Critical appraisal and further development of the methodology for open circuit calorimetry in neonates

IMPROVE ON PERFORMANCE OF INDIRECT CALORIMETRY FOR SMALL PRETERM INFANTS

An indirect calorimetry system of measuring oxygen consumption and carbon dioxide production has been frequently used for preterm infants. The energy consumption and metabolic measurements are based on flow-through technology. The noninvasive measurement feature of the indirect calorimeter is widely used in pediatric clinical research. However, the indirect calorimeter has several limitations for small preterm infants, particularly the ill infant weighing < 1.0 kg. In this paper, we propose some technologies and methodologies to improve the performance of the indirect calorimetry. According to these technologies and methodologies, we redesign the indirect calorimeter proposed in our pervious study. The laboratory evaluation at the different alcohol combustion rates and several exhaust flow rates is used to survey the improved performance. As the results, the accuracy and precision is enhanced by these methods and the lowest oxygen consumption rate, 4.35 ml/min, fits for baby weight of 0.66 kg. It is demonstrated that the performances of new indirect calorimetry are substantially improved. It can be applied to calculate the energy consumption and metabolic rate for low-birth-weight infants in clinical research.

Effect of a change in global metabolic rate on peripheral oxygen consumption in neonates

AIM

To evaluate the effect of an induced change in global metabolic rate on peripheral oxygen consumption (VO(2)) in healthy full term neonates.

SUBJECTS AND METHODS

Twenty four healthy full term neonates were studied. Peripheral VO(2) was measured by near infrared spectroscopy (NIRS) using arterial occlusion and measurement of the oxyhaemoglobin (HbO(2)) decrement slope. Global VO(2) was measured by open circuit calorimetry. Global and peripheral VO(2) were measured in each neonate before and after a routine bath. Abdominal and forearm skin temperatures were also recorded.

RESULTS

Nineteen neonates completed the study. Global VO(2) increased by 30.7% (p = 0.001), and peripheral VO(2) by 23.1% (p = 0.001). A correlation between the fractional changes in global and peripheral VO(2) was apparent (r = 0.76, p = 0.001). Abdominal skin temperature decreased by 0.8 degrees C (p = 0.001), and forearm skin temperature by 0.6 degrees C (p = 0.04).

CONCLUSIONS

Measurement of peripheral VO(2) using NIRS with arterial occlusion is responsive to conditions that increase global metabolic rate. Any change in global VO(2) must be taken into consideration during the interpretation of peripheral VO(2) measurements in neonates.

Effect of limb cooling on peripheral and global oxygen consumption in neonates

AIM

To evaluate peripheral oxygen consumption (VO(2)) measurements using near infrared spectroscopy (NIRS) with arterial occlusion in healthy term neonates by studying the effect of limb cooling on peripheral and global VO(2).

SUBJECTS AND METHODS

Twenty two healthy term neonates were studied. Peripheral VO(2) was measured by NIRS using arterial occlusion and measurement of the oxyhaemoglobin (HbO(2)) decrement slope. Global VO(2) was measured by open circuit calorimetry. Global and peripheral VO(2) was measured in each neonate before and after limb cooling.

RESULTS

In 10 neonates, a fall in forearm temperature of 2.2 degrees C (mild cooling) decreased forearm VO(2) by 19.6% (p < 0.01). Global VO(2) did not change. In 12 neonates, a fall in forearm temperature of 4 degrees C (moderate cooling) decreased forearm VO(2) by 34.7% (p < 0.01). Global VO(2) increased by 17.6% (p < 0.05).

CONCLUSIONS

The NIRS arterial occlusion method is able to measure changes in peripheral VO(2) induced by limb cooling. The changes are more pronounced with moderate limb cooling when a concomitant rise in global VO(2) is observed. Change in peripheral temperature must be taken into consideration in the interpretation of peripheral VO(2) measurements in neonates.

Comparison of face mask, head hood, and canopy for breath sampling in flow-through indirect calorimetry to measure oxygen consumption and carbon dioxide production of preterm infants < 1500 grams

Complete sampling of expired air is essential for accurate O2 consumption(CO2 production) [VO2(VCO2)] measurements with flow-through indirect calorimetry. In preterm infants complete sampling is critical, because only low sampling flows can be used. The accuracy of the various breath sampling systems at low flows and their patient compatibility is untested. We therefore measured 1) the accuracy of VO2(VCO2) measurements with a face mask, a head hood, and a canopy in vitro at low sampling flows; 2) the effect of breathing on measurements with the face mask; and 3) the effect of breath sampling systems on activity and body temperature of preterm infants. VO2(VCO2) were measured with a Deltatrac II. In vitro we used a methanol miniburner incorporated into a doll, which could simulate low VO2(VCO2) and tidal breathing. In vivo we studied seven preterm infants < 1500 g. With the face mask VO2(VCO2) measurements were accurate at a flow of 3 L/min (error -1 +/- 0.8%), when tidal volume was < 15 mL/breath and the distance between mask and manikin < 1 cm. With hood and canopy VO2(VCO2) were underestimated at a flow of 3 L/min (error -13 +/- 1% and -14 +/- 5%), and results were markedly influenced by body position. For accurate measurements, the hood needed a flow of 4.5 L/min, the canopy 8.3 L/min. In vivo the face mask did not increase heart rate, respiration, activity, or rectal temperature, but hood and canopy increased rectal temperature by 0.3-0.4 degree C. For VO2(VCO2) measurements in infants < 1500 g, a face mask should be used, which is accurate at low flows and does not change body temperature. Accuracy at low flows and patient compatibility of breath sampling systems should be evaluated and reported for VO2(VCO2) measurements in preterm infants.

Technical and methodologic considerations for performance of indirect calorimetry in ventilated and nonventilated preterm infants

OBJECTIVE

To evaluate and refine indirect calorimetry measurement techniques so that accurate metabolic measurements can be performed in mechanically ventilated and convalescing preterm infants who require supplemental oxygen.

DESIGN

Laboratory validation of an indirect calorimeter; clinical and laboratory assessments of technical problems in performing metabolic measurements; and clinical indirect calorimetry studies in mechanically ventilated and nonventilated preterm infants.

SETTING

Neonatal intensive care unit (ICU) in a tertiary care university hospital.

PATIENTS

Level II and level III mechanically ventilated (n = 10) and nonventilated (n = 14) neonatal ICU patients who required FIO2 levels ranging from 0.21 to 0.42.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

System calibration was assessed by combustion of 100% ethanol; the mean respiratory quotient was 0.667 +/- 0.001 (SEM). In addition, oxygen consumption (Vo2) and CO2 production (Vco2) were simulated by CO2/nitrogen infusions within the range expected for 0.5- to 7-kg infants. Mean relative errors were 0.6 +/- 0.3% and 1.8 +/- 0.3% for expected Vo2 and Vco2 values, respectively. In 27 mechanically ventilated patients with no audible endotracheal tube leak, measured endotracheal tube leak ranged from 0.0% to 7.5%. Fluctuations in FIO2 during mechanical ventilation were monitored in 30-min studies, using wall-source (n = 27) or tank-source (n = 11) supplemental oxygen. Mean FIO2 variation was 0.00075 +/- 0.00013 vs. 0.00011 +/- 0.00001 using wall-source and tank-source oxygen, respectively. Some of the difficulties of obtaining accurate measurements in supplemental hood oxygen studies were overcome by using tank-source vs. wall-source oxygen and a unique hood design.

CONCLUSIONS

Accurate indirect calorimetry studies can be performed in both ventilated and nonventilated infants weighing as little as 500 g, providing that sufficient attention is paid to technical and methodologic measurement details.