Defined as a collection of electrolyte abnormalities associated with a massive intracellular shift of electrolytes. Associated with aggressive nutritional rehabilitation of malnourished patients in e.g. malignancy, chronic organ dysfunction, inflammatory conditions (e.g. pancreatitis, colitis), the perioperative period as well as anorexia nervosa.

Clinical features

Sequelae of hypophosphataemia, hypokalaemia, hypocalcaemia, hypomagnesaemia, e.g.
Congestive heart failure, peripheral oedema, rhabdomyolysis, seizures, haemolysis and arrhythmias associated with electrolyte abnormalities (e.g. QT prolongation progressing to Torsades de Pointes)

Who is at risk?

Patients admitted to hospital typically have their nutrition assessed using the MUST tool (Malnutrition Universal Screening Tool)

• Patients are at risk if they haven’t eaten for about 5 days
• They are at higher risk if they have a
  • low BMI
  • have had marked (>10%) weight loss in the last few months
  • poor intake for >10 days
  • have low electrolytes prior to feeding
  • history of alcohol or drug abuse.

Management

• A-E stabilisation (especially if the patient is predisposed to developing arrhythmias)
• Early involvement of a dietitian and eating disorders team
• Daily monitoring & replacing electrolytes (see hypophosphataemia, hypomagnesaemia, hypocalcaemia)
• Vitamin replacement as per trust guidelines (typically IV Pabrinex for 3 days followed by oral vitamin B co strong & thiamine)
• A slow introduction of nutrition as guided by the dietetics team
• Using a resource such as the Royal College of Psychiatrists’ MARSIPAN checklist or the newer MEED resource to guide management provides a useful framework for assessing risk and initiating cautious refeeding.

Further reading & references

• Mehler, P., 2019. Anorexia nervosa in adults and adolescents: the refeeding syndrome. UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
• Siparsky, N., 2019. Overview of postoperative electrolyte abnormalities. UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
• Royal College of Psychiatrists. MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa (2nd edn) (Oct 2014)
• Royal College of Psychiatrists. Medical emergencies in eating disorders (MEED): Guidance on recognition and management

By Dr Shoaib Hussain