Correspondence |
Refeeding syndrome: life-threatening, underdiagnosed, but treatable
Sir,We report a successfully treated case of refeeding syndrome in a high-risk patient. A 73-year-old independent female presented with a 1-week history of diarrhoea and vomiting, lethargy, headache, dizziness and loss of appetite. She hardly ate for almost 10 days prior to admission. She had stable angina and temporal arterititis, diagnosed 4 weeks prior to this admission, for which she had been on a reducing dose of prednisolone 20 mg and azathioprine 50 mg daily. She was dehydrated on admission with a pulse of 110 bpm and a supine BP of 78/60 mmHg. Her routine blood tests including haematology, biochemistry and chest radiography and ECG were normal, except her urea and electrolytes (Table 1). Her ESR was 41 and CRP was 16.8 (normal <10 mg). She was resuscitated with intravenous fluids, potassium supplements, antibiotics and increasing doses of steroids. The diarrhoea and vomiting gradually settled, and she started to take a soft diet.
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On day 4 of her hospital stay, she developed profound weakness, numbness and parathesiae involving both hands and feet. Based on the clinical history and biochemistry results (Table 1), a diagnosis of refeeding syndrome was made and the patient immediately started on intravenous calcium, phosphate, magnesium and potassium infusions. After correction of electrolytes, her symptoms disappeared and she was discharged home fully independent.
Refeeding syndrome is a well recognized but underdiagnosed and potentially fatal condition, which occurs in patients with starvation from any cause, anorexia nervosa, diarrhoea and vomiting, alcoholism and after operations.1,2 Malnourished elderly patients and patients with neurological dysphagia who are being fed through nasogastric and percutaneous endoscopic gastrostomy tubes, may also be at risk. The syndrome can occur with parentral as well as enteral feeding and almost always develops during the early stages of refeeding.1,2
Although one of the predominant features of refeeding syndrome is hypophosphataemia, other essential features include rapid falls in plasma levels of potassium, and magnesium, sodium and water retention.2 The clinical features are non-specific and may go unrecognised.1–3 Not all patients who are refed develop the refeeding syndrome, but awareness of the condition and close monitoring of those patients at risk is very important. Dieticians and nutrition nurses have an important role in its recognition, education and management.
Serum phosphate, magnesium, calcium, potassium, urea and creatinine concentrations should be measured before feeding and repeated daily for 4 days after feeding is started.1 When hypophosphataemia occurs, for example, it should be corrected, in addition to other electrolyte abnormalities. Some authorities recommend correcting vitamin and trace element deficiencies, including thiamine, which should be given at least 30 min before feeding.2
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Barnsley District General Hospital Barnsley
Sheffield Institute for Studies on Ageing University of Sheffield Sheffield email: s.e.gariballa{at}sheffield.ac.uk
References
1. Hearing SD. Refeeding syndrome: is underdiagnosed and undertreated, but treatable. BMJ 2004; 328:908–9.
2. Cook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition 2001; 17:632–7.[CrossRef][Web of Science][Medline]
3. Mallet M. Refeeding syndrome. Age Ageing 2002; 31:65–6.
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