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Satoh D, Takeuchi K, Kawagoe I, Kisii J, Kudoh O, Hayashida M. Prognosis for major abdominal surgeries based on intraoperative low-dose nutrition: A metabolic perspective. Clin Nutr ESPEN 2023; 58:208-212. [PMID: 38057007 DOI: 10.1016/j.clnesp.2023.09.926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 09/19/2023] [Accepted: 09/23/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND & AIMS The optimal nutrition intake during surgery is unknown. This study aimed to investigate the prognosis of low-dose nutrition during laparoscopic colorectal cancer surgery. METHODS In the glucose and amino acids (GA) group, 20 patients were infused with glucose (75 g/L) and amino acids (30 g/L) at 60 mL/h and bicarbonate Ringer's solution. However, 20 patients in the control (C) group were infused with bicarbonate Ringer's solution without GA. The length of hospital stay was determined, and measurements were taken before (TI) and after (T2) the surgery under general anesthesia. RESULTS The lengths of hospital stay were comparable between the GA (13 days) and C (16 days) groups. Ketone body levels were 294 (C group) and 33 (GA group) μmol/L at T2. Nitrogen balance was 0.32 g (GA group) and -1.60 g (C group) at T2. CONCLUSIONS Although the lengths of hospital stay were comparable, ketone body levels, and nitrogen balance were significantly different (P < 0.01) between the two groups after surgery.
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Affiliation(s)
- Daizoh Satoh
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Kazuyo Takeuchi
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Jun Kisii
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Osamu Kudoh
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
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Jotterand Chaparro C, Pabion C, Tume L, Mehta NM, Valla FV, Moullet C. Determining energy and protein needs in critically ill pediatric patients: A scoping review. Nutr Clin Pract 2023; 38 Suppl 2:S103-S124. [PMID: 37721467 DOI: 10.1002/ncp.11060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients. METHODS An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data. RESULTS A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated. CONCLUSION This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Céline Pabion
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Lyvonne Tume
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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Hoeyer-Nielsen AK, Holmberg MJ, Grossestreuer AV, Yankama T, Berg KM, Donnino MW. OXYGEN CONSUMPTION AS AN EARLY WARNING SYSTEM IN THE CRITICALLY ILL. Shock 2023; 60:539-544. [PMID: 37752082 DOI: 10.1097/shk.0000000000002208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
ABSTRACT Introduction: In this study, we assessed whether changes in oxygen consumption (VO 2 ) and other metabolic parameters could be used as an early warning system for detecting clinical deterioration in mechanically ventilated patients. Methods: This was a prospective cohort study of adult patients requiring mechanical ventilation between February 2016 and March 2019. We looked for changes in VO 2 , carbon dioxide production (VCO 2 ), respiratory quotient (RQ), and end-tidal carbon dioxide (EtCO 2 ), occurring prior to clinical deterioration. Clinical deterioration was predefined as a requirement of vasopressor, an increase in serum lactate by 20% where at least one value was above 3 mmol/L, or a decrease in hemoglobin by 20% in the 4 hours prior to clinical deterioration. Results A total of 141 patients were included. There were no detectable changes in VO 2 , VCO 2 , and EtCO 2 within the 4 hours prior to any clinical deterioration. RQ increased significantly within the 4 hours prior to an increase in lactate as compared with no increase in lactate, but there were no detectable changes prior to other clinical deteriorations. Conclusions RQ has the potential to be an early marker of tissue hypoperfusion or mitochondrial dysfunction. However, future studies are necessary to evaluate the use of RQ as a bedside monitor in critical care settings.
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Affiliation(s)
| | | | - Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tuyen Yankama
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abdi F, Zuberi S, Blom JJ, Armstrong D, Pinto-Sanchez MI. Nutritional Considerations in Celiac Disease and Non-Celiac Gluten/Wheat Sensitivity. Nutrients 2023; 15:nu15061475. [PMID: 36986205 PMCID: PMC10058476 DOI: 10.3390/nu15061475] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/12/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
A gluten-free diet (GFD) is the only available treatment for celiac disease (CeD), and it may also improve symptoms in non-celiac gluten/wheat sensitivity (NCGWS). In CeD, gluten triggers an immune reaction leading to enteropathy, malabsorption, and symptoms; in NCGWS, the mechanism leading to symptoms is unknown, and neither wheat nor gluten triggers enteropathy or malabsorption. A strict GFD is, therefore, necessary for CeD, but a gluten-restricted diet (GRD) may suffice to achieve symptom control for NCGWS. Regardless of this distinction, the risk of malnutrition and macro- and micronutrient deficiencies is increased by the adoption of a GFD or GRD. Thus, patients with CeD or NCGWS should undergo nutritional assessment and subsequent monitoring, based on evidence-based tools, under the care of a multidisciplinary team involving physicians and dietitians, for the long-term management of their nutrition. This review gives an overview of available nutrition assessment tools and considerations for the nutritional management of CeD and NCGWS populations.
