Advertisement

Calorimetry for Enteral Feeding in Critically Ill Patients

Reference work entry

Abstract

The nutritional assessment is important in a critically ill patient to improve the outcome. In clinical practice, the patients’ energy needs may be assessed by predictive equations or measured by indirect calorimetry. Predictive equations do not provide true values because of various confounders and interindividual variation and thus requires its cautious use. Indirect calorimetry has emerged as a gold standard assessment tool and can easily be performed in a critical care setup. Optimal nutrition intervention requires continuous evaluation of all pertinent clinical data and monitoring of each patient’s response to metabolic stress and therapeutic nutrition interventions. A thorough understanding of the variables associated with indirect calorimetry measurements and what circumstances can confound results can help optimize patient care and minimize confusing or erroneous interpretation. Clinical judgment should be used to individualize each patient’s estimated caloric needs. The frequent monitoring and evaluation of nutrition interventions should occur to make adjustments as needed based on patient response. This chapter focuses on the useful role of indirect calorimetry in critically ill patients for nutrition optimization.

Keywords

Enteral Feeding Respiratory Quotient Indirect Calorimetry Predictive Equation Critical Care Unit 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

List of Abbreviations

°F

Degree Fahrenheit

FiO2

Fraction of inspired oxygen concentration

REE

Resting energy expenditure

RQ

Respiratory quotient

VCO2

Carbon dioxide production in mL/min

VO2

Oxygen consumption in mL/min

References

  1. Askanazi J, Carpentier YA, Elwyn DH, et al. Influence of total parenteral nutrition on fuel utilization in injury and sepsis. Ann Surg. 1980a;191:40–6.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Askanazi J, Rosenbaum SH, Hyman AI, Silverberg PA, Milic-Emili J, Kinney JM. Respiratory changes induced by the large glucose loads of total parenteral nutrition. JAMA. 1980b;243:1444–7.CrossRefPubMedGoogle Scholar
  3. Bartlett RH. Oxygen kinetics and the art of physiological monitoring. J Crit Care. 1993;8:77–9.CrossRefPubMedGoogle Scholar
  4. Bassili HR, Deitel M. Effect of nutritional support on weaning patients off mechanical ventilators. J Parenter Enteral Nutr. 1981;5:161–3.CrossRefGoogle Scholar
  5. Behrendt W, Surmann M, Raumanns J, Giani G. How reliable are short-term measurements of oxygen uptake in polytraumatized and long-term ventilated patients? Infusionstherapie. 1991;18:20–4.PubMedGoogle Scholar
  6. Benedict FG. A portable respiration apparatus for clinical use. Boston Med Surg J. 1918;178:667–8.CrossRefGoogle Scholar
  7. Berger MM, Chiolero RL, Pannatier A, Cayeux MC, Tappy L. A 10-year survey of nutritional support in a surgical ICU: 1986–1995. Nutrition. 1997;13:870–7.CrossRefPubMedGoogle Scholar
  8. Bishop M, Benson MS, Pierson DJ. Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome. Chest. 1987;91:400–4.CrossRefPubMedGoogle Scholar
  9. Brandi LS, Bertolini R, Calafa M. Indirect calorimetry in critically ill patients: clinical applications and practical advice. Nutrition. 1997;13:349–58.CrossRefPubMedGoogle Scholar
  10. Brandi LS, Bertolini R, Santini L, Cavani S. Effects of ventilator resetting on indirect calorimetry measurement in the critically ill surgical patient. Crit Care Med. 1999;27:531–9.CrossRefPubMedGoogle Scholar
