Review Question - QID 109125

This patient is an alcoholic who is likely malnourished and develops electrolyte abnormalities after receiving TPN, most consistent with refeeding syndrome. Slower initiation of TPN can help prevent this complication.

In patients who are malnourished at baseline, such as anorexics and alcoholics, TPN can trigger refeeding syndrome. Increased blood sugar from sudden nourishment enables protein, glycogen, and fat synthesis, which require phosphate, magnesium, and potassium. This causes characteristic depletion of these three electrolytes. For patients who are at risk of this complication, starting TPN at a low rate is an important preventative strategy.

Incorrect Answers:
Answer 2: Enteral nutrition by nasogastric tube is one option for maintaining nutritional status in sedated patients. However, refeeding syndrome may also occur with enteral nutrition and thus would not be prevented simply by changing the feeding method.

Answer 3: Initiation of furosemide is indicated in patients with congestive heart failure and subsequent fluid overload. Although this patient does have peripheral edema, this is likely a result of his refeeding syndrome, and administering furosemide may cause further electrolyte abnormalities.

Answer 4: Initiation of intermittent dialysis would be necessary for renal failure with electrolyte abnormalities such as hyperkalemia or hypercalcemia. Although this patient’s creatinine is higher than would be expected for such a thin man, this may be due to the intravascular depletion that often results from refeeding syndrome. Furthermore, his specific electrolyte abnormalities do not necessitate dialysis.

Answer 5: Use of low-sugar TPN is uncommon, even though TPN often causes hyperglycemia. More typically, an insulin regimen is started to maintain euglycemia. In addition, this patient’s glucose does not exceed the normal range for a non-fasting sample.

Bullet Summary:
Slow rate of initiation of total parenteral nutrition can help prevent refeeding syndrome.