Mortality after Nasogastric Tube Feeding Initiation in Long-Term Care Elderly with Oropharyngeal Dysphagia – The Contribution of Refeeding Syndrome

Abstract

Background: The refeeding syndrome (RS) is an underappreciated but clinically important entity characterized by acute electrolyte abnormalities, mainly hypophosphatemia, fluid retention and dysfunction of various organs and systems, which can result in significant morbidity and occasionally death. Objective: To examine the incidence of death cases and death causes following nasogastric tube (NGT) feeding initiation in frail elderly with particular reference to RS. Methods: Forty patients with feeding problems for at least 72 h before restarting of alimentation by NGT were included. Excluded were those in any critical clinical situation. Clinical parameters and nutritional assessment were recorded before and after refeeding. Blood samples were taken before, daily for the first 3 days and 1 week after refeeding initiation. Results: During the 1st week of refeeding, 9 patients (22.5%) died and within 1 month 10 more, summing to 47.5%. Most deaths were due to infectious causes [15 out of 19, (79%)]; some were due to no obvious reason [4 out of 19, (21%)]. Significant electrolyte changes were observed in the 2–3 days following refeeding. Significant were the decreases in phosphorus and elevations in potassium and lymphocytes (day 7). We found no correlations between the severity of decreases in levels of phosphorus and mortality. Conclusions: Mortality after NGT feeding initiation was high, mainly due to infectious complications. However, in a considerable number of patients hypophosphatemia was noted, suggesting that RS could be a contributory factor of mortality. Since this is a treatable condition, more attention should be paid to detecting and coping with this problem.

Refeeding hypophosphatemia: a potentially fatal danger in the intensive care unit

“…Hoffmann et al (4) showed a 30% mortality rate in hospitalized patients with severe hypophosphatemia. There was no increased mortality rate in the first 7 days of ICU stay in a study performed by Zeki et al (17), and, similarly, Lubart et al (30) did not find an increased mortality rate for 7 days and 1 month in 40 elderly patients with RH. In a study performed in 55 septic patients, severe hypophosphatemia increased mortality rates by 8-fold (2).…”

Incidencia de hipofosfatemia en pacientes ingresados no críticos con nutrición enteral

“…Lubart y cols. siguieron a 44 pacientes mayores que precisaban cuidados a largo plazo, a los que se les instauró NE por sonda nasogástrica por disfagia orofaríngea; al final de la primera semana de realimentación el 25% de los pacientes había presentado un fosfato sérico inferior a 1,6 mg/dl (11).…”

“…El 78,9% de los casos de hipofosfatemia se presentaron en los primeros cuatro días de SNE, lo que coincide con lo publicado en otros trabajos (11,13).…”

“…En este sentido, O'Connor y cols., en una revisión sistemática sobre hipofosfatemia de realimentación en adolescentes con anorexia nerviosa, no observaron correlación entre la tasa de realimentación (kcal/día) y la aparición de hipofosfatemia (16). La NE proporcionaba 17,7 (11,(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)8) mmol de fosfato/1.000 kcal. El análisis estadístico no mostró relación entre la cantidad de fosfato administrada y los niveles de fosfato sérico.…”

Artificial Nutrition and Hydration at the End of Life

“…In a prospective study of mortality following NG tube feeding initiation in frail elderly, 65% died within 6 months of the tube insertion. Significant electrolytic disturbances were seen following NG feeding from baseline (p < 0.005) (76).…”