Guidelines for Refeeding from Dextrose Solutions to Prevent Refeeding Syndrome
When initiating nutrition with dextrose solutions in malnourished patients, start with 5-10 kcal/kg/day for high-risk patients and 15-20 kcal/kg/day for moderate-risk patients, with gradual increases over 4-7 days, while providing prophylactic electrolyte supplementation and thiamine before carbohydrate administration. 1
Risk Assessment for Refeeding Syndrome
High-Risk Patients
- BMI < 16 kg/m²
- Unintentional weight loss > 15% in 3-6 months
- Little or no nutritional intake for > 10 days
- Low baseline levels of potassium, phosphate, or magnesium
- History of alcohol abuse 1
Moderate-Risk Patients
- BMI < 18.5 kg/m²
- Unintentional weight loss > 10% in 3-6 months
- Little or no nutritional intake for > 5 days 1
Protocol for Dextrose Administration
Initial Feeding Rates
- High-risk patients: Start with 5-10 kcal/kg/day
- Moderate-risk patients: Start with 15-20 kcal/kg/day 1
Advancement Schedule
- Increase caloric intake gradually over 4-7 days
- Monitor for signs of refeeding syndrome, particularly in the first 72 hours
- Night sweats are an early warning sign requiring immediate evaluation 1
Electrolyte Management
Prophylactic Supplementation (before starting dextrose)
- Potassium: 2-4 mmol/kg/day
- Phosphate: 0.3-0.6 mmol/kg/day
- Magnesium: 0.2 mmol/kg/day IV or 0.4 mmol/kg/day orally 1
Monitoring Schedule
- Check electrolytes (especially phosphate, potassium, and magnesium) daily during the first 72 hours
- Continue monitoring throughout the first week of refeeding 1
Vitamin Supplementation
- Administer thiamine 200-300 mg daily before starting dextrose solutions
- Provide multivitamin supplements to prevent other deficiencies 1
Fluid Management
- Track fluid balance closely, including intake and output
- Monitor daily weights
- Assess for edema and signs of fluid overload
- Initially restrict fluid intake to prevent overload
- Watch for signs of heart failure and pulmonary edema 1
Common Pitfalls to Avoid
Overly rapid refeeding: The most common error in managing malnourished patients is advancing nutrition too quickly 1
Inadequate electrolyte monitoring: Failure to check electrolytes daily in the first 72 hours can miss early signs of refeeding syndrome 1
Missing early warning signs: Night sweats are an important early indicator that should prompt immediate evaluation and adjustment of the nutritional plan 1
Overlooking thiamine supplementation: Administering dextrose without prior thiamine can precipitate Wernicke's encephalopathy 1
Poor fluid management: Both excessive and insufficient fluid can worsen symptoms 1
Special Considerations
- Continuous pump feeding can reduce gastrointestinal discomfort when absorptive capacity is diminished 2
- For enteral feeding, patients should be positioned at 30° or more during and for 30 minutes after feeding to minimize aspiration risk 2
- Close monitoring of fluid, glucose, and electrolyte status is essential in the first few days after starting nutritional support 2
- Life-threatening problems due to refeeding syndrome are particularly common in severely malnourished patients 2