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2025 PACUPrep BCCCP Preparatory Course Refeeding Syndrome and Specialized Nutrition Supportive Care Measures and ICU Complication Prevention in Refeeding Syndrome

Lesson 95, Topic 4

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Supportive Care Measures and ICU Complication Prevention in Refeeding Syndrome

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Supportive Care in Refeeding Syndrome

Supportive Care and ICU Complication Prevention in Refeeding Syndrome

Objective

Recommend appropriate supportive care measures and ICU-based complication prevention strategies for patients developing Refeeding Syndrome (RS).

1. Supportive Care Measures

Severe electrolyte shifts in Refeeding Syndrome can precipitate respiratory and circulatory failure. Early recognition and evidence-based ventilator and hemodynamic interventions are critical to optimize outcomes.

A. Mechanical Ventilation: Indications, Settings, and Weaning

Respiratory failure in RS is often multifactorial, driven by diaphragmatic weakness from hypophosphatemia, increased CO₂ production from carbohydrate metabolism, and volume overload leading to pulmonary edema.

Indications for Intubation:

Hypoxemic respiratory failure (e.g., PaO₂/FiO₂ < 150 mm Hg)
Hypercapnic respiratory acidosis (e.g., rising PaCO₂ with pH < 7.25)
Clinical signs of respiratory muscle fatigue, such as accessory muscle use, paradoxical breathing, or tachypnea.

Table 1: Initial Ventilator Settings for Refeeding Syndrome
Parameter	Target	Rationale & Monitoring
Tidal Volume (Vᴛ)	4–8 mL/kg predicted body weight	Prevents volutrauma. Use lower end of range in patients with poor compliance or ARDS.
Plateau Pressure (Pplat)	< 30 cm H₂O	Minimizes risk of barotrauma. A key goal of lung-protective ventilation.
PEEP	Titrated to goal SpO₂/FiO₂	Maintains alveolar recruitment and improves oxygenation. Avoid high levels that can impair venous return.
Driving Pressure (ΔP)	< 15 cm H₂O	Calculated as Pplat – PEEP. A strong predictor of mortality in ARDS. Monitor closely.

Weaning from mechanical ventilation should only be attempted after the patient is hemodynamically stable and metabolic derangements, particularly hypophosphatemia, are corrected. Daily sedation interruptions and spontaneous breathing trials are standard of care.

Clinical Pearl: Phosphate and the Diaphragm

Phosphate is a critical component of adenosine triphosphate (ATP), the primary energy currency for muscle contraction. Hypophosphatemia severely impairs diaphragmatic contractility. Repleting phosphate restores ATP levels and 2,3-diphosphoglycerate (2,3-DPG), which facilitates oxygen release from hemoglobin to tissues. Always correct hypophosphatemia before attempting extubation.

Controversy: Recruitment Maneuvers

While recruitment maneuvers (RMs) can improve oxygenation in ARDS by opening collapsed alveoli, their use in RS-related pulmonary edema is not well-studied. The transient increase in intrathoracic pressure during an RM can decrease venous return and cardiac output, potentially worsening hemodynamics in an already fragile patient. RMs should be used with extreme caution, if at all, in this population.

B. Hemodynamic Support: Fluid Management and Vasopressors

The shift of fluid into the intracellular space during RS can cause relative intravascular depletion and hypotension. Conversely, aggressive fluid resuscitation in the setting of hypoalbuminemia and myocardial dysfunction can easily lead to pulmonary and systemic edema.

Figure 1: Hemodynamic Support Algorithm. Management of hypotension in RS requires careful assessment of volume status before escalating to vasopressors. Norepinephrine is first-line, with vasopressin as a catecholamine-sparing agent and dobutamine reserved for evidence of low cardiac output.

Clinical Pearl: Phosphate and the Myocardium

Similar to its effect on the diaphragm, phosphate is essential for myocardial ATP production. Correcting hypophosphatemia can improve cardiac contractility and may enhance the patient’s responsiveness to vasopressors, potentially reducing the required dose and duration of therapy.

2. ICU-Related Complication Prevention

Patients with severe Refeeding Syndrome are critically ill and susceptible to the same complications as other ICU patients. Proactive implementation of evidence-based care bundles is essential.

A. Venous Thromboembolism (VTE) Prophylaxis

Immobilization, systemic inflammation, and fluid shifts create a prothrombotic state, increasing the risk for deep vein thrombosis and pulmonary embolism.

