Indirect Calorimetry Final

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KATRINA MAE S. GAMPONIA,M.D.

PERIE ADORABLE-WAGAN,M.D.



OBJECTIVES

1. Discuss the body’s metabolic response to

stress and illness

2. Discuss the theories and principles of indirect

calorimetry

3. Enumerate the indications for indirect

calorimetry

4. Apply data derived from indirect calorimetry

in a patient care setting



Case Study

• R.C., 59/M, Filipino

• CC: difficulty of breathing



History of Present Illness

1 day PTA

• Fever, non-productivecough, shortness of

breath, chest heaviness• Rx: ISDN – without relief



Review of Systems

• HEENT: No headache, no dizziness, no seizures, noblurring of vision, no tinnitus, no hearing loss, no nosebleeding, no hoarseness, no throat pain

• Respiratory: no snoring, no apneic episode, no

hemoptysis• Cardiovascular: no palpitations, (+) 2-3 pillow

orthopnea, (+) easy fatigability

• Gastrointestinal: No abdominal pain, nausea,

vomiting, no changes in bowel habits• Genitourinary: no urinary frequency, no dysuria, nohematuria

• Musculoskeletal: no joint pains



Past Medical History

• (-) asthma, allergies• (+) 2 vessel CAD s/p coronary angiogram (2008), advised

PCI

• (+) Congestive heart failure secondary to ischemic heartdisease

• (+) HCVD x 20 years• (+) DM x 20 years

• (+) Dyslipidemia

• (+) Chronic kidney disease secondary to type 2 DM/HTN

nephrosclerosis• Medications:

– ASA, Clopidogrel, ISDN, ISMN, Carvedilol, Losartan, Furosemide,Lacidipine, Atorvastatin, Fenofibrate, Intermediate acting insulin(30 units prebreakfast, 26 units predinner)



Personal and Social History

• Previous smoker 10 sticks/day x >20 years

• Occasional alcohol beverage drinker

Family History

• (+) HTN• (+) DM



Physical Examination

• Conscious, coherent, stretcher-borne, in respiratorydistress

• BP 160/90 mmHg, CR 95 bpm, RR 28 cpm, Temp 36.7C,BMI 28.2 (overweight)

• Pink palpebral conjunctiva, anicteric sclera• Non-hyperemic posterior pharyngeal wall, tonsils not

enlarged, no palpable CLN, (+) distended neck veins

• Symmetrical chest expansion, no retractions, (+)

bilateral rales, no wheezes• Adynamic precordium, apex beat at 6th LICS AAL,

normal rate, regular rhythm, distinct s1 and s2, (+) s3



Physical Examination

• Flabby abdomen, NABS, soft, non-tender, no

palpable masses

• Full pulses, (+) bilateral grade 3 pedal edema



Assessment

• Acute pulmonary congestion secondary to congestive heartfailure with acute LV dysfunction

• Congestive heart failure, functional class IV, secondary toischemic heart disease

• Coronary artery disease (2 vessel)• Rule out acute coronary syndrome

• Hypertension, uncontrolled

• Diabetes mellitus type 2

• COPD suspect

• Pneumonia, high risk

• Acute kidney injury, multifactorial in origin, on top of chronic kidney disease secondary to type 2 diabetesmellitus and hypertensive nephrosclerosis



Course in the Wards

Problem # 1: CARDIAC

– ECG, serial troponin and CK enzymes

– Rx: morphine, ASA, clopidogrel, losartan,

atorvastatin, furosemide, lacidipine, carvedilol,

nitrates

– Started on heart failure regimen, given diuretics,

fluid limitations, BP control



Problem # 2: RESPIRATORY

• Initial CXR – cardiomegaly with pulmonary congestivechanges, intercurrent pneumonia cannot be ruled out

•Intubated patient, started on Ampicillin-sulbactam

• ETA GSCS – Klebsiella pneumoniae, antibiotics shiftedto Ceftriaxone

• Rpt ETA GSCS – Stenotrophomonas maltophilia,

Ceftriaxone shifted to Levofloxacin• 2x self extubation

• Indirect calorimetry – 5th HD

• Weaning eventually started, antibiotics completed



Problem #3: RENAL

• Referred to nephrology• Due to increasing creatinine, underwent IJ

catheter insertion, underwent hemodialysis

• AVF creation



INDIRECT CALORIMETRY RESULTS

• DIET: 1800 kcal Nutren Diabetes, 2:1

concentration, continuous at 38 ml/hour

REE 1928 kcal/day

RQ 0.73

VO2 3.1 ml/kg/min

VCO2 .207 L/min



INTRODUCTION• Overall approach to managing critically ill patients

– Assessment and monitoring metabolic changes and determiningcaloric requirements

