Influence of body temperature, with or without sedation, on energy expenditure in severe head-injured patients

Comparative characteristics of some methods for estimating energy expenditure in critically ill mechanically ventilated patients

AIM

To compare the energy expenditure (EE) assessed by ventilator-derived carbon dioxide production (EE-VCO2-ventilator) and the energy expenditure calculated from six predictive equations with the gold standard energy expenditure measured with indirect calorimetry (IC) in mechanically ventilated patients.

Resting Energy Expenditure in the Critically Ill and Healthy Elderly-A Retrospective Matched Cohort Study

The use of indirect calorimetry to measure resting energy expenditure (mREE) is widely recommended as opposed to calculating REE (cREE) by predictive equations (PE). The aim of this study was to compare mREE with cREE in critically ill, mechanically ventilated patients aged ≥ 75 years and a healthy control group matched by age, gender and body mass index. The primary outcome was the PE accuracy rate of mREE/cREE, derived using Bland Altman plots. Secondary analyses included linear regression analyses for determinants of intraindividual mREE/cREE differences in the critically ill and interindividual mREE differences in the matched healthy cohort. In this retrospective study, 90 critically ill patients (median age 80 years) and 58 matched healthy persons were included. Median mREE was significantly higher in the critically ill (1457 kcal/d) versus the healthy cohort (1351 kcal/d), with low PE accuracy rates (21% to 49%). Independent predictors of mREE/cREE differences in the critically ill were body temperature, heart rate, FiO₂, hematocrit, serum sodium and urea. Body temperature, respiratory rate, and FiO₂ were independent predictors of interindividual mREE differences (critically ill versus healthy control). In conclusion, the commonly used PE in the elderly critically ill are inaccurate. Respiratory, metabolic and energy homeostasis variables may explain intraindividual mREE/cREE as well as interindividual mREE differences.

Nutritional Support for Pediatric Severe Traumatic Brain Injury

In critically ill children with severe traumatic brain injury (sTBI), nutrition may help facilitate optimal recovery. There is ongoing research regarding nutritional practices in the pediatric intensive care unit (PICU). These are focused on identifying a patient's most appropriate energy goal, the mode and timing of nutrient delivery that results in improved outcomes, as well as balancing these goals against inherent risks associated with nutrition therapy. Within the PICU population, children with sTBI experience complex physiologic derangements in the acute post-injury period that may alter metabolic demand, leading to nutritional needs that may differ from those in other critically ill patients. Currently, there are relatively few studies examining nutrition practices in PICU patients, and even fewer studies that focus on pediatric sTBI patients. Available data suggest that contemporary neurocritical care practices may largely blunt the expected hypermetabolic state after sTBI, and that early enteral nutrition may be associated with lower morbidity and mortality. In concordance with these data, the most recent guidelines for the management of pediatric sTBI released by the Brain Trauma Foundation recommend initiation of enteral nutrition within 72 h to improve outcome (Level 3 evidence). In this review, we will summarize available literature on nutrition therapy for children with sTBI and identify gaps for future research.

Methods for Estimating Energy Expenditure in Critically Ill Adults

Energy expenditure (EE) is the sum of metabolic activity within the body at a given time and comprises basal EE, diet-induced thermogenesis, and physical activity. In the intensive care unit, EE is most often assessed to determine a patient's caloric requirements. Energy expenditure also may be useful to understand disease states and the metabolic impact of interventions. Several methods for estimating EE are relevant for clinical use, including indirect calorimetry, predictive equations, exhaled carbon dioxide volume, and the Fick method. Indirect calorimetry is the preferred method for evaluating EE and is considered the gold standard for estimating EE in hospitalized patients. However, use of indirect calorimetry is not always practical or possible. Therefore, other methods of estimating EE must be considered. In this review, methods of evaluating EE in critically ill adults are examined and the benefits and limitations of each method are discussed, with practical considerations for use.

Early Hypermetabolism is Uncommon in Trauma Intensive Care Unit Patients

BACKGROUND

Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU).

METHODS

This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM).

RESULTS

Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m² ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge.

CONCLUSION

Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.

Nutritional and metabolic supplementation for the injured brain: an update

PURPOSE OF REVIEW

Energy dysfunction is increasingly recognized as a key factor in the pathogenesis of acute brain injury (ABI). This one characterized by a high metabolic rate and nitrogen loss is often associated with an undernutrition support. We review the metabolism evolution and nutritional status in brain injured patient and summarize evidence on nutritional support in this condition.

RECENT FINDINGS

The role of nutrition support for improving prognosis in brain injured patient has been underlined recently. A fast nutrition institution whatever the route is essential to prevent an imbalance in caloric support. Moreover, hypermetabolic state must be prevented with a sufficient nitrogen support. Glycemic control is particularly relevant in this group of patient, with the discovery of new fuel that could potentially improve cerebral metabolism and replace glucose. Few data support also the use of immunonutrition input in this group of patients.

SUMMARY

Nutritional support is a key parameter in brain injured patient and must be initiated quickly to counteract hypermetabolic state by caring to improve caloric and nitrogen input. Recent clinical data support the use of immunonutrition, glutamine and zinc in this particular setting.

Energy Expenditure in Older People Hospitalized for an Acute Episode

Weight loss and worsening of nutritional state is a frequent downfall of acute hospitalization in older people. It is usually accepted that acute inflammation is responsible for hypercatabolism. However, several studies suggest, on the contrary, a reduction in resting energy expenditure (REE). This study aimed to obtain a reliable measure of REE and total energy expenditure (TEE) in older patients hospitalized for an acute episode in order to better assess patients’ energy requirements and help understand the mechanisms of weight loss in this situation. Nineteen hospitalized older patients (mean age 83 years) with C-reactive protein (CRP) level >20mg/L were recruited. REE and TEE were measured using gold standard methods of indirect calorimetry and doubly labeled water (DLW), respectively. REE was then compared to data from a previous study on aged volunteers from nursing homes who were free of an acute stressor event. Energy requirements measured by DLW were confirmed at 1.3 × REE. Energy intake covered the needs but did not prevent weight loss in these patients. TEE was not increased in hospitalized patients and was not influenced by inflammation, while the relationship between REE and inflammation was uncertain. Our results suggest that lean mass remains the major determinant of REE in hospitalized older people and that weight loss may not be explained solely by a state of hypercatabolism.

