Refeeding syndrome in hospital patients referred for enteral and parenteral nutrition
Authors: Fleuret C. , Reidlinger D. , Whelan K. , Rio A. 
Published: July 2008

Background:  The reported incidence of refeeding syndrome is highly variable due to the heterogeneity of its definition, the electrolyte reference ranges used, patient populations investigated and the treatment protocols implemented (Marik & Bedigian, 1996; Fan et al., 2004). Recent guidelines have been published by the National Institute of Clinical Excellence on the identification and management of patients at risk of refeeding syndrome (NICE, 2006). The aim of this prospective observational study was to determine the incidence of refeeding syndrome in hospital patients referred for artificial nutrition and hydration (ANH) via the enteral or parenteral route, where national practice guidelines exist to prevent its occurrence.

Methods:  Data was collected as part of a larger, ongoing study at a London hospital. All patients referred to the Department of Nutrition and Dietetics for ANH had their feeding regimen and their risk of refeeding syndrome determined based upon the clinical decision of their dietitian and local guidelines. An independent researcher screened patients for inclusion into the study and then categorised their risk of refeeding syndrome based upon criteria from national guidelines (NICE, 2006). Patient characteristics, diet history, anthropometry, feed prescription and baseline serum phosphate, potassium and magnesium were recorded. Electrolytes were recorded every 3 days, up to 15 days, to determine clinical signs consistent with refeeding syndrome. Patients ‘at risk’ of refeeding syndrome were compared with those categorised as ‘not at risk’. Statistical analysis was conducted using SPSS version 15 and included descriptive statistics, McNemar's test and independent t‐tests for continuous data. Ethical approval was obtained from the appropriate committee.

Results:  Of the 24 patients recruited, only three (13%) were judged to be ‘at‐risk’ of refeeding syndrome by the patient's dietitian, compared with 18 (75%) who were identified as ‘at‐risk’ based upon criteria from national guidelines (P < 0.001). There were no significant differences in energy prescription (P = 0.836), energy delivery on the first day of feeding (P = 0.814) or serum electrolyte concentrations at any time point during feeding, when comparing patients identified as ‘at‐risk’ or ‘not at‐risk’ by national guidelines. Refeeding syndrome was not observed.

Discussion:  Adherence to the NICE guidelines (2006) for preventing refeeding syndrome was variable in these patients. However, patients identified as being ‘at‐risk’ according to these guidelines did not develop refeeding syndrome, despite frequently receiving energy prescriptions in excess of the recommendations.

Conclusions:  Patients who were categorised as ‘at risk’ of refeeding syndrome according to national guidelines did not always go on to develop the syndrome. The role of dietetic assessment of risk of refeeding syndrome warrants further investigation.

References  Fan, C., Ren, J., Wang, X. & Li, J. (2004) Refeeding syndrome in patients with gastrointestinal fistula. Nutrition 20, 346–350.

Marik, P.E. & Bedigian, M.K. (1996) Refeeding hypophosphatemia in critically ill patients in an intensive care unit. Arch. Surg. 131, 1043–1047.

National Institute for Clinical Excellence/National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. London: National Collaborating Centre for Acute Care.