Refeeding Syndrome

Refeeding Syndrome
1. Metabolic imbalance complicating initial refeeding of a severely malnourished patient
2. Occurs in first 7 days (typically first 3 days) if refeeding is too aggressive
3. Results in severe Electrolyte abnormalities with risk of Cardiac Dysrhythmias and death

Severely malnourished patients are starting with depleted energy and Electrolyte stores
1. Energy stores including glycogen, adipose tissue and Muscle are depleted
2. Electrolytes including Potassium, Magnesium and Phosphorus are depleted
3. Thiamine deficiency
High Caloric Intake reintroduced in a severely malnourished patient (e.g. Anorexia Nervosa)
1. Metabolism shifted to anabolic from catabolic
2. Triggers Insulin release
3. Insulin promotes intracellular shifts of Potassium, Magnesium, Phosphorus and water
4. Insulin stimulates glycogen, fat, and Protein synthesis and further depletes Electrolytes
Abrupt Electrolyte shifts result in potentially life-threatening complications
1. Hypophosphatemia results in diminished ATP and Muscle Weakness
2. Hypokalemia may result in Arrhythmias, Muscle Weakness and ileus
3. Hypomagnesemia risks Arrhythmias and Seizures
Fluid balance also shifts with refeeding
1. Risk of Fluid Overload (Congestive Heart Failure, Pulmonary Edema)

Rapid weight loss prior to refeeding
Rapid refeeding
Severe malnourishment
1. Body Mass Index <16 kg/m2
2. Unintentional Weight Loss >15% in the past three to six months
3. Minimal nutritional intake for >10 days
Preexisting Electrolyte deficiency prior to starting refeeding
Comorbidity
1. Chronic Malnutrition
2. Anorexia Nervosa
3. Alcoholism
4. Elderly
5. Postoperative patients
6. Diabetes Mellitus
7. Cancer
8. Morbidly obese patients with profound weight loss
9. Malabsorption (e.g. Inflammatory Bowel Disease, Cystic Fibrosis, Chronic Pancreatitis, short bowel syndome)
10. Long-term Diuretic use
11. Long-term Antacids (Magnesium or aluminum salts)

Monitor inpatients on telemetry
Electrocardiogram findings with risk of cardiovascular collapse
1. Prolonged QT interval (Risk of sudden death)
2. Bradycardia with Heart Rate <40 beats per minute

Obtain baseline labs prior to refeeding and monitor during refeeding
Avoid excessive Intravenous Fluids
Before starting refeeding
1. Normalize Electrolytes
2. Thiamine 300-400 mg daily orally
3. Vitamin B supplementation
Initiate weight gain slowly
1. See Anorexia Nervosa for management
2. See Specialized Nutritional Support
3. Start refeeding at one third or less of nutritional needs and gradually increase every 5-7 days
4. Limit initial Energy Intake to 20 to 25 kcal/kg/day
5. Early Consultation to nutrition specialist