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Home | Articles | Gastrointestinal | Refeeding Syndrome

Refeeding Syndrome

Last updated 3rd December 2020

Who Is At Risk And Why?

  1. Frail elderly, those with chronic alcohol/drug problems, eating disorders, other malnourished states and those who have not eaten for >5 days.
  2. Carbohydrate repletion increases insulin production which increases cellular uptake of K, PO4 and Mg leading to hypokalaemia, hypophosphataemia and hypomagnesaemia

Consequences of Refeeding

  1. Cardiac eg arrhythmia
  2. Respiratory eg respiratory depression
  3. Hepatic eg liver dysfunction
  4. Renal eg decreased concentrating ability
  5. Gastrointestinal eg constipation or diarrhoea
  6. Neuromuscular eg lethargy, weakness, paralysis, rhabdomyolysis
  7. Haematological eg haemolytic anaemia, thrombocytopenia

Criteria for Determining Risk of Refeeding Syndrome

  1. Patient has one or more of the following:
    1. BMI less than 16 kg/m2unintentional weight loss >15% within the last 3–6 months
    2. little or no nutritional intake for more than 10 days
    3. low levels of potassium, phosphate or magnesium prior to feeding.
  2. Or patient has two or more of the following:
    1. BMI less than 18.5 kg/m2
    2. unintentional weight loss >10% within the last 3–6 months
    3. little or no nutritional intake for more than 5 days
    4. a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

General Recommendations

  1. Start nutrition support at a maximum of 10kcal/kg/day (roughly 50% of requirements), increasing levels slowly to meet or exceed full needs by 4–7 days
  2. Use only 5 kcal/kg/day in extreme cases eg BMI <14 kg/m2 or negligible intake for >15 days – these patients may require cardiac monitoring esp if have already developed dysrhythmia
  3. Provide B vitamins immediately before and during the first 10 days of feeding – see below
  4. Provide oral, enteral or IV supplements of potassium, phosphate and magnesium unless pre-feeding plasma levels are high – see below for doses.
  5. Monitor U&E, Ca, PO4, Mg and BG daily during first week

Vitamin Supplementation

  1. Give Thiamine as Pabrinex 1 pair of ampoules IV daily for 48 hrs or until oral Thiamine 50mg qds can be administered
  2. Should also give Forceval 1 capsule daily, together with Folic acid 5mg od if folate deficient. Oral supplements should be continued at discharge in patients who are malnourished or who have inadequate diets.

When to Replace Potassium

    1. Mild deficiency 3.0-3.5mmol/l – will require 60-80mmol/day initially using Sando K (12mmol/tab) or Slow K (8 mmol/tab) orally
    2. Moderate deficiency 2.5-3.0mmol/l – aim for 100-120mmol/day by oral or IV routes
    3. Severe deficiency <2.5mmol/l – will require IV potassium at 10-20mmol/hr to give 240-480mmol/day initially
    4. Click here for more details on treatment of hypokalaemia

 

When to Replace Phosphate

    1. Mild hypophosphataemia 0.6-0.7mmol/l – no treatment required
    2. Moderate hypophosphataemia 0.3-0.6mmol/l – give Phosphate Sandoz 1-2 tabs (16-32mmol) orally tds
    3. Severe hypophosphataemia <0.3mmol/l – give Addiphos 20ml (40mmol) IV over at least 4 hours. NB 20ml Addiphos contains 40mmol phosphate, 30mml potassium and 30mmol sodium.
    4. Click here for more details on treatment of hypophosphataemia

 

When to Replace Magnesium

    1. Mild hypomagnesaemia 0.6-0.7mmol/l – no treatment required
    2. Moderate hypomagnesaemia 0.4-0.6mmol/l and asymptomatic – try Magnesium glycerophosphate 1-2 tabs (4-8mmol) tds orally
    3. Severe hypomagnesaemia <0.4mmol/l or symptomatic – give 20mmol Mg as 50ml of 10% magnesium sulphate in syringe over 24 hours
    4. Click here for more details on treatment of hypomagnesaemia

 

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