Continuous Indirect Calorimetry in Critically Injured Patients Reveals Significant Daily Variability and Delayed, Sustained Hypermetabolism

BACKGROUND

Previous studies have used using Indirect Calorimetry (IC) with solitary or sparse measurements of resting energy expenditure (REE). This "snapshot" may not capture the dynamic nature of metabolic requirements. Using continuous IC, we describe the variation of REE during the first days in the intensive care unit.

METHODS

Injured adults (≥18 years) requiring mechanical ventilation from March 2018 to September 2018 were enrolled. IC was initiated within 4 days of admission and continuous REE recorded until 14 days, extubation, or death. Multiple 10-minute periods collected during steady state were used to calculate daily REE maximum, minimum, average, and variability [(REEmax - REEmin/2)/average REE].

RESULTS

We included 55 patients. Median age was 38 [27-58] years, 38 (69%) were male, body mass index was 28 [25-33] kg/m² , and Acute Physiology and Chronic Health Evaluation II was 17 [14-24]. Mechanism of injury was: blunt (n = 38, 69%), penetrating (n = 9, 16%), and burn (n = 8, 15%). Average REE increased gradually from 1,663 kcal [1,435-2,143] to a maximum of 2,080 [1,701-2,336] on day 7, a relative 25% increase, which was sustained through day 14. REE variability ranged 8%-13% and was not reliably predicted by fever, tachycardia, elevated intracranial pressures, hypertension, or hypotension.

CONCLUSION

In critically injured patients, steady-state REE measurements display fluctuations over a 24-hour period and demonstrate a gradual rise over the first few days after injury. Continuous REE, if available, is recommended for more precise matching of energy delivery to metabolic requirements.

Use of Predictive Equations for Energy Prescription Results in Inaccurate Estimation in Trauma Patients

BACKGROUND

Overfeeding and underfeeding are associated with poor clinical outcomes. In the absence of indirect calorimetry (IC), the Society of Critical Care Medicine/ASPEN recommend prescribing 25-30 kcal/kg. The Harris-Benedict equation (HBE) multiplied by a stress factor is commonly applied in critically ill patients. We describe the difference between estimated and actual energy needs in critically injured patients.

METHODS

From March to November 2018, we collected demographics and energy needs determined by continuous IC (started within 4 days) in intubated adults. Ideal or adjusted body weight was used for 25-30 kcal/kg, and HBE was multiplied by a 1.3 stress factor (1.3HBE). Daily requirements up to 14 days, extubation, or death were calculated using all 3 methods and compared with IC.

RESULTS

Fifty-five subjects were included. Median age was 38 [27-58] years, 38 (69%) were male, body mass index was 28 [25-33] kg/m² , and Acute Physiology and Chronic Health Evaluation II score was 17 [14-24] Mechanism of injury was blunt (38, 69%), penetrating (9, 16%), and burn (8, 15%). By day 14, compared with measured energy requirements by IC, the other methods could result in a cumulative 1827-kcal (+7%) surplus (1.3HBE), a 1313-kcal (-5%) deficit (25 kcal/kg), or a 3950-kcal (+14%) surplus (30 kcal/kg) per patient over a median 9 days.

CONCLUSION

In critically injured patients, predictive equations for energy needs do not account for dynamic metabolic changes over time and could result in underfeeding or overfeeding. Adjusting daily prescription based on continuous IC may result in better individualized treatment.

Indirect calorimetry as point of care testing

Determining energy requirement is a fundamental of nutrition support. Indirect calorimetry (IC) has been long recognized as the gold standard for assessing basal or resting energy expenditure (REE). The measurement of REE is recommended particularly in the situation where adjustment of energy provision is critical. The result of the IC measurement can lead to changes in treatment and since the change can be carried out immediately at the bedside, this may be considered as point-of-care testing. Beyond the nutritional aspects, studies of energy expenditure with IC have brought out more understanding of the metabolic changes during the natural course of diseases or conditions as well as those related to the intervention. The literature in various disease states has shown that changes in energy expenditure may reveal hidden metabolic information that might be translated into clinical information and have the potential of being both prognostic indicators and/or treatment targets.

Indirect Calorimetry: A Practical Guide for Clinicians

This review provides clinicians with a comprehensive overview of indirect calorimetry including the principles, methodology, technologic advancements, benefits, and challenges. Clinical applications for indirect calorimetry and the potential limitations are specifically addressed for both the inpatient and outpatient setting. Measurement of energy expenditure is the most accurate method to assess energy needs. Indirect calorimetry remains a gold standard in measuring energy expenditure in the clinical settings. The benefits of providing optimal nutrition for recovery from illness and chronic health management are well documented. Indirect calorimetry offers a scientifically-based approach to customize a patient's energy needs and nutrient delivery to maximize the benefits of nutrition therapy. With recent advances in technology, indirect calorimeters are easier to operate, more portable, and affordable. Increased utilization of indirect calorimetry would facilitate individualized patient care and should lead to improved treatment outcomes.

Energy Expenditure and Protein Requirements After Traumatic Injury

Traumatic injury induces hypermetabolism. The degree of hypermetabolism can be variable, depending on the type of injury, the degree of inflammation, body composition, age, and treatment regimens. To estimate metabolic rate in some types of injury, predictive equations have been published. Some of these equations have been tested in validation studies. For other types of injury, equations do not exist. Some expert panels have recommended measuring in lieu of estimating metabolic rate, though studies have not been performed to determine whether clinical outcome is affected by the method used to determine energy requirements. Traumatically injured patients are usually catabolic, but protein needs after traumatic injury continue to be debated. Some suggest that 1.5 g protein per kg body weight is adequate and that any additional protein is simply oxidized, adding to the nitrogen load to be excreted. Alternately, protein intake >2.0 g/kg body weight increases the absolute rate of body protein synthesis, and achievement of nitrogen balance has been associated with survival. Thus, provision of high-protein feeding to achieve nitrogen balance might be worthwhile, even if that balance is achieved at the cost of additional nitrogen production.

Influence of different dialysis modalities in the measurement of resting energy expenditure in patients with acute kidney injury in ICU

BACKGROUND

Currently, the execution of indirect calorimetry, which is considered the gold standard for measuring energy expenditure, is not indicate during dialysis, and it may interfere on nutritional therapy of these patients. This study aimed to evaluate the resting energy expenditure (REE) in patients with severe acute kidney injury treated by different modalities of dialysis and to identify whether dialysis influences on REE.

