Synopsis
Identify patients vulnerable to refeeding before calories increase, start nutrition and vitamins safely, and detect phosphate, potassium, magnesium, thiamine and fluid complications early.
- Refeeding syndrome is the potentially fatal fluid, electrolyte and vitamin disturbance that follows renewed nutrition after depletion; oral food, supplements, tube feed, PN and intravenous dextrose can all contribute.
- Carbohydrate-driven insulin release shifts phosphate, potassium and magnesium into cells, increases thiamine use and promotes sodium and water retention, impairing cardiac, respiratory and neurological function.
- NICE high risk includes any one of BMI below 16, weight loss above 15% in three to six months, minimal intake beyond ten days, or low pre-feeding potassium, phosphate or magnesium.
Key red flags
Arrhythmia, syncope, chest pain, hypotension or acute heart failure after feeding starts requires immediate monitoring, electrolyte assessment and senior resuscitation support.
Investigation priorities
Classify vulnerability before any meaningful rise in energy delivery.
Management branches
A depleted or recently underfed patient is about to receive additional oral, enteral or parenteral energy.
- Obtain reliable recent intake, weight-loss percentage, BMI, alcohol and medicine history, comorbidity and baseline potassium, phosphate, magnesium, glucose and renal function.
- Identify high or extreme risk using NICE criteria and notify the responsible nutrition-experienced clinician before calories are prescribed.
Key medicines
ThiamineGive 200 to 300 mg orally daily immediately before and during the first ten days of feeding, or use an appropriate intravenous vitamin preparation when required.
Balanced multivitamin and trace-element supplementProvide a complete daily preparation from the start of feeding for the early repletion period specified by NICE and local policy.