Inpatient / Gastroenterology

Refeeding Syndrome

Last Updated: 1/26/2023

# Refeeding Syndrome


-- History: *** eating disorder, N/V/D, malignancy, GI disease; RFs: little/no nutrition for 5-10 days, older age, low BMI, low baseline electrolytes, unintended weight loss in short period of time, alcohol misuse

-- Clinical/Exam: *** tachycardia, tachypnea, edema; Phos – weakness, paresthesia, seizure, AMS, cramps; K and Mg – QTc, arrhythmia, weakness; Na retention (overload); Thiamine – Wernicke-Korsakoff, neuropathy

-- Data: *** K, Mg, Phos

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.



-- Monitor: BMP, Mg, Phos at least BID for 72 hours


-- Aggressive Repletion of K, Mg, Phos via IV

-- Thiamine and Multivitamin for all patients

-- Nutrition: reduced calories → full calorie goal over 5-10 days; reduce calories if the patient develops worsening edema

-- Na and fluid restriction for 7 days if c/f overload

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If You Remember Nothing Else

Refeeding syndrome is a life-threatening condition and is easily screened for, so its best to be over-cautious. The syndrome is the constellation of symptoms that occur with the depletion of electrolytes and vitamins associated with switching from a catabolic to an anabolic state. The biggest risks are arrythmias secondary to profound hypokalemia or hypomagnesemia. Trend BMP, Mg, and Phos BID for at least 72 hours, and slowly introduce calories or pull back if there is evidence of the syndrome developing.

Clinical Pearls

  • RFS reflects uncovered requirements when switching from a catabolic to an anabolic state with a depletion of electrolytes and vitamins, leading to symptoms related to their low states
  • Imminent RFS is diagnosed by phosphate decrease >30% from baseline or any two other lyte shifts below normal range within 72 hours of initiation of nutrition therapy; Manifest RFS is both the lyte shifts above and associated symptoms
  • Phosphate is a component of phospholipid membranes, RNA, and is involved with energy production and energy transfer (generation of ATP and creatinine phosphate), and regulation of release of oxygen from hemoglobin to tissues
  • Magnesium is a common co-factor in enzymatic processes including phosphorylating ADP to ATP
  • Potassium and Sodium maintain membrane gradients necessary for life – signal transduction, transport, etc.
  • High-risk patients can be treated prophylactically with thiamine, phosphate, and other lytes before starting

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