BCCCP: Refeeding Syndrome and Specialized Nutrition

Question 1 of 10

1. Question

A 58-year-old man is admitted to the ICU with septic shock and has been on mechanical ventilation for 5 days. He has a history of chronic alcoholism and poor oral intake for several weeks prior to admission. On day 6, enteral nutrition is initiated cautiously. Within 48 hours, he develops muscle weakness, tachycardia, and mild peripheral edema. Laboratory tests reveal serum phosphate of 1.2 mg/dL (normal 2.5–4.5 mg/dL), potassium 3.4 mEq/L, and magnesium 1.6 mg/dL. Considering the patient’s clinical presentation, timing of nutritional support, and laboratory findings, which biochemical abnormality is considered the MOST critical hallmark for the initial diagnosis of refeeding syndrome in the ICU setting?

Hypophosphatemia
Hypokalemia
Peripheral edema
New-onset confusion

Question 2 of 10

2. Question

A 62-year-old male with a history of chronic alcoholism and recent severe pancreatitis is admitted to the ICU. He is mechanically ventilated and has been receiving parenteral nutrition at 20 kcal/kg/day for the past 48 hours. Laboratory results reveal: phosphate 0.8 mg/dL (normal 2.5–4.5), potassium 2.9 mEq/L (3.5–5.0), magnesium 1.3 mg/dL (1.7–2.2), glucose 185 mg/dL (<140 fasting), and albumin 2.1 g/dL (3.5–5.0). Thiamine levels are pending. Considering this clinical context and laboratory data, which laboratory abnormality is the MOST critical for confirming the diagnosis of refeeding syndrome and guiding immediate management?

Hypophosphatemia
Hypokalemia
Hyperglycemia
Hypomagnesemia

Question 3 of 10

3. Question

A 55-year-old man with chronic alcoholism and minimal oral intake for the past 3 weeks presents for nutritional evaluation. He reports a 15% unintentional weight loss over the last month (BMI 17 kg/m²). Baseline laboratory studies reveal potassium 2.8 mEq/L, phosphorus 1.2 mg/dL, and magnesium 1.2 mg/dL. According to ASPEN consensus recommendations, which of the following best describes his refeeding syndrome risk and the most appropriate initial nutritional strategy?

High risk; initiate nutrition at 5–10 kcal/kg/day, administer thiamine 100 mg daily, and monitor serum phosphorus, potassium, and magnesium every 12 hours for the first 72 hours.
Moderate risk; initiate nutrition at 10–15 kcal/kg/day, administer thiamine 100 mg daily, and monitor serum electrolytes once daily for the first 3 days.
High risk; initiate nutrition at 15–20 kcal/kg/day, delay feeding until electrolytes normalize, and administer thiamine 200 mg daily.
Low risk; initiate nutrition at 20–25 kcal/kg/day, provide standard multivitamins, and monitor electrolytes only if symptoms of refeeding syndrome develop.

Question 4 of 10

4. Question

A 58-year-old man with severe acute pancreatitis has been NPO for 8 days and lost 10% of his body weight (current weight 50 kg). He is mechanically ventilated, hemodynamically stable on minimal vasopressors, and tolerates small sips of water. Laboratory studies show serum phosphate 1.5 mg/dL, potassium 2.8 mEq/L, and magnesium 1.2 mg/dL. Which initial nutritional strategy is most appropriate for this high-risk refeeding patient?

Initiate enteral nutrition via nasogastric tube at 10 kcal/kg/day using a feeding pump, after administering IV thiamine 200 mg and correcting phosphate, potassium, and magnesium to near-normal levels.
Initiate parenteral nutrition via a central line at 10 kcal/kg/day using an infusion pump, after administering IV thiamine and correcting electrolytes.
Initiate enteral nutrition via nasogastric tube at 20 kcal/kg/day using an infusion pump, after administering IV thiamine and correcting electrolytes.
Initiate peripheral parenteral nutrition with a dextrose–amino acid solution at 10 kcal/kg/day, after administering IV thiamine and correcting electrolytes.

Question 5 of 10

5. Question

A 58-year-old male patient with severe acute pancreatitis has experienced significant weight loss over the past month and presents with hypophosphatemia and hypokalemia. The ICU team is concerned about the high risk of refeeding syndrome as nutritional support is initiated. As the critical care pharmacist, you must recommend a nutritional strategy that balances acquisition costs and monitoring needs to minimize overall resource utilization and prevent complications in this high-risk patient. Which of the following nutritional support strategies BEST achieves this balance?

Initiate enteral nutrition at a low caloric goal with aggressive electrolyte repletion and frequent laboratory monitoring.
Initiate total parenteral nutrition (TPN) at a moderate caloric goal with standard electrolyte repletion and daily laboratory monitoring.
Provide oral nutritional supplements only, with minimal electrolyte repletion and weekly laboratory monitoring.
Initiate enteral nutrition at a high caloric goal with minimal electrolyte repletion and infrequent laboratory monitoring.