METHODS

This was a prospective cohort study that evaluated patients admitted in intensive care units with diagnosis of acute kidney injury AKIN-3, mechanically ventilated, and submitted to conventional hemodialysis (CHD), extended hemodialysis (EHD) or high volume peritoneal dialysis (HVPD). Indirect calorimetry was performed at pre dialysis time and during the dialysis procedure. Parameters that could change REE were also evaluated.

RESULTS

One-hundred patients undergoing 290 dialysis sessions were evaluated, with mean age 60.3 ± 17 years, 69% were male and 74% have died. There was no significant difference between REE of predialysis time and during dialysis time (2156 ± 659 kcal vs. 2100 ± 634 kcal, respectively, p = 0.15). No difference was observed in the REE before and during dialysis of different modalities. There were no differences between parameters pre and during dialysis of each modality. There was only a difference in norepinephrine dose, which was higher in pre dialysis time in HVPD and EHD modalities, compared with CHD modality. Moreover, during dialysis time, EHD modality had significantly higher VAD compared to other dialysis modalities.

CONCLUSION

The three evaluated modalities did not change REE. Indirect calorimetry can be performed during dialysis procedures and there was no difference between ventilation parameters, sedatives use, body temperature and VAD in both moments.

"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

BACKGROUND

Therapeutic moderate hypothermia (MH; T _core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH.

MATERIALS AND METHODS

Patients were randomized to 72 hours of MH or normothermia (NT; T _core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test.

RESULTS

Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2).

CONCLUSIONS

In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.

Clinical Guide for the Use of Metabolic Carts: Indirect Calorimetry--No Longer the Orphan of Energy Estimation

Critically ill patients often require nutrition support, but accurately determining energy needs in these patients is difficult. Energy expenditure is affected by patient characteristics such as weight, height, age, and sex but is also influenced by factors such as body temperature, nutrition support, sepsis, sedation, and therapies. Using predictive equations to estimate energy needs is known to be inaccurate. Therefore, indirect calorimetry measurement is considered the gold standard to evaluate energy needs in clinical practice. This review defines the indications, limitations, and pitfalls of this technique and gives practice suggestions in various clinical situations.

Resting energy expenditure and substrate oxidation rates correlate to temperature and outcome after cardiac arrest - a prospective observational cohort study

INTRODUCTION

Targeted temperature management improves outcome after cardiopulmonary resuscitation. Reduction of resting energy expenditure might be one mode of action. The aim of this study was to correlate resting energy expenditure and substrate oxidation rates with targeted temperature management at 33°C and outcome in patients after cardiac arrest.

METHODS

This prospective, observational cohort study was performed at the department of emergency medicine and a medical intensive care unit of a university hospital. Patients after successful cardiopulmonary resuscitation undergoing targeted temperature management at 33°C for 24 hours with subsequent rewarming to 36°C and standardized sedation, analgesic and paralytic medication were included. Indirect calorimetry was performed five times within 48 h after cardiac arrest. Measurements were correlated to outcome with repeated measures ANOVA, linear and logistic regression analysis.

RESULTS

In 25 patients resting energy expenditure decreased 20 (18 to 27) % at 33°C compared to 36°C without differences between outcome groups (favourable vs. unfavourable: 25 (21 to 26) vs. 21 (16 to 26); P = 0.5). In contrast to protein oxidation rate (favourable vs. unfavourable: 35 (11 to 68) g/day vs. 39 (7 to 75) g/day, P = 0.8) patients with favourable outcome had a significantly higher fat oxidation rate (139 (104 to 171) g/day vs. 117 (70 to 139) g/day, P <0.05) and a significantly lower glucose oxidation rate (30 (-34 to 88) g/day vs. 77 (19 to 138) g/day; P < 0.05) as compared to patients with unfavourable neurological outcome.

CONCLUSIONS

Targeted temperature management at 33°C after cardiac arrest reduces resting energy expenditure by 20% compared to 36°C. Glucose and fat oxidation rates differ significantly between patients with favourable and unfavourable neurological outcome.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00500825. Registered 11 July 2007.

Validation Study of Energy Requirements in Critically Ill, Obese Cancer Patients

BACKGROUND

Current guidelines from the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine (ASPEN/SCCM) regarding caloric requirements and the provision of nutrition support in critically ill, obese adults may not be suitable for similar patients with cancer. We sought to determine whether the current guidelines accurately estimate the energy requirements, as measured by indirect calorimetry (IC), of critically ill, obese cancer patients.

MATERIALS AND METHODS

This was a retrospective validation study of critically ill, obese cancer patients from March 1, 2007, to July 31, 2010. All patients ≥18 years of age with a body mass index (BMI) ≥30 kg/m(2) who underwent IC were included. We compared the measured energy expenditure (MEE) against the upper limit of the recommended guideline (25 kcal/kg of ideal body weight [IBW]) and MEE between medical and surgical patients in the intensive care unit.

RESULTS

Thirty-three patients were included in this study. Mean MEE (28.7 ± 5.2 kcal/kg IBW) was significantly higher than 25 kcal/kg IBW (P < .001), and 78% of patients had nutrition requirements greater than the current guideline recommendations. No significant differences in MEE between medical and surgical patients in the ICU were observed.

CONCLUSIONS

Critically ill, obese cancer patients require more calories than the current guidelines recommend, likely due to malignancy-associated metabolic variations. Our results demonstrate the need for IC studies to determine the energy requirements in these patients and for reassessment of the current recommendations.

Energy expenditure in children after severe traumatic brain injury

OBJECTIVE

To evaluate energy expenditure in a cohort of children with severe traumatic brain injury.

DESIGN

A prospective observational study.

SETTING

A pediatric neurotrauma center within a tertiary care institution.

PATIENTS

Mechanically ventilated children admitted with severe traumatic brain injury (Glasgow Coma Scale < 9) with a weight more than 10 kg were eligible for study. A subset of children was co-enrolled in a phase 3 study of early therapeutic hypothermia. All children were treated with a comprehensive neurotrauma protocol that included sedation, neuromuscular blockade, temperature control, antiseizure prophylaxis, and a tiered-based system for treating intracranial hypertension.

