Chapter 32, Ep 1 of 4: Refeeding, Malnutrition, and Enteral Access

Episode one of the GI Nutrition chapter builds the inpatient nutrition framework and the enteral access decisions. The organizing idea is that the labs lie and the instinct to feed faster is usually wrong. Refeeding syndrome is what happens when a starvation-adapted patient meets a carbohydrate load, so the active intervention is restraint with thiamine before glucose. Hospital malnutrition is not what a low albumin says it is, so GLIM separates the phenotypic deficit from the etiologic cause. And the route of nutrition follows the gut's functional state, with a functional gut winning every time.   Topics covered Refeeding syndrome and the electrolyte shift Thiamine before glucose and Wernicke NICE high-risk criteria Restrained calorie reintroduction Albumin as an inflammatory marker GLIM phenotypic plus etiologic criteria Functional gut and enteral access selection PEG techniques and complications Tube-feed diarrhea and the medication list   Key decisions Refeeding calories start at ten to twenty kilocalories per kilogram per day and advance over four to seven days, with thiamine two hundred to three hundred milligrams given before any glucose load and continued daily for five to seven days. Any single NICE criterion, a BMI below sixteen, weight loss above fifteen percent, more than ten days of negligible intake, or pre-feeding hypokalemia, hypophosphatemia, or hypomagnesemia, makes a patient high risk for refeeding. Albumin and prealbumin are negative acute-phase reactants suppressed by IL-six and TNF-alpha, so they are excluded from GLIM criteria and should never be treated as nutrition markers in an inflamed patient. GLIM malnutrition requires one phenotypic criterion, weight loss, low BMI, or reduced muscle mass, plus one etiologic criterion, reduced intake or assimilation or inflammation. A functional gut wins, so short-term feeds under four to six weeks use nasogastric or nasojejunal tubes and longer-term feeds use percutaneous endoscopic gastrostomy. PEG does not prevent aspiration or extend survival in advanced dementia and is not standard of care, so families should be counseled against it. Tube-feed diarrhea is worked up by reviewing the medication list for sorbitol vehicles, checking recent antibiotics, and sending a stool C. diff test before any formula change.   For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The framework and the organizing idea (00:31) - Refeeding syndrome and the electrolyte crash (03:01) - NICE high-risk criteria and restrained feeding (05:00) - Malnutrition versus catabolism, and the albumin trap (06:30) - GLIM phenotypic and etiologic criteria (09:19) - A functional gut wins: enteral access (10:05) - PEG techniques and complications (13:00) - Tube-feed diarrhea and the medication list