Presentation

Leaves, Wisley, August 2011

My presentation on Re-feeding Syndrome (RFS) went very well, although if I were to do it again I would make a few changes. The audience was small, and all were doctors. Last week was when all the junior doctors changed to a different department on rotation, so there were five brand new doctors in attendance, with their consultant and clinical educator who is one of my favourites. To be honest, any doctor that knows who I am is one of my favourites, but this one has been particularly helpful and welcoming.

The consultant kicked off by giving the new doctors a bit of information about how their placement was going to work, and then I was introduced by the registrar as a Senior Dietitian. I had to explain that despite my appearance I am actually a very Junior Dietitian, only two months old in Dietitian Years.

I embarked on the presentation, which I had been given ready-made by one of the senior Dietitians in the department, saving me no end of time in putting something together. I'd tweaked it a little bit, but not much. It wasn't designed for such a medical audience, so I had to supplement it with some hard facts about treatment, and then we talked a bit about how to manage ward procedures to cope with any patients who actually were at high risk of RFS.

So what exactly is Re-feeding Syndrome? It's "a potentially lethal derangement of blood electrolytes (potassium, phosphate, magnesium and sometimes others) caused by a switch to carbohydrate metabolism from fat and protein metabolism."

What that means in ordinary language is that in normal circumstances we use mainly carbohydrate for energy, adding to or removing from fat reserves if carb intake doesn't match energy expenditure. We don't store a whole lot of carbohydrate - I believe that when marathon runners hit the 'wall' it's when their stored glycogen is used up. For normal people, it would take about two days. After that, our metabolism switches to using mostly fat for energy, which works pretty well as a substitute, as you might expect. When the fat is gone (and to some extent, before the fat is gone) we turn to protein for energy, turning muscles into fuel.

The problem in RFS happens when carbohydrate intake starts up again, and metabolism switches from burning fat/protein to carbs. If the interruption was only a few days, and the individual was not underweight or malnourished to start with, then there's no problem. If it's a particularly thin person who hasn't eaten for more than 5 days (and there are a few other more obscure risk factors) then the risk rises with the rate of feeding. What actually happens is that energy generation using glucose starts up inside cells, which sucks the materials it needs out of the blood to make ATP for energy. The concentration of these electrolytes and vitamins in the blood drops, leading to potentially fatal consequences.

There are not many acute life-threatening conditions that a Dietitian encounters, so there is a good deal of emphasis on RFS in the Dietetics degree. I assess every patient I am asked to see, and if RFS is a possibility I will indicate it in every way I can - in the medical notes, nursing notes, and to the medical and nursing staff on duty.

The main approach for prevention of the Syndrome is to take great care not to feed the patient too much too quickly, and provide them with vitamin supplements. Monitoring the success of the approach is generally by way of monitoring levels of potassium, phosphate and magnesium in the blood, and replacing these if they drop. It is highly unlikely that someone will succumb following ordinary eating and drinking, but much more likely if they have had a period of no oral intake followed by tube feeding, as in the case of a stroke that has disrupted the process of swallowing, for example.

The way we manage tube feeding is that I write down the rate of delivery of the feed and the number of hours it should be given. On each successive day my regimen shows a slightly increased rate of feeding, and in someone at high risk, it is important to check blood results before the rate is increased. The main issue we face is that while I produce the feeding regimen, the nurses actually control the delivery of feed, and the doctors order blood results and review them. At the point when the rate of feeding increases, I definitely won't be there, but the nurse setting up the feed should check that a doctor has reviewed the blood results and approves the increase in feed rate. I wonder if this has ever happened. Mostly, I imagine, we've been lucky and nobody has died.

At the meeting, after I'd done my lecture, I presented this problem and asked for suggestions. The best that we could come up with was the liberal use of a highlighter pen in notes and other records to ensure that the risk is not overlooked, and checkboxes to be ticked to try and ensure that blood results are reviewed appropriately. I have two potential re-feeders at the moment, so we'll see if it makes any difference.