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Affiliation(s)
- Fardowsa Abdi
- Department of Medicine, Faculty of Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Saania Zuberi
- Department of Medicine, Faculty of Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Jedid-Jah Blom
- Department of Medicine, Faculty of Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - David Armstrong
- Department of Medicine, Faculty of Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Maria Ines Pinto-Sanchez
- Department of Medicine, Faculty of Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1, Canada
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External Validation with Accuracy Confounders of VCO 2-Derived Predicted Energy Expenditure Compared to Resting Energy Expenditure Measured by Indirect Calorimetry in Mechanically Ventilated Children. Nutrients 2022; 14:nu14194211. [PMID: 36235863 PMCID: PMC9571636 DOI: 10.3390/nu14194211] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Optimal energy provision, guided by measured resting energy expenditure (REE) and determined by indirect calorimetry (IC), is fundamental in Intensive Care Units (ICU). Because IC availability is limited, methods to predict REE based on carbon dioxide production (VCO2) measurements (REEVCO2) alone have been proposed as a surrogate for REE measured by IC (REEIC). The study aimed at externally and internally validating the accuracy of the REEVCO2 as an alternative to REEIC in mechanically ventilated children. A ventilator’s integrated gas exchange module (E-COVX) was used to prospectively measure REEIC and predict REEVCO2 on 107 mechanically ventilated children during the first 24 h of admission. The accuracy of the REEVCO2 compared to REEIC was assessed through the calculation of bias and precision, paired median differences, linear regression, and ROC analysis. Accuracy within ±10% of the REEIC was deemed acceptable for the REEVCO2 equation. The calculated REEVCO2 based on respiratory quotient (RQ) 0.89 resulted in a mean bias of −72.7 kcal/day (95% limits of agreement −321.7 to 176.3 kcal/day) and a high coefficient of variation (174.7%), while 51.4% of the calculations fell outside the ±10% accuracy rate. REEVCO2 derived from RQ 0.80 or 0.85 did not improve accuracy. Only measured RQ (Beta 0.73, p < 0.001) and no-recorded neuromuscular blocking agents (Beta −0.13, p = 0.044) were independently associated with the REEVCO2−REEIC difference. Among the recorded anthropometric, metabolic, nutrition, or clinical variables, only measured RQ was a strong predictor of REEVCO2 inaccuracy (p < 0.001). Cutoffs of RQ = 0.80 predicted 89% of underestimated REEIC (sensitivity 0.99; specificity 0.89) and RQ = 0.82 predicted 56% of overestimated REEIC (sensitivity of 0.99; specificity 0.56). REEVCO2 cannot be recommended as an alternative to REEIC in mechanically ventilated children, regardless of the metabolic, anthropometric, or clinical status at the time of the evaluation.
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Briassoulis G, Briassouli E, Ilia S, Briassoulis P. External Validation of Equations to Estimate Resting Energy Expenditure in Critically Ill Children and Adolescents with and without Malnutrition: A Cross-Sectional Study. Nutrients 2022; 14:nu14194149. [PMID: 36235803 PMCID: PMC9572704 DOI: 10.3390/nu14194149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
We evaluated the validity of sixteen predictive energy expenditure equations for resting energy expenditure estimation (eREE) against measured resting energy expenditure using indirect calorimetry (REEIC) in 153 critically ill children. Predictive equations were included based on weight, height, sex, and age. The agreement between eREE and REEIC was analyzed using the Bland−Altman method. Precision was defined by the 95% limits of the agreement; differences > ±10% from REEIC were considered clinically unacceptable. The reliability was assessed by the intraclass correlation coefficient (Cronbach’s alpha). The influence of anthropometric, nutritional, and clinical variables on REEIC was also assessed. Thirty (19.6%) of the 153 enrolled patients were malnourished (19.6%), and fifty-four were overweight (10.5%) or obese (24.8%). All patients received sedation and analgesia. Mortality was 3.9%. The calculated eREE either underestimated (median 606, IQR 512; 784 kcal/day) or overestimated (1126.6, 929; 1340 kcal/day) REEIC compared with indirect calorimetry (928.3, 651; 1239 kcal/day). These differences resulted in significant biases of −342 to 592 kcal (95% limits of agreement (precision)−1107 to 1380 kcal/day) and high coefficients of variation (up to 1242%). Although predicted equations exhibited moderate reliability, the clinically acceptable ±10% accuracy rate ranged from only 6.5% to a maximum of 24.2%, with the inaccuracy varying from −31% to +71.5% of the measured patient’s energy needs. REEIC (p = 0.017) and eREE (p < 0.001) were higher in the underweight compared to overweight and obese patients. Apart from a younger age, malnutrition, clinical characteristics, temperature, vasoactive drugs, neuromuscular blockade, and energy intake did not affect REEIC and thereby predictive equations’ accuracy. Commonly used predictive equations for calculating energy needs are inaccurate for individual patients, either underestimating or overestimating REEIC compared with indirect calorimetry. Altogether these findings underscore the urgency for measuring REEIC in clinical situations where accurate knowledge of energy needs is vital.
