Understanding Refeeding Syndrome in Critically Ill Patients: A Narrative Review

Abstract

Refeeding syndrome (RS) is defined as the spectrum of metabolic and biochemical disorders related to rapid nutritional replenishment after a prolonged period of fasting. It is caused by an abrupt shift in electrolytes and fluid among intra- and extracellular compartments, leading to metabolic disturbances like hypophosphatemia, vitamin deficiency, and fluid overload. RS often remains underdiagnosed due to variability in definition and diagnostic criteria adopted, overlapping clinical features with other complications and low awareness among clinicians. Critically ill individuals, particularly those admitted to intensive care units (ICUs), represent a cohort with peculiar features that may heighten RS risk due to their baseline frailty, frequent undernutrition, and the metabolic stress of acute illness. However, studies specifically conducted in ICU settings have yielded conflicting results regarding incidence rates, prognostic impact, and specific risk factors. Despite these differences, all evidence consistently highlights RS as a frequent and serious complication in critically ill patients. Early detection and prevention are essential, relying on prompt nutritional assessment at ICU admission, careful monitoring of serum electrolytes before and during refeeding, and a conservative caloric approach to nutrient reintroduction, alongside supportive therapy and electrolyte supplementation if RS manifestations occur. Clinicians should be aware of the significant prevalence and potential severity of RS in critically ill patients, along with the ongoing challenges related to its early recognition, prevention, and optimal nutritional management. This review aims to provide a comprehensive overview of the current knowledge on the incidence, prognostic impact, risk factors, clinical manifestations, and nutritional management of RS in critically ill patients while highlighting existing evidence gaps and key areas requiring clinical attention.

Keywords: ICU; critical care; hypophosphatemia; nutrition; refeeding; refeeding syndrome.

Figure 1

Overview of clinical phases and uncertainties in the management of refeeding syndrome in critically ill patients. The recognition and management of RS in this setting can be conceptually divided into three key stages, namely patient admission to the ICU, reintroduction of nutrients, and manifest refeeding syndrome. Around each phase, relevant clinical practices (green/orange/red bubbles) and areas of ongoing uncertainty or debate (pale pink bubbles) are illustrated. While the importance of early nutritional assessment, RS risk stratification, and electrolyte monitoring and supplementation is well established, further research is needed to better define ICU-specific risk factors and to determine optimal refeeding protocols in terms of both caloric progression and macronutrient composition.