2023 Parenteral Nutrition Case Study

Initiating home parenteral nutrition therapy in a patient at high risk of refeeding syndrome after COVID-19 infection

Authors: Lily Wu, RD, CSR, CNSC; Christine Miller, PharmD; Karen Khu; Michelle Dela Cruz, LVN – Soleo Health

Taraneh Razavi, MD, APC – Stanford Health Care

Background

An emerging finding about COVID-19 is its effect on nutrition and weight loss. The COVID-19 symptoms of fatigue, altered taste or smell, and lack of appetite are well-known. But COVID-19 may have a more profound effect on clinical nutrition status. Severely infected patients treated in an intensive care unit (ICU) will require nutrition support. But two recent studies also highlight the importance of nutrition support in COVID-19 patients managed in non-ICU units or at home. Approximately one-third of ambulatory COVID-19 patients are at risk of experiencing weight loss ≥5%.^1,2 The case study presented here discusses home start total parenteral nutrition (TPN) in a patient recently diagnosed with COVID-19 at high risk for refeeding syndrome.

Case Study

A 92-year-old patient was diagnosed with COVID-19 on 06/08/2022. Over the next week, she was hospitalized twice to manage symptoms of acute mental status changes, lethargy, aphasia, hypotension, and loss of appetite. The patient received nirmatrelvir/ritonavir, remdesivir, and bebtelovimab to treat COVID-19 at different times between 06/09/2022-06/18/2022. She remained COVID positive and continued to deteriorate clinically. On 06/20/2022, the patient began receiving 24/7 homecare, including intravenous fluids of dextrose 5% in normal saline (D5NS) 1000 mL daily for three days. She continued to experience loss of appetite and had no bowel movement for 3 days. On 06/23/2022 she was referred to this specialty infusion provider to initiate TPN therapy in the home setting. The patient’s BMI was 18.2 kg/m2. Lab results revealed potassium 3.0 mmol/L, phosphate 1.6 mg/dL, and magnesium 1.6 mg/dL. Significant risk of refeeding syndrome was identified by low BMI (16-18.5 kg/m2) and the level of hypophosphatemia, hypokalemia, and hypomagnesemia.

Discussion

The ASPEN Consensus Recommendations for Refeeding Syndrome describe the repletion of electrolyte levels before introducing calories to prevent end-organ damage associated with refeeding syndrome (respiratory muscle dysfunction, decreased cardiac contractility, cardiac arrhythmias, and encephalopathy).³

Conclusion

This case study highlights the successful initiation of home TPN therapy in a patient at high risk of refeeding syndrome post COVID-19 infection. Although home start TPN and the risk of refeeding syndrome are not new concepts, they must be considered in the setting of COVID-19. Given the effects COVID-19 has on taste, smell, and appetite and the recent finding that one-third of patients with COVID infection may experience weight loss of ≥5%, nutrition support and patient education are vital components of overall patient care.