From the Guidelines
Refeeding syndrome in elderly vagrant patients should be managed with a gradual increase in calorie intake over the first three days to avoid complications, as recommended by the most recent ESPEN practical guideline 1.
Key Considerations
- The patient's electrolytes, particularly phosphate, potassium, and magnesium, should be checked and corrected before refeeding begins 1.
- Thiamine 200-300mg daily should be administered for at least 3-5 days before starting nutritional support, along with a multivitamin supplement 1.
- Electrolytes should be monitored daily for the first week, then 2-3 times weekly until stable 1.
- For severe deficiencies, IV replacement should be provided: potassium (maximum 40 mmol/L via peripheral line), phosphate (0.08-0.16 mmol/kg over 4-6 hours), and magnesium (8-16 mmol over 4 hours) 1.
Patient Vulnerability
- Elderly vagrant patients are particularly vulnerable due to chronic malnutrition, alcoholism, and multiple comorbidities 1.
- The syndrome occurs because reintroducing nutrition stimulates insulin release, driving electrolytes into cells and causing potentially fatal cardiac, neurological, and hematological complications 1.
Multidisciplinary Approach
- A multidisciplinary approach involving dietitians, nurses, and physicians is essential for safe refeeding in this high-risk population 1.
- The most recent ESPEN practical guideline recommends starting enteral nutrition (EN) and parenteral nutrition (PN) early and gradually increasing it over the first three days to avoid refeeding syndrome 1.
From the Research
Refeeding Syndrome in Elderly Vagrant Patients
- Refeeding syndrome is a potentially lethal complication of refeeding in patients who are severely malnourished from whatever cause 2
- The main clinical problems may relate to hypophosphataemia, hypomagnesaemia and hypokalaemia with a risk of sudden death; thiamine deficiency with the risk of Wernike's encephalopathy/Korsakoff psychosis and sodium/water retention 3
- It is difficult to predict patients at risk of refeeding problems, so there must be a high clinical suspicion on refeeding any malnourished patient (including any who have had no or very little nutrition for over 5 days) 3
Prevention and Treatment
- Generous vitamin and electrolyte supplementation may be given while monitoring closely and increasing the calorie intake reasonably rapidly from 10 to 20 kcal/kg/24 hours 3
- Refeeding should commence at 10 kcal/kg per day in patients at risk, and increased slowly 4
- Thiamine, vitamin B complex and multi-vitamin supplements should be started with refeeding 4
- New NICE guidelines state that pre-feeding correction of electrolyte and fluid deficits is unnecessary, but should be done concurrently with re-feeding 4
Associated Conditions
- Wernicke's Encephalopathy (WE) is a neurological condition characterized by ophthalmoplegia, ataxic gait, and altered mental status, often precipitated by thiamine deficiency 5
- WE can occur in conjunction with refeeding syndrome, and prevention of this condition is a clinical challenge for most physicians 5
- Refeeding syndrome can prolong the neurologic symptoms of WE and lead to an extended hospital stay and significant physical debility 6