INTERVENTIONS

Within the first week after injury, indirect calorimetry measurements were performed daily when the patient's condition permitted.

MEASUREMENTS AND MAIN RESULTS

Data from 13 children were analyzed (with a total of 32 assessments). Measured energy expenditure obtained from indirect calorimetry was compared with predicted resting energy expenditure calculated from Harris-Benedict equation. Overall, measured energy expenditure/predicted resting energy expenditure averaged 70.2% ± 3.8%. Seven measurements obtained while children were hypothermic did not differ from normothermic values (75% ± 4.5% vs 68.9% ± 4.7%, respectively, p = 0.273). Furthermore, children with favorable neurologic outcome at 6 months did not differ from children with unfavorable outcome (76.4% ± 6% vs 64.7% ± 4.7% for the unfavorable outcome, p = 0.13).

CONCLUSIONS

Contrary to previous work from several decades ago that suggested severe pediatric traumatic brain injury is associated with a hypermetabolic response (measured energy expenditure/predicted resting energy expenditure > 110%), our data suggest that contemporary neurocritical care practices may blunt such a response. Understanding the metabolic requirements of children with severe traumatic brain injury is the first step in development of rational nutritional support goals that might lead to improvements in outcome.

Energy expenditure during barbiturate coma

BACKGROUND

Barbiturate coma may have a significant effect on metabolic rate, but the phenomenon is not extensively studied. The primary purpose of the current study was to compare the metabolic rate of general critical care patients with those requiring barbiturate coma. A secondary purpose was to evaluate the accuracy of the Penn State prediction equation between these 2 groups of patients.

MATERIALS AND METHODS

Indirect calorimetry was used to measure the resting metabolic rate of mechanically ventilated, critically ill patients in a barbiturate coma and those of similar height, weight, and age but not in a barbiturate coma. Measurements of resting metabolic rate were compared with predictions using the Penn State equation accounting for body size, body temperature, and minute ventilation.

RESULTS

The barbiturate coma group had a lower resting metabolic rate than the control group that remained lower even after adjustment for predicted healthy metabolic rate and maximum body temperature (1859 ± 290 vs 2037 ± 289 kcal/d, P = .020). When minute ventilation was also included in the analysis, the resting metabolic rate between the groups became statistically insignificant (1929 ± 229 vs 2023 ± 226 kcal/d, P = .142). The Penn State equation, which uses these variables, was accurate in 73% of the control patients and also the barbiturate coma patients.

CONCLUSION

Resting metabolic rate is moderately reduced in barbiturate coma, but the decrease is out of proportion with changes in body temperature. However, if both body temperature and minute ventilation are considered, then the change is predictable.

Energy expenditure in patients with severe head injury: controlled normothermia with sedation and neuromuscular blockade

OBJECTIVES

Providing optimal caloric intake is important for patients with severe traumatic brain injury. Insufficient nutrition worsens prognosis, and excessive nutrition may lead to complications such as weaning delay from mechanical ventilation. However, using controlled normothermia with sedation and neuromuscular blockade for patients with anticipated severe brain edema, the optimal caloric intake is still unclear.

METHODS

Ten patients with severe traumatic brain injury were studied. All patients received midazolam and vecuronium or pancuronium to control body temperature to 36.0°C. Energy expenditure was measured using indirect calorimetry. Age, body height, body weight, heart rate, blood pressure, body temperature, and minute ventilation volume were evaluated at the time of the study. Differences between the mean measured energy expenditures (MEEs) and predicted basal energy expenditures (PEEs from the Harris-Benedict equation) were analyzed using paired t test. Furthermore, the relationships between these variables and MEEs were analyzed with multiple regression analysis.

RESULTS

The result of MEE was 1279±244 kcal/d. When compared with PEE, MEE/PEE was 87.2% ± 10%. Multiple regression analysis showed that age, body height, body weight, heart rate, and minute ventilation volume were related with MEE.

CONCLUSIONS

Energy expenditure in patients with severe traumatic brain injury who need mechanical ventilation and have received controlled normothermia with sedation and neuromuscular blockade was 13% less than predicted basal levels. Energy expenditure might be obtained from age, body height, body weight, heart rate, and minute ventilation.

Comparison of whole-body cooling and selective head cooling on changes in urinary 8-hydroxy-2-deoxyguanosine levels in patients with global brain ischemia undergoing mild hypothermia therapy

BACKGROUND

We evaluated changes in the levels of urinary 8-hydroxy-2-deoxyguanosine (8-OHdG) in patients undergoing mild hypothermia therapy and compared 8-OHdG expressions in those receiving whole-body cooling or selective head cooling.

MATERIAL/METHODS

The subjects were 15 patients undergoing mild hypothermia therapy following resuscitation after cardiac arrest in our intensive care unit. We divided the patients into 2 groups receiving either whole-body cooling or selective head cooling, according to their circulatory stability. We examined urinary 8-OHdG level for 1 week and neurological outcomes 28 days after admission.

RESULTS

We observed significant decreases in urinary 8-OHdG levels on days 6 and 7 compared with that on day 1 in the whole-body cooling group. Furthermore, we noted significantly lower urinary 8-OHdG levels after days 5, 6 and 7 in the whole-body cooling group than in the selective head-cooling group. Neurological outcomes were similar in both groups.

CONCLUSIONS

Mild hypothermia therapy with whole-body cooling had a greater effect on the suppression of free radical production than selective head cooling. However, selective head cooling might be an appropriate indication for patients with circulatory instability after resuscitation, because it provides neuroprotection similar to that of whole-body cooling.

Description and prediction of resting metabolic rate after stroke and traumatic brain injury

OBJECTIVE

To compare the effect of stroke on the metabolic rate compared with the effect of traumatic brain injury and to determine whether the metabolic rate is predictable in both types of brain injury.

METHODS

Indirect calorimetry was conducted prospectively in mechanically ventilated patients within the first 6 d of admission to a critical care unit owing to ischemic stroke, hemorrhagic stroke, isolated traumatic brain injury, or traumatic brain injury with collateral injuries. Clinical data were collected simultaneously and a predicted value of the resting metabolic rate was calculated using the Penn State equation (using body size, body temperature, and minute ventilation).

