A 69-year-old male, body mass index 17.5 kg/m2, is commenced on total parenteral nutrition (TPN) following surgery for a gastric malignancy. Four days later he develops increasing breathlessness and hypotension. Blood results are as follows:
|
Test |
Value |
Normal Adult Range |
|
Haemoglobin* |
109 G/L |
115 – 155 |
|
White Cell Count* |
13.6 x 109 /L |
4.0– 11.0 |
|
Platelets |
178 x 109 /L |
150 – 400 |
|
Urea* |
10.3 mmol/L |
3.0– 8.0 |
|
Creatinine |
84 µmol/L |
45– 90 |
|
Sodium |
145 mmol/L |
134 – 146 |
|
Potassium* |
1.8 mmol/L |
3.4– 5.0 |
|
Chloride* |
115 mmol/L |
98– 108 |
|
Bicarbonate* |
14 mmol/L |
22– 32 |
|
Calcium (albumin adjusted)* |
1.82 mmol/L |
2.15 – 2.6 |
|
Albumin* |
26 G/L |
35– 50 |
|
Magnesium* |
0.41 mmol/L |
0.7– 1.1 |
|
Phosphate inorganic* |
0.26 mmol/L |
0.8– 1.5 |
|
Glucose* |
18.6 mmol/L |
3.0– 5.4 |
Refeeding syndrome (Nutritional recovery syndrome).
An underweight elderly gentleman gets TPN after a prolonged period of malnutrition. It does not take a massive cognitive effort to recognise refeeding syndrome, given the hypokalemia and hypophosphataemia.
Refeeding syndrome is discussed in greater detail elsewhere.
Its typical biochemical features are:
Lesser known abnormalities include:
The shortness of breath and hypotension in this case are likely to a combination of low phosphate and fluid overload in the context of myocardial atrophy. Arrhythmia and respiratory muscle weakness cannot be ruled out.
Hearing, Stephen D. "Refeeding syndrome." BMJ 328.7445 (2004): 908-909.
Stanga, Z., et al. "Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment." European journal of clinical nutrition 62.6 (2008): 687-694.
Kraft, Michael D., Imad F. Btaiche, and Gordon S. Sacks. "Review of the refeeding syndrome." Nutrition in Clinical Practice 20.6 (2005): 625-633.
Khan, Laeeq UR, et al. "Refeeding syndrome: a literature review."Gastroenterology research and practice 2011 (2010).