Initiation, Advancement, and Acute Complications of Parenteral Nutrition BOX 4.5 Examples of Risk Factors for Refeeding Syndrome10,40,41


AIDS Anorexia nervosa Cancer/ oncology treatment


Chronic malnutrition, as often seen in older adults or those with cirrhosis, cardiac cachexia, or chronic obstructive pulmonary disease


Chronic alcohol or other substance use disorders


Dysphagia and esophageal motility disorders


When a carbohydrate source is reintroduced (from any source, includ-


ing oral intake, enteral nutrition, PN, or dextrose-containing IV fluids), carbohydrate metabolism resumes with glucose as the major energy source and a subsequent increase in insulin production. The increased insulin secretion leads to cellular uptake of glucose, phosphate, magne- sium, and potassium. In addition, insulin affects the renal tubules, caus- ing sodium and fluid retention.10,40,42,43 Clinical manifestations of refeeding syndrome may include, but are not limited to, the following:


ƒ abnormal glucose metabolism (due to the release of glucocorti- coids)


ƒ electrolyte imbalances (specifically hypophosphatemia, hypo- kalemia, and hypomagnesemia)


ƒ thiamin deficiency (due to either underlying malnutrition or the increased use of thiamin for carbohydrate metabolism)


ƒ fluid and sodium retention The consequences of these manifestations can be life-threatening


and include cardiac, respiratory, and neurologic injury.10 Refer to Box 4.6 on page 66 for strategies to prevent and treat refeeding syndrome.10,39-41,44


Diabetes mellitus (uncontrolled) Malabsorption diseases


Morbid obesity with rapid weight loss, including post–bariatric surgery


Prolonged fasting or a period with little to no nutrition


Postoperative recovery Severe malnutrition


65


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