Refeeding syndrome is a dangerous shift of fluids and electrolytes that can happen when a starved or severely malnourished person starts eating or receiving nutrition support again. Insulin released by the new carbohydrate load drives phosphate, potassium and magnesium into the cells, and the low blood levels can cause heart failure, arrhythmias and weakness.
Key symptoms
- Weakness and muscle pain in the first days of feeding
- Shortness of breath and fatigue
- Leg swelling from fluid retention
- Confusion, numbness or seizures in severe cases
- Palpitations from heart rhythm problems
What you find on exam
- Low body weight or BMI and a history of poor intake
- Edema and signs of fluid overload
- Fast or irregular pulse
- Muscle weakness and shallow breathing
Tests
- Phosphate, potassium and magnesium before feeding and daily for the first days
- Glucose, sodium and kidney function
- ECG for arrhythmias and QT changes
- Daily weight and fluid balance chart
Treatment basics
- Identify high-risk patients before feeding starts
- Start nutrition slowly and increase it over several days
- Give thiamine before and during early feeding
- Replace phosphate, potassium and magnesium as needed
- Monitor labs, fluids and heart rhythm closely
Red flags
- Phosphate falling sharply after feeding starts
- Breathlessness, edema or new heart failure
- Arrhythmia, seizure or sudden confusion
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; Open RN, Nursing Fundamentals 2e. Written by Making Synapses. Making Synapses is not affiliated with these organizations.