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Affiliation(s)
- George Briassoulis
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, 71110 Heraklion, Greece
- Postgraduate Program “Emergency and Intensive Care in Children Adolescents and Young Adults”, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Correspondence: ; Tel.: +30-2810-394675
| | - Efrossini Briassouli
- Infectious Diseases Department “MAKKA”, First Department of Paediatrics, “Aghia Sophia” Children’s Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, 71110 Heraklion, Greece
- Postgraduate Program “Emergency and Intensive Care in Children Adolescents and Young Adults”, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Panagiotis Briassoulis
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, 71110 Heraklion, Greece
- Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Energy Expenditure in Mechanically Ventilated Korean Children: Single-Center Evaluation of a New Estimation Equation. Pediatr Crit Care Med 2020; 21:e522-e529. [PMID: 32453925 DOI: 10.1097/pcc.0000000000002335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Accurate assessments of energy expenditure are vital for determining optimal nutritional support, especially in critically ill children. We evaluated current methods for energy expenditure prediction, in comparison with indirect calorimetry, and developed a new estimation equation for mechanically ventilated, critically ill Korean children. DESIGN Single-center retrospective study. SETTING Fourteen-bed pediatric medical ICU in a tertiary care children's hospital. PATIENTS Pediatric patients admitted to the PICU between October 2017 and September 2019 with a measured energy expenditure by indirect calorimetry. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total 95 pediatric patients (70 in derivation cohort for development of a new predictive equation and 25 in validation cohort) were included. Mean measured energy expenditure of group A was 66.20 ± 15.35 kcal/kg/d. All previously established predictive equations underestimated the predicted energy expenditure, compared with the measured energy expenditure, except the Food and Agriculture/World Health Organization/United Nations University equation. The Schofield-Height and Weight equation showed the best performance among the tested predictive equations for the entire cohort (least bias, -68.58 kcal/d; best percentage, 108.46% ± 33.60%) compared with the measured energy expenditure. It was also the best performing predictive equation in subgroup analysis by age, sex, nutritional status, and organ failure. Because some discrepancies remained between the measured energy expenditure and predicted energy expenditures, we developed a new estimation equation using multiple regression analysis and those variables significantly associated with our current measured energy expenditures: Energy expenditure = -321.264 + 72.152 × (body weight, kg)-1.396 × (body weight) + 5.668 × height (cm) + organ dysfunction* (*hematologic, 76.699; neurologic, -87.984). This new estimation equation showed the least bias and best percentage compared with previous predictive equations (least bias, 15.51 kcal/d; best percentage, 102.30% ± 28.10%). CONCLUSIONS There are significant disparities between measured and calculated energy expenditures. We developed a new estimation equation based on measured energy expenditure data that shows better performance in mechanically ventilated Korean children than other equations. This new estimation equation requires further prospective validation in pediatric series with a range in body habitus.
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Rogobete AF, Grintescu IM, Bratu T, Bedreag OH, Papurica M, Crainiceanu ZP, Popovici SE, Sandesc D. Assessment of Metabolic and Nutritional Imbalance in Mechanically Ventilated Multiple Trauma Patients: From Molecular to Clinical Outcomes. Diagnostics (Basel) 2019; 9:diagnostics9040171. [PMID: 31683927 PMCID: PMC6963656 DOI: 10.3390/diagnostics9040171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 12/26/2022] Open
Abstract
The critically ill polytrauma patient is characterized by a series of metabolic changes induced by inflammation, oxidative stress, sepsis, and primary trauma, as well as associated secondary injuries associated. Metabolic and nutritional dysfunction in the critically ill patient is a complex series of imbalances of biochemical and genetic pathways, as well as the interconnection between them. Therefore, the equation changes in comparison to other critical patients or to healthy individuals, in which cases, mathematical equations can be successfully used to predict the energy requirements. Recent studies have shown that indirect calorimetry is one of the most accurate methods for determining the energy requirements in intubated and mechanically ventilated patients. Current research is oriented towards an individualized therapy depending on the energy consumption (kcal/day) of each patient that also takes into account the clinical dynamics. By using indirect calorimetry, one can measure, in real time, both oxygen consumption and carbon dioxide production. Energy requirements (kcal/day) and the respiratory quotient (RQ) can be determined in real time by integrating these dynamic parameters into electronic algorithms. In this manner, nutritional therapy becomes personalized and caters to the patients’ individual needs, helping patients receive the energy substrates they need at each clinically specific time of treatment.
