Assessment of risk of re-feeding syndrome:

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients on refeeding following a period of starvation (NICE, 2006). This is particularly common in patients receiving artificial refeeding, but is possible with oral refeeding (particularly if oral nutritional supplements are prescribed). The patient should be considered at risk of refeeding syndrome if they meet the following criteria (NICE 2006).

If the patient has one or more of the following:

  • Body mass index <16 kg/m2
  • Unintentional weight loss >15% in the past three to six months
  • Little or no nutritional intake for >10 days
  • Low levels of potassium, phosphate, or magnesium before feeding

Or the patient has two or more of the following:

  • Body mass index <18.5 kg/m2
  • Unintentional weight loss >10% in the past three to six months
  • Little or no nutritional intake for >5 days
  • History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

If the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by NICE (2006):

  • Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days
  • Restore circulatory volume and monitoring fluid balance and overall clinical status closely
  • Provide immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin/ trace element supplement once daily
  • Provide oral, enteral or intravenous supplements of potassium (likely requirement 2–4 mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. Pre-feeding correction of low plasma levels is unnecessary
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