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c 0 0 l f Q q 505.272 795.717 67.026 -65.964 re W n q 1 0 0 1 519.242 734.133 cm 0 0 m -.8005 0 -1.1143 -.9731 -1.1143 -1.7559 c -1.1143 -2.1693 -1.0061 -2.3347 -.8384 -2.3347 c -.33 -2.3347 .2217 -1.0686 .3462 -.3116 c .384 -.0571 l .2759 -.025 .1514 0 0 0 c h .3732 -3.0536 m .2488 -3.8106 -.1623 -4.3833 -1.1901 -4.3833 c -1.4875 -4.3833 -1.7147 -4.3389 -1.9148 -4.2624 c -1.8013 -3.709 l -1.5957 -3.8234 -1.3307 -3.8868 -1.0818 -3.8868 c -.5247 -3.8868 -.1948 -3.6324 -.0757 -2.9136 c 0 -2.4302 .0649 -2.182 .2488 -1.5013 c .238 -1.5013 l .054 -1.9593 -.3516 -2.8247 -1.0061 -2.8247 c -1.3956 -2.8247 -1.6066 -2.532 -1.6066 -1.8636 c -1.6066 -.6994 -1.0873 .4521 .0811 .4521 c .3895 .4521 .6761 .4138 .925 .3566 c .3732 -3.0536 l f Q Q q 1 0 0 1 522.028 734.108 cm 0 0 m -.5895 0 -.9845 -.7765 -.9845 -1.5715 c -.9845 -2.0424 -.8222 -2.3032 -.4164 -2.3032 c .1082 -2.3032 .568 -1.6415 .568 -.7192 c .568 -.2548 .3895 0 0 0 c h -.4977 -2.7931 m -1.1738 -2.7931 -1.4821 -2.3924 -1.4821 -1.667 c -1.4821 -.4072 -.8006 .4834 .0757 .4834 c .7844 .4834 1.0764 .0127 1.0764 -.6554 c 1.0764 -1.9597 .3138 -2.7931 -.4977 -2.7931 c f Q q 1 0 0 1 524.943 734.108 cm 0 0 m -.5896 0 -.9844 -.7765 -.9844 -1.5715 c -.9844 -2.0424 -.8222 -2.3032 -.4164 -2.3032 c .1082 -2.3032 .568 -1.6415 .568 -.7192 c .568 -.2548 .3895 0 0 0 c h -.4977 -2.7931 m -1.1738 -2.7931 -1.4821 -2.3924 -1.4821 -1.667 c -1.4821 -.4072 -.8006 .4834 .0757 .4834 c .7843 .4834 1.0764 .0127 1.0764 -.6554 c 1.0764 -1.9597 .3138 -2.7931 -.4977 -2.7931 c f Q q 1 0 0 1 527.972 734.133 cm 0 0 m -.8006 0 -1.1144 -.9731 -1.1144 -1.7559 c -1.1144 -2.1693 -1.0062 -2.3347 -.8384 -2.3347 c -.33 -2.3347 .2217 -1.0686 .3461 -.3116 c .384 -.0571 l .2758 -.025 .1514 0 0 0 c h .6057 -1.6221 m .5353 -2.0609 .465 -2.5001 .4272 -2.7609 c -.0487 -2.7609 l -.0055 -2.4874 .0973 -2.0675 .2596 -1.4758 c .2487 -1.4694 l .0539 -1.9593 -.3516 -2.8247 -1.0062 -2.8247 c -1.3955 -2.8247 -1.6067 -2.532 -1.6067 -1.8636 c -1.6067 -.6994 -1.0928 .4521 .0811 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-.3786 -2.2266 c -.4111 -2.7039 l -.568 -2.742 -.7573 -2.7675 -.9141 -2.7675 c -1.4659 -2.7675 -1.6065 -2.462 -1.493 -1.7432 c -1.2064 0 l -1.7526 0 l -1.6769 .4454 l -1.136 .4454 l -.9682 1.4697 l -.4652 1.6031 l -.6546 .4454 l .0757 .4454 l 0 0 l f Q q 1 0 0 1 540.287 734.038 cm 0 0 m -.4977 .1652 -1.0278 -1.0753 -1.1685 -1.9531 c -1.282 -2.6658 l -1.7581 -2.6658 l -1.2495 .4962 l -.7845 .4962 l -.8277 .2224 -.9034 -.1147 -1.0603 -.6681 c -1.0494 -.6743 l -.7465 .0951 -.422 .6551 .0973 .5535 c 0 0 l f Q q 1 0 0 1 541.293 735.056 cm 0 0 m -.1785 0 -.3083 .1656 -.2974 .3627 c -.292 .5789 -.1351 .7444 .0434 .7444 c .2164 .7444 .3517 .5853 .3409 .3883 c .3301 .1718 .1732 0 0 0 c h -.4002 -3.6836 m -.8761 -3.6836 l -.3624 -.5216 l .1137 -.5216 l -.4002 -3.6836 l f Q q 1 0 0 1 543.543 734.089 cm 0 0 m -.7302 0 l -.9952 -1.6543 l -1.0712 -2.1439 -1.0169 -2.2777 -.7518 -2.2777 c -.6005 -2.2777 -.4868 -2.2585 -.3787 -2.2266 c -.4111 -2.7039 l -.5682 -2.742 -.7574 -2.7675 -.9141 -2.7675 c 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-1.877 1.6542 l -1.8066 2.1058 -1.7092 2.6976 -1.6389 3.162 c -1.1683 3.162 l -1.2008 2.952 -1.2765 2.5893 -1.4659 1.9149 c -1.455 1.9149 l -1.2008 2.5831 -.7734 3.2254 -.2108 3.2254 c .2867 3.2254 .4544 2.812 .3516 2.1504 c 0 0 l f Q q 1 0 0 1 552.684 734.133 cm 0 0 m -.8006 0 -1.1143 -.9731 -1.1143 -1.7559 c -1.1143 -2.1693 -1.0062 -2.3347 -.8384 -2.3347 c -.33 -2.3347 .2217 -1.0686 .3461 -.3116 c .384 -.0571 l .2758 -.025 .1514 0 0 0 c h .4273 -2.7609 m -.0541 -2.7609 l -.0054 -2.4874 .0973 -2.0675 .2597 -1.4758 c .2488 -1.4694 l .0541 -1.9593 -.3517 -2.8247 -1.0062 -2.8247 c -1.3955 -2.8247 -1.6066 -2.532 -1.6066 -1.8636 c -1.6066 -.6994 -1.0928 .4521 .0811 .4521 c .3895 .4521 .6761 .4138 .9248 .3566 c .6381 -1.4121 .5408 -2.0037 .4273 -2.7609 c f Q q 1 0 0 1 554.479 731.372 cm 0 0 m -.476 0 l .2759 4.6445 l .752 4.6445 l 0 0 l f Q q 1 0 0 1 558.547 733.994 cm 0 0 m -.1462 .0765 -.3031 .1208 -.4923 .1208 c -1.1738 .1208 -1.4932 -.7823 -1.4932 -1.5012 c -1.4932 -1.8323 -1.4012 -2.1696 -.9305 -2.1696 c -.7195 -2.1696 -.4923 -2.1122 -.3247 -2.0166 c -.3571 -2.5193 l -.5464 -2.6022 -.7954 -2.672 -1.0658 -2.672 c -1.7635 -2.672 -2.0015 -2.2266 -2.0015 -1.6288 c -2.0015 -.4197 -1.4229 .5919 -.46 .5919 c -.2382 .5919 -.0596 .5536 .108 .4963 c 0 0 l f Q q 1 0 0 1 560.374 734.133 cm 0 0 m -.8005 0 -1.1143 -.9731 -1.1143 -1.7559 c -1.1143 -2.1693 -1.006 -2.3347 -.8383 -2.3347 c -.3298 -2.3347 .2219 -1.0686 .3463 -.3116 c .384 -.0571 l .2759 -.025 .1516 0 0 0 c h .4274 -2.7609 m -.0541 -2.7609 l -.0054 -2.4874 .0974 -2.0675 .2598 -1.4758 c .249 -1.4694 l .0543 -1.9593 -.3514 -2.8247 -1.006 -2.8247 c -1.3954 -2.8247 -1.6063 -2.532 -1.6063 -1.8636 c -1.6063 -.6994 -1.0926 .4521 .0812 .4521 c .3896 .4521 .6763 .4138 .925 .3566 c .6383 -1.4121 .541 -2.0037 .4274 -2.7609 c f Q q 1 0 0 1 563.452 734.038 cm 0 0 m -.4974 .1652 -1.0275 -1.0753 -1.1683 -1.9531 c -1.2818 -2.6658 l -1.7579 -2.6658 l -1.2493 .4962 l -.7842 .4962 l -.8275 .2224 -.9032 -.1147 -1.0601 -.6681 c -1.0492 -.6743 l -.7463 .0951 -.4218 .6551 .0974 .5535 c 0 0 l f Q q 1 0 0 1 564.999 734.159 cm 0 0 m -.4273 0 -.714 -.4388 -.8384 -.9734 c -.0053 -.9351 .3625 -.7378 .3625 -.3561 c .3625 -.1273 .2166 0 0 0 c h -.8979 -1.3932 m -.9141 -1.4888 -.9249 -1.6477 -.9249 -1.7622 c -.9249 -2.252 -.7789 -2.3793 -.3463 -2.3793 c -.0919 -2.3793 .1786 -2.3093 .4111 -2.1949 c .4111 -2.6531 l .1516 -2.7738 -.1622 -2.8437 -.5139 -2.8437 c -1.1304 -2.8437 -1.4171 -2.532 -1.4171 -1.8193 c -1.4171 -.5916 -.8384 .4327 .0541 .4327 c .6277 .4327 .844 .0892 .844 -.2861 c .844 -.9672 .2542 -1.3423 -.8979 -1.3932 c f Q EMC /P <>BDC q 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n BT /TT4 1 Tf 12 0 0 12 22.339 485.1662 Tm 1 .89 0 0 k 0 Tc 0 Tw (Key points)Tj ET EMC /P <>BDC /GS2 gs BT /TT6 1 Tf 10 0 0 10 83.6808 485.1662 Tm 0 0 0 1 k ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT2 1 Tf 8 0 0 8 22.339 467.4969 Tm 0 0 0 .8 k (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 467.4969 Tm (Refeeding syndrome describes the clinical and biochemical problems )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 455.4969 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 455.4969 Tm [(that may result from feeding malnourished patients \(orally)74.2(, enterally )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.175 443.4969 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 443.4969 Tm (or parenterally\).)Tj ET EMC /P <>BDC BT 8 0 0 8 86.8664 443.4969 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 425.8276 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 425.8276 Tm (Hypophosphatemia is the most commonly used marker of refeeding )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 413.8276 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 413.8276 Tm -.005 Tc (syndrome. It commonly occurs when artificial nutritional support is started)Tj ET EMC /P <>BDC BT 8 0 0 8 287.5049 413.8276 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 401.8276 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 401.8276 Tm (\(especially with carbohydrate\) and can very occasionally cause death. )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 389.8276 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 389.8276 Tm -.025 Tc [(Hypomagnesaemia, hypokalaemia and hypo \(or hyper\) glycaemia also occur)55.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 290.123 389.8276 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 292.3457 389.8276 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 372.1584 Tm (3.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 372.1584 Tm (Orally/enterally fed patients are more likely to develop refeeding)Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 360.1584 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 360.1584 Tm (hypophosphataemia than those given parenteral nutrition.)Tj ET EMC /P <>BDC BT 8 0 0 8 234.9836 360.1584 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 342.489 Tm -.01 Tc (4.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 342.489 Tm [(Confusion can be due to thiamine deficiency \(W)18.1(ernicke)18.1(s encephalopathy\))]TJ ET EMC /P <>BDC BT 8 0 0 8 287.2483 342.489 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 330.489 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 330.489 Tm (and if untreated may lead to a permanent loss of short-term memory )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 318.489 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 318.489 Tm [(\(Korsakof)18.1(f psychosis\).)]TJ ET EMC /P <>BDC BT 8 0 0 8 109.3899 318.489 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 300.8196 Tm (5.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 300.8196 Tm (Sodium/water retention \(oedema\) is common with refeeding especially )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 288.8196 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 288.8196 Tm (with carbohydrate and can lead to cardiac failure.)Tj ET EMC /P <>BDC BT 8 0 0 8 205.1672 288.8196 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 271.1504 Tm (6.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 271.1504 Tm [(Due to dif)18.1(ficulties with definitions the patients at high risk can be hard to )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.175 259.1504 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 259.1504 Tm (determine. UK NICE guidelines are helpful but not a completely reliable )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 247.1504 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 247.1504 Tm (predictor so need careful consideration. Clinicians need to be aware of )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 235.1504 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 235.1504 Tm (refeeding problems and assume most malnourished patients are at risk.)Tj ET EMC /P <>BDC BT 8 0 0 8 284.7492 235.1504 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 217.4812 Tm (7.