Attitudes to NICE guidance on refeeding syndrome

Any discussion on the risks of the refeeding syndrome should include the increased threat of infection that may often be silent in malnutrition.1 Malnourished patients may develop infection without showing the usual septic markers—such as an increased temperature, leucocyte count, or C reactive protein. We therefore advocate septic screening and a low threshold for broad spectrum antibiotic cover for any patients with unexplained hypothermia, hypoglycaemia, and evidence of malnutrition.

Patients at high risk of the syndrome may also be at risk of acute renal failure, which may be missed as they have only slightly raised urea and creatinine measurements because of low muscle mass, leading to low production of these metabolites. When this occurs, renal dysfunction may hide low serum and total body electrolyte concentrations, and hence serum potassium, magnesium, and phosphate may be reassuringly normal or even high. They are at even greater risk of precipitate falls in these circulating electrolytes once simultaneous nutritional and fluid therapy has started.

Our unpublished survey of doctors, nurses, pharmacists, and dietitians (all members of their respective nutrition societies) on their attitudes to the guidance from the National Institute for Health and Clinical Excellence (NICE)2 showed widespread disparities in practice. Only 44% (8/19) of doctors compared with 70% (49/70) of dietitians followed the guidance. Overall, 39% (57/146) of all responders thought the guidance represented safe practice, whereas 36% (53/146) thought they were excessively cautious. Some responders thought that NICE guidelines were an obstacle to providing adequate nutrition, while others had never seen a case of the refeeding syndrome despite having always started nutritional supplementation at 100% of estimated requirements.