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Affiliation(s)
- Alexandru Florin Rogobete
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | - Ioana Marina Grintescu
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania.
| | - Tiberiu Bratu
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
| | - Ovidiu Horea Bedreag
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | - Marius Papurica
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | | | - Sonia Elena Popovici
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | - Dorel Sandesc
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
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Poulsen MK, Thomsen LP, Kjaergaard S, Rees SE, Karbing DS. Reliability of, and Agreement Between, two Breath-by-Breath Indirect Calorimeters at Varying Levels of Inspiratory Oxygen. Nutr Clin Pract 2019; 34:767-774. [PMID: 30714634 DOI: 10.1002/ncp.10250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Indirect calorimetry (IC) is considered the accurate way of measuring energy expenditure (EE). IC devices often apply the Haldane transformation, introducing errors at inspiratory oxygen fraction (FiO2 ) >60%. The aim was to assess measurement reliability and agreement between an unevaluated IC (device 2) (Beacon Caresystem, Mermaid Care A/S, Noerresundby, Denmark) not using Haldane transformation and an IC that does (device 1) (Ecovx, GE, Helsinki, Finland) at varying FiO2 . METHODS Twenty healthy male subjects participated, with 16 completing the study (33 ± 9 years, 83.3 ± 16 kg, 1.83 ± 0.08 m). Subjects were mechanically ventilated in pressure support (3cmH2 O; positive end-expiratory pressure: 3cmH2 O) at FiO2 of 21%, 50%, 85%, and 21% for 15 minutes at each FiO2 . Mean EE, oxygen consumption (VO2 ), and CO2 production (VCO2 ) were compared within and between devices across FiO2 levels. RESULTS Device 2 showed within-device EE significant differences at 21% vs 50% FiO2 and device 1 for VCO2 at 50% vs. 85% FiO2 . For all variables, both devices showed reliable measurements at 21% and 50% FiO2 , but at 85%, FiO2 bias and limits of agreement increased. Between devices, there were significant differences for EE at both 21% and 85% FiO2 for VO2 and for VCO2 at 85% FiO2 . CONCLUSION Both systems measured EE, VO2 , and VCO2 at 21%-85% FiO2 reliably but with bias at 85% FiO2 . The devices were in agreement at 21% and 50% FiO2 , but further studies need to confirm accuracy at high FiO2 .
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Affiliation(s)
- Mathias Krogh Poulsen
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Lars Pilegaard Thomsen
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Søren Kjaergaard
- Department of Anesthesiology, Aalborg University Hospital, Aalborg, Denmark
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Frankenfield DC. Factors Related to the Assessment of Resting Metabolic Rate in Critically Ill Patients. JPEN J Parenter Enteral Nutr 2018; 43:234-244. [PMID: 30462858 DOI: 10.1002/jpen.1484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 10/15/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Predicting resting metabolic rate (RMR) in mechanically ventilated, critically ill patients is an important part of the nutrition care in such patients. METHODS RMR and associated clinical data from various studies of mechanically ventilated, critically ill patients were combined, and the impact of body size, age, reason for admission, and sedation level were analyzed along with prediction methods of RMR (the American Society for Parenteral and Enteral Nutrition [ASPEN] standards and the Penn State equation). RESULTS Among 826 measurements, trauma patients had a higher RMR than surgical and medical patients (2077 ± 290 vs 1987 ± 282 kcal/d; P < .0001). RMR was not different in sedated vs unsedated patients. Wide ranges of weight (27-374 kg) and age (18-95 years) were captured. The relationships between weight and RMR and RMR and age were curvilinear. For weight-based ratio methods of RMR prediction, <50% of predictions were within the range in which they were designed to work. The accuracy of the Penn State equation was better in some weight categories than others. New equations based on a wider range of body weights and ages are presented. CONCLUSIONS Curvilinear functions exist for weight and age in relation to RMR, but extraordinary levels of each are required for the curve to become apparent. The ASPEN energy standards (kcal/kg body weight) fail to predict RMR because the relationship is more complex than a simple ratio. The Penn State equations are better able to model these relationships. The new versions of the equation presented here await validation.
