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