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 217.4812 Tm (When feeding malnourished patients, carbohydrate must be introduced )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 205.4812 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 205.4812 Tm [(slowly \(non-protein energy usually 50% CHO and 50% lipid\). )55.2(Additional )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.175 193.4812 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 193.4812 Tm (phosphate, B vitamins, potassium and magnesium should be given at the)Tj ET EMC /P <>BDC BT 8 0 0 8 290.1086 193.4812 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 181.4812 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 181.4812 Tm (same time as the feeding. Little or sometimes no sodium is given. )Tj ET EMC /P <>BDC BT 8 0 0 8 264.7297 181.4812 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 163.812 Tm (8.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 163.812 Tm (Nutritional support to the at-risk patient should start at no more than 50% )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 151.8119 Tm (of estimated needs for the first 24-48 hours. In patients at very high risk, )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 139.8119 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 139.8119 Tm (UK NICE guidelines suggest initially being even more cautious \(10 kcal/ )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 127.8119 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 127.8119 Tm (kg/24 hrs\) \(PENG suggest 10-20 kcal/kg/24 hour\) but increasing quickly )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 115.8119 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 115.8119 Tm (with appropriate monitoring.)Tj ET EMC /P <>BDC BT 8 0 0 8 129.5617 115.8119 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.339 98.1426 Tm (9.)Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 98.1426 Tm (Health professions experienced in refeeding problems \(for the severe )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 86.1426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 86.1426 Tm (cases a multidisciplinary nutritional support team \(NST\)\) should manage )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 74.1426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 74.1426 Tm [(these patients. )55.2(As they may fall, the phosphate, potassium, magnesium )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.175 62.1426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 62.1426 Tm (and glucose must be monitored \(especially after the first feed and daily )Tj ET EMC /P <>BDC BT 8 0 0 8 24.175 50.1426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 30.843 50.1426 Tm (until stable\). )Tj ET EMC /P <>BDC BT 8 0 0 8 76.1984 50.1426 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 12 0 0 12 303.356 485.1662 Tm 1 .89 0 0 k (Explanations)Tj ET EMC /P <>BDC /GS2 gs BT /TT6 1 Tf 10 0 0 10 378.0395 475.1656 Tm 0 0 0 1 k ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT2 1 Tf 8 0 0 8 303.356 470.2816 Tm 0 0 0 .8 k (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 470.2816 Tm (Refeeding deaths were first described when food became available to )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 458.2316 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 458.2316 Tm (the inhabitant of a town/city that had been surrounded and starved into )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 446.1816 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 446.1816 Tm [(submission. )18.1(The earliest record relates to the Siege of Jerusalem by the )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 434.1316 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 434.1316 Tm [(Romans in )55.2(AD 70. Evidence of deaths with parenteral nutrition is scarce )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 422.0816 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 422.0816 Tm (and relates to large amounts of glucose provision with inadequate )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 410.0316 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 410.0316 Tm (electrolytes.)Tj ET EMC /P <>BDC BT 8 0 0 8 354.5435 410.0316 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.356 392.3123 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 392.3123 Tm (The start of refeeding with carbohydrate or glucose causes insulin )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 380.2623 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 380.2623 Tm (secretion and this