# Situation: A 52-year-old man with alcohol use disorder is admitted for poor oral intake. He has eaten very little for the past 12 days. He is 1.70 m tall, weighs 48 kg today, and his usual weight is 60 kg. The team plans nasogastric (NG) tube feeding. He has no documented heart, kidney, or liver failure. The physician orders the feeding to start at a low rate, with thiamine and daily laboratory checks. His wife asks why the team will not give him his full needs right away. Which explanation is MOST accurate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630266  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 52-year-old man with alcohol use disorder is admitted for poor oral intake. He has eaten very little for the past 12 days. He is 1.70 m tall, weighs 48 kg today, and his usual weight is 60 kg. The team plans nasogastric (NG) tube feeding. He has no documented heart, kidney, or liver failure.

The physician orders the feeding to start at a low rate, with thiamine and daily laboratory checks. His wife asks why the team will not give him his full needs right away. Which explanation is MOST accurate?

## 보기

1. Starved bowel mucosa cannot yet absorb full-strength formula
2. Full feeding would overload a liver weakened by alcohol use
3. Feeding triggers insulin, which drives minerals into cells **✔ 정답**
4. A large volume stretches the stomach and causes vomiting

**정답: 3**

## 해설

After prolonged starvation, carbohydrate intake triggers insulin release, which moves phosphate, potassium, and magnesium from the blood into the cells. Blood levels can fall to dangerous values, causing weakness, respiratory failure, heart failure, and dysrhythmias (refeeding syndrome). Starting at a low calorie level, giving thiamine, and checking electrolytes often prevent this.

## 심화 해설

Why a low starting rate is needed

This patient has lost 12 kg (20% of usual body weight) over a short period and has had almost no intake for 12 days. That pattern places him at high risk for refeeding syndrome, a life-threatening metabolic disturbance that can occur when nutrition is reintroduced after prolonged starvation or severe malnutrition [1][3].

The most accurate explanation to the wife is that carbohydrate feeding stimulates insulin secretion, and insulin drives phosphate, potassium, and magnesium from the blood into cells. During starvation, total body stores of these electrolytes are already depleted even if serum levels look normal. When insulin rises after feeding begins, the remaining extracellular electrolytes shift rapidly into the intracellular compartment, causing dangerous drops in serum levels [1][4].

Key point! Hypophosphatemia is the hallmark of refeeding syndrome, but hypokalemia and hypomagnesemia occur together because insulin promotes cellular uptake of all three ions [4].

| Electrolyte shift | Mechanism | Clinical consequence |
| --- | --- | --- |
| Phosphate | Insulin-driven intracellular shift plus use in ATP production as glucose metabolism resumes | Muscle weakness, respiratory failure, impaired cardiac contractility, hemolysis |
| Potassium | Insulin activates Na-K-ATPase, moving potassium into cells | Dysrhythmias, ileus, weakness, cardiac arrest |
| Magnesium | Intracellular shift with glucose and phosphate uptake | Dysrhythmias, tetany, seizures, refractory hypokalemia |

The clinical picture can progress from subtle symptoms to severe neurological or cardiac events, including arrhythmia, seizure, encephalopathy, and death [1][4]. Fluid retention and sodium shifts also contribute to hemodynamic instability during the early refeeding phase [4].

Watch out! Serum electrolyte levels may appear normal before feeding starts because the depleted state is masked by the extracellular distribution. The danger appears only after insulin surges following carbohydrate intake [1][3].

This is why the team’s plan includes starting at a low calorie level, administering thiamine before or with feeding, and checking electrolytes daily. Thiamine is a critical cofactor for carbohydrate metabolism; refeeding increases thiamine demand, and deficiency can precipitate Wernicke encephalopathy or lactic acidosis [3][4]. Electrolyte monitoring allows early detection and replacement before severe complications develop [3].

The other options do not explain the primary concern. Starved bowel mucosa can absorb formula, and while a weakened liver or gastric distention may be considerations in some patients, the dominant, life-threatening risk in this scenario is the insulin-mediated electrolyte shift of refeeding syndrome [1][3][4].References (research sources)

- [1]Refeeding Syndrome.Research articleRunde J, Sentongo T (2019) · DOI: 10.3928/19382359-20191017-02

- [3][Refeeding syndrome : Pathophysiology, risk factors, prevention, and treatment].Research articleWirth R, Diekmann R, Janssen G, Fleiter O, Fricke L, Kreilkamp A (2018) · DOI: 10.1007/s00108-018-0399-0

- [4][The refeeding syndrome].Research articleLambers WM, Kraaijenbrink B, Siegert CE (2015)

## 임상 시나리오

Refeeding Syndrome PreventionStart low, go slow in high-risk starvation
In a patient with 12 days of minimal intake and 20% weight loss, starting full feeding can trigger refeeding syndrome. Carbohydrate intake stimulates insulin, which shifts phosphate, potassium, and magnesium into cells, causing dangerous serum electrolyte drops.

The hallmark is hypophosphatemia, but monitor all three electrolytes together. Consequences include muscle weakness, respiratory failure, heart failure, and dysrhythmias.

CautionGive thiamine before or with feeding, start at a low calorie rate, and check electrolytes daily. Serum levels may appear normal before refeeding because total body stores are already depleted.

## 핵심 개념

- **Refeeding syndrome** — Potentially fatal shifts in fluids and electrolytes when nutrition is restarted after prolonged starvation
- **Hypophosphatemia** — Hallmark electrolyte abnormality of refeeding syndrome, causing weakness and respiratory or cardiac failure
- **Insulin** — Hormone released after carbohydrate intake that drives phosphate, potassium, and magnesium into cells
- **Thiamine** — Vitamin B1 given before or with refeeding to prevent Wernicke encephalopathy and support carbohydrate metabolism
- **NG tube feeding** — Enteral nutrition delivered via nasogastric tube, started at low rate in high-risk malnourished patients

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