Refeeding hypophosphatemia in critically ill patients in an intensive care unit. A prospective study
P. E. Marik and M. K. Bedigian
Department of Critical Care Medicine, St. Vincent Hospital, Worcester, USA.
BACKGROUND: Hypophosphatemia has been reported after refeeding of
malnourished patients. Nutritional support is often delayed in patients in
the intensive care unit (ICU) as a consequence of enteral intolerance and
bowel hypomotility. OBJECTIVE: To determine the incidence, risk factors,
and clinical impact of refeeding hypophosphatemia in a heterogeneous group
of patients in an ICU. DESIGN: Prospective, noninterventional study.
SETTINGS: Surgical and medical ICUs of a university-affiliated community
hospital. PATIENTS: Sixty-two patients in the ICU who were refed after
being starved for at least 48 hours were prospectively followed up.
INTERVENTIONS: None. MAIN OUTCOME MEASURES: Each patient had a nutritional
assessment prior to the initiation of nutritional support. Serum phosphate,
magnesium, and calcium levels were measured at baseline, and these
measurements were repeated daily. Refeeding hypophosphatemia was considered
to have developed in patients whose serum phosphorus level fell by more
than 0.16 mmol/L to below 0.65 mmol/L. RESULTS: Twenty-one patients (34%)
experienced refeeding hypophosphatemia. In 6 patients, the serum phosphorus
level fell below 0.32 mmol/L. The only risk factor studied that could
predict the development of hypophosphatemia was the serum prealbumin
concentration (mean +/- SD, 127 +/- 34 vs 79 +/- 40 g/L, P < .001).
Seventeen (81%) of these 21 patients in whom hypophosphatemia developed had
a prealbumin concentration less than 110 g/L compared with that in 12 (30%)
of the patients who did not experience this complication (P < .001). In
those patients in whom refeeding hypophosphatemia developed, the serum
phosphorus level reached a mean +/- SD nadir of 1.9 +/- 1.1 days after
feeding was started. Although the Acute Physiology and Chronic Health
Evaluation II score was similar (mean +/- SD, 19 +/- 6 vs 18 +/- 7), the
length of mechanical ventilation (mean +/- SD, 10.5 +/- 5.2 vs 7.1 +/- 2.8
days; P = .04) and the length of hospital stay (mean +/- SD, 12.1 +/- 7.1
vs 8.2 +/- 4.6 days; P = .01) were significantly longer in those patients
who experienced hypophosphatemia compared with those patients who did not
experience this complication. CONCLUSIONS: Refeeding hypophosphatemia
occurs commonly in critically ill patients in the ICU. Starvation for a
period as short as 48 hours and poor nutritional status predispose to this
syndrome. Patients at risk should be refed slowly, and the serum phosphorus
level should be closely monitored and supplemented as required.
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