1. Protocolized Weaning and De-escalation of Intensive Therapies

As metabolic derangements from refeeding syndrome resolve, a stepwise reduction of ventilatory, hemodynamic, and nutritional support is critical. This approach prevents rebound electrolyte shifts and iatrogenic fluid overload, ensuring a smooth transition toward recovery. The core principle is to balance caloric advancement with electrolyte and fluid stability, guided by close laboratory and hemodynamic monitoring.

Criteria for Weaning Mechanical Ventilation and Vasopressors

Readiness for weaning from life support combines respiratory, hemodynamic, neurologic, and metabolic criteria. While local protocols may vary, these criteria are adapted from general ICU best practices.

Mechanical Ventilation Weaning Criteria:

• Metabolic Stability: Resolution of major electrolyte abnormalities (e.g., phosphate ≥0.8 mmol/L, potassium ≥3.5 mmol/L, magnesium ≥0.7 mmol/L).
• Oxygenation: PaO₂/FiO₂ ratio >150–200, PEEP ≤8 cmH₂O, and FiO₂ ≤0.5.
• Hemodynamic Stability: Minimal or no vasopressor support (e.g., norepinephrine ≤0.05 mcg/kg/min) with a mean arterial pressure (MAP) ≥65 mmHg.
• Neurologic Status: Patient is awake, able to follow commands (RASS 0 to –1).
• Respiratory Muscle Strength: Adequate tidal volume (≥5 mL/kg), Rapid Shallow Breathing Index (RSBI) <105, and Negative Inspiratory Force (NIF) <–20 cmH₂O.

Vasopressor Weaning Criteria:

• Sustained MAP ≥65 mmHg off or on a very low-dose vasopressor for at least 12 hours.
• Evidence of adequate tissue perfusion, such as a serum lactate <2 mmol/L and euvolemia.

Stepwise Reduction Protocols and Monitoring

An algorithmic approach is recommended to safely advance nutrition while managing electrolytes and fluids.

• Caloric Advancement: Initiate nutrition at 5–15 kcal/kg/day. Once electrolytes are stable, increase calories by 10–20% daily. Hold advancement if phosphate falls below 0.65 mmol/L, potassium below 3.2 mmol/L, or magnesium below 0.7 mmol/L.
• Electrolyte Monitoring: Check serum phosphate, potassium, and magnesium every 8–12 hours during the initial repletion and weaning phase. Once stable, transition to daily monitoring.
• Fluid Management: Carefully calculate insensible losses and restrict sodium intake to ≤1 mmol/kg/day until euvolemia is achieved. Diuretics or ultrafiltration may be necessary for significant fluid overload, especially in patients with cardiac or renal dysfunction.
• Cardiac & Volume Assessment: Monitor daily weights, strict intake/output, and jugular venous pressure (JVP). Consider echocardiography for new or persistent signs of heart failure or volume overload.

2. Intravenous to Enteral Medication Conversion

Transitioning from intravenous (IV) to enteral therapies is a key milestone in patient recovery. This step reduces the risks associated with IV lines, such as infection and phlebitis, but requires careful assessment of gastrointestinal (GI) function and appropriate adjustments to drug formulations to ensure efficacy.

Assessment of Gastrointestinal Function and Enteral Access

Before switching medication routes, clinicians must confirm the GI tract is ready and that enteral access is secure.

• GI Function: Look for signs of tolerance, such as the presence of bowel sounds, gastric residual volumes <250 mL, and the absence of high-output fistulas or intractable vomiting.
• Enteral Access: The type of feeding tube (nasogastric, nasojejunal, PEG, PEJ) influences medication administration strategies. Always verify tube position with recent imaging or pH testing before use.

Drug Formulation, Bioavailability, and Dosing Adjustments

Not all IV doses have a direct oral equivalent. It is crucial to select appropriate enteral formulations and adjust doses to account for differences in bioavailability. Always flush the feeding tube with 15–30 mL of water before and after each dose to maintain patency. Be mindful of potential drug-nutrient interactions (e.g., phenytoin, tetracyclines, PPIs).

3. Post-ICU Syndrome (PICS) Risk Identification and Mitigation

Post-ICU Syndrome (PICS) is a constellation of new or worsened impairments in physical, cognitive, and mental health that arise after critical illness. Patients recovering from severe refeeding syndrome are at high risk due to prolonged ICU stays, mechanical ventilation, and metabolic encephalopathy. Early implementation of the ABCDEF bundle is a proven strategy to mitigate these sequelae.

High-Risk Patient Characteristics

Proactively identify patients predisposed to PICS to target interventions. Key risk factors include:

• Prolonged ICU stay (>7 days) or mechanical ventilation (>48 hours)
• Use of continuous deep sedation for more than 72 hours
• Episodes of ICU delirium
• Preexisting conditions such as frailty, malnutrition, or cognitive impairment
• Advanced age (>65 years)

Implementation of the ABCDEF Bundle

The ABCDEF bundle is a multidisciplinary, evidence-based framework that reduces delirium, shortens the duration of ventilation, and improves long-term patient outcomes. Consistent, daily application of all six components provides the greatest benefit.

4. Medication Reconciliation and Discharge Planning

A robust and meticulous discharge process is essential to ensure a safe transition of care, reduce the risk of readmission, and support the patient’s long-term recovery from refeeding syndrome.

Comprehensive Medication and Nutrition Review

• Reconciliation: Systematically review and reconcile every inpatient medication with the patient’s home regimen. Discontinue all IV electrolyte infusions once stable enteral absorption is confirmed.
• Evaluation: Assess all discharge medications for potential drug-nutrient interactions with the prescribed enteral nutrition formula.
• Simplification: Simplify the medication regimen whenever possible, aligning it with outpatient formularies to reduce complexity and cost for the patient.

Structured Patient and Caregiver Education

• Teach-Back Method: Use the teach-back method to confirm understanding of key instructions, including oral supplement dosing, feeding tube care, and the signs and symptoms of electrolyte imbalance.
• Written Materials: Provide clear, written schedules for medications and feeds, along with contact information for the clinical team.

Clear Handoff and Follow-Up

• Handoff Documentation: Ensure discharge summaries include the rationale for medication changes, target laboratory values, and the responsible outpatient providers for follow-up.
• Outpatient Monitoring: Schedule follow-up serum electrolyte checks 48–72 hours post-discharge, then weekly or as needed until fully stable.
• Multidisciplinary Support: Arrange for outpatient visits with a nutritionist and clinical pharmacist. Utilize telehealth for early check-ins to detect and manage potential complications.