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Affiliation(s)
- David C Frankenfield
- Department of Clinical Nutrition, Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.,Department of Nursing, Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Spanaki AM, Tavladaki T, Dimitriou H, Kozlov AV, Duvigneau JC, Meleti E, Weidinger A, Papakonstantinou E, Briassoulis G. Longitudinal Profiles of Metabolism and Bioenergetics Associated with Innate Immune Hormonal Inflammatory Responses and Amino-Acid Kinetics in Severe Sepsis and Systemic Inflammatory Response Syndrome in Children. JPEN J Parenter Enteral Nutr 2018; 42:1061-1074. [PMID: 29338093 DOI: 10.1002/jpen.1050] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Experimental data indicate that sepsis influences the mitochondrial function and metabolism. We aim to investigate longitudinal bioenergetic, metabolic, hormonal, amino-acid, and innate immunity changes in children with sepsis. METHODS Sixty-eight children (sepsis, 18; systemic inflammatory response syndrome [SIRS], 23; healthy controls, 27) were enrolled. Plasma amino acids were determined by high-performance liquid chromatography (HPLC); flow-cytometry expressed as mean fluorescence intensity (MFI) of heat shock protein (HSP) levels from monocytes (m) and neutrophils (n); resistin, adiponectin, and extracellular (e) HSPs evaluated by ELISA; ATP levels in white blood cells by luciferase luminescent assay; lipid peroxidation products (TBARS) by colorimetric test; nitrite and nitrate levels by chemiluminescent assay; biliverdin reductase (BVR) activity by enzymatic assay; and energy-expenditure (EE) by E-COVX. RESULTS Resistin, eHSP72, eHSP90α, and nitrate were longitudinally higher in sepsis compared with SIRS (p<0.05); mHSP72, nHSP72, VO2 , VCO2 , EE, and metabolic pattern were repressed in sepsis compared with SIRS (p<0.05). Septic patients had lower ATP and TBARS compared with controls on day 1, lower ATP compared with SIRS on day 3 (p<0.05), but higher levels of BVR activity. Sepsis exhibited higher phenylalanine levels on day 1, serine on day 3; lower glutamine concentrations on days 3 and 5 (p<0.05). Resistin, inversely related to ATP, was independently associated with sepsis, along with mHSP72 and eHSP90α (p<0.05); TBARS and VO2 were independently associated with organ failure (p<0.05)). Septic nonsurvivors had malnutrition, persistently repressed metabolism, mHSP72, and induced resistin and adiponectin (p<0.05). CONCLUSIONS A pattern of early longitudinal induction of metabolic-hormones and eHSP72/HSP90α, repression of bioenergetics and innate immunity, hypo-metabolism, and amino-acid kinetics changes discriminate sepsis from SIRS; malnutrition, hypo-metabolism, and persistently increased resistin and adiponectin are associated with poor outcome.
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Affiliation(s)
- Anna Maria Spanaki
- Pediatric Intensive Care Unit, University Hospital, Medical School, University of Crete, Heraklion, Greece
| | - Theonymfi Tavladaki
- Pediatric Intensive Care Unit, University Hospital, Medical School, University of Crete, Heraklion, Greece
| | - Helen Dimitriou
- Pediatric Hematology - Oncology, Medical School, University of Crete, Heraklion, Greece
| | - Andrey V Kozlov
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA, Vienna, Austria
| | | | - Eftychia Meleti
- Pediatric Hematology - Oncology, Medical School, University of Crete, Heraklion, Greece
| | - Adelheid Weidinger
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA, Vienna, Austria
| | | | - George Briassoulis
- Pediatric Intensive Care Unit, University Hospital, Medical School, University of Crete, Heraklion, Greece
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12
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Satoh D, Toda N, Yamamoto I. Effects of intraoperative nutrients administration on energy expenditure during general anesthesia. Nutrition 2017; 45:37-40. [PMID: 29129235 DOI: 10.1016/j.nut.2017.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 05/13/2017] [Accepted: 06/17/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Recent reports have shown that intraoperative infusions of glucose and amino acids exert anticatabolic effects. The appropriate dosages of these amino acids and glucose during general anesthesia remain unknown. METHODS Patients who underwent esophagectomy for thoracic esophageal cancer were infused with acetated Ringer's solution that contained glucose and amino acids (B1 group [10 patients]: glucose, 3 g/h; amino acids, 1.2 g/h; B2 group [12 patients]: glucose, 4.5 g/h; amino acids, 1.8 g/h) or did not contain glucose and amino acids (C group, 10 patients). The measured energy expenditure was measured by indirect calorimetry. Nitrogen balance was measured during the anesthesia, and the lengths of the hospital stay were recorded. RESULTS Resting energy expenditure (B1: 1230 ± 228; B2: 1317 ± 282; C: 1012 ± 153 kcal/h; B2 vs C, P < 0.05) and nitrogen balance (B1: -1.78 ± 0.78 g; B2: -0.85 ± 0.98 g; C: -2.94 ± 2.4 g; B2 vs C, P < 0.05) differed significantly between the B2 and C groups. The lengths of the hospital stay differed between the B2 and C groups (B1: 29 ± 15 d; B2: 18 ± 6 d; C: 37 ± 27 d; B2 vs C, P = 0.06). CONCLUSIONS The administration of amino acids and glucose increased measured energy expenditure, alleviated nitrogen balance, and may decrease the length of the hospital stay.