RESULTS

One hundred thirty patients were measured. Ischemic stroke showed a lower incidence of fever, a lower body temperature, and a lower resting metabolic rate than the other groups; whereas in hemorrhagic stroke, these variables were similar to the trauma groups. Sedation decreased the resting metabolic rate, but this effect seemed particular to the trauma patients. The Penn State equation predicted the resting metabolic rate accurately 72% of the time, and when its component variables of body temperature and minute ventilation were controlled in an analysis of variance, all the differences among the brain injury and sedation groups were eliminated.

CONCLUSION

Stroke is a hypermetabolic event most of the time. Body size, temperature, and minute ventilation explain most of the variation in the resting metabolic rate after traumatic and non-traumatic brain injuries. The Penn State equation therefore predicts the resting metabolic rate in brain-injured patients no matter the mechanism of injury.

Early peak temperature and mortality in critically ill patients with or without infection

PURPOSE: To determine whether fever is associated with an increased or decreased risk of death in patients admitted to an intensive care unit (ICU) with infection. METHODS: We evaluated the independent association between peak temperature in the first 24 h after ICU admission and in-hospital mortality according to whether there was an admission diagnosis of infection using a database of admissions to 129 ICUs in Australia and New Zealand (ANZ) (n = 269,078). Subsequently, we sought to confirm or refute the ANZ database findings using a validation cohort of admissions to 201 ICUs in the UK (n = 366,973). RESULTS: A total of 29,083/269,078 (10.8%) ANZ patients and 103,191/366,973 (28.1%) of UK patients were categorised as having an infection. In the ANZ cohort, adjusted in-hospital mortality risk progressively decreased with increasing peak temperature in patients with infection. Relative to the risk at 36.5-36.9°C, the lowest risk was at 39-39.4°C (adjusted OR 0.56; 95% CI 0.48-0.66). In patients without infection, the adjusted mortality risk progressively increased above 39.0°C (adjusted OR 2.07 at 40.0°C or above; 95% CI 1.68-2.55). In the UK cohort, findings were similar with adjusted odds ratios at corresponding temperatures of 0.77 (95% CI 0.71-0.85) and 1.94 (95% CI 1.60-2.34) for infection and non-infection groups, respectively. CONCLUSIONS: Elevated peak temperature in the first 24 h in ICU is associated with decreased in-hospital mortality in critically ill patients with an infection; randomised trials are needed to determine whether controlling fever increases mortality in such patients.

Is there an accurate method to measure metabolic requirement of institutionalized children with spastic cerebral palsy?

OBJECTIVES

This study hypothesized that there is no difference between energy expenditure measured by indirect calorimetry (IC) and that estimated by predicted formulas compared with the actual intake of children with spastic cerebral palsy (CP).

METHODS

Fifteen children aged 3 to 18 years with spastic CP and associated complications were recruited. IC was used to measure mean energy expenditure (MEE) compared with 3 predicted equations for energy expenditure (PEE), including body surface area (BSA), the recommended daily allowance (RDA), and an equation designed specifically for patients with CP. Friedman and paired t tests were used to examine the variance between PEE and MEE. Intraclass correlation coefficient (ICC) was used to explore the correlation between MEE and PEE. The pretest and posttest core temperatures were compared using the Wilcoxon signed rank test.

RESULTS

Mean ± standard deviation MEE was 800.5 ± 295.7 kcal/d; BSA was 1,213.4 ± 171.2 kcal/d; RDA was 1,928.1 ± 341.0 kcal/d; and CP was 1,603.1 ± 215.8 kcal/d. The actual diet intake provided 935.3 ± 222.9 kcal/d. Post hoc analysis revealed a significant difference between mean MEE and PEE (P < .001) but not mean actual intake (P = .128). In addition, the ICC of MEE vs PEE was 0.635 at a 95% confidence interval, indicating a weak correlation. In addition, mean pretest body temperature was 36.4°C ± 1°C, and mean posttest body temperature was 35.8°C ± 2°C.

CONCLUSIONS

The study showed that MEE was significantly different from PEE, but not from actual intake. This warrants further exploration to develop a population-specific PEE for children with spastic CP.

Fever and agitation in elderly ICU patients: a descriptive study

OBJECTIVE

To investigate the association between fever and agitation in elderly, critically ill patients.

SETTING

Medical-surgical Intensive Care Unit (ICU) of a Greek, tertiary care hospital.

RESEARCH METHODOLOGY

Descriptive, quantitative study conducted from October 2005 to September 2006. Patient temperature was measured by a tympanic membrane or an axillary thermometer. Agitation-Sedation scale was used for evaluating agitation. Variables found to contribute to agitation in previous studies were also collected.

RESULTS

One hundred sixty-one patients > or =65 years, who were consecutively admitted to the ICU, were enrolled. Fever was found to be an independent predictor of agitation (OR, 1.86; 95% CI, 1.02-3.49). High fever (>39.3 degrees C), was associated with a higher possibility for patients to manifest severe agitation (p=0.046).

CONCLUSION

Considering the significant adverse consequences of agitation, antipyretic therapy may be recommended for the elderly ICU population, especially when fever is combined with other factors predisposing to agitation or when fever becomes high.

Relationship between energy balance and complications after subarachnoid hemorrhage

BACKGROUND

Subarachnoid hemorrhage patients are hypermetabolic and at risk for developing medical complications. A relationship was hypothesized between energy balance and complications following subarachnoid hemorrhage.

METHODS

Fifty-eight consecutive poor-grade subarachnoid hemorrhage patients (mean age, 58; range, 26-86; 66% women) were studied between 2005 and 2007. Caloric intake and energy expenditure were assessed. In-hospital complications over the first 14 days posthemorrhage were defined as renal failure, fever (>38.3 degrees C), any infection, anemia, hyperglycemia (>11 mmol/L), and myocardial infarction. Energy balance was calculated by subtracting energy expenditure from caloric intake.