activated the glycolytic pathway and the decarboxcylic )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 368.2123 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 368.2123 Tm (acid cycle so that phosphate is rapidly used and moves from the )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 356.1623 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 356.1623 Tm (extracellular space to the intracellular one causing serum levels to fall. )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 344.1123 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 344.1123 Tm [(Blood phosphate levels below 0.32 mmol/L)37.1( are considered severe in )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 332.0623 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.6946 332.0623 Tm (the literature. )Tj ET EMC /P <>BDC BT 8 0 0 8 363.6086 332.0623 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 314.3429 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 314.3429 Tm [(Hypophosphataemia has many ef)18.1(fects including muscular weakness )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 302.2929 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 302.2929 Tm (\(especially of the diaphragm leading to respiratory failure\), biventricular )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 290.243 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 290.243 Tm (cardiac failure and arrhythmias, a low white cell count with dysfunctional )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 278.1931 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 278.1931 Tm -.01 Tc (white cells, abnormal liver function tests and many neurological problems, )Tj ET EMC /P <>BDC BT 8 0 0 8 305.4318 266.143 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 266.143 Tm 0 Tc (including cranial nerve palsies, a lower motor neuron type paralysis, )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 254.0929 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 254.0929 Tm [(ataxia, tremor)55.2(, fits and coma.)]TJ ET EMC /P <>BDC BT 8 0 0 8 414.5709 254.0929 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.356 236.3736 Tm (3.)Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 236.3736 Tm (Oral/enteral feeding is more commonly associated with )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 224.3236 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 224.3236 Tm (hypophosphataemia than parenteral nutrition probably because of )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 212.2737 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 212.2737 Tm [(the incretin)37.1( ef)18.1(fect of carbohydrate in the bowel. If the same amount )]TJ ET EMC /P <>BDC BT 8 0 0 8 303.356 200.2237 Tm (of glucose is given on separate occasions orally and intravenously; )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 188.1736 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 188.1736 Tm -.01 Tc (the amount of insulin released is much greater after the oral glucose.)Tj ET EMC /P <>BDC BT 8 0 0 8 549.509 188.1736 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 176.1236 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 176.1236 Tm (This may be due to the secretion of upper gut peptide hormones \(gastric )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 164.0735 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 164.0735 Tm [(inhibitory peptide \(GIP\) and glucagon like peptide-1 \(GLP-1\)\). )18.1(The high )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 152.0236 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 152.0236 Tm (insulin levels will cause more glucose to enter the cells and be used to )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 139.9736 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 139.9736 Tm [(make )55.2(A)74.2(T)0(P)18.1( and thus further exacerbate the hypophosphataemia.)]TJ ET EMC /P <>BDC BT 8 0 0 8 537.9303 139.9736 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.356 122.3044 Tm (4.)Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 122.3044 Tm (Thiamine is used in the glycolytic and decarboxycylic acid cycles and )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 110.3044 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 110.3044 Tm [(with their reactivation circulating thiamine is utilised. )18.1(Thiamine deficiency )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 98.3044 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 98.3044 Tm [(can lead to the development of W)18.1(ernicke)18.1(s encephalopathy which is a )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 86.3044 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 86.3044 Tm [(triad of encephalopathy)74.2(, ataxia and ocular dysfunction \(nystagmus\).)]