– Avoiding malnourishment and overfeeding

• Incidence of malnourishment is high for those with either

acute or chronic cardiopulmonary disease and especially for

those who require prolonged periods of mechanical

ventilation, those with sepsis, burns, trauma, and generalized

infections.

• Excessive calories, especially from high CHO feedings

– increased levels of oxygen consumption and metabolic rate

– increase ventilation requirements and may result in respiratory muscle

fatigue or respiratory failure



• Malnutrition - primary or secondary causes

• Secondary malnutrition

– result of acute or chronic diseases that alter

nutrient intake or metabolism, particularly

diseases that cause acute or chronic inflammation

• Protein-energy malnutrition (PEM) – affects 1/3 - 1/2 of patients on general medical

and surgical wards in hospitals

• The consistent finding that nutritional statusinfluences patient prognosis underscores the

importance of preventing, detecting, and

treating malnutrition.



Physiologic Characteristics of

Hypometabolic and Hypermetabolic

State

Metabolic characteristics and nutritional needs

of hypermetabolic patients who are stressedfrom injury, infection, or chronic inflammatory

illness differ from those of hypometabolic

patients who are unstressed but chronically

starved









Physiologic

characteristics

Hypometabolic,

Nonstressed Patient

Hypermetabolic,

Stressed Patient

Metabolic rate, O2

consumption

Cytokines,

catecholamines,

glucagon, cortisol,

insulin

Proteolysis,

gluconeogenesis

Ureagenesis, urea

excretion

Fat catabolism, fatty acid

utilization

Relative Absolute

Adaptation to starvation Normal Abnormal

If the metabolic rate (energy requirement) is not matched by energy intake, weight loss

results, slowly in hypometabolism and quickly in hypermetabolism



Physiologic

characteristics

Hypometabolic,

Nonstressed Patient

Hypermetabolic,

Stressed Patient

Cytokines,

catecholamines,glucagon, cortisol,

insulin

Proteolysis,

gluconeogenesis

- Major aim: provide the glucogenic

amino acids (esp. alanine and

glutamine)- Protein breakdown for

gluconeogenesis is minimized,

especially as ketones derived from

fatty acids become the substrate

preferred

- gluconeogenesis increases and in

proportion to the degree of the

insult to increase the supply of

glucose (the major fuel of

reparation).

- Glucose is the only fuel that can be

utilized by hypoxemic tissues

(anaerobic glycolysis), white blood

cells, and newly generated

fibroblasts



Estimating Nutrional Requirements

and Determining Caloric Needs

• Nutritional assessment can be viewed as atriad of assessment techniques incorporatinganthropometric measurements, screening of

biochemical indices, andpredicting/measuring energy expenditure

Anthropometrics Biochemical Indices Predicting/Measuring

EE

Ideal body weight Creatinine-heights index Equations

Triceps skin fold

measurements

Lymphocytes count Calorimetry

Arm circumference Trasnferrin and albumin

levels

Indirect calorimetry



COMPONENTS OF TOTAL ENERGY

EXPENDITURE

Journal of Dietician Ass of Australia 2007



WHAT IS CALORIMETRY?

• Measure of how much energy we expend

• Usually measures Resting Energy Expenditure (REE):number of calories being burned at rest per day.

• Depending on body size, a healthy adult may burnfrom 1000 to 3000 Kcal per day just to maintainnormal body functions.

• This varies hugely with disease

25Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette,MHS 11/09/2005



DIRECT CALORIMETRY

measures heat exchange between body and the environment

Place patient in thermally sealed room and measure how muchthey warm the air in the room.