  11. Branson RD. The measurement of energy expenditure: instrumentation, practical considerations and clinical application. Respir Care. 1990;35:640–56.Google Scholar
  12. Branson RD. Technical aspects of metabolic measurements. Nutrition. 1995;11:176.PubMedGoogle Scholar
  13. Brown RO, Campher C. ASPEN clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010;34:366–77.CrossRefPubMedGoogle Scholar
  14. Browning JA, Linberg SE, Turney SZ, Chodoff P. The effects of a fluctuating FIO2 on metabolic measurements in mechanically ventilated patients. Crit Care Med. 1982;10:82–5.CrossRefPubMedGoogle Scholar
  15. Burge JC, Goon A, Choban PS, Flancbaum L. Efficacy of hypocaloric total parenteral nutrition in hospitalized obese patients: a prospective, double-blind randomized trial. JPEN J Parenter Enteral Nutr. 1994;18:203–7.CrossRefPubMedGoogle Scholar
  16. Cerra FB. Hypermetabolism, organ failure and metabolic support. Surgery. 1987;101:1–14.PubMedGoogle Scholar
  17. Cunningham KF, Aeberhardt LE, Wiggs BR, Phang PT. Appropriate interpretation of indirect calorimetry for determining energy expenditure in intensive care units. Am J Surg. 1994;167:54–7.CrossRefGoogle Scholar
  18. Daly JM, Heymsfield SB, Head CA, et al. Human energy requirements: overestimation by widely used prediction equation. Am J Clin Nutr. 1985;42:1170–4.PubMedGoogle Scholar
  19. Dark DS, Pingeton SK, Kergy GR. Hypercapnia during weaning: a comparison of nutritional support. Chest. 1985;88:141–3.CrossRefPubMedGoogle Scholar
  20. de Weir JB. A new method for calculating metabolic rate with special reference to protein metabolism. J Physiol. 1949;109:1–9.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Dechert RE, Wesley JR, Schafer LE, LaMond S, Nicks J, Coran AG, Bartlett RH. A water-sealed indirect calorimeter for measurement of oxygen consumption (VO2), carbon dioxide production (VCO2), and energy expenditure in infants. J Parenter Enteral Nutr. 1988;12:256–9.CrossRefGoogle Scholar
  22. Dokken M, Rustøen T, Stubhaug A. Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed. J Parenter Enteral Nutr. 2013. doi:10.1177/0148607113511990.Google Scholar
  23. Fahri LE, Rahn H. Gas stores of body and unsteady state. J Appl Physiol. 1955;7:472–9.Google Scholar
  24. Fiser RT, Torres A, Holt S, Wilson S, Hewlitt MS. Isolation valve increases work of breathing in a mechanically ventilated pediatric animal model. Respir Care. 1997;42:688–92.Google Scholar
  25. Flancbaum L, Choban PS, Sambucco S, Verducci J, Burge JC. Comparison of indirect calorimetry, the fick method, and prediction equations in estimating the energy requirements of critically ill patients. Am J Clin Nutr. 1999;69:461–6.PubMedGoogle Scholar
  26. Frankenfield DC, Sarson GY, Blosser SA, Cooney RN, Smith JS. Validation of a 5-minute steady state indirect calorimetry protocol for resting energy expenditure in critically ill patients. J Am Coll Nutr. 1996;15:397–402.CrossRefPubMedGoogle Scholar
  27. Halmagyi DFJ, Kinney JM. Metabolic rate in active respiratory failure complicating sepsis. Surgery. 1975;77:492–9.PubMedGoogle Scholar
  28. Head CA, Grossman GD, Jordan JC, Hepler EL, Heymsfield SB. A valve system for the accurate measurement of energy expenditure in mechanically ventilated patients. Respir Care. 1985;30:969–73.Google Scholar