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 74.3044 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 74.3044 Tm [(In the long-term this may progress to the irreversible Korsakof)18.1(f)-18.1()18.1(s )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.192 62.3044 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 62.3044 Tm (syndrome, which is characterised by permanent short-term )Tj ET EMC /P <>BDC BT 8 0 0 8 305.192 50.3044 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.8599 50.3044 Tm (memory loss.)Tj ET EMC /P <>BDC BT 8 0 0 8 359.4224 50.3044 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 9 0 0 9 22.6772 814.1643 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .015015 806.78 595.29 1.417 re f EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 14.3571 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 191.2006 14.3571 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 23.6772 508.2451 Tm 0 0 0 .8 k [(Jeremy Nightingale, Peter )18.1(T)37.1(urner)55.2(, )55.2(Aminda De Silva, and the BIF)55.2(A)55.2( Committee)]TJ ET EMC /P <>BDC BT 6 0 0 6 510.4381 41.029 Tm (Continued over page...)Tj ET EMC /P <>BDC BT 7 0 0 7 412.0978 14.4439 Tm 0 0 0 0 k (Reviewed: 26.10.2022. Next review due 26.10.2024)Tj ET EMC Q endstream endobj 69 0 obj <>/ExtGState<>>> endobj 77 0 obj <> endobj 145 0 obj <>stream /Figure <>BDC q 1 i -15.701 718.718 625.343 -710.979 re 297.645 420.96 m W* n 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n /GS3 gs q 689.024 104.165 -90.478 598.499 12.509 -81.865 cm /Im1 Do Q EMC /Artifact <>BDC Q q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n 1 .1 0 .1 k /GS1 gs .015015 0 595.29 31.482 re f EMC /P <>BDC BT /TT4 1 Tf 9 0 0 9 22.6772 814.1656 Tm 1 .15 0 0 k 0 Tc 0 Tw [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .015015 806.781 595.29 1.4171 re f EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 14.3583 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 191.2007 14.3583 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /Artifact <>BDC 0 0 0 .08 k 22.677 163.178 549.698 219.95 re f EMC /P <>BDC BT 9 0 0 9 39.7135 361.0509 Tm 1 .89 0 0 k (Suggested reading)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 120.7267 361.0509 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 345.2162 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 345.2162 Tm 0 0 0 .8 k [(Gozansky DM, Herman RH. W)37.1(ater and sodium retention in the fasted and refed human. )55.2(Am J Clin Nutr 1971; 24: 869-71.)]TJ ET EMC /P <>BDC BT 8 0 0 8 476.5769 345.2162 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 329.3816 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 329.3816 Tm 0 0 0 .8 k [(W)18.1(einsier RL, Krumdieck CL. Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited. )55.2(Am J )]TJ 56.3965 0 TD (Clin Nutr )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2175 316.3816 Tm (1981; 34: 393-9.)Tj ET EMC /P <>BDC BT 8 0 0 8 106.487 316.3816 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 300.547 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 300.547 Tm 0 0 0 .8 k (National Institute for Health and Clinical Excellence. Nutrition support in adults. Clinical guidelines 2006.)Tj ET EMC /P <>BDC BT 8 0 0 8 415.0848 300.547 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 284.7123 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 284.7123 Tm 0 0 0 .8 k [(Stanga Z, Brunner )55.2(A, Leuenberger M, Grimble RF)110.8(, Shenkin )55.2(A, )55.2(Allison SP)128.9(, Lobo DN. Nutrition in clinical practice-the refeeding sy)]TJ 56.2881 0 TD (ndrome: )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2175 271.7123 Tm (illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 2008: 62: 687-94. )Tj ET EMC /P <>BDC BT 8 0 0 8 387.0728 271.7123 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 255.8777 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 255.8777 Tm 0 0 0 .8 k [(Zeki S, Culkin )55.2(A, Gabe SM, Nightingale JM. Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adu)]TJ 59.0332 0 TD (lt in )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2175 242.8777 Tm [(patients. Clin Nutr 201)74.2(1; 30: 365-8. )]TJ ET EMC /P <>BDC BT 8 0 0 8 173.9206 242.8777 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 227.043 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 227.043 Tm 0 0 0 .8 k [(Friedli N, Stanga Z, Sobotka L, Culkin )55.2(A, Kondrup J, Laviano )55.2(A, Mueller B, Schuetz P)128.9(.)0( Revisiting the refeeding syndrome: Result)]TJ 56.5112 0 TD (s of a )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2175 214.043 Tm [(systematic review)55.2(. Nutrition 2017; 35: 151-160.)]TJ ET EMC /P <>BDC BT 8 0 0 8 214.5262 214.043 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 198.2084 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 198.2084 Tm 0 0 0 .8 k [(Culkin )55.2(A, White R. Refeeding syndrome. In: )55.2(A)55.2( pocket guide to clinical nutrition 5th edition, 2018. British Dietetic )55.2(Associatio)]TJ 53.9175 0 TD (n.)Tj ET EMC /P <>BDC BT 8 0 0 8 486.2293 198.2084 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 39.7135 182.3738 Tm 1 .89 0 0 k ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.2175 182.3738 Tm 0 0 0 .8 k [(De Silva )55.2(A, Nightingale JMD. Refeeding Problems/Syndrome. In Intestinal Failure 2nd Edition Springer \(in press\).)]TJ ET EMC /P <>BDC BT 8 0 0 8 448.4089 182.3738 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 776.0669 Tm (5.)Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 776.0669 Tm (The release of insulin \(largely by glucose\) and the availability of energy )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 764.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 764.0669 Tm [(\(A)74.2(TP\) reactivates the cell membrane Na+/K+ pump which expels sodium )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 752.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 752.0669 Tm [(from the cell and allows magnesium and potassium in. )18.1(The expulsion of )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 740.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 740.0669 Tm (sodium into the interstitial space is followed by water and may result in )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 728.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 728.0669 Tm (oedema. Serum potassium and magnesium concentrations may fall )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 716.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 716.0669 Tm [(further)55.2(, so close monitoring is needed.)]TJ ET EMC /P <>BDC BT 8 0 0 8 166.3685 716.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 698.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 698.3976 Tm (Patients at high risk of refeeding problems should receive about )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 686.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 686.3976 Tm (20 ml fluid/kg and <1 mmol/kg sodium. Sodium excretion is limited in )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 674.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 674.3976 Tm (refeeding and excess provision combined with that liberated from cells )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 662.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 662.3976 Tm (can lead to )Tj ET EMC /P <>BDC BT 8 0 0 8 72.5443 662.3976 Tm -.01 Tc (circulatory overload \(heart failure and severe oedema\), which )Tj ET EMC /P <>BDC BT 8 0 0 8 24.7529 650.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 650.3976 Tm (is dangerous)Tj ET EMC /P <>BDC BT 8 0 0 8 76.0301 650.3976 Tm 0 Tc ( in combination with cardiac atrophy from malnutrition)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 638.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 638.3976 Tm (and/or arrhythmias. Extreme caution should be observed when )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 626.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 626.3976 Tm (giving electrolytes in 0.9% NaCl \(154 mmol Na/l\) due to the risk of )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 614.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 614.3976 Tm (sodium and fluid overload and if using 5% dextrose the energy content )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 602.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 602.3976 Tm (needs to be taken into consideration \(200 kcal/l\). Ideally electrolytes )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 590.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 590.3976 Tm (should be added to the parenteral nutrition bag and oral preparations in )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 578.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 578.3976 Tm (water should be used where possible for oral and enteral tube feeding. )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 566.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 566.3976 Tm [(However)55.2(, it is important to remember that intestinal failure patients may )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 554.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 554.3976 Tm (need additional sodium and fluid to replace gastrointestinal losses from )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 542.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 542.3976 Tm -.01 Tc (stomas, fistulas, drains or enteral tubes)Tj ET EMC /P <>BDC BT 8 0 0 8 167.0786 542.3976 Tm 0 Tc (.)Tj ET EMC /P <>BDC BT 8 0 0 8 169.3013 542.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 524.7282 Tm (6.)Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 524.7282 Tm (The UK NICE guidelines \(below\), while good, are not completely reliable )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 512.