Refeeding Syndrome
24/8/10
Boateng, B.S., et al (2010) “Refeeding syndrome: Treatment considerations based on
collective analysis of literature case reports” Nutrition 26:156-167
Ormerod, C. et al (2010) “Refeeding syndrome: a clinical review” British Journal of Hospital
Medicine, Vol 71 (12) page686-690
RFS
= a group of clinical findings that occur in severely malnourished individuals undergoing
nutritional support.
- more common than we think.
- prolonged starvation -> provision of nutritional supplementation from any route.
- chronic malnutrition leads to protein catabolism with total body phosphate depletion despite
normal serum phosphate
- introduction of carbohydrates leads to an anabolic state which unmasks total body
phosphate depletion and leads to precipitous drop in serum phosphate
- insulin + glucose = massive uptake of phosphate, K+ and Mg2+ into cells
RISK FACTORS – any one who may be malnourished:
Decreased intake
-
eating disorders
alcoholism
depression
fasting
vomiting
dysphagia
Crohns
malabsorption
chemotherapy
short bowel syndrome
prolonged NBM
bariatric surgery
Increased catabolism
- inflammatory process
- cancer
CLINICAL FEATURES
CVS: arrhythmia, HT, CHF
GI: abdo pain, constipation, vomiting, anorexia
MUSCU: weakness, myalgias, rhabdomyolysis, osteomalacia
Jeremy Fernando (2011)
RESP: SOB, ventilator dependence, respiratory muscle weakness -> requiring intubation and
ventilation
NEURO: weakness, paraesthesia, ataxia, delirium, coma, central pontine myelinosis, seizures,
Korsakoff’s syndrome or Wernicke’s encephalopathy (confusion, ataxia, ophthalmoplegia)
METABOLIC: infections, thrombocytopaenia, haemolysis, anaemia
HAEM: reduced 2,3 DPG production -> left shift of oxyHb dissociation curve
OTHER: ATN, Wernicke’s encephalopathy, liver failure
INVESTIGATIONS
-
hypophosphataemia
hypokalaemia
hypomagnesaemia
hyperglycaemia
thiamine deficiency (erthryocyte transketolase or thiamine level)
trace elements deficiencies
MANAGEMENT
Summary of Management
Jeremy Fernando (2011)
(1) recognize patients at risk
(2) provide adequate electrolytes, vitamin (thiamine, water and fat soluble) and micronutrient
(Zn, Fe, Se) supplementation
(3) careful fluid resuscitation to avoid fluid overload
(4) cautious and gradual energy restoration
(5) monitoring of critical laboratory indices
Resuscitate
A – may need intubation for encephalopathy and bulbar dysfunction with aspiration
B – ventilation because of respiratory muscle weakness with hypercapnic respiratory failure
C – correction of electrolytes c/o arrhythmias, cautious slow volume resuscitation, central
access and invasive monitoring if haemodynamically unstable
D – may have profound weakness, cerebellar dysfunction, delirium and coma -> responds to
slow correction of electrolytes
Electrolyte abnormalities + Acid Base Disturbance
Hypophosphataemia (<1.0 mmol/L) – replace either IV or PO
Hypokalaemia (<3.5mmol/L) – replace IV or PO
Hypomagnesaemia (<0.7mmol/L) – replace IV or PO
Hyponatraemia – don’t correct rapidly unless symptomatic (less than 10mmol/L/day)
Hyperglycaemia - monitor -> insulin if required
Anti-dote
Nil – supportive care
Underlying cause
- screen those at risk
Feed
-
<20% of basal energy expenditure to start
10kcal/kg/day
aim to get to normal nutrition over 1 week
titrate feed to resolution of symptoms and laboratory parameters
Vitamins (minimum of 10 days)
Vitamin B1 (thiamine) – 300mg IV LD prior to starting nutrition -> 100mg/day
Vitamin B6 (pyridoxine) – 1.7mg/day
Vitamin B12 (cobalamine) – IM injection
Folate – 400mcg/day
Fat soluble vitamins – DEKA – can be replaced via feed
Micronutrients
Selenium – 100-400mcg/day LD -> 20-70mcg/day
Zinc – 10-30mg/day LD -> 2.5-5mg/day
Iron – no loading dose required -> 10mg/day PO
Jeremy Fernando (2011)
Disposition
- managed in an HDU/ICU environment if severe
Jeremy Fernando (2011)