Continuous Professional Development

Rosemary flowering in the garden, March 2012

The lecture last week was one of a weekly series held in a side room off one of 'my' wards, covering aspects of elderly medicine. Following a recent incident, one of my favourite doctors suggested that it would good if I gave one of the lectures about re-feeding syndrome, which is a potentially fatal condition that may arise when someone who has had little or no dietary intake for more than five days starts to eat (or is fed). At the time I was less twitchy about my workload, and conscious of the need for evidence of CPD (continuous professional development), so I agreed.

Every two years, all professionals regulated by the HPC (Health Professions Council) are required to re-register. To ensure that professional standards are maintained, 5% of the registrants, selected at random, are required to submit a portfolio of evidence to demonstrate that they are engaging in CPD and keeping up with the latest developments in their particular field. CPD might consist of attending a professional meeting or a training course, a written piece of reflection on a particular case or condition, or researching an aspect of practice, and as in this case, delivering a lecture about it. If a Dietitian is unable to produce a satisfactory portfolio then registration may be withheld, meaning that he or she is no longer allowed to practise as a Dietitian. Loss of job and livelihood ensues.

The week before my lecture I thought it would be useful to see the room and hear someone else talk, to judge the kind of thing that might be expected. In a tiny room with space for no more than about fifteen chairs squashed together we were offered supermarket sandwiches, crisps, fruit and chocolate by a rep (I would have written 'lunch' but thought you might imagine something more lavish). The first part of the lecture (which is all I could stay for) was about admissions to hospital and mortality of stroke patients in the local area compared with a different local area, an English region and England as a whole. It was mostly attended by doctors, from the most junior Foundation Year trainees up to the senior consultants. The senior consultants asked many detailed searching questions, and I am now thoroughly apprehensive. But it was nice to mix with the doctors off-ward, where it is possible to converse on a social level - two lanes out of three have been closed on a main route into the hospital; that part of our journeys, normally less than 5 minutes, took 45 minutes. We talked quite a bit about how late each of us had been that morning.

Clinical Supervision is an opportunity for us three newly-qualified and newly-appointed Dietitians to have some scheduled time with a more senior colleague, and can also be used as evidence of CPD. In my first supervision we talked about the generalities of the job and about specific patients, where there is some ambiguity about the treatment, the patient or our role.

For example, one of the main things we all seem to experience is how much we should contribute to the overall holistic care of the patient. For example, patients who have the capacity to make their own decisions are entitled to make decisions that we think are unwise, and we have to deal with the consequences. A patient for whom swallowing has been deemed 'unsafe' (i.e. food or fluid is at risk of entering the lungs rather than the oesophagus), may refuse to have a tube placed, in which case the lead consultant usually allows the staff to offer food and drink on the basis that this is better than allowing the patient to starve.

In this situation, the Speech and Language Therapists will not advise on the 'safest' texture of food or thickening of drink, on the basis that their professional opinion is that the patient should not be eating or drinking anything. The lead consultant generally rules that the patient should then be offered thickened fluids and a puree diet, because these will probably cause the fewest problems. The patient's nutritional requirements will almost certainly not be met without supplements, but should Dietitians similarly withdraw from the situation, or continue to recommend nutritional supplements that may cause harm if taken?

The consensus in the Clinical Supervision meeting was that we should recommend that supplements are offered, since it is in the patient's best interests to have a sufficient dietary intake, and if the patient has capacity and chooses an unsafe route of ingestion, then that is their right. Our discussion also concluded that we should challenge the consultant's ruling on puree diet and thickened fluids, because this form of intake is generally unpalatable and limiting, and if a patient chooses to eat unsafely rather than be tube-fed safely, they might as well be offered an unsafe appetising menu, rather than gloop which is also unsafe.

In future Clinical Supervision meetings we hope to invite experts to talk about various aspects of practice, such as how much we should know about diabetes on the wards, and what might influence our choice of feed regimen. I'm hoping we'll also plan some more evenings out, because last week's night out was great. I had two drinks (double my usual intake) and reached home well after normal bedtime.