Energy expenditure and components evaluation Nutrition Hosp 2011;26(3):430-440





Metabolic measurements using indirect calorimetry DuringMechanical Ventilation—2004 Revision & Update

• Indirect calorimetry for the determination of:

– oxygen consumption (VO2)

– carbon dioxide production (VCO2) – respiratory quotient (RQ)

– resting energy expenditure (REE)

AMERICAN ASSN OF RESPIRATORY CARE CLINICAL PRACTICE GUIDELINE28



Indirect Calorimetry

• These values are then converted to an REE via

a metabolic computer using the Weir

equation.

• The Weir equation also requires the

measurement of daily urinary nitrogen (UN) to

represent protein metabolism not reflected in

exhaled gas analysis

Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette,MHS 11/09/2005



HARRIS-BENEDICT EQUATION

Men 66 + {13.7 x wt (kg)} + {5 x ht (cm)} – {6.8 xage (yrs)}

Women 655 + {9.6 x wt (kg)} + {1.8 x ht (cm)} – {4.7 x age (yrs)}

30Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette,MHS, 11/09/2005



PREDICTIVE EQUATIONS VS IC

Pt Diagnosis H-B

Kcal/day

Indirect

CalorimetryKcal/day

Variance

Kcal/day%

error

1 Obstructive Jaundice 1098 2199 - 1101 50%

2 Liver Transplant 1496 1531 - 35 2%

3 Liver Transplant-cryptogenic cirrhosis

1855 2421 - 566 23%

4 Pneumonectomy,pneumonia, bronchfistula

1255 2695 - 1440 53%

5 Crohn’s disease-subtotal colectomy

1091 820 + 271 33%



Comparison of Predictive Equations for Resting Energy

expenditure in Overweight and Obese Adults

• P = 82 participants

ages between 30 and 60 years

BMI ≥ 25 kg/m2

• I = Predictive equations vs IC

•M= descriptive cross-sectional study

Journal of Obesity Volume 2011





CLINICAL INVESTIGATION

• INDIRECT CALORIMETRY

Generally considered superior alternative to predictive

equations.

NUTRITIONAL LOAD IN CRITICALLY ILL : THE CHANGING CONCEPTS, Dr D P Samaddar; SAARC J

Anaesth 2008; 1(2) : 135-141 34



INDIRECT CALORIMETRY

Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette,MHS, 11/09/2005



RESPIRATORY QUOTIENT

Respiratory Quotients for Various Substrates -- RQ = VCO2 ÷ VO2



FUEL OXIDATION

Carbohydrates

• C6H12O6 + 6 O2 → 6 CO2 + 6 H2O

• R.Q. = 6 CO2 / 6 O2 = 1

Fats• C16H32O2 + 23 O2 → 16 CO2 + 16 H2O

• R.Q. = 16 CO2 / 23 O2 = 0.696

Proteins

• C72H112N18O22S + 77 O2 → 63 CO2 + 38 H2O + SO3 + 9 CO(NH2)2

• R.Q. for albumin is 63 CO2/ 77 O2 = 0.818



The objectives of Indirect Calorimetry

1. To accurately measure the REE and RQ

to guide nutritional support

2. To allow determinations of substrate

utilization in conjunction with UNmeasurements



The objectives of

Indirect Calorimetry

3. To determine the VO2 as a guide for

monitoring the work of breathing and

targeting adequate oxygen delivery

3. To assess the contribution of metabolism to ventilation









INDICATIONS

Severe sepsisMultiple trauma

COPD

Exhibiting hyper- or hypometabolic symptoms

Failure to wean from mechanical ventilation

Increased oxygen cost of breathing

Failure in responding to traditional nutritional support regimens



INDICATIONS

• Neurologic trauma

• Paralysis

• Acute pancreatitis

• Cancer with residual tumor burden

• Amputations

44



INDICATIONS

•Patients who fail to respond adequately toestimated nutritional needs

• Patients who require long-term acute care

• Extremely obese patients

45



Assessment of patients

• Exhibit wide fluctuations in ventilation

• Cardiac output are usually not good candidate

• The immediate postoperative period (< 24

hours post surgery)

