How to manage refeeding syndrome in at-risk patients?

Management of Refeeding Syndrome in At-Risk Patients

For patients at high risk of refeeding syndrome, treatment should start with low caloric intake (5-15 kcal/kg/day) with gradual increase over 5-10 days, alongside prophylactic electrolyte supplementation and thiamine administration before initiating nutrition. 1, 2

Identifying At-Risk Patients

Patients at high risk for refeeding syndrome include those with:

• Starvation for >10 days or significant weight loss >15% 1
• Low serum magnesium (<0.7 mmol/L) 1
• Oncologic patients, patients with eating disorders, chronic vomiting or diarrhea 1
• Older age and high Nutritional Risk Screening scores (≥3) 1
• Comorbidities 1

Initial Nutritional Approach

1. Starting Caloric Intake:

   • Begin with 5-15 kcal/kg body weight per day 1, 2
   • Macronutrient distribution: 40-60% carbohydrate, 30-40% fat, and 15-20% protein 1

2. Progression:

   • Gradually increase caloric intake over 5-10 days 1
   • Monitor clinical features and laboratory values during progression 1

3. Protein Requirements:

   • Maintain adequate protein intake despite low-calorie diet 1
   • For BMI <30: at least 1 g/kg actual body weight/day
   • For BMI ≥30: at least 1 g/kg adjusted body weight/day 1

Electrolyte Management

Prophylactic Supplementation (Even with Mild Deficiency)

• Phosphate: 0.3-0.6 mmol/kg/day 2
• Potassium: 2-4 mmol/kg/day 2, 3
• Magnesium: 0.2 mmol/kg/day IV or 0.4 mmol/kg/day orally 2
• Thiamine: 300 mg IV before initiating nutrition therapy, followed by 200-300 mg IV daily for at least 3 more days 2

Monitoring Protocol

• Monitor serum levels of phosphate, magnesium, potassium, and thiamine closely during the first 72 hours 1
• Continue monitoring throughout the refeeding process, with special attention to the first week 1

Route of Administration

• Enteral nutrition is preferred over parenteral when possible 2
• For patients with gastric feeding intolerance:
  • Consider prokinetic agents (IV erythromycin 100-250 mg three times daily as first-line therapy) 1, 2
  • If ineffective, consider postpyloric feeding 1

Management of Complications

If refeeding syndrome develops despite preventive measures:

1. For hypophosphatemia, hypokalemia, or hypomagnesemia:

   • Increase supplementation based on serum levels
   • Consider temporary reduction in feeding rate until electrolytes normalize 4, 5

2. For fluid overload:

   • Monitor fluid balance carefully
   • Consider fluid restriction if edema develops 4

3. For cardiac complications:

   • Monitor ECG for changes (peaked T-waves, prolonged QT interval)
   • Correct electrolyte abnormalities promptly 3

Special Considerations

• Older patients: May have higher risk due to comorbidities and reduced physiological reserve 1
• Severely malnourished: May require even more cautious refeeding approach 6
• Recent evidence: Higher-calorie protocols (1,500 kcal) may be safe in some adult patients with eating disorders, with potentially lower risk of hypoglycemia than traditional low-calorie approaches 7

Pitfalls to Avoid

• Starting nutrition without prophylactic electrolyte supplementation
• Failing to administer thiamine before initiating nutrition
• Increasing caloric intake too rapidly
• Inadequate monitoring of electrolytes, especially in the first 72 hours
• Overlooking refeeding risk in obese patients who may still have malnutrition 1

By following this structured approach to refeeding in at-risk patients, clinicians can minimize the potentially life-threatening complications of refeeding syndrome while effectively addressing malnutrition.