REFEEDING SYNDROME GUIDELINE

t FOR ADULTS
What is Refeeding Syndrome?

Refeeding is potentially a fatal condition defined by severe electrolyte

and fluid shifts as a result of a rapid reintroduction of nutrition after a Nutritional Support
period of inadequate nutritional intake. The route of nutrition does not
affect the risk of refeeding , therefore oral, enteral and parenteral All initiation of feeding should be slow and cautious whether oral,
nutrition can precipitate refeeding in severely starved patients. Risk enteral or parenteral.
can be categorised as; at risk, high risk or severe risk. Refer all patients to the dietitian RSCH ext 4290, PRH ext 8313

What are the clinical features? Parenteral nutrition

 Hypokalaemia  Hyperglycaemia PN is never started out of hours with the exception of patients in critical
 Hypomagnesaemia  Cardiac arrhythmias care.
 Hypophosphataemia  Fluid imbalances
 Encephalopathy  Pulmonary oedema Enteral nutrition
(Wernicke – Korsakoff)  Cardiac failure
The following regimen can be initiated if out of hours.
 Refer to the NG care bundle and to the dietitians ‘Out of Hours’
Management of a patient at risk of refeeding: enteral regimes available on the wards
 In all enterally fed patients continue with the same regimen daily
All Patients until dietetic assessment
 If a patient is on a fluid restriction ensure the total volume of the
 Monitor U&E, Mg, Ca and PO 4 prior to feeding and daily until feed and flushes administered does not exceed the restriction
stable.
 Commence correction of electrolyte deficits prior to feeding if Oral nutrition
possible, peripheral replacement may be suitable (see overleaf).
You do not need to delay feeding as long as correction of  All patients should be allowed to continue eating and drinking as
deficits has started. they have done previously just prior to admission if it is
 Monitor blood glucose QDS until established on full feeding considered to be safe. If there are any concerns please consider a
regimen (the dietitian will advise when to discontinue SALT assessment
monitoring)  Avoid supplement drinks as these may precipitate re-feeding due
 Monitor fluid balance closely and keep a 24 hour record chart to calorie load (unless prescribed by a dietitian).
 In patients at high and severe risk, limit all oral intake during
Catagorising Refeeding Risk initial 24 hours of refeeding
 Accurately record all oral intake on fluid balance sheet and food
Completion of the MUST tool, food history charts and a weight record chart
history will help with this assessment

Patients who should be considered at risk of refeeding

 Little or no nutritional intake for more than 5 days Vitamin supplementation for patients at high or severe risk

Patients who should be considered at high risk of refeeding Vitamins should be started preferably on the day that feeding is due to
One or more of the following: be reintroduced and at least 30 minutes prior to any nutritional support.
 Little or no nutritional intake for more than 10 days (Alcohol withdrawal patients with suspected Wernickes may require
 BMI < 16 higher doses of Pabrinex. ITU may also use higher doses)
 Unintentional weight loss of more than 15% within the previous
3-6 months. Intravenous
 Low K, Mg, PO4 prior to feeding  Pabrinex I+II once daily for 3 days OR

Two or more of the following: Oral

 Little or no nutritional intake for more than 5 days  Thiamine 100mg BD for 10 days,
 BMI < 18.5  Vitamin B Co Strong 1 TDS for 10 days
 Unintentional weight loss of more than 10% within the previous  Forceval capsule 1 OD for 10 days OR
3-6 months.
 History of alcohol abuse or drugs including insulin, Enteral
chemotherapy, antacids or diuretics  Thiamine 100mg BD for 10 days (dispersed in 20mls water
in a 60ml syringe)
Patients who should be considered at severe risk of refeeding  Forceval soluble 1 OD for 10 days, dispersed in 20ml water in a
 BMI <14 60ml syringe) or Dalivit 0.6ml OD for 10 days
 Little or no intake for more than 15 days
(Oral or enteral supplementation is not necessary after IV Pabrinex)

1 of 2
 ELECTROLYTES IN REFEEDING SYNDROME
 Electrolyte levels are likely to drop when feeding is reintroduced as the electrolytes move from extracellular to intracellular
compartments.
 Ensure you take into account all fluids given (TPN, oral intake, electrolyte supplementation and IV drugs) when assessing a
patients fluid and electrolyte requirements.
 The oral route can be used if available and appropriate, though be aware oral absorption will be low and erratic and might not be
suitable for more urgent supplementation and IV supplementation will be more suitable if the pre-feeding levels are significantly
low or there is a significant drop once feeding is started
 Feeding does not need to be withheld until electrolytes are corrected
 Supplementation should be started prior to feeding and continued whilst the feeding depending on the access
 All the electrolyte doses below can be given either peripherally or centrally
 Consider critical care referral if severe risk of re-feeding syndrome or unable to maintain electrolytes with peripheral regimes.

Check baseline U&Es, PO4, adj Ca & adj Mg (combined biochemistry code ‘TPN’) and LFTs prior to feeding.
Monitor daily until patient is stable

How to supplement electrolytes?

Please note that these levels of electrolyte replacement may not be suitable for cardiac, renal and critical care patients

Electrolyte Route Dose Comments

Potassium IV  20-40 mmol per litre over a minimum of 4  Always use premixed manufacturers bags
hours  Rate >20 mmol/hr need continuous ECG monitoring
 40mmol in 500ml is possible via a central  Check for hypomagnesaemia
line over a minimum of 4 hours if fluid over
loaded
PO  Sando K 2 tabs TDS  Each tablet contains: 12mmol K

Phosphate IV  See Phosphate Polyfusor prescription  500ml of a Phosphate Polyfusor contains:

https://nww.bsuh.nhs.uk/search/?q=phosphate  50mmol phosphate, 81mmol sodium, 9.5mmol
potassium
PO  Phosphate Sandoz 2 tabs TDS, review  Each tablet contains:
after 2/7 PO4 16.1mmol, Na 20.4mmol, K 3.1mmol
 May cause diarrhoea
Magnesium IV  8mmol magnesium sulphate 50% (4ml) in  Each 10ml vial contains 20mmol magnesium (ie.
100ml NaCl 0.9% over 1 hour. 2mmol/ml)
 If severe give 20mmol magnesium sulphate  Mg sulphate 50% must always be diluted, mix well to
50% (10ml) in a minimum of 250ml NaCl avoid ‘layering’
0.9% over 4 hours (longer slower infusions  Caution in renal patients
are more effective  Avoid in patients with heart block and myocardial
damage

PO  Mag glycerophosphate 8mmol TDS review  Each tablet contains 4mmol Mg

after 2/7  May cause severe diarrhoea
 Second line: Mg aspartate 1 sachet
(10mmol) BD review after 2/7
Calcium IV  Check Mg and replace first if deficient  Ca 10% (1g in 10ml) contains 2.25mmol Ca
 Give 10ml calcium gluconate 10% over of  Can be used undiluted
5minutes  ECG monitoring required during and after injection

Calcium PO  Calcichew tablets 1 TDS  Each tablet contain 12.5mmol Ca

 Caution may act as a PO4 binder in renal patients

Reference: NICE Nutrition Support in Adults, February 2006, SPS and

Medusa
2 of 2 Author: Tracey-Leigh Smalley, NST Pharmacist
Approved by DTC: July 2017
Review date: July 2019