Refeeding syndrome: multimodal monitoring and clinical manifestation of an internal severe neurotrauma

Abstract

Refeeding syndrome (RFS) is a rare, potentially life-threatening, condition seen in malnourished patients starting refeeding. RFS may provoke seizures and acute encephalopathy and can be considered an internal severe neurotrauma in need of specific treatment. The objective was to describe course of disease, treatment and, for the first time, multimodal monitoring output in a comatose patient suffering RFS. After gastric-banding and severe weight loss, the patient initiated self-starving and was transferred to our intensive care unit (ICU) following rapid refeeding. At arrival, seizures, decrease in consciousness (GCS 7) and suspected acute encephalitis was presented. Serum albumin was 8 g/l. Intracranial pressure (ICP), invasive blood pressure and electrocardiography (ECG) were monitored. Pressure reactivity (PR x) and compliance (RAP) were calculated. The patient developed congestive heart failure, anuria and general oedema despite maximal neuro-and general ICU treatment. Global cerebral oedema and hypoperfusion areas with established ischemia were seen. ECG revealed massive cardiac arrhythmia and disturbed autonomic regulation. PR x indicated intact autoregulation (−0.06 ± 0.18, mean ± SD) and relatively normal compliance (RAP = 0.23 ± 0.13). After 15 days the clinical state was improved, and the patient returned to the primary hospital. RFS was associated with serious deviations in homeostasis, high ICP levels, ECG abnormalities, kidney and lung affections. It is of utmost importance to recognize this rare syndrome and to treat appropriately. Despite the severe clinical state, cerebral autoregulation and compensatory reserve were generally normal, questioning the applicability of indirect measurements such as PR x and RAP during neuro-intensive care treatment of RFS patients with cerebral engagement.

Cerebellar tonsillar herniation in sudden death of an adolescent anorexia nervosa patient: a case report

“…Sundström et al reported a case in which the patient suffered from a disturbance of consciousness during the refeeding period from prolonged malnourishment due to causes other than AN, and intracranial pressure monitoring (ICP) showed a marked increase in intracranial pressure. In their case report, the initial calorie level was 1800 kcal/day, which was higher than recommended and suggested to be a risk factor for cerebral edema [14].…”

“…It is known that when refeeding severely undernourished patients, electrolytes are transferred into the cells due to an increase in insulin concentration caused by elevated blood glucose levels, resulting in a decrease in serum phosphorus, potassium, and magnesium levels, and this condition is known as refeeding syndrome [2,[9][10][11][12]. Many published guidelines recommend an initial calorie level of 10 kcal/day for high-risk patients and 5-10 kcal/day for very high-risk patients to prevent RS [2,[9][10][11][12]14]. Although the initial calories in the present case were within the recommended range, it is possible that the patient had a sudden change due to fatal arrhythmia.…”