From the Guidelines
Refeeding syndrome can be prevented by introducing nutrition slowly in at-risk patients, starting at about 25% of caloric needs and gradually increasing over 3-7 days, while closely monitoring electrolytes, as recommended by the most recent guidelines 1. To manage refeeding syndrome, it is essential to identify high-risk patients, including those with significant weight loss, minimal or no nutritional intake for more than 5 days, or those with conditions such as alcoholism, anorexia nervosa, or chronic malnutrition. The syndrome develops because refeeding triggers insulin release, causing rapid shifts of phosphate, potassium, magnesium, and thiamine into cells, leading to dangerously low serum levels 1. Preventive management includes:
- Daily supplementation with thiamine (200-300mg) and multivitamins
- Careful electrolyte replacement:
- Phosphate (0.3-0.6 mmol/kg/day) 1
- Potassium (2-4 mmol/kg/day) 1
- Magnesium (0.2 mmol/kg/day if supplied intravenously or 0.4 mmol/kg/day if supplied orally) 1 Electrolytes should be monitored daily for the first week, with particular attention to phosphate levels, which typically drop within 48-72 hours of refeeding. Clinical manifestations of refeeding syndrome include cardiac arrhythmias, respiratory failure, seizures, and neuromuscular dysfunction, which can develop rapidly and lead to multi-organ failure if not promptly addressed. In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, home enteral nutrition (EN) or parenteral nutrition (PN) may be recommended in suitable patients 1.
From the Research
Risks of Refeeding Syndrome
- Refeeding syndrome is a potentially fatal condition that can occur in malnourished patients when feeding is commenced after a period of starvation 2
- The syndrome is characterized by hypophosphatemia, electrolyte shifts, and metabolic and clinical complications 2
- High-risk patients include the chronically under-nourished and those with little intake for greater than 10 days 2
- Patients with dysphagia are at particular risk 2
- Electrolyte abnormalities, such as hypophosphatemia, hypomagnesemia, and hypokalaemia, can occur in patients commencing total parenteral nutrition (TPN) despite nutritional assessment, treatment, and follow-up in accordance with national recommendations 3
Management Strategies
- Awareness and identification of at-risk patients is crucial to improving management 2
- Refeeding should commence at 10 kcal/kg per day in patients at risk, and increased slowly 2, 4
- Thiamine, vitamin B complex, and multi-vitamin supplements should be started with refeeding 2, 5
- Initial measurement of thiamine level and serum electrolytes, including phosphate and magnesium, and their supplementation if necessary, play an important role in preventing refeeding syndrome 6
- Close monitoring of serum electrolytes is essential during the refeeding process 6, 4
- 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 4