Indirect Calorimetry (171)

Fink Chapter 225

Haugen et al 2007 Nutrition in clinical practice vol22 N4 p377-88
o We are becoming increasingly aware of the importance of nutrition in the ICU
setting
o Definitions
o TEE total energy expenditure (TEE=BEE+DIT+AEE)
o BEE basal energy expenditure energy required to maintain bodys
basic cellular metabolic activity and organ function
Ideally measured after fasting 5hours, no physical activity, no
stimulants (nicotine, caffeine etc)
o REE Resting energy expenditure used in place of BEE in hospitalized
patients because BEE is not usually feasible
o DIT diet induced thermogenesis energy used during substrate
metabolism
o AEE Activity energy expenditure energy used in physical activity
o Adequate nutritional support is rarely achieved
o Patients are either under- or over- fed
o Parenteral nutrition often results in overfeeding leading to complications
of hyperglycemia, increased inflammation and infection, liver function
abnormalities and CO2 retention
o Enteral nutrition is often associated with feeding intolerance high gastric
residuals lead to reflux, emesis, aspiration and diarrhea
Leads to underfeeding which leads to an increase in complications
and increased mortality
o Multiple formulae to predict energy requirements
o Harris-Benedict (1919)
Men = 66.5 + (13.75 x kg) + (5.003 x cm) - (6.775 x age)

Women = 65.1 + (9.563 x kg) + (1.850 x cm) - (4.676 x age)

If you get little to no exercise

Daily calories needed= BMR x 1.2

If you exercise lightly(1-3 days per week)

Daily calories needed= BMR x 1.375

If you exercise moderately (3-5 days per week)

Daily calories needed= BMR x 1.55

If you exercise heavily (6-7 days per week)

Daily calories needed= BMR x 1.725

If you exercise very heavily (i.e. 2x per day, extra heavy

workouts)

Daily calories needed= BMR x 1.9

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Owen
Ro
Robertson
Reid
Frankenfield

o Penn State
o Ireton-Jones
o Many studies have been done comparing formulae to calorimetry
MacDonald - % formulae vs indirect calorimetry
No formula was good for all BMIs in all conditions
o

Calorimetry
o Measurement of heat produced to quantify TEE
o Total body heat is measured in a thermally sealed chamber
o Very accurate but cumbersome, expensive and requires technical expertise

Indirect Calorimetry
o Used in place of direct calorimetry
o Energy expenditure is quantified under specific conditions by measuring
respiratory gases (O2 consumed and CO2 produced)
These numbers are then inserted into the Weir equation

Energy Expenditure (kcal/day) = [(VO2 X 3.941) + (VCO2 X 1.11) +

(uN2 X 2.17)] X 1440
The urinary Nitrogen (uN2) factor is usually excluded because it
accounts for <4% of the true energy expenditure
Can also be done using the Fick equation by comparing the A-V O2
contents and using cardiac output
Period of measurement
24 hours is the old standard
Recent evidence suggests that 30 minutes is almost as accurate
One trial demonstrated that 5 minute measurements were as good as 30
minutes but the patients had to be stable
One measurement or many
There is a great deal of day to day variation in energy expenditure (may
be as great as 35%)
Day to day measurements affected by temperature but not by illness
severity score
Daily measurements may be necessary

Value of energy balance

o Negative energy balance is associated with
Longer duration of mechanical ventilation
Longer ICU stay
Development of pressure sores
Renal failure
Sepsis
Hemodynamic instability
*it may be that the sicker patients dont get fed rather than not being fed
makes them sicker

Energy balance of -10, 000kcal associated with increased mortality

Respiratory Quotient (RQ)

o Ratio between VCO2 and VO2 (VCO2/VO2)
o If glucose is completely oxidized in a system the quotient is 1
o Lipid = 0.69, Protein = 0.81
o If a value for RQ is found to be outside the normal range (0.67-1.2) then the
measurement is likely inaccurate
o Poor measurement occurs when
Poor seal with air leak
Hemodialysis
Patient agitation or pain
Residual anesthetic gasses
FiO2 >60%

Limitations of IC
o VCO2 and VO2 are calculated using volumes of inspired and expired volumes
(Ve) but
Inspired volumes (Vi) are difficult to accurately measure so they are
estimated using the Haldane transformation which assumes static
volumes of N2 in inspired and exhaled gasses
Vi = [(FeN2/FiN2) Ve]

Types of machines
o Douglas Bag
GOLD STANDARD

Person breathes ambient air through a 1-way valve connected to an

airtight container (Douglas bag)

Expired gas is sampled; relative concentrations of O2 and CO2 are

measured by electronic gas analyzers

Comparison is made between the composition of inspired and expired

air: VO2 and VCO2 are determined

Challenges: expensive analyzer equipment, requires technical expertise

o Metabolic Cart (this is what we use)

Person breathes into mask or through mouthpiece connected to metabolic

cart
Gas analyzers and airflow measurement

Mixing chamber: gas samples are continuously obtained and analyzed

from a mixing chamber within the metabolic cart

Breath-by-breath: analysis from an external sample port on a breathing

valve
In some instances, the metabolic cart has been designed to collect a gas

sample using either mixing chamber or breath-by-breath procedure

Accurate and well-accepted in clinical settings

Challenges: costly and requires technical expertise to maintain

Special considerations
o Extreme obesity (BMI>40)
It is very difficult to estimate energy expenditure in these patients and IC

may be the onlt useful method

o Post op bariatric surgery
Energy expenditure may change very rapidly with changing gbody

composistion
o HIV infected patients
Hypermetabolism may play a role in wasting associated with the disease

Difficult to estimate using formulae

o IHD
Hemodialysis removes CO2 from the venous bed and therefore changes

the FeCO2 and it may take 24 hours to reequilibrate - as such wait 24

hours after hemo run
o CRRT
Similar problem removes CO2 but not O2 can lose up to 35% of CO2

In addition the temperature of the patient may decrease on CRRT

No good guidelines for the interpretation of IC in these situations

o Deep sedation/paralysis
Significantly reduce energy expenditure

IC should be performed during and post deep sedation