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 512.7282 Tm (at identifying those who develop refeeding problems; hence there must )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 500.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 500.7282 Tm -.01 Tc [(be a high degree of clinical suspicion. )18.1(There are publications that support)]TJ ET EMC /P <>BDC BT 8 0 0 8 283.864 500.7282 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 488.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 488.7282 Tm [(for a low serum magnesium or low IGF-1 improving their sensitivity)74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 268.8842 488.7282 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 24.5131 470.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 470.059 Tm (UK NICE risk factors for developing refeeding syndrome )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 247.6732 470.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 458.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 458.059 Tm (One or more of the following:)Tj ET EMC /P <>BDC BT 8 0 0 8 133.8998 458.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 446.059 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 446.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.6848 446.059 Tm 0 0 0 .8 k (BMI <16 kg/m)Tj ET EMC /P <>BDC BT 4.8 0 0 4.8 89.2592 448.3839 Tm (2)Tj ET EMC /P <>BDC BT 8 0 0 8 91.9287 446.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 434.059 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 434.059 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 434.059 Tm 0 0 0 .8 k ( Unintentional weight loss >15% within last 3-6 months)Tj ET EMC /P <>BDC BT 8 0 0 8 229.4532 434.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 422.059 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 422.059 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 422.059 Tm 0 0 0 .8 k ( Little or no nutritional intake for more than 10 days)Tj ET EMC /P <>BDC BT 8 0 0 8 216.3399 422.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 410.059 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 410.059 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 410.059 Tm 0 0 0 .8 k ( Low potassium, magnesium or phosphate prior to feeding.)Tj ET EMC /P <>BDC BT 8 0 0 8 244.3555 411.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 399.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.181 399.0089 Tm [(T)55.2(wo or more of the following:)]TJ ET EMC /P <>BDC BT 8 0 0 8 133.4506 399.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 776.0669 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 776.0669 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 776.0669 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 776.0669 Tm (BMI <18.5 kg/m)Tj ET EMC /P <>BDC BT 4.8 0 0 4.8 376.7803 778.3918 Tm (2)Tj ET EMC /P <>BDC BT 8 0 0 8 379.4498 776.0669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 764.0168 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 764.0168 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 764.0168 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 764.0168 Tm (Unintentional weight loss >10% within last 3-6 months)Tj ET EMC /P <>BDC BT 8 0 0 8 511.5263 764.0168 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 751.9668 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 751.9668 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 751.9668 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 751.9668 Tm (Little or no nutritional intake for more than 5 days)Tj ET EMC /P <>BDC BT 8 0 0 8 493.9639 751.9668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.6021 739.9167 Tm 1 .89 0 0 k -.01 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 739.9167 Tm 0 Tc ()Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 739.9167 Tm 0 0 0 .8 k -.01 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 739.9167 Tm [(A)55.2( history of alcohol abuse or drugs including insulin, chemotherapy)74.2(,)]TJ ET EMC /P <>BDC BT 8 0 0 8 553.3081 739.9167 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 727.8668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 727.8668 Tm (antacids or diuretics.)Tj ET EMC /P <>BDC BT 8 0 0 8 393.9015 727.8668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5263 710.1475 Tm (7.)Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 710.1475 Tm (The UK NICE guidelines are considered by many to be cautious in )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 698.0975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 698.0975 Tm [(the amount of energy given when feeding first begins. )18.1(The non-protein )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 686.0475 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 686.0475 Tm (energy is generally given as 50% carbohydrate and 50% lipid to reduce )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 673.9975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 673.9975 Tm (the initial carbohydrate load though it is not always easy to do this if )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 661.9475 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 661.9475 Tm [(relying on standard products. )18.1(The UK NICE guideline also recommends )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 649.8975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 649.8975 Tm (that B vitamins and a balanced multivitamin/trace element supplement )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 637.8475 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 637.8475 Tm (are given immediately before and during the first 10 days of feeding.)Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 625.7975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 625.7975 Tm (Intravenous B vitamins are usually given for 3-5 days.)Tj ET EMC /P <>BDC BT 8 0 0 8 501.9014 625.7975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5263 608.0782 Tm -.01 Tc (8.)Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 608.0782 Tm (Patients considered to have a high risk of refeeding problems should )Tj ET EMC /P <>BDC BT 8 0 0 8 305.6021 596.0282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 596.0282 Tm (start)Tj ET EMC /P <>BDC BT 8 0 0 8 327.1891 596.0282 Tm 0 Tc [( feeding very cautiously)74.2(, especially those fed enterally)74.2(. Malnourished )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 583.9782 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 583.9782 Tm [(patients are likely to be intracellularly depleted of K, Mg and PO4. )18.1(This )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 571.9282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 571.9282 Tm (depletion might not be reflected in pre-feeding plasma electrolytes levels )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 559.8782 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 559.8782 Tm -.02 Tc (which may appear normal. For this reason, UK NICE Guidelines recommend)Tj ET EMC /P <>BDC BT 8 0 0 8 571.6095 559.8782 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.6197 547.8282 Tm -.015 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 547.8282 Tm (generous)Tj ET EMC /P <>BDC BT 8 0 0 8 344.4296 547.8282 Tm 0 Tc ( levels of electrolytes \(except sodium\) should be provided )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 535.7782 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 535.7782 Tm (prophylactically )Tj ET EMC /P <>BDC BT 8 0 0 8 368.9443 535.7782 Tm -.01 Tc (where possible \(2-4 mmol/kg K, 0.3-.06 mmol/kg PO4 )Tj ET EMC /P <>BDC BT 8 0 0 8 305.6021 523.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 523.7282 Tm (and 0.2-0.4 mmol/kg)Tj ET EMC /P <>BDC BT 8 0 0 8 383.4368 523.7282 Tm 0 Tc ( mg\) unless plasma levels are high in accordance )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 511.6782 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 511.6782 Tm (with expert supervision. )Tj ET EMC /P <>BDC BT 8 0 0 8 397.8466 511.6782 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5263 494.0089 Tm (9.)Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 494.0089 Tm (Close monitoring is required to identify hypophosphataemia, )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 482.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 482.0089 Tm (hypomagnesaemia, hypokalaemia and hypoglycaemia )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 470.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 470.0089 Tm (\(or hyperglycaemia\) so that prompt replacement therapy may be given. )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 458.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 458.0089 Tm (This is important especially in those enterally/orally fed in whom )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 446.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 446.0089 Tm (monitoring is often not performed as meticulously as in those receiving )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 434.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 434.0089 Tm [(parenteral nutrition. )18.1(The expertise in monitoring and treating these )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 422.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 422.0089 Tm (patients lies with healthcare professionals with training and experience. )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 410.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 410.0089 Tm (This is usually a dietitian but in more severe cases the hospital's )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 398.0089 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 398.0089 Tm [(multidisciplinary NST)110.8(.)]TJ ET EMC /P <>BDC BT 7 0 0 7 419.3826 15.4452 Tm 0 0 0 0 k (Reviewed: 26.10.2022. 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