Medical Nutrition Therapy for
Refeeding Syndrome
Rachel Hammerling
Concordia College, Moorhead MN
Objectives
• Be able to describe refeeding syndrome
(RFS)
• Be able to describe the pathophysiology of
starvation
• Identify the main pathophysiologic features
of RFS
• Be able to identify signs & symptoms
• Identify recommended treatment &
standards of care
• Be able to explain ethical issues involved
with treatment & care
Discovery of RFS
• Observed & described after WWII
• Victims of starvation experienced
cardiac and/or neurologic dysfunction
– After being reintroduced to food
• Today, rarely see patients who are
severely malnourished, as WWII
victims were, in the 1st week
– Neurologic signs & symptoms develop
later
What is RFS?
• Potentially fatal shifts in fluids & electrolytes
• May occur in malnourished patients receiving
artificial refeeding
– Enterally or parenterally
• Complex syndrome
– Sodium & fluid imbalance
– Changes in glucose, protein, fat metabolism
– Thiamine deficiency
– Hypokalemia
– Hypomagnesaemia
Understanding Starvation
• Glucose = main fuel
– Shifts to protein & fat
• Insulin ↓ due to ↓ availability of glucose
• Catabolism of protein → loss of cellular &
muscle mass → atrophy of vital organs &
internal organs
• Respiratory & cardiac function ↓ due to
muscular wasting & fluid/electrolyte
imbalances
• Body is now surviving by slowly consuming
itself
How common is RFS?
• True incidence is unknown
• Study of 10,197 patients, incidence of
hypophosphatemia = 43 %
– Malnutrition one of strongest risk
factors
• Parenteral patients = 100% incidence
of hypophosphatemia
Pathogenesis
• Electrolytes & minerals involved
1)
2)
3)
4)
Phosphorus
Potassium
Magnesium
Glucose
Main Pathophysiologic
Features
• Disturbances of body-fluid
distribution
• Abnormal glucose & lipid
metabolisms
• Thiamine deficiency
• Hypophosphatemia
• Hypomagnesemia
• Hypokalemia
Disturbances of Body-Fluid
Distribution
• Can influence
body functions:
1) Cardiac failure
2) Dehydration or
fluid overload
3) Hypotension
4) Pre-renal
failure
5) Sudden death
• CHO refeeding
– ↓ water & sodium
excretion, resulting in
weight gain
• Protein & fat refeeding
– Result in weight loss &
urinary sodium
excretion
– Hypernatremia along
with azotemia &
metabolic acidosis
Abnormal Glucose & Lipid
Metabolisms
• Glucose
– Suppress gluconeogenesis → reduced AA
usage
• Less-negative N balance
– Hyperglycemia
• Glucose → fat (Lipogenesis)
– Hypertriglyceridemia, fatty liver, &
abnormal liver function tests
Thiamine Deficiency
• Can result in Wernicke’s encephalopathy or
Korsakov’s syndrome, associated with:
– Ocular disturbance
– Confusion
– Ataxia
• loss of ability to coordinate muscular movement
– Coma
– Short-term memory loss
– Confabulation
• Confusion of imagination with memory
Hypophosphatemia
• Predominant feature of RFS
• Impaired cellular-energy pathways
– Adenosine triphosphate
– 2,3-diphosphoglycerate
• Impaired skeletal-muscle function
– Including weakness & myopathy
• Seizures & perturbed mental state
• Impaired blood clotting processes &
hemolysis also can occur
Hypomagnesemia
• Most cases not clinically significant
• Severe cases:
– Cardiac arrhythmias
– Abdominal discomfort
– Anorexia
– Tremors, seizures, & confusion
– Weakness
Hypokalemia
• Features are numerous:
– Cardiac arrhythmias
– Hypotension
– Cardiac arrest
– Weakness
– Paralysis
– Confusion
– Respiratory Depression
Signs & Symptoms
• Electrolyte imbalance
– Hypokalemia
– Hypophosphatemia
– Hypomagnesemia
• REMEMBER: Even an overweight or
obese patient can be malnourished &
a victim for RFS
Identifying Patients at High Risk of
Refeeding Problems
• NICE Guidelines
(National Institute for Health & Clinical
Excellence)
• Either patient has 1 or more:
–
–
–
–
BMI <16
Unintentional weight loss >15% in past 3-6 mo
Little/no nutritional intake for 10 days
Low levels of potassium, phosphate, or magnesium before
feeding
• Or patient has 2 or more:
–
–
–
–
BMI <18.5
Unintentional weight loss >10% in past 3-6 mo
Little/no nutritional intake for >5 days
History of alcohol misuse or drugs
Patients at high risk:
•
•
•
•
Anorexia nervosa
Chronic alcoholism
Oncology patients
Postoperative
patients
• Elderly
• Uncontrolled
diabetes mellitus
• Chronic
malnutrition:
– Marasmus
– Prolonged fasting or
low energy diet
– Morbid obesity with
weight loss
• Long term antacid
users
• Long term diuretic
users
Gastrointestinal Fistula
patients
• Usually reveals chronic malnutrition
– Due to damaged Gl tract & severe
abdominal sepsis
• High risk for RFS
• Be aware of condition & treat the
same
– Diarrhea commonly occurs & can be
treated by enteral nutrition
Intervention: Objectives
1) Gradually correct starvation
– Use less than full levels of calorie & fluid
requirements
2) Advance calories & volume
– Monitor cardiac & respiratory side effects
3) Correct vitamin & mineral
deficiencies
– Especially with symptoms
Intervention: Objectives Cont.
