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Refeeding Syndrome

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphataemia. However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia. Patients with a history of alcohol abuse, anorexia nervosa, or little or no nutritional intake for the last 5-7 days are at particular risk.

Awareness of refeeding syndrome and identification of patients at risk is crucial as the condition is preventable and the metabolic complications are avoidable. The triad of confusion, ataxia, and ophthalmoplegia in Wernicke's encephalopathy can present if refeeding syndrome is not suspected and managed appropriately.

There is a high risk of developing refeeding problems if:

• One or more of the following:
  • BMI <16 kg/m².
  • Unintentional weight loss >15% within the last 3-6 months.
  • Little or no nutritional intake for more than 10 days.
  • Low levels of potassium, phosphate, or magnesium prior to feeding.
• Or if two or more of the following:
  • BMI <18.5 kg/m².
  • Unintentional weight loss >10% within the last 3-6 months.
  • Little or no nutritional intake for more than 5 days.
  • A history of alcohol abuse, anorexia nervosa or drugs including insulin, chemotherapy, antacids, or diuretics.

Management

For patients who are at risk of refeeding syndrome:

• Check Na, K, Ca, PO₄, and Mg.
• Before feeding starts, give:
  • Thiamine 100 mg IV or PO, then thiamine 100 mg PO or IV TDS for 3 days.
  • Vitamin B Complex 2 tabs PO BD. This preparation contains vitamins B1, B2, B3, and B6.
  • A multivitamin preparation should also be given once daily.
  • Vitamin supplementation should be discontinued 5 days after feeding is established unless patient is severely malnourished.

For severely affected patients or if Wernicke's encephalopathy is suspected:

• Check Na, K, Ca, PO₄, and Mg.
• Before feeding starts, give:
  • Thiamine 400 mg IV or IM, followed by thiamine 400 mg IV or IM TDS for 2 days. Then give thiamine 200 mg IV or IM daily for a further 5 days.
  • Vitamin B Complex 2 tabs PO BD. This preparation contains vitamins B1, B2, B3, and B6.
  • Continue with thiamine 100 mg PO BD and Vitamin B Complex 2 tabs PO BD and multivitamin tablets until signs resolve or plateau.

Contact dietitian to start feeding.

• Rehydrate carefully. Avoid use of IV glucose (glucose load may induce refeeding syndrome). IV rehydration will need to be given via an infusion pump.
• Supplement and/or correct levels of the following unless prefeeding levels are high:
  • Potassium: suggest 2-4 mmol/kg/day PO or IV.
  • Phosphate: 0.3-0.6 mmol/kg/day PO (sodium acid phosphate) or IV (potassium dihydrogen phosphate).
  • Magnesium: 0.2 mmol/kg/day IV or 0.4 mmol/kg/day PO.
  • Calcium supplements may also be needed.

    Note: Approximate conversions mmol to mg are: phosphate 1 mmol ≈ 31 mg, potassium 1 mmol ≈ 39 mg, and magnesium 1 mmol ≈ 24 mg.

    Note: For further management of phosphate and magnesium replacement and PN in general, refer to the guidelines available in the Surgical Progressive Care Unit (SPCU) which is in Ward 15.

• Monitor Na, K, PO₄, Ca, and Mg for the first 2 weeks and amend treatment as appropriate.

References:

Mehanna et al BMJ 2008;336: 1495-1498.

K Sriram, W. Manzanares, K Joseph, Thiamine in Nutrition Therapy Nutrition in Clinical Practice 2012; Vol27(1)41-50

Topic Code: 17211