Save Ganga Campaigner Swami Died of Starvation or Refeeding Syndrome?
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Posted: Tuesday, June 14, 2011
by Dr K K Aggarwal
Heart Care Foundation of India
Nine days fast by Ramdev, death of another swami in Uttarakhand after 115 days fast and now a threat by Anna Hazare to go into fast again has opened a new chapter for one to revise the knowledge as to how to deal with such a person especially one is breaking the fast.
The 35 years old swami who died was protesting the Uttarakhand government's refusal to ban mining along a stretch of Ganga near Rishikesh. He had been on a fast since February 19 2011. On April 27, officials shifted him to Haridwar district hospital as his condition deteriorated but he still refused to touch food. When he slipped into coma on May 2, he was rushed to HIMS and put on life support system. The president of Haridwar Citizen Council, alleged the seer suffered a heart attack at Haridwar district hospital after being injected poison by hospital staff. Did he die of refeeding syndrome or the starvation effects is the question in the mind of the medical fraternity?
Any individual who has had negligible nutrient intake for 5 consecutive days is at risk. It occurs within four days of starting to feed. Patients who weigh less than 70 percent of ideal body weight or lose weight rapidly are at greatest risk for the syndrome.
During prolonged fasting the body conserve muscle and protein breakdown by switching to ketone bodies derived from fatty acids as the main energy source. The liver decreases its rate of gluconeogenesis thus conserving muscle and protein. Many intracellular minerals become severely depleted during this period, although serum levels may remain normal. Insulin secretion is suppressed and glucagon secretion is increased.
During re-feeding the metabolism shifts from a catabolic to an anabolic state. Insulin is released on carbohydrate intake resulting in increased glycogen, fat and protein synthesis. Insulin release triggers cellular uptake of potassium, phosphate, and magnesium which are already depleted and the stores rapidly become used up. When the serum concentrations of these electrolytes are reduced, serious complications, such as irregular heart beat can occur. Patients can also develop fluid and electrolyte imbalance, low phosphate levels, neurologic, lung, heart, neuromuscular, and blood related complications.
Irregular heart rhythm is the most common cause of death with other significant risks including confusion, coma and convulsions and cardiac failure. The diagnostic feature is presence of low phosphate, potassium, magnesium, vitamin B1 levels and fluid overload with edema feet. Low phosphate levels is the essential criteria for diagnosis.
If the refeeding syndrome occurs, doctors should immediately slow nutritional replenishment and correct low levels of phosphates, potassium and magnesium while monitoring the cardiovascular system.
In patients at risk of re-feeding syndrome, nutritional support is initially delivered at a maximum of 10 kcal/kg/day and raised gradually to full needs within a week. In extreme cases this energy intake is limited to 5 kcal/kg/day.
Before and during the first 10 days of feeding, it is important to give 200-300 mg oral thiamine a day, 1-2 vitamin B complex tablets three times a day or intravenous vitamin B, and a balanced multivitamin and mineral supplement each day.
One should monitor and supplement oral, enteral, or intravenous potassium, phosphate and magnesium in such patients.
On average, patients should receive 2-4 mmol/kg/day potassium, 0.3-0.6 mmol/kg/day phosphate, and 0.2 mmol/kg/day intravenous or 0.4 mmol/kg/day oral magnesium.
Moderately to severely ill patients with marked edema or a serum phosphorous < 2 mg/dL should be hospitalized to intravenously correct electrolyte deficiencies.
About the author: Padmashri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal is a Senior Consultant, Physician, Cardiologist at Delhi based Moolchand Medcity; President Heart Care Foundation of India; Chairman Ethical Committee Delhi Medical Council and has served as the Research and Academic Wing Heads of National Indian Medical Association.
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