RESULTS

Enteral nutrition was begun 1 day posthemorrhage (range, 0-5 days). Recommended (mean +/- SD) caloric intake was 28 +/- 3 kcal/kg/d, and the actual was 14 +/- 5 kcal/kg/d. Enteral nutrition accounted for 67% of caloric intake; propofol and dextrose infusions accounted for 33% of caloric intake. Cumulative energy balance over the first 7 days was -117 +/- 53 kcal/kg. The average energy balance during the first 7 days after subarachnoid hemorrhage significantly correlated with the total number of infectious complications (r = -0.5, P < .001) but not medical complications (r = -0.2, P = .1). After adjustment for Hunt-Hess grade, fever, hyperglycemia, and anemia, negative energy balance during the first 7 days after subarachnoid hemorrhage correlated with the number of infectious complications (P = .01).

CONCLUSIONS

Infectious complications after subarachnoid hemorrhage are associated with negative energy balance. Studies are needed to better understand the impact of negative energy balance on outcome after subarachnoid hemorrhage.

Peak body temperature predicts mortality in critically ill patients without cerebral damage

OBJECTIVES

We investigated whether mortality in intensive care unit (ICU) patients without cerebral damage is associated with fever manifestation and characteristics.

METHODS

Patients admitted to a medical-surgical ICU between October 2005 and July 2006 were prospectively studied. Exclusion criteria were acute brain injury, intracerebral/subarachnoid hemorrhage, ischemic stroke, and brain surgery. An ear-based or axillary thermometer was used to measure body temperature. The association between fever (ear-based temperature, >38.3 degrees C), fever characteristics, and ICU mortality was evaluated using univariate and multivariate analysis.

RESULTS

Two hundred and thirty-nine patients were enrolled. Fever was not associated with ICU mortality after adjustment for confounding patient factors. A significant dose-response increase of ICU mortality according to 1 degree C increments of peak body temperature was demonstrated, whereas peak body temperature was an independent predictor of ICU mortality.

CONCLUSION

These findings imply that, although fever is not generally associated with mortality in patients without cerebral damage, it can be harmful and should be suppressed when it becomes very high. Rigorous clinical trials are needed to help establish antipyretic therapy guidelines.

Nutritional requirements of surgical and critically-ill patients: do we really know what they need?

Malnutrition remains a problem in surgical and critically-ill patients. In surgical patients the incidence of malnutrition ranges from 9 to 44%. Despite this variability there is a consensus that malnutrition worsens during hospital stay. In the intensive care unit (ICU), 43% of the patients are malnourished. Although poor nutrition during hospitalisation may be attributable to many factors, not least inadequacies in hospital catering services, there must also be the question of whether those patients who receive nutritional support are being fed appropriately. Indirect calorimetry is the ‘gold standard’ for determining an individual's energy requirements, but limited time and financial resources preclude the use of this method in everyday clinical practice. Studies in surgical and ICU patient populations have been reviewed to determine the ‘optimal’ energy and protein requirements of these patients. There are only a small number of studies that have attempted to measure energy requirements in the various surgical patient groups. Uncomplicated surgery has been associated with energy requirements of 1·0–1·15×BMR whilst complicated surgery requires 1·25–1·4×BMR in order to meet the patient's needs. Identifying the optimal requirements of ICU patients is far more difficult because of the heterogeneous nature of this population. In general, 5·6 kJ (25 kcal)/kg per d is an acceptable and achievable target intake, but patients with sepsis or trauma may require almost twice as much energy during the acute phase of their illness. The implications of failing to meet and exceeding the requirements of critically-ill patients are also reviewed.

Nursing Workload Associated With Fever in the General Intensive Care Unit

Background Fever in a patient in the intensive care unit necessitates several nursing tasks. Moreover, factors associated with increased patient care needs may be associated with fever.

Objective To identify relationships between fever and characteristics of fever and nursing workload at the patient level.

Methods A prospective study was conducted in a medical-surgical intensive care unit. The sample consisted of 361 patients consecutively admitted from October 2005 to August 2006. Each patient’s body temperature was measured by using a tympanic membrane or an axillary thermometer. The Therapeutic Intervention Scoring System-28 was used to measure nursing workload.

Results A total of 188 patients (52.1%) had fever. Mean daily scores on the Therapeutic Intervention Scoring System and on 5 of its 7 categories were significantly higher for febrile patients than for nonfebrile patients. Fever was an independent predictor of the mean daily scores for all patients (P &lt; .001). Peak body temperature but not duration of fever also was an independent predictor of mean daily scores for febrile patients (P &lt; .001).

Conclusion In a general intensive care unit, fever in patients should be taken into consideration for the proper allocation of nursing personnel.

[Evaluation of energy expenditure in children. Physiological and clinical implications and measurement methods]

The present article reviews the importance of the study of energy metabolism and its methods of assessment in children. Classically, energy requirements have been assessed by predictive equations based on anthropometric data. However, there are several physiologic and pathogenic states that may cause discrepancies between estimated and real values and consequently direct measurements of energy expenditure should be used. The gold standard to assess total energy expenditure during prolonged periods is the doubly labeled water method, which is mainly used for research studies. The best approach for resting energy expenditure determination in the clinical setting is indirect calorimetry. However, this method does not provide data on energy consumption under free-living conditions and its use in some critical care patients is restricted by technical limitations. Several other approaches to assess activity have been developed, based on heart rate, body temperature measurements, motion sensors and combined methods.

Physical antipyresis in critically ill adults

Nurses use a variety of methods to cool critically ill patients, even though there are no guidelines for the treatment of temperature elevation in this population. In order to determine whether physical methods of antipyresis, such as the application of cooling blankets, are appropriate for use in the ICU, and if so which methods are best, the authors conducted a literature review. Their findings raise concerns about whether external cooling methods should be used at all in the absence of hyperthermia or cerebral damage. In addition, the authors give an overview of the causes and effects of temperature elevation, focusing mostly on fever.A literature review examines external cooling methods for use in the ICU. The findings raise some doubts.

