From the Guidelines
For refeeding syndrome patients experiencing nausea and fullness despite conservative measures, I recommend initiating nutrition support slowly, with 5-10 kcal/kg for the first 24 hours, and monitoring serum electrolytes frequently, as suggested by the most recent guidance from 2024 1. This approach is crucial in preventing refeeding syndrome, which can be fatal. The key is to start with a low caloric intake and gradually increase it, while closely monitoring electrolyte levels, particularly potassium, magnesium, and phosphorus.
- Reduce caloric intake to 5-10 kcal/kg/day initially, as recommended by the 2024 guidance 1.
- Increase caloric intake by small increments (100-200 calories every 2-3 days) as tolerated.
- Monitor serum electrolytes (potassium, magnesium, and phosphorus) before initiating nutrition support and at least every 24 hours for the first 3 days, and longer if electrolyte abnormalities persist, as advised by the 2024 guidance 1.
- Consider anti-emetic medications, such as ondansetron 4-8mg every 8 hours or promethazine 12.5-25mg every 6 hours, for nausea management.
- Small, frequent meals (6-8 per day) with low-fat, low-fiber content may help reduce fullness.
- Ensure proper electrolyte replacement, particularly phosphorus, potassium, and magnesium, as deficiencies can worsen gastrointestinal symptoms. The pathophysiology of refeeding syndrome involves the body's shift from fat to carbohydrate metabolism during refeeding, causing fluid shifts and increased insulin production that can lead to electrolyte abnormalities and gastrointestinal distress, as explained in the 2017 ESPEN guidelines 1. This cautious approach allows the body to gradually adapt to nutritional reintroduction while minimizing discomfort.
From the Research
Refeeding Syndrome and Nausea
- Refeeding syndrome is a potentially serious condition that can occur when feeding is commenced after a period of starvation, and it is characterized by hypophosphataemia, electrolyte shifts, and metabolic and clinical complications 2.
- Patients who are at high risk of refeeding syndrome, such as those with chronic under-nutrition or little intake for greater than 10 days, should undergo a risk assessment and stratification before starting nutritional therapy 3.
- The occurrence of refeeding syndrome during nutritional therapy must be continuously evaluated, and appropriate steps taken if necessary, including adapted energy and fluid support during the replenishment phase 3.
Management of Refeeding Syndrome
- Refeeding should commence at 10 kcal/kg per day in patients at risk, and increased slowly, with thiamine, vitamin B complex, and multi-vitamin supplements started with refeeding 2.
- A multidisciplinary metabolic team can help diagnose and manage refeeding syndrome, and standardizing a nutrition care plan can potentially decrease complication rates and overall mortality 4.
- Awareness of the condition is crucial for identifying patients at risk, preventing its occurrence, and improving management, and a unifying definition for refeeding syndrome and its severity classification has been proposed by the American Society for Parenteral and Enteral Nutrition (ASPEN) 5.
Nausea and Vomiting
- Nausea and vomiting can be a symptom of refeeding syndrome, and management focuses on relieving symptoms and preventing morbidity, often requiring antiemetic therapy 6.
- Ondansetron and metoclopramide can be used as second-line antiemetics in women with nausea and vomiting, but the choice of antiemetic therapy may vary depending on individual patient needs and guidelines 6.