Wacker: Refeeding Syndrome: Recognizing and Treating

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