[Effects of sedative agents on metabolic demand]

Literature about the effects of sedative drugs on the metabolic demand of critically ill patients is relatively old and of relatively poor quality. Most are experimental or observational studies. Level of evidence is therefore relatively low corresponding to "expert opinion". The effects of analgesics and hypnotics on tissue metabolic demand associated remain difficult to be adequately quantified. They are essentially related to a decreased neuro-humoral response to stress. This response involves principally the sympathetic system, which could be effectively blocked by most of the anesthetic agents. Other factors could participate to the observed reduction in tissue metabolic demand, as a decrease in spontaneous muscular activity, a reduction in work of breathing and/or a decrease in body temperature. The relative contribution of these different factors will depend on the clinical situation of the patient. Proper effects of anesthetic agents on cellular metabolism are limited as they can only decrease the functional component of this metabolism especially at the level of the heart and to some extent, at the level of the brain. Although the control of the sympathetic activity may be beneficial in critically ill patient, complete sympathetic blockade could be detrimental. Indeed, when oxygen transport to the tissues is acutely reduced, the sympathetic system plays an important role in the redistribution of blood flow according of local metabolic demand. The complete blunting of the neuro-humoral response to stress and therefore of the sympathetic system alters this physiological mechanism and results in a decrease in tissue oxygen extraction capabilities. An imbalance between tissue oxygen demand and delivery could appear with the development of cellular hypoxia. The institution of sedation in a critically ill patient requires careful evaluation of the sedation level using an appropriate scale. In patients in whom a reduction in metabolic demand is specifically requested, but also in patients with limited oxygen transport, the effects of sedative agents on the oxygen consumption-oxygen delivery relationship must also be monitored. The choice of the different agents to be administered will depend on the predefined objectives. As far as intravenous agents are concerned, there is no evidence than one association is more efficient in reducing patient's metabolic demand.

Nonventilatory interventions in the acute respiratory distress syndrome

Acute respiratory distress syndrome was first described in 1967. Acute respiratory distress syndrome and acute lung injury are diseases the busy intensivist treats almost daily. The etiologies of acute respiratory distress syndrome are many. A significant distinction is based on whether the insult to the lung was direct, such as in pneumonia, or indirect, such as trauma or sepsis. Strategies for managing patients with acute respiratory distress syndrome/acute lung injury can be subdivided into 2 large groups, those based in manipulation of mechanical ventilation and those based in nonventilatory modalities. This review focuses on the nonventlilatory strategies and includes fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production, or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists. Most of these therapies either have not been studied in large trials or have failed to show a benefit in terms of long-term patient mortality. Many of these therapies have shown promise in terms of improved oxygenation and may therefore be beneficial as rescue therapy for severely hypoxic patients. Recommendations regarding the use of each of these strategies are made, and an algorithm for implementing these strategies is suggested.

Controversies in the determination of energy requirements

To avoid any negative outcomes associated with under- or overfeeding it is essential to estimate nutrient requirements before commencing nutrition support. The energy requirements of an individual vary with current and past nutritional status, clinical condition, physical activity and the goals and likely duration of treatment. The evidence-base for prediction methods in current use, however, is poor and the equations are thus open to misinterpretation. In addition, most methods require an accurate measurement of current weight, which is problematic in some clinical situations. The estimation of energy requirements is so challenging in some conditions, e.g. critical illness, obesity and liver disease, that it is recommended that expenditure be measured on an individual basis by indirect calorimetry. Not only is this technique relatively expensive, but in the clinical setting there are several obstacles that may complicate, and thus affect the accuracy of, any such measurements. A review of relevant disease-specific literature may assist in the determination of energy requirements for some patient groups, but the energy requirements for a number of clinical conditions have yet to be established. Regardless of the method used, estimated energy requirements should be interpreted with care and only used as a starting point. Practitioners should regularly review the patient and reassess requirements to take account of any major changes in clinical condition, nutritional status, activity level and goals of treatment. There is a need for large randomised controlled trials that compare the effects of different levels of feeding on clinical outcomes in different disease states and care settings.

24-hour indirect calorimetry in mechanically ventilated critically ill patients

BACKGROUND

Energy imbalance in critically ill, mechanically ventilated patients may lead to medical complications. The nutrition care team needs accurate, noninvasive, rapid methods to estimate energy requirements. We investigated whether brief measurements of indirect calorimetry at any time of the day would give valid estimates of 24-hour energy expenditure (EE).

METHODS

EE of 12 mechanically ventilated critically ill patients (6 men, 6 women, mean +/- SD age 67 +/- 18 years, weight 70.2 +/- 8.8 kg) was recorded every minute during 24 hours by indirect calorimetry. All patients were continuously fed enteral nutrition.

RESULTS

Mean +/- SD EE was 1658 +/- 279 kcal/d (6941 +/- 1167 kJ/d). Within patients, EE during the day fluctuated by 234 kcal in the most constant patient to 1190 kcal in the least constant patient, with a mean fluctuation of 521 kcal (12 patients). No statistically significant difference (p = .53) in mean EE between morning (6-12 hours, 1676 kcal), afternoon (12-18 hours, 1642 kcal), evening (18-24 hours, 1658 kcal), and night (0-6 hours, 1655 kcal) was found. A 2-hour instead of a 24-hour measurement resulted in a maximal error of 128 kcal (536 kJ), which was <10% of the average EE. The maximal error decreased with longer time intervals.

CONCLUSIONS

In mechanically ventilated critically ill patients, 24-hour indirect calorimetry measurements can be replaced by shorter (>/=2 hours) measurements. Time of day did not affect EE.

Fever and standard monitoring parameters of ICU patients: a descriptive study

OBJECTIVE

To investigate the effect of fever episodes and fever characteristics on heart rate, arterial blood pressure and arterial oxygen saturation of intensive care unit (ICU) patients.

METHODS

This was a prospective study conducted in the medical-surgical ICU of General University Hospital of Patras, Greece. All patients who were consecutively admitted from October 2005 to February 2006 and manifested fever during ICU stay were enrolled. A tympanic membrane or an axillary thermometer was used for the measurement of patient temperature. Standard monitoring parameters were recorded by nursing personnel at 1-h intervals.

RESULTS

Seventy-five ICU patients manifested fever during the study period. Increase of core temperature during fever episodes was followed by a significant increase in heart rate (p<0.001) and decreases in arterial blood pressure (p<0.001) and arterial oxygen saturation (p=0.002). Alterations of heart rate and arterial blood pressure were significantly affected by magnitude of fever, while alteration of arterial oxygen saturation was affected by etiology of fever.

CONCLUSIONS

The present findings confirmed the effect of fever episodes on standard monitoring parameters of ICU patients. However, alterations of these parameters, although statistically significant, were not clinically important and cannot guide antipyretic treatment.

