From the Guidelines
Refeeding syndrome is a potentially life-threatening condition that occurs in individuals who are malnourished or have undergone significant caloric restriction, upon reintroduction of nutrition.
Characteristics of Refeeding Syndrome
It is characterized by severe shifts in electrolytes, including:
- Hypophosphatemia
- Hypokalemia
- Hypomagnesemia which can lead to:
- Cardiac arrhythmias
- Respiratory failure
- Other complications 1, 2.
Risk Factors
The risk of developing refeeding syndrome increases with the degree of the patient's nutritional depletion 1, 3.
Treatment
Treatment involves gradual reintroduction of calories, typically starting with 10-20 kcal/kg/day, and close monitoring of electrolyte levels, with supplementation of:
- Phosphorus
- Potassium
- Magnesium as needed, such as: + Potassium phosphate 1-2 mmol/kg/day + Magnesium sulfate 1-2 g/day 1, 4, 5.
Prevention
Prevention of refeeding syndrome is crucial, and it is recommended to:
- Screen patients at risk for refeeding syndrome, including those with: + Chronic insufficient dietary intake + Uncontrollable malabsorption + Severe chronic undernutrition + Anorexia nervosa + Depleted patients with acute illness 2, 3
- Start nutritional support with a hypocaloric diet and increase step by step over five to ten days, according to the individual’s risk of the refeeding syndrome and clinical features 3. It is also important to supply vitamin B1 in daily doses of 200-300 mg as well as a balanced micronutrient mixture 1, 5.
Monitoring
Close monitoring of electrolyte levels, including potassium, phosphate, and magnesium, is essential to prevent and manage refeeding syndrome 1, 4, 5. By following these guidelines, healthcare professionals can help prevent and manage refeeding syndrome, reducing the risk of complications and improving patient outcomes 1, 2, 3.
From the Research
Definition and Characteristics of Refeeding Syndrome
- Refeeding syndrome (RS) is characterized by electrolyte imbalances that can occur in malnourished and abruptly refed patients 6.
- Typical features of RS are hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency 6, 7, 8.
- It is a potentially life-threatening condition that can affect both adults and children, although there is scarce evidence in the pediatric literature 6.
Risk Factors and Prevention
- Risk factors for the syndrome include starvation, chronic alcoholism, anorexia nervosa, and surgical interventions that require lengthy periods of fasting 8.
- Prevention of the syndrome includes identification of individuals at risk, controlled hypocaloric nutritional intake, and supplementary electrolyte replacement 8, 9.
- A proper strategy should start with small amounts of low-calorie fluids and gradually increasing the calorie content and amount of food over several days 6.
- Close monitoring of electrolyte levels is critical, and prophylactic use of dietary supplements such as thiamine may be required to correct any imbalances that may occur 6, 9.
Clinical Manifestation and Treatment
- The presence of various accepted RS definitions and the inclusion of heterogeneous patient populations in the literature has led to discrepancies in reported incidence rates in patients requiring treatment at an intensive care unit (ICU) 7.
- RFS may provoke seizures and acute encephalopathy and can be considered an internal severe neurotrauma in need of specific treatment 10.
- Refeeding syndrome is a rare, potentially life-threatening, condition seen in malnourished patients starting refeeding, and it is of utmost importance to recognize this rare syndrome and to treat appropriately 10.
- Screening for RFS using simple diagnostic criteria based on serum phosphate levels identified critically ill patients with an increased demand for electrolyte substitutions 7.