What guidelines should I follow for the gradual reintroduction of nutrition in patients at risk of refeeding syndrome?

Guidelines for gradual reintroduction of nutrition in patients at risk of refeeding syndrome:

• Start nutrition support cautiously at a maximum of 10 kcal/kg/day, increasing slowly to meet or exceed full nutritional needs over 4 to 7 days.
• In extreme cases (e.g., BMI less than 14 kg/m2 or negligible intake for more than 15 days), start at only 5 kcal/kg/day and monitor cardiac rhythm continuously.
• Restore circulatory volume and monitor fluid balance and overall clinical status closely during refeeding.
• Provide full requirements of fluids, electrolytes, vitamins, and minerals from the outset of feeding.
• Administer oral thiamin 200 to 300 mg daily, vitamin B complex (1 or 2 tablets three times daily), or intravenous vitamin B if necessary, plus a balanced multivitamin or trace element supplement daily for the first 10 days of feeding.
• Supplement potassium (2 to 4 mmol/kg/day), phosphate (0.3 to 0.6 mmol/kg/day), and magnesium (0.2 mmol/kg/day intravenous or 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high; pre-feeding correction of low plasma levels is not required.
• Begin feeding at no more than 50% of estimated target energy and protein needs in seriously ill or injured patients, building up to full needs over 24 to 48 hours if tolerated.
• For patients who have eaten little or nothing for more than 5 days, start nutrition support at no more than 50% of requirements for the first 2 days before increasing feed rates if no refeeding problems occur.

These recommendations apply to patients identified as high risk by criteria such as BMI less than 16 kg/m2, significant recent weight loss, prolonged little or no nutritional intake, or low pre-feeding electrolyte levels, among others. Care should be provided by healthcare professionals skilled in nutrition support with expert knowledge of nutritional requirements and refeeding syndrome management ¹.