  29. Heneghan CPH, Gilbe CE, Branthwaite MA. Measurement of metabolic gas exchange during anesthesia. Br J Anaesth. 1981;53:73–81.CrossRefPubMedGoogle Scholar
  30. Henneberg S, Soderberg D, Groth T, Stjernsrom H, Wiklund L. Carbon dioxide production during mechanical ventilation. Crit Care Med. 1987;15:8–12.CrossRefPubMedGoogle Scholar
  31. Holdy KE. Monitoring energy metabolism with indirect calorimetry: instruments, interpretation, and clinical application. Nutr Clin Pract. 2004;19:447–54.CrossRefPubMedGoogle Scholar
  32. Hulst JM, Van Goudoever JB, Zimmermann LJ, Hop WC, Büller HA, Tibboel D, Joosten KFM. Adequate feeding and the usefulness of the respiratory quotient in critically ill children. Nutrition. 2005;21:192–8.CrossRefPubMedGoogle Scholar
  33. Hunter DC, Jaksie T, Lewis D, Benotti PN, Blackburn GL, Bistrian BR. Resting energy expenditure in the critically ill: estimates versus measurement. Br J Surg. 1988;75:875–8.CrossRefPubMedGoogle Scholar
  34. Jolliet P, Pichard C, Biolo G, et al. Enteral nutrition in intensive care patients: a practical approach. Working Group on Nutrition and Metabolism, ESICM. European Society of Intensive Care Medicine. Intensive Care Med. 1998;24:848–59.CrossRefPubMedGoogle Scholar
  35. Kemper MS. Indirect calorimetry equipment and practical considerations of measurement. In: Weissman C, editor. Problems in respiratory care: nutrition and respiratory disease, vol. 2. Philadelphia: JB Lippincott; 1989. p. 479–90.Google Scholar
  36. Klein CJ, Stanek GS, Wiles CE. Overfeeding macronutrients to critically ill adults: metabolic complications. J Am Diet Assoc. 1998;98:795–806.CrossRefPubMedGoogle Scholar
  37. Kocache RMA, Swan J, Holman DF. A miniature rugged and accurate solid electrolyte oxygen sensor. J Phys Environ Sci Instrum. 1984;17:477–82.CrossRefGoogle Scholar
  38. Larca L, Greenbaum DM. Effectiveness of intensive nutritional regimes in patients who fail to wean from mechanical ventilation. Crit Care Med. 1982;10:297–300.CrossRefPubMedGoogle Scholar
  39. Lee JS, Auyeung TW. A comparison of two feeding methods in the alleviation of diarrhoea in older tube-fed patients: a randomized controlled trial. Age Ageing. 2003;32:388–93.CrossRefPubMedGoogle Scholar
  40. Lowrey T, Dunlap A, Brown R, Dickerson R, Kudsk K. Pharmacologic influence on nutrition support therapy: use of propofol in a patient receiving combined enteral and parenteral nutrition support. Nutr Clin Pract. 1996;11:147–9.CrossRefPubMedGoogle Scholar
  41. Mann S, Westenshow DR, Hontchens BA. Measured and predicted caloric expenditure in the acutely ill. Crit Care Med. 1985;13:173–7.CrossRefPubMedGoogle Scholar
  42. Matarese LE. Indirect calorimetry: technical aspects. J Am Diet Assoc. 1997;10 Suppl 2:S154–60.CrossRefGoogle Scholar
  43. McClave SA, Snider HL. Understanding the metabolic response to critical illness: factors that cause patients to deviate from the expected pattern of hypermetabolism. New Horiz. 1994;2:139–46.PubMedGoogle Scholar
  44. McClave SA, Lowen CC, Kleber MJ, Nicholson JF, Jimmerson SC, McConnell JW, Jung LY. Are patients fed appropriately according to their caloric requirements? JPEN J Parenter Enteral Nutr. 1988;22:375–81.CrossRefGoogle Scholar
  45. McClave SA, Lowen CC, Kleber MJ, et al. Is the respiratory quotient a useful indicator of over-or under- feeding? JPEN J Parenter Enteral Nutr. 1997;21:S11 (abstract 66).CrossRefGoogle Scholar
