Jo Prickett

8/2/2019 Jo Prickett

1/19

Refeeding Syndrome

Joanna Prickett

North Bristol NHS Trust


2/19

Definition

Severe fluid and electrolyte shifts andrelated metabolic complications in

malnourished patients undergoing

refeeding.


3/19

Consequences of Starvation

Decreased insulin and increased glucagon secretion. With aswitch from glucose towards ketone bodies as a source ofenergy

Glycogen stores used

BMR decreases

Brain adapts to using ketones

Atrophy of all organs

Reduced Lean Body Mass

Abnormal liver function


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Consequences of starvation

Deficiency of vitamins and trace elements

Whole body depletion of potassium, magnesium and phosphate

Increased intracellular and whole body sodium and water

Impaired cardiac, intestinal and renal reserve, leading to reduced

ability to excrete excess sodium and water

Serum concentrations of electrolytes maintained within normal limits


5/19

Refeeding

Increased insulin release leads to increased

uptake of glucose, phosphate and potassium

into cells. Magnesium is used as a co-factor for

cellular pump activity

Reactivation of the Na/K membrane pump leads

to further movement of K into cells with asimultaneous movement of sodium and fluid out

of cells


6/19

Refeeding

Reduced phosphate is associated withincreased urinary magnesium excretion

Stimulation of protein synthesis leads toincreased anabolic tissue growth which in turnleads to increased cellular demand forphosphate, potassium, glucose and water


7/19

Refeeding

Excess glucose can lead to hyperglycaemia and

fat abnormalities

Reduced sodium and water excretion

Increased cellular thiamine utilisation due to its

role as a co-factor for carbohydrate metabolism


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Consequences of electrolyte

abnormalitiesElectrolytes Consequence

PO4 Acute ventilatory failureArrythmias

Confusion

Congesive heart failure

Lethargy, weaknessRhabdomyolysis

K+ Arrythmias

Cardiac arrestConstipation / ileus

Polyuria / polydipsia

Respiratory depressionWeakness

Mg+4 Anorexia

ArrythmiasConfusion

Diarrhoea / constipation

Weakness


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Incidence

0.2-5% hospital patients have

hypophosphataemia

Incidence is increased in certain groups

Incidence in patients receiving nutrition support

has been reported to be 30-40%


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Patients at Risk of Refeeding

Those who have had very little or no food

intake for >5 days especially if alreadyundernourished (BMI 5% within the

last 3-6 months)


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Patients at High Risk of

RefeedingPatients with any of the following:

BMI < 16 kg/m2

Unintentional weight loss >15% within the last 3-6

months

Very little or no nutrition for >10 days

Low levels of potassium, magnesium or phosphate

prior to feeding


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Patients at High Risk of

RefeedingPatients with 2 or more of the following:

BMI < 18.5 kg/m2

Unintentional weight loss >10% within the last 3-6

months

Very little or no nutrition for >5 days

A history or alcohol abuse or some drugs including

insulin, chemotherapy, antacids or diuretics


13/19

Feeding patients who are at

riskIntroduce feeding at maximum 50% of total energy

requirements for the first 2 days before increasing to full

requirements if no biochemical abnormalities

Meet full requirements for fluid, electrolytes, vitamins and

minerals from day 1 of feeding

Monitor appropriate biochemistry including potassium,phosphate and magnesium (see chapter on monitoring)


14/19


high riskConsider starting nutrition at maximum 10

kcal/kg and increase slowly to meet full

requirements by 4-7 days.

Any increase in feed should be dependent on

trends in biochemistry


15/19


high riskPotassium, magnesium and phosphate supplementation

from the outset (unless blood levels are already high):

Potassium (likely requirement 2-4 mmol/kg/day)Magnesium (likely requirement 0.2 mmol/kg/day

IV, 0.4 mmol/kg/day oral)

Phosphate (likely requirement 0.3-0.6

mmol/kg/day)


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high riskImmediately before and during first 10 days of feeding:

Oral thiamine 200-300mg/day

Vitamin B co strong 1-2 tds or full dose IV vitamin

B

Multivitamin and trace element supplement

Restore circulatory volume and monitor fluid balance

closely

Monitor appropriate biochemistry including, potassium,

phosphate and magnesium


17/19


high riskIn extreme case eg

BMI 15 days

Pre-feeding Hypokalaemia, hypophosphataemia or

hypomagnesaemia

Consider starting feed at 5kcal/kg

It is not necessary to correct electrolyte levels prior to

feeding if this cautious approach is used


18/19


high riskBeware of very malnourished, dehydrated patients with

renal impairment and consequently normal or high

potassium and phosphate levels.

It is also easy to overlook significant renal impairment in

patients with very low BMI and recent starvation who have

very low creatinine and urea production.


19/19

References

Brook M.J. & Melnik G 1995. The Refeeding Syndrome: An approach tounderstanding its complications and preventing it occurrence. Pharmacotherapy15(6):713-26.

Crook M.A. et al 2001. The importance of the Refeeding Syndrome. Nutrition

17:632-7.

Keys A. et al 1950. The Biology of Human Starvation vols 1,2. MinneapolisUniversity of Minnesota Press.

Marinella M.A. 2003. The Refeeding Syndrome and Hypophosphataemia. NutritionReviews 61(9):320-3.

NICE 2006 Nutrition Support in Adults

Solomon S.L. et al 1990 The Refeeding Syndrome: A Review. J. Parent. & EnteralNutrition 14(1):90-7.

Terelevich A. et al 2003. Refeeding Syndrome: Effective and safe treatment withphosphates polyfusor Aliment Pharmacol Ther 17:1325-1329

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