4) Nutrition support in patients at risk
should be increased slowly
– Assuring adequate amounts of vitamins
& minerals
5) Organ function, fluid balance, &
serum electrolytes
– Monitor daily during 1st week & less
frequently after
Intervention: Objectives Cont.
6) Monitor for neurological,
hematological, & metabolic
complications
– Of hypokalemia, hypophosphatemia, &
hyperglycemia
7) Prevent sudden death
Intervention: Food & Nutrition
•
•
•
•
Begin 20 kcal/kg for 1st 3 days
Progress to 25 kcal/kg
Gradually ↑ by 7th day
Protein start slow, ↑ gradually
– To protect & restore lean body mass
• Restrict CHO to 150-200 g/day
– To prevent rapid insulin surge
• CHO in PN
– Initiate at 2 mg/kg/min
– Fat calories should make up the difference
Intervention: Food & Nutrition
• Maintain fluid balance
– Adjust when edema exists
• Adjust for sodium & potassium
– Depending on lab values until normal
• Supplements
– Thiamin
– Other vitamins & minerals as needed
Common Drugs Used
• Replacement of phosphorus,
potassium, & magnesium
• Insulin
– Used to correct hyperglycemia levels
– Monitor blood glucose levels during
refeeding
Recommendation for Phosphate
Phosphate
Dose
Maintenance requirement
0.3-0.6 mmol/kg/day orally
Mild hypophosphatemia
(0.6-0.85 mmol/l)
0.3-0.6 mmol/kg/day orally
Moderate hypophosphatemia
(0.3-0.6 mmol/l)
9 mmol infused into peripheral vein
over 12 hours
Severe hypophosphatemia
(<0.3 mmol/l)
18 mmol infused into peripheral vein
over 12 hours
Recommendation for
Magnesium
Magnesium
Dose
Maintenance requirement
0.2 mmol/kg/day intravenously
(or 0.4 mmol/kg/day orally )
Mild to moderate hypomagnesaemia Initially 0.5 mmol/kg/day over 24
(0.5-0.7 mmol/l)
hours intravenously, then 0.25
mmol/kg/day for 5 days
intravenously
Severe hypomagnesaemia
(<0.5 mmol/l)
24 mmol over 6 hours intravenously,
then as for mild to moderate
hypomagnesaemia (above)
Intervention: Nutrition
Education, Counseling, & Care
Management
• Focus on adequate nutrient intake
• Consider referral if food insecurity is
a concern
• Offer guidelines according to
discharge intervention plan
• Physician may suggest long-term
medication use or therapies
NICE Guidelines for Management
Ethical Issues with RFS
• Roles between dietitian, counselor,
nurse, doctor, and other professionals
• Working with anorexia patients,
oncology patients or older patients
• Ethnic & religious differences
– Muslim patients
– Non-English speaking patients
Summary Points
• RFS is caused by rapid refeeding after
a period of undernutrition
• Characterized by hypophosphatemia
• Patients at high risk: undernourished,
little or no energy intake for > 10 days
• Start refeeding at low levels
• Correction of electrolyte & fluid
imbalances before feeding IS NOT
necessary
References
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