Artificial nutrition and nutritional support and refeeding syndrome

Artificial nutritional support is needed when a patient is unable to absorb sufficient nutrition from normal diet. NICE guidance recommends that enteral and parenteral nutrition is supervised by a multidisciplinary nutrition team and that clear goals of nutritional support are defined and reviewed regularly. The combination of nutrition and control of the systemic inflammatory response enables the patient to become anabolic. If possible the enteral route should be used, most commonly nasogastric feeding. Recent NPSA alerts have highlighted the risks of nasogastric tube misplacement and hospitals should have clear policies about checking tube position. Percutaneous gastrostomy feeding is useful for longer term enteral feeding. In the past decade jejunal feeding has reduced the use of parenteral feeding in critical care and upper gastrointestinal disease. Feeding into the distal small bowel beyond a fistula or a proximal stoma can also avoid parenteral nutrition. Parenteral nutrition may be life saving, but may also result in serious complications such as septicaemia due to line infection. Metabolic complications have been less common since ‘standard’ PN bags became widely available. Refeeding syndrome may occur in severely malnourished patients who recommence feeding. Complex electrolyte disorders, such as hypophosphataemia, hypomagnesaemia and hypokalaemia may result, owing to cellular utilization of phosphate. Feeding should be recommenced slowly with careful electrolyte monitoring.