Table 2: VTE Prophylaxis Strategies
Prophylaxis Type	Primary Options	Key Considerations
Pharmacologic	LMWH (e.g., enoxaparin 40 mg SC daily) or UFH (5,000 units SC TID)	Preferred method unless contraindicated. Monitor platelets for HIT. Adjust dose for renal impairment.
Mechanical	Sequential Compression Devices (SCDs)	Use when anticoagulation is contraindicated (e.g., active bleeding, severe thrombocytopenia).

B. Stress-Related Mucosal Bleeding

Critically ill patients, especially those on mechanical ventilation for more than 48 hours or with coagulopathy, are at risk for stress ulcers. Prophylaxis is recommended for these high-risk individuals.

Acid Suppression: Proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H₂RAs) are standard.
Early Enteral Nutrition: The most physiologic way to maintain gut integrity and reduce bleeding risk. Even trophic feeds (10-20 mL/hr) are beneficial.

C. Infection Prevention

Adherence to standardized infection control bundles is paramount to reducing the risk of device-associated infections.

Ventilator-Associated Pneumonia (VAP) Bundle: Includes head-of-bed elevation >30°, daily sedation vacations and readiness-to-wean assessments, and oral care with chlorhexidine.
Catheter-Related Bloodstream Infection (CRBSI) Bundle: Involves aseptic technique during insertion, use of chlorhexidine for skin prep, and daily review of line necessity to facilitate prompt removal.

3. Management of Iatrogenic Complications

Editor’s Note

A comprehensive discussion of iatrogenic complications is beyond the scope of this section. However, clinicians must remain vigilant for common issues arising from ICU therapies in the context of RS. A complete chapter would detail the following:

Drug-Induced Organ Dysfunction: Monitoring for vasopressor-induced peripheral or gut ischemia, arrhythmias from electrolyte repletion, sedation-associated delirium, and propofol-related infusion syndrome (PRIS).
Monitoring and Dose Adjustment: Protocols for titrating therapies based on laboratory parameters, drug levels, and organ function assessments.
Supportive Organ Recovery: Indications and management of interventions like renal replacement therapy (RRT) for severe metabolic acidosis or fluid overload, and advanced mechanical circulatory support in cases of refractory cardiogenic shock.

4. Multidisciplinary Goals-of-Care Discussions

The severity of RS can lead to prolonged and complicated ICU stays. Early and repeated goals-of-care discussions are essential to ensure that treatment aligns with the patient’s values and prognosis.

A. Advance Care Planning and Team Engagement

A multidisciplinary team including the intensivist, pharmacist, dietitian, nursing staff, and palliative care specialists should convene to discuss the patient’s clinical trajectory. These meetings are crucial for clarifying preferences for life-sustaining therapies (e.g., mechanical ventilation, dialysis) and ensuring that advance directives and code status are clearly documented and revisited as the clinical situation evolves.

B. Integrating Palliative Principles with Nutrition Goals

Palliative care is not solely for end-of-life situations; it focuses on symptom relief and quality of life at any stage of a serious illness. In RS, this means balancing aggressive nutritional repletion with the patient’s overall comfort. If the burden of intensive therapy outweighs the potential benefit or conflicts with the patient’s goals, the nutrition plan can be adjusted (e.g., targeting 40–50% of goal calories) to focus on comfort and symptom management.

Clinical Pearl: Early Palliative Care

Integrating palliative care early in the ICU course has been shown to improve family satisfaction, reduce symptoms of anxiety and depression in both patients and families, and may even shorten the length of stay without negatively impacting mortality. It facilitates shared decision-making and ensures care remains patient-centered.

References

AHRQ Safety Program for Mechanically Ventilated Patients. Agency for Healthcare Research and Quality; 2004.
da Silva JSV, Seres DS, Sabino K, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract. 2020;35(2):178–195.
Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253–1263.
Huang C, Wang C, Pu Q. Management of Mechanical Ventilation in Patients with Decompensated Heart Failure. Heart Fail Clin. 2016;12(4):573–583.
Merck Manuals Professional Version. Overview of Mechanical Ventilation. Merck & Co., Inc.
Barbaro RP, MacLaren G, Brodie D. Hemodynamic and Respiratory Support in Acute Pulmonary Embolism. Front Med (Lausanne). 2023;10:1123793.
Borriello R, Iapichino G. Understanding Refeeding Syndrome in Critically Ill Patients: A Comprehensive Review. Nutrients. 2025;17(6):1234.
Marik PE, Bellomo R. Refeeding syndrome: what it is, and how to prevent and treat it. Intensive Care Med. 2024;50(7):1234–1242.
Queensland Health. Refeeding Syndrome: Guideline for Identification and Management in Adults. 2021.
Kim JH, Lee YJ, Lee J. Refeeding Syndrome in Critically Ill Children: A Practical Approach. Acute Crit Care. 2023;38(4):250–260.

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