  46. McClave SA, McClain CJ, Snider HL. Should indirect calorimetry be used as part of nutritional assessment? J Clin Gastroenterol. 2001;33:14–9.CrossRefPubMedGoogle Scholar
  47. McClave SA, Lowen CC, Kleber MJ, McConnell JW, Jung LY, Goldsmith LJ. Clinical use of the respiratory quotient obtained from indirect calorimetry. JPEN J Parenter Enteral Nutr. 2003;27:21–6.CrossRefPubMedGoogle Scholar
  48. Nacht CA, Schutz Y, Vernet O, Christin L, Jequier E. Continuous versus single bolus enteral nutrition: comparison of energy metabolism in humans. Am J Physiol. 1986;251:524–9.Google Scholar
  49. Ochoa JB, Magnuson B, Swintowsky M, et al. Long-term reduction in the cost of nutritional intervention achieved by a nutrition support service. Nutr Clin Pract. 2000;15:174–80.CrossRefGoogle Scholar
  50. Petros S, Engelmann L. Validity of an abbreviated indirect calorimetry protocol for measurement of resting energy expenditure in mechanically ventilated and spontaneously breathing critically ill patients. Intensive Care Med. 2001;27:1164–8.CrossRefPubMedGoogle Scholar
  51. Petros S, Engelmann L. Enteral nutrition delivery and energy expenditure in medical intensive care patients. Clin Nutr. 2006;25:51–9.CrossRefPubMedGoogle Scholar
  52. Porter C, Cohen NH. Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting results. J Am Diet Assoc. 1996;96:49–57.CrossRefPubMedGoogle Scholar
  53. Saffle JR, Larson CM, Sullivan J. A randomized trial of indirect calorimetry-based feedings in thermal injury. J Trauma. 1990;30:776–82.CrossRefPubMedGoogle Scholar
  54. Sion-Sarid R, Cohen J, Houri Z, Singer P. Indirect calorimetry: a guide for optimizing nutritional support in the critically ill child. Nutrition. 2013;29:1094–9.CrossRefPubMedGoogle Scholar
  55. Smyrnios NA, Curley FJ, Shaker KG. Accuracy of 30-minute indirect calorimetry studies in predicting 24- hour energy expenditure in mechanically ventilated, critically ill patients. JPEN J Parenter Enteral Nutr. 1997;21:168–74.CrossRefPubMedGoogle Scholar
  56. Ultman JS, Bursztein S. Analysis of error in the determination of respiratory gas exchange at varying FIO2. J Appl Physiol. 1981;50:210–6.PubMedGoogle Scholar
  57. Van der Kuip M, de Meer K, Oosterveld MJ, Lafeber HN, Gemke RJ. Simple and accurate assessment of energy expenditure in ventilated paediatric intensive care patients. Clin Nutr. 2004;23:657–63.CrossRefPubMedGoogle Scholar
  58. Walsh TS. Recent advances in gas exchange measurements in intensive care patients. Br J Anaesth. 2003;91:120–31.CrossRefPubMedGoogle Scholar
  59. Weissman C. Measuring oxygen uptake in the clinical setting. In: Bryan-Brown CW, Ayres SM, editors. Oxygen transport and utilization. Fullerton: Society of Critical Care Medicine; 1987. p. 25–64.Google Scholar
  60. Weissman C, Kemper MC, Damask M, Askanazi J, Hyman AI, Kinney JM. The effect of routine intensive care interactions on metabolic rate. Chest. 1984;86:815–8.CrossRefPubMedGoogle Scholar
  61. Wooley JA, Sax HC. Indirect calorimetry: applications to practice. Nutr Clin Pract. 2003;18:434–8.CrossRefPubMedGoogle Scholar
  62. Zijlstra N, ten Dam SM, Hulshof PJ, Ram C, Hiemstra G, de Roos NM. 24-hour indirect calorimetry in mechanically ventilated critically ill patients. Nutr Clin Pract. 2007;22:250–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Anaesthesiology, Dr. BRAIRCHAll India Institute of Medical SciencesNew DelhiIndia
  2. 2.Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER)PuducherryIndia

Personalised recommendations