Rigaud et al outlined the management of a severely malnourished patient near death and showing "the king penguin syndrome." The authors are from Hopital Bichat-Claude Bernard in Paris.


A severely malnourished patient who is near death will show a paradoxical increase in the resting energy expenditure. There coincides with increased catabolism of essential proteins previously spared. A similar pattern is shown in the king penguin Aptenodytes patagonicus in the terminal stages of starvation.


Patients will show a very low body mass index, which may be < 10 kg per square meter.


Management recommendations:

(1) Immediate intravenous resuscitation with an infusion replacing potassium, phosphorus and vitamins. This should be low in sodium chloride. The target glucose administration is 75-100 g per day.

(2) On the second day continuous enteral nutritionis started:

(2a) target energy input is 0.5 times the resting energy expenditure (REE)

(2b) protein intake is limited to 0.75 g per kg per day

(3) On the third day:

(3a) target energy input is 1.0 times the resting energy expenditure (REE)

(3b) protein intake is limited to 1.5 g per kg per day

(4) For the next 2 weeks the target energy input is 1.5 times the REE.



• The resting energy expenditure was typically 1,000 kcal per day.


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