From the Guidelines
Refeeding syndrome is a potentially life-threatening condition that occurs when nutrition is reintroduced too quickly after a period of malnutrition, characterized by fluid and electrolyte abnormalities, particularly hypophosphatemia, hypokalemia, and hypomagnesemia, and can lead to cardiac, neurological, and respiratory complications. The signs and symptoms of refeeding syndrome include:
- Fluid retention with peripheral edema
- Congestive heart failure
- Cardiac arrhythmia
- Respiratory failure
- Delirium
- Encephalopathy
- Severe organ dysfunctions
- Hypophosphatemia
- Hypokalaemia
- Hypomagnesemia
- Hypocalcaemia These symptoms typically appear within 2-4 days of refeeding and result from the body's metabolic shift from fat to carbohydrate metabolism, causing rapid intracellular movement of electrolytes and fluid shifts 1. Patients at high risk of developing refeeding syndrome include those with chronic alcoholism, severe chronic undernutrition, anorexia nervosa, or depleted patients with acute illness 1.
The diagnostic criteria for refeeding syndrome include fluid imbalance, disturbed glucose homeostasis, hyperlactatemia, and electrolyte disturbances such as hypophosphatemia, hypomagnesemia, and hypokalaemia 1. Screening for patients at risk of refeeding syndrome involves assessing factors such as BMI, unintentional weight loss, and little or no intake for more than 10 days 1.
According to the most recent guidelines, nutrition support should be initiated slowly, with close monitoring of serum electrolytes and cardiorespiratory function to avoid complications 1. The recommended initial energy intake is 5-10 kcal/kg for the first 24 hours, with monitoring of serum electrolytes at least every 24 hours for the first 3 days 1.
In terms of prevention and management, it is essential to identify patients at risk of refeeding syndrome and implement a gradual and monitored approach to nutrition support, with aggressive electrolyte repletion and cardiorespiratory monitoring as needed 1. Additionally, thiamine and other B vitamins should be administered intravenously starting before any feed is started, continuing for at least the first three days of feeding 1.
Overall, the key to preventing and managing refeeding syndrome is a careful and gradual approach to nutrition support, with close monitoring of electrolytes and cardiorespiratory function, and aggressive intervention as needed 1.
From the Research
Signs and Symptoms of Refeeding Syndrome
The signs and symptoms of refeeding syndrome can be severe and life-threatening, and may include:
- Electrolyte imbalance, particularly hypophosphatemia, hypokalaemia, and hypomagnesaemia 2, 3, 4, 5
- Cardiac complications, such as arrhythmias and cardiac failure 2, 4
- Pulmonary complications, such as respiratory failure 2, 4
- Gastrointestinal complications, such as nausea, vomiting, and diarrhea 2, 4
- Metabolic abnormalities, such as thiamine deficiency and disorder of sodium and fluid balance 3, 5
- Neurological complications, such as confusion, seizures, and coma 4
Risk Factors for Refeeding Syndrome
Patients at risk of developing refeeding syndrome include:
- Those with moderate to severe malnutrition 2, 4
- Those who have had little or no nutritional intake for more than 10 days 6
- Those with a history of dysphagia or other conditions that affect nutritional intake 6
- Head and neck cancer patients, particularly those with prolonged periods of poor nutritional intake 6
Prevention and Management of Refeeding Syndrome
Prevention and management of refeeding syndrome involve:
- Identifying patients at risk and taking measures to prevent its occurrence 2, 3, 4, 5, 6
- Commencing refeeding at a low calorie intake (10 kcal/kg per day) and increasing slowly 6
- Providing electrolyte supplementation and laboratory monitoring 3, 6
- Administering thiamine, vitamin B complex, and multi-vitamin supplements with refeeding 6
- Correcting electrolyte and fluid deficits concurrently with re-feeding 6