Refeeding Syndrome

A.S.P.E.N. Recommendations

• 10-20 kcal/kg for the first 24 hours; advance

by 33% of goal every 1-2 days; including
parenteral glucose.
• In patients of moderate-high risk, holding
nutrition or increasing of calories until
electrolytes are supplemented and/or
normalized
• Thiamine & Multivitamins: 100 mg/d for 5-7
days in patients with malnutrition

Moderate Significant
Risk Risk
BMI 16-18.5 kg/m² <16 kg/m²
Wt. Loss 5% in 1 mo. 7.5% in 3 mo.
>10% in 6 mo.
Intake NPO 5-6 days, NPO >7 days,
<75% of needs <50% of needs
for >7 days, or for >5 days, or
<75% needs in <50% needs

Lab Markers
1 mo.
Minimally/
for > 1 mo.
Moderate/
Oncology Nutrition
normal low
levels
significantly
low levels
Formulary
Loss of Moderate loss Severe loss
Subcutaneous
Fat
Loss of Moderate loss Severe loss
Muscle Mass
High-Risk Moderate Severe
Comorbidities disease disease

Lab Markers
Phosphate <2.7 mg/dL
Potassium <3.6 mg/dL
Magnesium <1.8 mg/dL
Thiamine <1.7 mg/dL

Clinical Signs/Symptoms
• Confusion
• Weakness
• Fatigue
• Inability to breathe
• High blood pressure
• Seizures
• Heart arrhythmias
• Heart failure
• Coma
 Adult Oncology Patients
(GI, Lung, Prostate, and Thyroid)
Liver Cancer
Estimated Energy (Including patients with ascites, cirrhosis, or
• Cancer, repletion, weight gain 30-35 kcal/kg encephalopathy)
• Cancer, inactive, non-stress 25-30 kcal/kg • Energy:
• Cancer, hypermetabolic, stressed 35 o 25-40 kcal/kg based on dry weight or
kcal/kg determined ideal body weight for
• Sepsis 25-30 kcal/kg patients with ascites
• Hematopoietic cell transplant 30-35 kcal/kg o 35-40 kcal/kg for patients with stable
• Non-critically ill and critically ill, obese 11-14 cirrhosis
(Actual body weight), 22-25 (IBW) o 25-35 kcal/kg for patients without
encephalopathy
o 35 kcal/kg for patients with acute
Estimated Protein
encephalopathy
• Renal Disease:
o 30-40 kcal/kg for stable patients who
o Pre-dialysis 0.6-0.8 g/kg
are malnourished
o Hemodialysis 1.2-1.3 g/kg, up to 1.5-
o 15-20 kcal/kg to start, if there is
1.8 g/kg
refeeding risk
o Peritoneal dialysis 1.5-2.5 g/kg
• Protein:
• Cirrhosis/Hepatic failure 1.0-1.2 g/kg
o 1.0-1.5 g/kg for all patients, except
• Cancer 1.0-1.5 g/kg those with encephalopathy
• Cancer/cachexia 1.5-2.5 g/kg o 1.0 g/kg for patients with acute
• Bone marrow/transplant 1.5 g/kg encephalopathy
• Inflammatory bowel disease 1.0-1.5 g/kg
• Short bowel syndrome 1.0-1.5 g/kg Head and Neck Cancer
• BMI>27 with normal renal and hepatic • Energy
function 1.5-2.0 (of IBW with hypocaloric o Normometabolic 25-30 kcal/kg
feeding) o Hypermetabolic or goal of weight
• BMI>30 but <35 or BMI>35 but <40, trauma gain 30-35 kcal/kg
(ICU) 1.9 g/kg (of IBW with hypocaloric o Obese 21-25 kcal/kg
feeding) • Protein
• BMI>40, trauma (ICU) 2.5 g/kg (of IBW with o Non-stressed 1.0-1.5 g/kg
hypocaloric feeding) o Hypermetabolic or protein-losing
• Pulmonary disease 1.2-1.5 g/kg enteropathy 1.5-2.5 g/kg
• Critical illness (trauma, sepsis) 1.5-2.0 g/kg • Fluid 30-35 ml/kg

Estimated Fluid Ovarian Cancer

• A.S.P.E.N. 20-40 mL/kg/day or • Energy
1-1.5 mL/kcal o Malnourished 30-35 kcal/kg
• RDA 1 mL/kcal o Well-nourished 25-30 kcal/kg
• Body Surface Area (BSA) 1500 mL/m^2, • Protein
or BSA x 1500 mL o Normal renal function, 1.0-1.5 g/kg
o Cancer cachexia 1.5-2.5 g/kg
Breast Cancer
• Energy 25-30 kcal/kg Pancreatic and Bile Duct Cancer
• Protein 1.2-1.5 g/kg with normal renal • Preoperatively 25 kcal/kg
function • Postoperative recovery from
pancreaticoduodenectomy 30 kcal/kg
Esophageal Cancer
• Energy 30-35 kcal/kg
• Protein 1.0-1.2 g/kg if weight is stable and
patient is non-stressed; 1.2-1.6 g/kg if
patient is stressed and has been losing
weight and lean body mass