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Affiliation(s)
- Daizoh Satoh
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Postgraduate Medical School, Miyagi, Japan.
| | - Noriko Toda
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Postgraduate Medical School, Miyagi, Japan
| | - Ichiro Yamamoto
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Postgraduate Medical School, Miyagi, Japan
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13
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Drábková Z, Schramel JP, Kabeš R. Determination of physiological dead space in anaesthetized horses: a method-comparison study. Vet Anaesth Analg 2017; 45:73-77. [PMID: 29246713 DOI: 10.1016/j.vaa.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 04/03/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare two methods of Bohr-Enghoff physiological dead space to tidal volume ratio (Vd/VtBohr-Enghoff) determination using a mixing chamber and an E-CAiOVX metabolic monitor. STUDY DESIGN Prospective, clinical, method-comparison study. ANIMALS Twenty horses anaesthetized for elective orthopaedic procedures. METHODS Horses were anaesthetized with isoflurane in oxygen and the lungs were mechanically ventilated (Vt 15±2 mL kg-1). Arterial blood was sampled to provide arterial partial pressure of carbon dioxide (PaCO2) for dead space calculation using a metabolic monitor. Mixed expired partial pressure of carbon dioxide (PēCO2) obtained from the custom-made mixing chamber was recorded at the time of arterial blood sampling. Dead space fraction was calculated using the Enghoff modification of the Bohr equation. Agreement between the methods was assessed by Bland-Altman test. A clinically acceptable error was defined to be ≤ 10%. RESULTS Forty-nine simultaneous Vd/VtBohr-Enghoff results were obtained. There was no clinically significant bias between the mixing chamber and E-CAiOVX. The limits of agreement were within a priori defined error (bias±95% limits of agreement: -0.022±0.078). CONCLUSIONS AND CLINICAL RELEVANCE Acceptable agreement was found between the two methods. The E-CAiOVX metabolic monitor might be a suitable device for measuring Vd/VtBohr-Enghoff in anaesthetized horses.
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Affiliation(s)
- Zuzana Drábková
- Equine Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic.
| | - Johannes P Schramel
- Anaesthesiology and Perioperative Intensive Care Medicine, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Radovan Kabeš
- Equine Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
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Ferreruela M, Raurich JM, Llompart-Pou JA, Colomar A, Ayestarán I. Effect of FiO 2 in the measurement of VO 2 and VCO 2 using the E-COXV metabolic monitor. Med Intensiva 2017; 41:461-467. [PMID: 28283325 DOI: 10.1016/j.medin.2016.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/02/2016] [Accepted: 12/14/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We evaluated the effect of changes in FiO2 on the bias and accuracy of the determination of oxygen consumption (V˙O2) and carbon dioxide production (V˙CO2) using the E-COVX monitor in patients with mechanical ventilation. DESIGN Descriptive of concordance. SETTING Intensive Care Unit. PATIENTS OR PARTICIPANTS Patients with mechanical ventilation. INTERVENTIONS We measured V˙O2 and V˙CO2 using the E-COVX monitor. Values recorded were the average in 5min. Two groups of 30 patients. We analyzed: 1) the reproducibility in the measurement of V˙O2 and V˙CO2 at FiO2 0.4, and 2) the effect of the changes in FiO2 on the measurement of V˙O2 and V˙CO2. Statistical analysis was performed using Bland and Altman test. VARIABLES OF MAIN INTEREST Bias and accuracy. RESULTS 1) FiO2 0.4 reproducibility: The bias in the measurement of V˙O2 and V˙CO2 was 1.6 and 2.1mL/min, respectively, and accuracy was 9.7 to -8.3% and 7.2 to -5.2%, respectively, and 2) effect of FiO2 on V˙O2: The bias of V˙O2 measured at FiO2 0.4 and 0.6 was -4.0mL/min and FiO2 0.4 and 0.8 was 5.2mL/min. Accuracy between FiO2 0.4 and 0.6 was 11.9 to -14.1%, and between FiO2 0.4 and 0.8 was 43.9 to -39.7%. CONCLUSIONS The E-COVX monitor evaluates V˙O2 and V˙CO2 in critical patients with mechanical ventilation with a clinically acceptable accuracy until FiO2 0.6.
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Affiliation(s)
- M Ferreruela
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, España
| | - J M Raurich
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, España.
| | - J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, España
| | - A Colomar
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, España
| | - I Ayestarán
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, España
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Rogobete AF, Sandesc D, Papurica M, Stoicescu ER, Popovici SE, Bratu LM, Vernic C, Sas AM, Stan AT, Bedreag OH. The influence of metabolic imbalances and oxidative stress on the outcome of critically ill polytrauma patients: a review. BURNS & TRAUMA 2017; 5:8. [PMID: 28286784 PMCID: PMC5341432 DOI: 10.1186/s41038-017-0073-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/23/2017] [Indexed: 05/03/2023]
Abstract
The critically ill polytrauma patient presents with a series of associated pathophysiologies secondary to the traumatic injuries. The most important include systemic inflammatory response syndrome (SIRS), sepsis, oxidative stress (OS), metabolic disorders, and finally multiple organ dysfunction syndrome (MODS) and death. The poor outcome of these patients is related to the association of the aforementioned pathologies. The nutrition of the critically ill polytrauma patient is a distinct challenge because of the rapid changes in terms of energetic needs associated with hypermetabolism, sepsis, SIRS, and OS. Moreover, it has been proven that inadequate nutrition can prolong the time spent on a mechanical ventilator and the length of stay in an intensive care unit (ICU). A series of mathematical equations can predict the energy expenditure (EE), but they have disadvantages, such as the fact that they cannot predict the EE accurately in the case of patients with hypermetabolism. Indirect calorimetry (IC) is another method used for evaluating and monitoring the energy status of critically ill patients. In this update paper, we present a series of pathophysiological aspects associated with the metabolic disaster affecting the critically ill polytrauma patient. Furthermore, we present different non-invasive monitoring methods that could help the intensive care physician in the adequate management of this type of patient.