Resting energy expenditure during mechanical ventilation and its relationship with the type of lesion

BACKGROUND

Resting energy expenditure (REE) of critically ill patients is usually calculated according to basal energy expenditure obtained from Harris-Benedict equations traditionally corrected by different stress factors, resulting in a variable accuracy for the individual patient. The objective of this study was to investigate whether or not the type of lesion affects the metabolism level of critically ill patients treated with mechanical ventilation. We performed a retrospective study measuring the REE of critically ill patients with 3 different types of lesions (trauma, medical, surgical) who were treated with mechanical ventilation and sedation. Each lesion group of patients was matched with another group, differing in the type of lesion, according to gender, age, and weight.

METHODS

Eighty-seven from a database of 175 critically ill patients undergoing indirect calorimetry were necessary for matching. Twenty matched pairs of patients for each of the following different type of lesion were obtained: medical vs surgical, medical vs trauma, and surgical vs trauma.

RESULTS

The mean REE difference was 52 kcal/d (95% confidence interval [CI] of -136 -241 kcal/d) for the medical vs surgical group, 5 kcal/d (95% CI -236 -247 kcal/d) for the medical vs trauma group and 43 kcal/d (95% CI of -132-219 kcal/d) for the surgical vs trauma group. No statistically significant differences between groups were found in the measured REE. We did not find statistically significant differences in the measured REE of patients with and without infection.

CONCLUSIONS

Critically ill patients with different types of lesion treated with mechanical ventilation have similar measured REE.

Accurate Determination of Energy Needs in Hospitalized Patients

OBJECTIVE

To evaluate the accuracy of seven predictive equations, including the Harris-Benedict and the Mifflin equations, against measured resting energy expenditure (REE) in hospitalized patients, including patients with obesity and critical illness.

DESIGN

A retrospective evaluation using the nutrition support service database of a patient cohort from a similar timeframe as those used to develop the Mifflin equations.

SUBJECTS/SETTING

All patients with an ordered nutrition assessment who underwent indirect calorimetry at our institution over a 1-year period were included.

INTERVENTION

Available data was applied to REE predictive equations, and results were compared to REE measurements.

MAIN OUTCOME MEASURES

Accuracy was defined as predictions within 90% to 110% of the measured REE. Differences >10% or 250 kcal from REE were considered clinically unacceptable.

STATISTICAL ANALYSES PERFORMED

Regression analysis was performed to identify variables that may predict accuracy. Limits-of-agreement analysis was carried out to describe the level of bias for each equation.

RESULTS

A total of 395 patients, mostly white (61%) and African American (36%), were included in this analysis. Mean age+/-standard deviation was 56+/-18 years (range 16 to 92 years) in this group, and mean body mass index was 24+/-5.6 (range 13 to 53). Measured REE was 1,617+/-355 kcal/day for the entire group, 1,790+/-397 kcal/day in the obese group (n=51), and 1,730+/-402 kcal/day in the critically ill group (n=141). The most accurate prediction was the Harris-Benedict equation when a factor of 1.1 was multiplied to the equation (Harris-Benedict 1.1), but only in 61% of all the patients, with significant under- and over-predictions. In the patients with obesity, the Harris-Benedict equation using actual weight was most accurate, but only in 62% of patients; and in the critically ill patients the Harris-Benedict 1.1 was most accurate, but only in 55% of patients. The bias was also lowest with Harris-Benedict 1.1 (mean error -9 kcal/day, range +403 to -421 kcal/day); but errors across all equations were clinically unacceptable.

CONCLUSIONS

No equation accurately predicted REE in most hospitalized patients. Without a reliable predictive equation, only indirect calorimetry will provide accurate assessment of energy needs. Although indirect calorimetry is considered the standard for assessing REE in hospitalized patients, several predictive equations are commonly used in practice. Their accuracy in hospitalized patients has been questioned. This study evaluated several of these equations, and found that even the most accurate equation (the Harris-Benedict 1.1) was inaccurate in 39% of patients and had an unacceptably high error. Without knowing which patient's REE is being accurately predicted, indirect calorimetry may still be necessary in difficult to manage hospitalized patients.

Metabolism and nutrition in patients with moderate and severe traumatic brain injury: A systematic review

PRIMARY OBJECTIVE

To examine the evidence on the metabolic state and nutritional treatment of patients with moderate-to-severe traumatic brain injury (TBI).

RESEARCH DESIGN

A systematic review of the literature.

METHODS AND PROCEDURES

From 1547 citations, 232 articles were identified and retrieved for text screening. Thirty-six studies fulfilled the criteria and 30 were accepted for data extraction.

MAIN OUTCOMES AND RESULTS

Variations in measurement methods and definitions of metabolic abnormalities hampered comparison of studies. However, consistent data demonstrated increased metabolic rate (96-160% of the predicted values), of hypercatabolism (-3 to -16 g N per day) and of upper gastrointestinal intolerance in the majority of the patients during the first 2 weeks after injury. Data also indicated a tendency towards less morbidity and mortality in early fed patients.

CONCLUSIONS

The impact of timing, content and ways of administration of nutritional support on neurological outcome after TBI remains to be demonstrated.

Energy expenditure in children with severe head injury: lack of agreement between measured and estimated energy expenditure

BACKGROUND

The purpose of this study was to test the hypotheses that estimates of resting energy expenditure (REE) vary significantly from measured energy expenditure in a population of head-injured children and are not accurate for use in determining nutrition needs in this population.

METHODS

This is a retrospective study of 30 children with severe head injury, with Glasgow Coma Scale (GCS) score of <8 and needing mechanical ventilation. Measured REE was obtained using indirect calorimetry. Estimated REEs were calculated using Harris-Benedict, World Health Organization (WHO), Schofield, and White formulas. Severity of illness was calculated using Pediatric Risk of Mortality (PRISM) score. Agreement between measured REE and estimated REE was tested using the Bland-Altman method. Correlation coefficient between PRISM score and measured REE was calculated using Spearman test.

RESULTS

More than half of the estimates of REE differed from measured REE by >10%. Significant disagreement between estimated REE and measured REE was demonstrated using the Bland-Altman method. There was no correlation between severity of illness and measured REE to explain the inaccuracies of REE estimates.

CONCLUSION

Energy expenditure in critically ill children cannot be estimated accurately; hence, nutrition for critically ill children with head injury should be provided according to measurement of REE to avoid the consequences of overfeeding or malnutrition.