Refeeding syndrome: what it is, and how to prevent and treat itBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a301 (Published 26 June 2008) Cite this as: BMJ 2008;336:1495
All rapid responses
It was welcome to see the article by Mehanna et al(1) raising awareness of the refeeding syndrome (RFS) and highlighting some of the risks and clinical syndromes that can arise when nutritional support is instigated injudiciously. However we feel that there are a few additional points that should be considered.
Any discussion relating to risks around RFS should include the increased threat of infection that may often be silent in the context of malnutrition and very malnourished patients may therefore develop infection without showing the usual septic markers such as an increased temperature, white count or CRP. We would therefore advocate septic screening and a low threshold for broad spectrum antibiotic cover for any patients with unexplained hypothermia, hypoglycaemia and evidence of malnutrition.
In addition, patients at high risk of RFS may also be at risk of acute renal failure, which may be missed as they only have slightly raised ureas and creatinines due to low muscle mass leading to low production of these metabolites. When this occurs, renal dysfunction may hide low serum and total body electrolyte concentrations, and hence serum potassium, magnesium and phosphate may be reassuringly normal or even high. They are at even greater risk of precipitate falls in these circulating electrolytes once simultaneous nutritional and fluid therapy has started.
We agree that clinicians should be alert to the possibility of this syndrome developing in ‘at risk’ patients. We sought to quantify the level of knowledge regarding RFS that currently exists in clinical practice and found there was confusion about its management, even amongst professionals with an expressed interest in nutrition.
This survey, yet to be reported, of doctors, nurses, pharmacists and dietitians, (all members of their respective nutrition societies) on their attitudes to the NICE guidance(2) on RFS syndrome, revealed widespread disparities in practice. Only 44% of doctors as opposed to 70% of dietitians actually followed NICE guidance. Thirty nine percent of all responders felt the guidance represented safe practice whilst 36% felt they were excessively cautious. Some responders felt that, ‘NICE guidelines have created an obstacle to providing adequate nutrition,’ and others felt that they had never seen a case of RFS despite starting nutritional supplementation at 100% of estimated requirements throughout their career.
These data show that practice relating to RFS is split within the UK and highlight the importance of trying to obtain clinical evidence to inform practice when dealing with groups at risk of RFS.
1 Hisham M Mehanna, Jamil Moledina & Jane Travis. Refeeding syndrome: what it is, and how to prevent and treat it BMJ 2008;336:1495- 1498 (28 June)
2 National Institute for Health and Clinical Excellence. Nutrition support in adults. Clinical guideline CG32. 2006. www.nice.org.uk/page.aspx?o=cg032
Competing interests: None declared
Competing interests: No competing interests