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Affiliation(s)
- Alexandru Florin Rogobete
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
| | - Dorel Sandesc
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
| | - Marius Papurica
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
| | - Emil Robert Stoicescu
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Sonia Elena Popovici
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Lavinia Melania Bratu
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Corina Vernic
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Adriana Mariana Sas
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Adrian Tudor Stan
- Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Ovidiu Horea Bedreag
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
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Validation of ventilator-derived VCO 2 measurements to determine energy expenditure in ventilated critically ill children. Clin Nutr 2016; 36:452-457. [PMID: 26803170 DOI: 10.1016/j.clnu.2016.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS Indirect calorimetry (IC) is considered the gold standard to determine resting energy expenditure (REE) but its availability in PICUs worldwide is limited. Ventilator-derived VCO2 could potentially improve the possibility of performing REE measurements. We investigated whether ventilator-derived VCO2 values are comparable to IC-derived VCO2 values and can clinically be used in clinical practice to determine REE. METHODS VCO2-values were simultaneously collected in mechanically ventilated children from IC (Deltatrac®) and Servo-I® ventilator on a minute base over at least 10 min period of steady state. REE was calculated using the modified Weir formula (for IC) or REE = 5.5*VCO2 (L/min)*1440 (for the Servo-I values) and compared with frequently used predictive equations by Schofield and the WHO to calculate REE. RESULTS Measurements were performed in 41 children; median age 2 years. The mean relative difference between VCO2 measured by IC and Servo-I® was 15.6% (p = 0.002), and limits of agreement in the Bland-Altman analysis were wide. Comparable measurements, defined as a difference ≤10% between IC and Servo-I® VCO2 values, were seen in 18 (44%) children, but this proportion was 70% in children ≥15 kg. In this group, REE could be accurately predicted using Servo-I® derived VCO2 values and this method was superior to the use of predictive equations. The Servo-I® derived VCO2 values were not sufficiently accurate for the large proportion of children weighing <15 kg. CONCLUSIONS In children ≥15 kg, VCO2 measurements of the Servo-I® seem sufficiently accurate for use in clinical practice and may be used to determine energy expenditure in the future.
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Abstract
The primary end point when treating acute shock is to restore blood circulation, mainly by reaching macrocirculatory parameters. However, even if global haemodynamic goals can be achieved, microcirculatory perfusion may remain impaired, leading to cellular hypoxia and organ damage. Interestingly, few methods are currently available to measure the adequacy of organ blood flow and tissue oxygenation. The rise in tissue partial pressure of carbon dioxide (CO2) has been observed when tissue perfusion is decreased. In this regard, tissue partial pressure of CO2 has been proposed as an early and reliable marker of tissue hypoxia even if the mechanisms of tissue partial pressure in CO2 rise during hypoperfusion remain unclear. Several technologies allow the estimation of CO2 content from different body sites: vascular, tissular (in hollow organs, mucosal or cutaneous), and airway. These tools remain poorly evaluated, and some are used but are not widely used in clinical practice. The present review clarifies the physiology of increasing tissue CO2 during hypoperfusion and underlines the specificities of the different technologies that allow bedside estimation of tissue CO2 content.
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Abstract
The ideal set of variables for nutritional monitoring that may correlate with patient outcomes has not been identified. This is particularly difficult in the PICU patient because many of the standard modes of nutritional monitoring, although well described and available, are fraught with difficulties. Thus, repeated anthropometric and laboratory markers must be jointly analyzed but individually interpreted according to disease and metabolic changes, in order to modify and monitor the nutritional treatment. In addition, isotope techniques are neither clinically feasible nor compatible with the multiple measurements needed to follow progression. On the other hand, indirect alternatives exist but may have pitfalls, of which the clinician must be aware. Risks exist for both overfeeding and underfeeding of PICU patients so that an accurate monitoring of energy expenditure, using targeted indirect calorimetry, is necessary to avoid either extreme. This is very important, since the monitoring of the nutritional status of the critically ill child serves as a guide to early and effective nutritional intervention.
