Refeeding Hypophosphatemia in Critically Ill Patients in an Intensive Care Unit: A Prospective Study

doi:10.1001/archsurg.1996.01430220037007

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Vol. 131 No. 10, October 1996

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Refeeding Hypophosphatemia in Critically Ill Patients in an Intensive Care Unit

A Prospective Study

Paul E. Marik, MD; Mary Kay Bedigian, MS, RD, CNSD

Arch Surg. 1996;131(10):1043-1047.

Abstract

Background
Hypophosphatemia has been reported after refeeding of malnourishedpatients. Nutritional support is often delayed in patients inthe intensive care unit (ICU) as a consequence of enteral intoleranceand bowel hypomotility.

Objective
To determine the incidence, risk factors, and clinical impactof refeeding hypophosphatemia in a heterogeneous group of patientsin an ICU.

Design
Prospective, noninterventional study.

Settings
Surgical and medical ICUs of a university-affiliated communityhospital.

Patients
Sixty-two patients in the ICU who were refed after being starvedfor at least 48 hours were prospectively followed up.

Interventions
None.

Main Outcome Measures
Each patient had a nutritional assessment prior to the initiationof nutritional support. Serum phosphate, magnesium, and calciumlevels were measured at baseline, and these measurements wererepeated daily. Refeeding hypophosphatemia was considered tohave developed in patients whose serum phosphorus level fellby 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 developmentof hypophosphatemia was the serum prealbumin concentration (mean± SD, 127±34vs79±40 g/L;P<.001). Seventeen(81%) of these 21 patients in whom hypophosphatemia developedhad a prealbumin concentration less than 110 g/L compared withthat in 12 (30%) of the patients who did not experience thiscomplication (P<.001). In those patients in whom refeedinghypophosphatemia developed, the serum phosphorus level reacheda mean ± SD nadir of 1.9 ± 1.1 days after feedingwas started. Although the Acute Physiology and Chronic HealthEvaluation II score was similar (mean± SD, 19±6vs 18±7), the length of mechanical ventilation (mean±SD,10.5±5.2vs7.1±2.8 days; P=.04) and the lengthof hospital stay (mean±SD, 12.1±7.1 vs 8.2±4.6days; P=.01) were significantly longer in those patients whoexperienced hypophosphatemia compared with those patients whodid not experience this complication.

Conclusions
Refeeding hypophosphatemia occurs commonly in critically illpatients in the ICU. Starvation for a period as short as 48hours and poor nutritional status predispose to this syndrome.Patients at risk should be refed slowly, and the serum phosphoruslevel should be closely monitored and supplemented as required.

Arch Surg.
1996;131:1043-1047

Author Affiliations

From the Departments of Critical Care Medicine (Dr Marik) and Nutrition and Food Services (Ms Bedigian), St Vincent Hospital, and University of Massachusetts, Worcester.

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