Who That Refeeds

Apocryphal stories are not in short supply in medical history. One worth examining is the tragedy of the deaths that occurred in the days following the liberation of the European concentration camps at the end of World War 2.

One of these camps, Bergen-Belsen, which unlike Auschwitz did not employ gas chambers or mass executions, had 60 000 survivors within its grim walls when the Allied troops arrived in 1945. Typhus and starvation had already taken unthinkable numbers of people by then (including Anne Frank, an extraordinary loss for literature and humanity). But when the Allied troops arrived, and immediately gave food to the brutally emaciated inmates, the horror was compounded by a significant percentage of them dropping dead, some reportedly within minutes. For a time it was believed that the stomachs and intestines of the prisoners had shrunk so much they were unable to digest anything. The word around was that the soldiers were killing the prisoners with kindness.

But, of course, as we understood more over time, it became clear that what was occurring was classic refeeding syndrome, an underdiagnosed problem we may fail to recognise in the theatre of critical care today.

Reviewing this condition, it can occur in any malnourished patient. It may be in the setting of prolonged decreased nutritional intake, such as in anorexia or alcoholism, or decreased absorption, in the classic malabsorptive patterns of short bowel syndrome, inflammatory bowel disease, or severe chronic pancreatitis. When a glucose load is given suddenly to those at risk, there are potentially fatal shifts in fluid and electrolytes. The main culprit is phosphate, but it is a complex syndrome, with effects on sodium and fluid balance, as well as disruption to glucose, fat and protein metabolism, with thiamine deficiency, hypokalemia, and hypomagnesemia.

During prolonged fasting and periods of malnutrition, massive regulatory hormonal and metabolic changes attempt to prevent protein (and therefore muscle) breakdown. Fatty acids are relied upon, and intracellular minerals become severely depleted, even if serum levels remain pleasantly normal. At the moment of refeeding, insulin levels shoot up with the glucose load, and glycogen, protein and fat synthesis skyrockets. This also causes massive intracellular shifts of the already depleted electrolytes. Cue the protean features of the clinical syndrome: congestive heart failure, GI disturbances, Wernickes encephalopathy, but, uppermost, the sequelae of sudden, profound hypophosphatemia.

Now we in Emergency Medicine can, quite rightly, be accused of being a little phosphatist. We tend to poo poo the importance of this molecule, leaving its attention to the intensivists, who are far more fond of it than we are. And mostly that is fair tactic, except in refeeding syndrome, where the phosphate, which has been steadily depleted over time, and then is made to fall precipitously with the shifts of a glucose load, can drop so low it has profound and life-threatening effects: respiratory failure, ataxia, diffuse muscle weakness, bulbar dysfunction with aspiration, and seizures. Thus the ED physician must be alert to its relevance in these situations.

As a general outline for managing refeeding syndrome, the key features are to recognise the patients at risk, replace fluid judiciously, prepare to test and replace (and retest) critical electrolytes (phosphate, of course, but also potassium, magnesium and calcium) under generous thiamine cover, and then give consideration to the micronutrients (the rare birds of emergency medicine, eg selenium and zinc) plus the smorgasbord of other necessary vitamins. They should all be admitted to an HDU/ICU environment if possible for tailored replacement.

But let us return to its place in history. The reports of the freed prisoners dropping dead at the bite of a Hersheys Bar is a myth that circulated for many a year (plausible, I appreciate – Americans, what IS that chocolate?). But these sudden deaths were rare, their numbers exaggerated. The deaths, commensurate with the pathophysiology of refeeding syndrome, occurred over days. It was tragedy, layered on tragedy.

If nothing else, this history, and its connection with the modern presentation of this syndrome, should be another opportunity for us never to forget man’s inhumanity to man. And it is as good an opportunity as ever to revisit the gift that was Primo Levi. Levi survived Auschwitz, and was able to write about it in a way nobody else has throughout history. In ‘If This Is A Man,’ he shines the light on the one of humanity’s darkest hours. I cannot implore you enough to read it. He, a chemist, also wrote autobiographically about The Periodic Table, just to circle back to the wonders of the elements, phosphorus, in particular. If I may end by quoting Levi:

“You who live safe
In your warm houses,
You who find warm food
And friendly faces when you return home.
Consider if this is a man
Who works in mud,
Who knows no peace,
Who fights for a crust of bread,
Who dies by a yes or no.”