Case Presentation:

A 69 year old AA male, transferred from nursing home, with AMS and seizures after lack of medications and oral intake for 3 days. PMHx included CKD, Parkinson's with dementia and DM 2. On examination, patient was afebrile with mild tachycardi, focal seizures were present responsive to D50, lorazepam and phenytoin. Remainder of exam was remarkable for severe cachexia, dry mucus membranes and a chronic in‐dwelling foley. Labs demonstrated Na 162 meq/l, Cl 132 meq/l, glucose 7 mg/dl, BUN 73 mg/dl, creatinine 1.6 mg/dl and WBCs of 17.9k with bandemia. U/Awas negative for leukocytes; CXR was unremarkable. He was admitted to the ICU with a diagnosis of AMS and seizures due to hypernatremia, hypoglycemia and dehydration with presumed sepsis of undetermined cause. Patient was started on IVFs, empiric antibiotics with subsequent correction of hypernatremia. Despite discontinuation of metformin and IV glucose, the patient continued to have intermittent hypoglycemia attributable to severe malnutrition and concomitant renal failure. A PEG tube was placed and tube feeds (TFs) were started with titration to goal rate. Five days after initiation of TFs, Phos level was 0.2 mg/dl, K 3.5 meq/l, Ca 6.2 mg/dl (corrected 7.3 mg/dl) and Mg 1.8 mg/dl. Rhabdomyolysis was present with CPK at 865 mg/dl. Electrolytes were repleted and remained within normal limits after multiple IV runs of K Phos and Mg. The patient's hospital course was complicated by colitis with eventual cardiopulmonary arrest. Despite aggressive ICU care, patient developed multisystem organ failure. The family eventually withdrew care leading to his death.

Discussion:

Refeeding syndrome, a phenomenon that occurs in starved/ malnourished patients following the initiation of aggressive enteral/ TPN, is characterized by life‐threatening fluid and electrolyte imbalances of hypophosphatemia, hypomagnesemia, hypokalemia which classically occur on the 4th day of feeding resumption. Risk factors include hx of anorexia nervosa, kwashiorkar/marasmus, chronic alcoholism, chronic underfeeding, morbid obesity with massive weight loss, post‐operative state, malignancy and patients with neurological dysphagia being fed through NG/PEG tubes. Clinical features include rhabdomyolysis, hypotension, seizures, respiratory failure, arrhythmias, coma, and sudden death. These classically occur with phosphate levels < 1.54mg/dl (0.50 mmol). The mechanism involves shift from fat/protein to carbohydrate metabolism and secretion of insulin with refeeding, stimulating cellular uptake of Phos and K with resultant profound hypophosphatemia and hypokalemia. Management includes identifying at risk patients, starting feeds at a low rate (25‐50 % of estimated requirement) and increasing by 100 ‐ 200 kcals/day.

Conclusion:

This syndrome is preventable by careful monitoring of electrolytes and with aggressive repletion as indicated.

Author Disclosure Block:

V. Melinamani, None; K. Iqbal, None; M. Parker, None.