Abstract: OBJECTIVE To deepen the understanding of refeeding syndrome among medical staff. METHODS Through report a case of refeeding syndrome, the author reviewed relevant literatures both at home and abroad, elaborated on risk screening, risk grade assessment, diagnoses, and how to start nutritional therapy safely for refeeding syndrome, and summarized the treatment experience. RESULTS The nutritional status of the patient was clearly improved by supplementing vitamin B₁, correcting electrolyte disorders, supplying low calories early, and managing fluids. CONCLUSION The refeeding syndrome is one of the most common complications of nutritional therapy. Medical staff should identify high-risk groups early and develop an individualized nutritional treatment plan for them in order to make full use of nutritional therapy.