Question 6 of 10

6. Question

A 58-year-old, 70 kg man with a history of chronic alcoholism and malnutrition is admitted to the ICU with septic shock. He had minimal oral intake for 7 days, and on ICU day 5 you initiate parenteral nutrition at 20 kcal/kg/day (1,400 kcal/day). On day 3 of PN (ICU day 7), he develops persistent severe hypophosphatemia (serum phosphate 0.5 mg/dL), hypokalemia (serum K⁺ 2.8 mEq/L), and hypomagnesemia (serum Mg²⁺ 0.8 mg/dL) despite intravenous repletion (phosphate 40 mmol/day, potassium 60 mEq/day). He also has new 2+ pitting peripheral edema and frequent premature ventricular contractions. Vital signs are BP 100/60 mm Hg, HR 110 bpm irregular, RR 18 breaths/min, SpO₂ 96% on 2 L O₂, and his NRS-2002 nutritional risk score is 5 (high risk). Laboratory and clinical findings are consistent with refeeding syndrome. What is the MOST appropriate adjunctive management step to prioritize in this patient?

Increase the rate of intravenous electrolyte infusions beyond current dosing
Administer a loop diuretic (e.g., furosemide) to reduce peripheral edema
Reduce parenteral nutrition calories to ~50% of goal (~10 kcal/kg/day) and advance slowly
Begin high-dose IV thiamine (200 mg daily) plus a multivitamin infusion

Question 7 of 10

7. Question

A 58-year-old man in the ICU with a 3-week history of starvation is started on total parenteral nutrition (TPN). Within 48 hours, he develops severe hypophosphatemia (1.2 mg/dL), hypokalemia (2.8 mEq/L), and hypomagnesemia (1.1 mg/dL). He is septic with Pseudomonas aeruginosa bacteremia and is receiving meropenem 1 g IV every 8 hours as a 30-minute infusion. His cumulative fluid balance is +8 L from aggressive resuscitation. Considering his risk for refeeding syndrome, electrolyte derangements, and altered meropenem pharmacokinetics in fluid overload, what is the MOST appropriate immediate management?

Increase TPN calories to target goals, administer IV potassium and magnesium supplementation, and switch meropenem to a 24-hour continuous infusion.
Decrease TPN calories, administer IV phosphate, potassium, and magnesium supplementation, and continue meropenem 1 g IV every 8 hours via 30-minute infusion.
Decrease TPN calories, administer IV phosphate, potassium, and magnesium supplementation, and give meropenem 1 g IV over a 3-hour prolonged infusion.
Discontinue TPN, administer IV phosphate supplementation only, and increase meropenem to 2 g IV every 8 hours via 30-minute infusion.

Question 8 of 10

8. Question

A 45-year-old man with chronic alcoholism and prolonged poor oral intake is admitted to the ICU for septic shock requiring assist-control ventilation and norepinephrine. Enteral nutrition was started 12 hours ago at 10 kcal/kg/day due to severe malnutrition, and thiamine was given prior to feeding. Labs now show phosphate 0.8 mg/dL, potassium 2.9 mEq/L, magnesium 1.3 mg/dL, and glucose 180 mg/dL. Which intervention should be prioritized as the MOST critical next step in his pharmacotherapy?

Increase enteral nutrition to the full caloric goal (30 kcal/kg/day) immediately.
Administer intravenous phosphate, potassium, and magnesium replacement.
Initiate a continuous insulin infusion to control hyperglycemia.
Hold enteral feeding and recheck electrolytes before advancing nutrition.

Question 9 of 10

9. Question

A 58-year-old critically ill patient with prolonged malnutrition is started on nutritional support. Within 48 hours, the patient develops rapid declines in serum potassium, magnesium, and phosphate levels. Telemetry reveals new premature ventricular contractions. The critical care pharmacist is consulted to optimize monitoring and prevent further complications. Which monitoring parameter should the pharmacist prioritize?

Daily blood glucose monitoring and point-of-care glucose checks
Continuous cardiac rhythm monitoring and frequent serum electrolyte assessments
Hourly fluid intake/output measurement and central venous pressure monitoring
Daily serum thiamine concentration and serial neurological examinations

Question 10 of 10

10. Question

A 55-year-old man (weight 60 kg) with chronic alcoholism and a 3-week history of minimal oral intake is admitted to the ICU on continuous renal replacement therapy (CRRT) for acute kidney injury. Laboratory results show serum potassium 2.8 mmol/L, phosphate 0.4 mmol/L, and magnesium 0.5 mmol/L. He is at very high risk for refeeding syndrome. Which of the following is the MOST appropriate initial nutritional and electrolyte management plan?

Initiate enteral nutrition at 10 kcal/kg/day (~600 kcal/day), increase by ≤5 kcal/kg/day as tolerated; replete phosphate 0.3–0.6 mmol/kg/day, potassium 1–1.5 mmol/kg/day, magnesium 0.2–0.4 mmol/kg/day; administer thiamine 200 mg IV daily for ≥5 days; target protein up to 2.5 g/kg/day.
Initiate enteral nutrition at 10 kcal/kg/day (~600 kcal/day), increase by ≤5 kcal/kg/day as tolerated; target protein 1.5 g/kg/day; replete electrolytes as above; omit thiamine.
Initiate enteral nutrition at 15 kcal/kg/day (~900 kcal/day), increase by ≤5 kcal/kg/day; target protein 1.5 g/kg/day; replete electrolytes; administer thiamine 200 mg IV daily.
Initiate parenteral nutrition at 10 kcal/kg/day (~600 kcal/day); replete phosphate, potassium, magnesium at the same rates; administer thiamine 200 mg IV daily; delay enteral feeding due to CRRT fluid concerns.

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