Clinical Signs and Symptoms of Refeeding Syndrome

Refeeding syndrome occurs when malnourished individuals receive rapid nutritional supplementation, leading to electrolyte imbalances and metabolic complications. The hallmark feature is hypophosphatemia, but other electrolyte disturbances (hypokalemia, hypomagnesemia) and fluid imbalances also contribute to the condition.

Clinical Features:

1. Electrolyte Imbalances:
   • Hypophosphatemia → Weakness, confusion, seizures, cardiac failure
   • Hypokalemia → Muscle weakness, arrhythmias, paralytic ileus
   • Hypomagnesemia → Tetany, tremors, cardiac arrhythmias
2. Cardiac Complications:
   • Congestive heart failure
   • Arrhythmias
   • Hypotension and shock
3. Neurological Manifestations:
   • Confusion, delirium
   • Seizures
   • Paresthesia
4. Respiratory Failure:
   • Weakness of respiratory muscles
   • Hypoventilation
5. Hematological Changes:
   • Hemolysis
   • Leukocyte dysfunction leading to infections
6. Metabolic Disturbances:
   • Hyperglycemia
   • Fluid retention and edema

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Management of Refeeding Syndrome

1. Identification and Risk Assessment:

• High-risk patients: Chronic malnutrition (e.g., anorexia nervosa, prolonged fasting, cancer, post-surgical patients, alcohol use disorder)
• Look for weight loss (>10% in 1-2 months), low BMI, prolonged fasting, and electrolyte abnormalities before feeding

2. Correction of Electrolyte Imbalances:

• Phosphorus: 0.3-0.6 mmol/kg IV (if severe hypophosphatemia <0.3 mmol/L)
• Potassium: 3-4 mmol/kg/day
• Magnesium: 0.2 mmol/kg IV if symptomatic

3. Controlled Refeeding:

• Start with 10 kcal/kg/day and gradually increase over 4-7 days
• Monitor electrolytes and fluid balance daily
• Prefer oral/enteral nutrition over parenteral nutrition if possible

4. Thiamine and Vitamin Supplementation:

• 100 mg IV thiamine before initiating nutrition, then 100 mg daily for at least 5-7 days
• Multivitamin supplements to correct deficiencies

5. Monitoring:

• Daily monitoring of electrolytes (phosphate, potassium, magnesium), fluid balance, glucose levels, and cardiac function
• Adjust nutritional intake based on electrolyte status

6. Preventative Strategies:

• Slow refeeding, especially in high-risk patients
• Close monitoring in the first 72 hours when refeeding syndrome risk is highest
• Early involvement of a nutritionist and multidisciplinary team