Review of the Refeeding Syndrome

Abstract

Refeeding syndrome describes a constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. We reviewed literature on refeeding syndrome and the associated electrolyte abnormalities, fluid disturbances, and associated complications. In addition to assessing scientific literature, we also considered clinical experience and judgment in developing recommendations for prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk for developing refeeding syndrome, institute nutrition support cautiously, and correct and supplement electrolyte and vitamin deficiencies to avoid refeeding syndrome. We provide suggestions for the prevention of refeeding syndrome and suggestions for treatment of electrolyte disturbances and complications in patients who develop refeeding syndrome, according to evidence in the literature, the pathophysiology of refeeding syndrome, and clinical experience and judgment.

Refeeding hypophosphatemia: a potentially fatal danger in the intensive care unit

“…Hypophosphatemia is commonly missed due to nonspecific signs and symptoms and phosphorus level measurements are not included in most of the biochemistry panels (8 Hypophosphatemia can result in cardiac arrhythmia, respiratory failure, rhabdomyolysis, and confusion (14)(15)(16). Hypopotassemia may lead to muscle paralysis, rhabdomyolysis, muscle necrosis, respiratory failure, and myocardial contraction disorders and hypomagnesemia may cause changes in electrocardiography, tetanus, and convulsions (19). Altered diaphragmatic contractility, respiratory muscle fatigue, and respiratory failure were detected in the patients with malnutrition and hypophosphatemia, which resulted in longer durations of mechanical ventilation (20)(21)(22)(23).…”

Risk factors for gastrointestinal complications in critically ill children with transpyloric enteral nutrition

“…We have found no previous references to associations of these alterations with gastrointestinal complications in critically ill patients. Both alterations can reduce intestinal motility and increase abdominal distention However, it is also possible that hypokalemia and hypophosphatemia are secondary to gastrointestinal intolerance or refeeding (Marik and Bedigian, 1996;Kraft et al, 2005), or owing to catecholamine administration (Body et al, 1983) or high cytokine levels (Barak et al, 1998).…”

Metabolic and Nutrition Support in the Chronic Critical Illness Syndrome

“…For these reasons precautions must be taken when instituting nutrition support in patients at high risk for the refeeding syndrome. 53 …”

“…If refeeding syndrome is suspected, then carbohydrate should be limited until the phosphate levels have stabilized. 53 Vitamin D should be started in all cases of hypophosphatemia, due to the high prevalence of this deficiency among all hospital patients and particularly among CCI patients. 28 Careful attention should be paid to signs of overfeeding, with timely reduction of nutrients when indicated.…”