Introduction:Starvation ketoacidosis (SKA) is a rare cause of ketoacidosis in the general population but can be seen with malignancy. Patients often respond well to treatment, but some rarely develop refeeding syndrome (RFS) as their electrolytes drop to dangerous levels causing organ failure. Typically, RFS can be managed with low-calorie feeds, but sometimes patients require a halt in feeds until their electrolyte imbalances are managed.Case report:We discuss a woman with synovial sarcoma on chemotherapy who was diagnosed with SKA and then developed severe RFS after treatment with intravenous dextrose. Phosphorus, potassium, and magnesium levels dropped precipitously and remained fluctuant for 6 days. She also developed normal sinus ventricular tachycardia, premature ventricular beats, and bigeminy. She could not tolerate calorie supplementation at that time. She was managed with electrolyte repletions until clinically stable and then progressed to a liquid diet.Discussion:We present a unique case of severe SKA that resulted in RFS requiring nihil per orem (NPO) treatment for 6 days. There are no specific guidelines for SKA or RFS management. Patients with pH < 7.3 may benefit from baseline serum phosphorus, potassium, and magnesium levels. Clinical trials are needed to further study which patients may benefit from starting at a low-calorie intake versus those that require holding nutrition until clinically stable.Conclusion:Completely stopping caloric intake until a patient’s electrolyte imbalance improves is an important management aspect of RFS to underscore and study, as grave complications can occur even with cautious refeeding regimens.