Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment

Abstract

The refeeding syndrome is a potentially lethal complication of refeeding in patients who are severely malnourished from whatever cause. Too rapid refeeding, particularly with carbohydrate may precipitate a number of metabolic and pathophysiological complications, which may adversely affect the cardiac, respiratory, haematological, hepatic and neuromuscular systems leading to clinical complications and even death. We aimed to review the development of the refeeding syndrome in a variety of situations and, from this and the literature, devise guidelines to prevent and treat the condition. We report seven cases illustrating different aspects of the refeeding syndrome and the measures used to treat it. The specific complications encountered, their physiological mechanisms, identification of patients at risk, and prevention and treatment are discussed. Each case developed one or more of the features of the refeeding syndrome including deficiencies and low plasma levels of potassium, phosphate, magnesium and thiamine combined with salt and water retention. These responded to specific interventions. In most cases, these abnormalities could have been anticipated and prevented. The main features of the refeeding syndrome are described with a protocol to anticipate, prevent and treat the condition in adults.

Vitamin B1 in critically ill patients: needs and challenges

“…As glycolysis is re-engaged when initiating refeeding the requirement of thiamine-dependent enzymes intensifies, exhausting any thiamine stores available, potentially leading to the associated metabolic and neurological complications of TD. Although there is no direct evidence that links thiamine supplementation to improving the status of RFS, recommendations from case reports, reviews and guidelines all support thiamine administration prior to commencing and during the course of refeeding [2,50,51,71,[106][107][108]. In addition, parenteral or enteral refeeding is one of the main risk factors associated with RFS, along with alcoholism, post-bariatric surgery, cancer and anorexia [101].…”

Symposium 5: Joint BAPEN and Nutrition Society Symposium on ‘Feeding size 0: the science of starvation’ Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock

“…What is apparent is that there are many lessons to be learned across the specialities, from Africa to UK and vice versa. The clinical experience of managing severe malnutrition in Africa, which is complicated by severe electrolyte perturbations, shock and complex complications of gastroenteritis, have also been highlighted in the management of difficult complex gastroenterological and nutritional problems and the refeeding syndrome (40) . The risk of development of the refeeding syndrome was discussed and common factors identified, Simultaneous measurement of cardiac output (CO; using an ultrasound cardiac monitor (USCOM ultrasonic cardiac output monitor; USCOM Ltd, Sydney, NSW, Australia)) and systemic vascular resistance (SVR; which is computed by the USCOM ultrasonic cardiac output monitor using anthropometric data) in children with clinical features of shock just before or after fluid resuscitation stabilisation, which shows evidence of underfilling of the intravascular compartment.…”

“…including the severity of the underlying malnutrition, overaggressive nutritional support in the early stages before adequate supplements of phosphate, thiamine, K and Mg and associated conditions that exacerbate micronutrient, electrolyte and mineral depletion (40) .…”

Incidencia de hipofosfatemia en pacientes ingresados no críticos con nutrición enteral

“…Esto está en relación con diversos factores, como el tipo de población analizada, el tipo de soporte nutricional que recibían los pacientes, el punto de corte de fosfato sérico por debajo del que se recogían datos, etc. Muchos de los resultados de que se dispone proceden de trabajos diseñados para el estudio del síndrome de realimentación, para el cual es difícil dar una definición precisa y que posee un amplio espectro de presentación, desde casos asintomáticos hasta otros con síntomas peligrosos para la vida (12). En este sentido, Skipper, en una revisión sistemática sobre el tema, plantea la pregunta de si sería necesaria una nueva definición de síndrome de realimentación y distinguirlo de la hipofosfatemia de realimentación (13).…”