Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited

Although cachectic patients are relatively well adapted to their calorically deprived state, they are prone to acute metabolic imbalances when infused with hypertonic solutions of dextrose and amino acids. Of particular concern is hypophosphatemia and its associated disorders of cardiac, pulmonary, hematological, and neuromuscular functions. This report describes two chronically malnourished but stable patients who were given aggressive total parenteral nutrition support, which was rapidly followed by acute cardiopulmonary decompensation associated with severe hypophosphatemia and other metabolic abnormalities. Despite attempts at correction, progressive multiple systems failure led to death. In light of the high prevalence of hospital malnutrition and the ready availability of total parenteral nutrition, attention is brought to these examples of how overzealous nutrition repletion can paradoxically precipitate deterioration in clinical status.