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20
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Smallwood CD, Mehta NM. Gas exchange measurement during pediatric mechanical ventilation – Agreement between gas sampling at the airway and the ventilator exhaust. Clin Nutr 2013; 32:988-92. [DOI: 10.1016/j.clnu.2013.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/13/2013] [Accepted: 03/15/2013] [Indexed: 12/01/2022]
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Dokken M, Rustøen T, Stubhaug A. Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed. JPEN J Parenter Enteral Nutr 2013; 39:344-52. [PMID: 24255088 DOI: 10.1177/0148607113511990] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Monitoring nutrition therapy is essential in the care of critically ill children, but the risk of nutrition failure seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutrition support. MATERIALS AND METHODS Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded and compared with the required energy intake (measured energy expenditure plus 10%); energy intake was classified as underfeeding (<90% of required energy intake), adequate feeding (90%-110%), or overfeeding (>110%). The reasons for interruptions to enteral and parenteral nutrition were recorded. RESULTS In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2%, 18.3%, and 60.5% of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children (median, 37.2 kcal/kg/d; range, 16.81-66.38 kcal/kg/d), but the variation within each child was small. Respiratory quotient had low sensitivity of 21% and 27% for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutrition support. CONCLUSION The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.
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Affiliation(s)
- Mette Dokken
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Tone Rustøen
- Division of Emergencies and Critical Care, Department of Research and Development, Ullevål, Oslo University Hospital, Oslo, Norway Unit of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Audun Stubhaug
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway Faculty of Medicine, University of Oslo, Oslo, Norway
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Briassoulis G, Briassouli E, Tavladaki T, Ilia S, Fitrolaki DM, Spanaki AM. Unpredictable combination of metabolic and feeding patterns in malnourished critically ill children: the malnutrition-energy assessment question. Intensive Care Med 2013; 40:120-2. [PMID: 24132384 DOI: 10.1007/s00134-013-3123-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2013] [Indexed: 11/29/2022]
Affiliation(s)
- G Briassoulis
- Pediatric Intensive Care Unit, School of Health Sciences, University Hospital of Heraklion, University of Crete, 71110, Heraklion, Crete, Greece,
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Abstract
OBJECTIVE To examine the role of targeted indirect calorimetry in detecting the adequacy of energy intake and the risk of cumulative energy imbalance in a subgroup of critically ill children suspected to have alterations in resting energy expenditure. We examined the accuracy of standard equations used for estimating resting energy expenditure in relation to measured resting energy expenditure in relation to measured resting energy expenditure and cumulative energy balance over 1 week in this cohort. DESIGN A prospective cohort study. SETTING Pediatric intensive care unit in a tertiary academic center. INTERVENTIONS A subgroup of critically ill children in the pediatric intensive care unit was selected using a set of criteria for targeted indirect calorimetry. MEASUREMENTS Measured resting energy expenditure from indirect calorimetry and estimated resting energy expenditure from standard equations were obtained. The metabolic state of each patient was assigned as hypermetabolic (measured resting energy expenditure/estimated resting energy expenditure >110%), hypometabolic (measured resting energy expenditure/estimated resting energy expenditure <90%), or normal (measured resting energy expenditure/estimated resting energy expenditure = 90-110%). Clinical variables associated with metabolic state and factors influencing the adequacy of energy intake were examined. MAIN RESULTS Children identified by criteria for targeted indirect calorimetry, had a median length of stay of 44 days, a high incidence (72%) of metabolic instability and alterations in resting energy expenditure with a predominance of hypometabolism in those admitted to the medical service. Physicians failed to accurately predict the true metabolic state in a majority (62%) of patients. Standard equations overestimated the energy expenditure and a high incidence of overfeeding (83%) with cumulative energy excess of up to 8000 kcal/week was observed, especially in children <1 yr of age. We did not find a correlation between energy balance and respiratory quotient (RQ) in our study. CONCLUSIONS We detected a high incidence of overfeeding in a subgroup of critically ill children using targeted indirect calorimetry The predominance of hypometabolism, failure of physicians to correctly predict metabolic state, use of stress factors, and inaccuracy of standard equations all contributed to overfeeding in this cohort. Critically ill children, especially those with a longer stay in the PICU, are at a risk of unintended overfeeding with cumulative energy excess.
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Samra T, Sharma S, Pawar M. Metabolic monitors as a diagnostic tool. J Clin Monit Comput 2011; 25:149-50. [PMID: 21590359 DOI: 10.1007/s10877-011-9282-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 05/04/2011] [Indexed: 10/18/2022]
Abstract
Metabolic measurements using indirect calorimetry aid in nutritional assessment and management in intensive care units. They are used during weaning from mechanical ventilator and can calculate work of breathing also. We would like to report a case in which these monitors helped diagnose and manage a child with hypometabolism.
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Affiliation(s)
- Tanvir Samra
- Department of Anesthesia and Intensive Care, Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, Connaught Place, New Delhi 110001, India.
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Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children. Br J Nutr 2011; 105:731-7. [PMID: 21272396 DOI: 10.1017/s0007114510004162] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.
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