Question 19

When a patient is fed parenterally after a period of starvation certain metabolic problems can  occur.  Please  list these problems, and  outline  your principles  of management  for each.

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College Answer

The refeeding syndrome is associated with a number of metabolic problems, which in general can be diminished by the gradual introduction of nutrients (eg. limit to 20 kcals/kg for first day), anticipation and pre-emptive replacement, and the careful monitoring of the patient.  These changes are more likely to occur in the severely malnoursished or those who have had a rapid weight loss. They can occur with both enteral and parenteral feeding.

Associated problems include:

•    Hypophosphatemia (which may be severe and associated with impaired myocardial function, weakness, rhabdomyolysis and even seizures), which is treated by replacement, but may be prevented to some degree by additional pre-emptive phosphate replacement

•    Hypokalaemia and hypomagnesemia (which can lead to weakness, and arrhythmias)

require monitoring and replacement

•    Thiamine deficiency (which may result in Wernicke’s encephalopathy) requiring thiamine replacement in anticipation or treatment

•    Fluid overload and cardiac failure (multifactorial), avoiding with careful monitoring and replacement


Refeeding syndrome is discussed in greater detail elsewhere.

Examples of previous SAQs on this topic include the following:

  • Question 26.1 from the first paper of 2013 (characteristic features: name four)
  • Question 19 from the second paper of 2009 ( four characteristic features and five complications)
  • Question 28 from the second paper of 2007 (clinical and biochmical features of refeeding syndrome)
  • Question 19 from the first paper of 2005 (biochemical abnormalities and their management)

In the interest of click economy, I will include the table of refeeding syndrome complications here.

Organ System Complications of Refeeding Syndrome


  • Heart failure (overload) due to atrophy
  • Hypotension and shock
  • Cardiac arrhythmia


  • LFT derangement due to acute fatty liver
  • Diarrhoea due to intestinal atrophy
  • Delayed gastric emptying
  • Arrhythmias


  • Acute tubular necrosis



  • Respiratory muscle weakness
  • Prolonged ventilator weaning


  • Muscle weakness
  • Tetany
  • Rhabdomyolysis due to low phosphate


  • Seizures
  • Coma
  • Delirium


  • Phagocyte dysfunction
  • Increased susceptibility to sepsis


Hearing, Stephen D. "Refeeding syndrome." BMJ 328.7445 (2004): 908-909.


Stanga, Z., et al. "Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment." European journal of clinical nutrition 62.6 (2008): 687-694.


Kraft, Michael D., Imad F. Btaiche, and Gordon S. Sacks. "Review of the refeeding syndrome." Nutrition in Clinical Practice 20.6 (2005): 625-633.


Khan, Laeeq UR, et al. "Refeeding syndrome: a literature review."Gastroenterology research and practice 2011 (2010).