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Internal Medicine


Answer 3
  1. Maximal caloric replacement over the initial12 hours of hospitalization will improve her outcome. A cardinal rule in reinstituting nutrition (especially parenteral or enteral nutrition) is the “start low and go slow” concept. Patients with anorexia nervosa are at high risk for life-threatening electrolyte depletion and fluid shifts, which can impair cardiac performance and result in fatal ventricular arrhythmias as well as respiratory muscle weakness precipitating acute respiratory failure.3 In prisoners of war who were placed on vigorous nutritional repletion regimens after prolonged starvation, complications such as cardiac failure, arrhythmias, and sudden death frequently occurred.2 Other complications include hypophosphatemia-induced rhabdomyolysis, hemolysis, and phagocyte dysfunction.4 It is prudent to begin nutritional support in low amounts and increase over several days, with careful monitoring of serum electrolytes and cardiac rhythm.

    REFERENCES
    1.
     Marinella MA. Refeeding syndrome. In: Frequently overlooked diagnoses in acute care. Philadelphia: Hanley & Belfus; 2003:79-83.

    2. Solomon SM, Kirby DF. The refeeding syndrome: a review. JPEN J Parenter Nutr 1990;14:90-7.

    3. Kohn MR, Golden NH, Shenker IR. Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health 1998;22:239-43.

    4. Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition 2001;17:632-7.

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