Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm

Natalie Friedli; Zeno Stanga; Alison Culkin; Martin Crook; Alessandro Laviano; Lubos Sobotka; Reto W Kressig; Jens Kondrup; Beat Mueller; Philipp Schuetz

doi:10.1016/j.nut.2017.09.007

Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm

Nutrition. 2018 Mar:47:13-20. doi: 10.1016/j.nut.2017.09.007. Epub 2017 Sep 25.

Authors

Affiliations

¹ Medical University Department, Clinic for Endocrinology, Metabolism and Clinical Nutrition, Kantonsspital Aarau, Aarau and Medical Faculty of the University of Basel, Basel, Switzerland.
² Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital and University of Bern, Bern, Switzerland.
³ Department of Nutrition and Dietetics, St Mark's Hospital, Harrow, United Kingdom.
⁴ Department of Clinical Biochemistry, Lewisham Hospital NHS Trust, London, United Kingdom.
⁵ Department of Clinical Medicine, Sapienza University, Rome, Italy.
⁶ Department of Medicine, Medical Faculty and Faculty Hospital Hradec Kralove, Charles University, Prague, Czech Republic.
⁷ University Center for Medicine of Aging, Felix Platter Hospital and University of Basel, Basel, Switzerland.
⁸ Clinical Nutrition Unit, Rigshospitalet University Hospital, Copenhagen, Denmark.
⁹ Medical University Department, Clinic for Endocrinology, Metabolism and Clinical Nutrition, Kantonsspital Aarau, Aarau and Medical Faculty of the University of Basel, Basel, Switzerland. Electronic address: schuetzph@gmail.com.

PMID: 29429529
DOI: 10.1016/j.nut.2017.09.007

Abstract

Objectives: Refeeding syndrome (RFS) can be a life-threatening metabolic condition after nutritional replenishment if not recognized early and treated adequately. There is a lack of evidence-based treatment and monitoring algorithm for daily clinical practice. The aim of the study was to propose an expert consensus guideline for RFS for the medical inpatient (not including anorexic patients) regarding risk factors, diagnostic criteria, and preventive and therapeutic measures based on a previous systematic literature search.

Methods: Based on a recent qualitative systematic review on the topic, we developed clinically relevant recommendations as well as a treatment and monitoring algorithm for the clinical management of inpatients regarding RFS. With international experts, these recommendations were discussed and agreement with the recommendation was rated.

Results: Upon hospital admission, we recommend the use of specific screening criteria (i.e., low body mass index, large unintentional weight loss, little or no nutritional intake, history of alcohol or drug abuse) for risk assessment regarding the occurrence of RFS. According to the patient's individual risk for RFS, a careful start of nutritional therapy with a stepwise increase in energy and fluids goals and supplementation of electrolyte and vitamins, as well as close clinical monitoring, is recommended. We also propose criteria for the diagnosis of imminent and manifest RFS with practical treatment recommendations with adoption of the nutritional therapy.

Conclusion: Based on the available evidence, we developed a practical algorithm for risk assessment, treatment, and monitoring of RFS in medical inpatients. In daily routine clinical care, this may help to optimize and standardize the management of this vulnerable patient population. We encourage future quality studies to further refine these recommendations.

Keywords: Hypophosphatemia; Nutritional therapy; Refeeding syndrome; Treatment recommendation.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Algorithms*
Consensus
Decision Support Techniques*
Evidence-Based Practice / standards
Humans
Inpatients
Mass Screening / standards*
Nutrition Assessment*
Practice Guidelines as Topic
Refeeding Syndrome / diagnosis
Refeeding Syndrome / prevention & control*
Risk Assessment / standards
Risk Factors