Definition

Refeeding syndrome encompasses a number of complications which can occur upon the feeding of malnourished patients.  Severe fluid and electrolyte shifts occur in the body in response to the supply of nutrients (oral, enteral or parenteral).  This can lead to cardiac, renal, respiratory, neuromuscular, metabolic, hepatic and gastrointestinal problems.

What happens during refeeding?

There is a switch from fat to carbohydrate metabolism – this causes an increased release of insulin as a result of the high glucose load.  There is an increased uptake of glucose, phosphorous, potassium, magnesium and water into the cells (intracellular) hence depleting levels in the blood.  Thiamine (vitamin B1) is an essential co-enzyme in carbohydrate metabolism, hence needs to be administered during the refeeding process.

Please follow the following steps 

1.Patients who are identified at risk of Refeeding Syndrome should be referred to the dietitian as soon as possible for full nutritional assessment.

2.Please discuss with the medical team regarding B vitamin supplementation i.e. Pabrinex ampoules I and II daily for 48-72hours.  

3.Please follow pathway overleaf to identify those patients who are at risk.

Step 1: Initial Referral to Dietitian - Identify “at risk” patients

Although the ICU setting is a more stable environment with regards to the monitoring of electrolytes and bloods sugars it is still important that all staff are aware of the risks of Refeeding Syndrome.   Please consider the following things prior to initiation of enteral or parenteral feeding in the ICU patient.

           *PLEASE OBTAIN RECENT BODY WEIGHT if possible*

Refer the patient to the dietitian on admission on ext: 54777 or bleep 1508 (JCUH), stating that the patient is at risk of refeeding syndrome and the reason for refeeding risk. 

Malnutrition is a long term problem which can not be corrected overnight.  Aggressive feeding can do more harm to the patient with malnutrition than withholding feeding or introducing feed slowly.

Even if the patients bloods are normal this does not exclude them from being at risk of refeeding syndrome.

Be aware that IV dextrose above 5% may exacerbate the refeeding syndrome.

Step 2

Follow step 2 and 3 of the pathway until the dietitian assesses the patient (refer to the flowchart).

                                                                                                   (click to enlarge)

IV drug administration guidelines

This is guidance for the administration of drugs when the patient who requires electrolyte supplementation in ICU.

Phosphate Supplementation

Central

Potassium acid phosphate (KHPO4) can be given as 40 mmols in 60mls of 0.9% NaCl and given over 6 hours using a central line.

Peripherally 

Phosphate polyfusor is given as 500mls this contains 81mmols of sodium, 9.1mmols o potassium, 50mmols of phosphate.  This is given over 6 hours using a peripheral line.

Potassium Supplementation

Central

Potassium chloride (KCl) can be given as 60mmols in 60mls of 0.9% NaCl and given over 6 hours, but can be given more quickly over 3 hours both ways through a central line.

Magnesium Supplementation

Central

Magnesium sulphate (MgSO4) can be given as 40mmols made up with 60mls of 5% glusose or 0.9% NaCl and given over 6 hours through a central line.

Peripherally

Magnesium sulphate (MgSO4) can be given as 40mmols made up with 250mls of 5% glusose or 0.9% NaCl and given over 6 hours through a peripheral line. 

Step 3: Emergency Enteral Feeding Regimen prior to Dietetic Assessment

Commence feeding as follows until seen by a dietitian.

Please correct any low levels of Mg, PO4 and K with medication (See Step 2)

*PLEASE OBTAIN RECENT BODY WEIGHT*

Stage 1: Feed at 10kcals/Kg body weight per day

Feed over 16 hours (4hrs on 2hrs)

Stage 2: Feed at 15kcals/Kg body weight per day 

Feed over 16 hours (4hrs on 2hrs)

Stage 3: Feed at 20kcals/KG body weight per day

Feed over 16 hours (4hrs on 2hrs)

*Please meet fluid requirements with additional IVI or flushes via feeding tube*

*DO NOT EXCEED STAGE 3*

i.e 55Kg Body weight patient

Stage 1:

55 x 10 = 550kcals

550ml of standard feed (35ml/hr x 16hrs) (4hrs on 2hrs off)

Stage 2:

55 x 15 = 825kcals

825ml of standard feed (52ml/hr x 16hrs) (4hrs on 2hrs off)

Stage 3:

55 x 20 = 1100kcals

1100ml of standard feed (69ml/16hrs) (4hrs on 2hrs off)

*PLEASE REFER TO THE DIETITIAN AS SOON AS POSSIBLE*

*Or Alternatively*

Step 3: Emergency Parenteral Feeding Regimen prior to Dietetic Assessment

Commence feeding as follows until seen by a dietitian.

Please correct any low levels of Mg, PO4 and K with medication (See Step 2)

*PLEASE OBTAIN RECENT BODY WEIGHT*

Stage 1:

Use standard Nutriflex Peri 1875 bag with additions

Rate = 35ml/hr x 24hrs 

(DISCARDING THE REMAINDER OF THE BAG AFTER 24 HOURS)

This provides

840ml fluid, 643kcals, 3.9g of N2, 34mmol of Na+, 20mmol of K+ and 5mmol of PO42-.

Stage 2:

Use standard Nutriflex Peri 1875 bag with additions

Rate = 55ml/hr x 24hrs

(DISCARDING THE REMAINDER OF THE BAG AFTER 24 HOURS)

1320ml fluid, 1005kcals, 6g of N2, 53mmol of Na+, 32mmol of K+ and 8mmol of PO42-.

*Please meet fluid requirements with additional IVI or flushes via feeding tube*

*DO NOT EXCEED STAGE 2*

*PLEASE REFER TO THE DIETITIAN AS SOON AS POSSIBLE*