohydrate metabolism and a sudden increase in insulin levels after refeeding which leads to increased cellular uptake of phosphate. Formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle depletes intracellular ATP and 2,3-diphosphoglycerate in red blood cells, leading to cellular dysfunction and inadequate oxygen delivery to the body's organs. Refeeding increases the basal metabolic rate. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes including phosphate, potassium, magnesium, glucose, and thiamine. Significant risks arising from refeeding syndrome include confusion, coma, convulsions, and death.

This syndrome can occur at the beginning of treatment for anorexia nervosa when patients are reintroduced to a healthy diet. The shifting of electrolytes and fluid balance increases cardiac workload and heart rate. This can lead to acute heart failure. Oxygen consumption is also increased which strains the respiratory system and can make weaning from ventilation more difficult.


Refeeding syndrome can be fatal if not recognized and treated properly. An awareness of the condition and a high index of suspicion are required in order to make the diagnosis. If potassium, phosphate or magnesium are low then this should be corrected. Prescribing thiamine, vitamin B complex (strong) and a multivitamin and mineral is recommended. Biochemistry should be monitored regularly until it is stable. Energy intake should remain only 50-70% that of normally required for the first 3-5 days.

If you're not stocked well up on vitamins, you need to be.


suek said...

How long a period of starvation triggers the condition that requires this treatment? You mention anorexia - what level of severe malnutrition - meaning how low a level of nutrition for how long?

Flight-ER-Doc said...

In order to be effective in patients suffering from refeeding syndrome, the thiamine (Vitamin B-1) needs to be administered IM or IV. Taking a vitamin tablet won't do it.

MamaLiberty said...

We won't likely have lab tests and vitamin pills around. Best is to take a page from old timers who knew how to deal with this naturally.

Any time someone has been starved, even for a few weeks, they simply need to be restrained and reintroduced to regular food slowly, in small amounts at first.

It takes great patience and fortitude not to feed a starving person all they want, but you'll likely kill them if you indulge in this. The body will take some significant time to readjust to a normal diet. A few vitamin pills are not going to make the difference.

Start with thin soup/broth with salt. They may actually vomit it out. Let them rest, and try it again later. When they can tolerate this, give a small amount of yogurt thinned with milk or water. This will start the replacement of vital microorganisms in the gut.

When they can tolerate that, repeat both while reducing the dilution. They can then slowly be reintroduced to other foods, starting with well cooked meats, then vegetables such as winter squash and potatoes - start small and build for everything you try.

Be sure to provide all the fresh water they will drink.

Grains and fruit should be introduced last. No coffee or alcohol should be tried until a normal diet has been tolerated for at least a week or two.

There are probably other good approaches, but I think this is most likely to be possible in a crash situation.

Anonymous said...

MamaLiberty, good post, but to keep it PC you got to name what you're treating, calling it some fancy syndrome. Something like common sense syndrome.
Then you got to put a number on it so's all the health care providers can get paid.
Most of the numbers are taken filling a book bigger than bomie's care bill so's you'll have to come up with your own unique number
I was thinkin', maybe 3151313151419514195
Now we got a lot of spec ops folks and other spooks and they'll crunch the numbers with their crays, but for folks that don't have that stuff it means common sense in code and the code is pretty simple.
Mountain rifleman

pdxr13 said...

Mama Liberty has the right approach. They didn't starve all at once and they aren't going to put on 30 pounds this week. We may not have medical supplies, but we will have some knowledge.

Lessons learned feeding in the 3rd world will serve us at home.

The patient will be in a state of very thrifty calorie consumption, so 800 calories distributed over a day of eating chicken broth (fatty!) and a half a piece of bread will be a net positive if they can keep it down.

Some will die. Anorexics die in spite of a full medical support available today, but they die over YEARS. The most tragic cases will be the children who will be permanently damaged by malnutrition, never to become healthy full-sized adults. Adults who were healthy actually recover well from starvation "camp-style" as POW's and WWII camp inmates demonstrated after liberation.

A product used in the hungry 3rd world to save children is called "PlumpyNut" which is packed with vitamins and calories. It's expensive at retail in the 'States, but is priced well as pallets and cases for "missions".

A suggestion of my neighbor (somewhat an expert on poorly-functioning digestion of CF patients) is that a functioning digestive system processing non-caloric input will recover quicker than a shut-down one. It might be advantageous to eat non-digestible stuff like non-toxic newspaper in addition to camp-"food" of roasted rodent and whatever, if you knew or suspected that food/liberation is forthcoming shortly. It takes internal calories to do this, so it's a strategy with a potential cost.

Stock preserved food deep and distributed, with cooking implements included in caches. Keep the chickens safe and happy until their time to be served. God help us all.


DB said...

Vitamins come from the food you eat. As long as you are stock with a healthy and balanced diet you should be fine. Lots of vegetables and whole grains and beans.

Anonymous said...

In europe they are planning a run on the banks on decemebr 7, take all the money out. Spread the word


Rhodes said...

Mike how ya getting along some of us worry about ya a bit given whats coming, looks like sooner than many thought.

Thanks for this type of info even with a Medical Self-help course way back during the cold war this was not taught.

Dick's Dad said...

The Brits had developed a system for this for treating starving peasants in India and were able to use it with the survivors in the camps in their areas of Germany.

I'll have a look around to see if I can find any freely available copies.

Defender said...

Congress is voting whether to move forward on S.510, the Food Safety Modernization Act, right now.