Wacker: Refeeding Syndrome: Recognizing and Treating

Today we present a talk by David Wacker MD, PhD, one of our recently graduated University of Maryland EM/IM/CCM critical care fellows and new addition to the University of Minnesota. Today he presents a fantastic talk on what happens when we become TOO aggressive with ICU feeding. The history lesson alone is worth the listen, but it is a topic that is often overlooked and misdiagnosed. You might be surprised after this talk at just how many of these patients you have missed!

Clinical Pearls (assisted by David Wacker)

  • Starvation
    • Physiology and metabolism alter to an energy-conserving starvation state
      • Serum insulin levels decrease, and changes such as hypothermia, bradycardia, hypotension, and whole-body vitamin and electrolyte deficiencies develop
  • Refeeding
    • Insulin levels suddenly rebound → re-activation of previously dormant metabolic pathways →  increased consumption of already-depleted electrolytes and vitamins
    • Phosphorous is classically the most-affected
      • Often reaching life threateningly low levels, but potassium, magnesium, calcium and thiamine can also be deranged
    • Oliguria may result from increased sodium and water resorption in the kidney with carbohydrate refeeding
      • Fluid retention + cardiac atrophy occurring during starvation → acute heart failure and volume overload
    • Patients at risk for the refeeding syndrome:
      • Reduced BMI (< 18.5 kg/m2)
      • Significant weight loss (10% or more over 6 months)
      • Little or no nutrition for greater than 5 days
  • Avoidance of Refeeding Syndrome
    • Refeeding should begin slowly at no more than 10 Kcal/kg/day (5 Kcal/kg/day for severe cases)
      • Gradually increase over 7-10 days
      • If effects of refeeding develop, the rate of feeding should be decreased or paused and then restarted at a lower rate
    • Serum electrolytes (including calcium, magnesium, and phosphorous) should be monitored at least daily
      • Cardiac monitoring provided for severe cases
    • Thiamine, B vitamins, selenium and multivitamin supplementation x 10 days

Suggested Reading

  1. Khan LU, Ahmed J, Khan S, Macfie J. Refeeding syndrome: a literature review. Gastroenterol Res Pract. 2011;2011. [PubMed link]
  2. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008 Jun 28;336(7659):1495-8. [PubMed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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