25th July 2023

Acute Management

Patients at high risk of malnutrition must be identified early to prevent and monitor for refeeding syndrome. High risk patients include those who are frail, have existing comorbidities, low physiological reserve, chronic malnutrition, chronic alcoholism, postoperative and have long term use of antacids and antibiotics.

Refeeding syndrome is a potentially fatal condition that develops due to the shift of electrolytes and fluids in a malnourished patient post commencement of enteral or parenteral nutrition. Biochemically it can present as electrolyte deficiencies, namely hypophosphatemia, hypomagnesemia, and hypokalemia. Fluid balance abnormalities, abnormal glucose metabolism and thiamine deficiency, can also occur. Hence, patients should be assessed for dehydration, hypoglycaemia, anaemia, and infection alongside malnutrition.

To prevent refeeding syndrome:

• Check and correct electrolyte levels prior to commencement of nutrition, with subsequent daily checks for a week and at least three times the following week.
• Electrolyte supplementation, either orally, enterally or intravenously, should be given unless levels are high prior to commencement of nutrition.
• Refeeding started at no more than 50% of normal energy requirements in high-risk patients, i.e. in those who have eaten little or nothing for more than five days, with the aim to increase the rate if tolerated.
• For high-risk patients, nutritional energy repletion started slowly with a maximum of 10kcal/kg/24hrs, and the rate increased to meet full needs over 4-7 days.
• For Patients who are severely malnourished, i.e., BMI of 14 or less, or have had a negligible intake for two weeks or more, refeeding should start at a maximum of 5kcal/kg/24hrs with cardiac monitoring.