• recent wound or burn debridement



Conditions for Conducting a Study

Continous approach

• Minimum of 12 hours

• Continous basis

Obtain an accurate reflectionof Total energy expenditure

that would include periods

of rest, sleep and activity

Intermittent approach

• Selection of time period

• Resting measurement of

energy expenditure can beobtained





CONDITIONS FOR STUDYVentilated patients

• patient needs to be resting but not asleep

• room should be quiet and at 20-25o C

• FiO2 < 40%

• No FiO2 adjustment within 90 mins prior to procedure

• 30 minutes after changes in FiO2, PEEP, and TVsettings on mech vent

• Suctioning not allowed 30 mins before

49



TECHNICAL CONSIDERATIONS

FiO2 stability

Steady state conditions

System leak





bl f



Acceptable Ranges for

Indirect Calorimetry Data



METABOLIC CONDITIONS

• HYPOMETABOLIC REE < 90%

• NORMOMETABOLIC REE 90-110%

• HYPERMETABOLIC REE > 110%

54

CALCULATION OF CALORIES



CALCULATION OF CALORIESBASED ON STRESS

FEVER BEE x 1.1 (for each C

rise above normalTemp)

STRESS

MILD BEE x 1.2

MODERATE BEE x 1.4SEVERE BEE x 1.6

SAARC J ANEST 2008; 1 (2): 135-141 55

CALCULATION OF CALORIES BASED



CALCULATION OF CALORIES BASEDON ACTIVITY

• ON VENTILATOR BEE x 0.85

• UNCONSCIOUS BEE x 1.0

• AWAKE ON BED BEE x 1.1

• SITTING ON CHAIR BEE x 1.2

56

CALCULATION OF CALORIES BASED



CALCULATION OF CALORIES BASEDON STRESS

• MINOR SURGERY BEE x 1.2

• TRAUMA BEE x 1.3

• SEPSIS BEE x 1.6

• SEVERE BURNS BEE x 2.1

57





INTERPRETATION OF DATA

RQ

0.85-.90 Target range for RQ. Mixed level of

substrate oxidation

>1.0 Overfeeding

0.9-1.0 Carbohydrate oxidation

0.7-0.8 Fat and protein primarysubstrates for metabolism

0.67-1.3 Non-steady state conditions J. Greenwood VCH ICU



Wooley, J. Indirect Calorimetry:

Applications in Practice, 2006



Indirect Calorimtery: The Medical CityExperience

(A Demographic Profile of In-Patients

who underwent Indirect Calorimetry at

The Medical City from January 2008 to

January 2009)

Maria Patricia Puno, MD

Pamela Romero, MD

INDIRECT CALORIMETRY: THE




MEDICAL CITY EXPERIENCE

• Objectives: The purpose of this study is todescribe the patients who have undergoneIndirect Calorimetry while admitted at The

Medical City from January 2008 to January2009.

• Subjects: 19 years old and above

admitted

84 subjects

5 excluded

Puno and Romero





MEDICAL CITY EXPERIENCE

• Method:

Retrospective

Chart review

Descriptive study

Puno and Romero





THE MEDICAL CITY EXPERIENCE






CASES PER ORGAN

SYSTEM

# of cases =91 Percentage (%)

Pulmonary 45 50.54

Rheumatology 1 1.1Gastroenterology 3 3.29

Endocrine & Metabolism 11 12.09

Oncology 8 8.8

Infectious disease 12 13.19

Cardiology 7 7.69

Neurology 2 2.2

Nephrology 1 1.1

Puno and Romero











Results:

• NMS overestimation of patients energy

(p value 0.000) compared to Indirect calorimetry

Conclusion:

Indirect calorimetry is still the more accurate

means of obtaining REE confirming its position

as the gold standard.



THE MEDICAL CITY ICU

69

45%FEMALE

55%MALE

GENDER DISTRIBUTION OF IC PATIENTS

N = 251



THE MEDICAL CITY ICU

70

19-60 yo48%

> 61 yo52%

AGE DISTRIBUTION OF IC PATIENTS

N = 251



71

OPD32%

ICU

21%

FLOORS47%

LOCATION OF IC PATIENTS

N = 251



SUMMARY

• IC is a valuable tool available• Knowledge of the metabolic response to

sepsis, injury, and burns is crucial in

managing these patients.• Accurate assessments of EE and substrate

utilization are now possible.

73



SUMMARY … •

Reduce the incidences of malnutrition andproblems associated with overfeeding patients,especially those who require mechanicalventilation.

• Usefulness in determining dietary needs and asa tool for ventilator management anddiagnosing cardiopulmonary failure.

74



ACKNOWLEDGEMEMT

• Dra.JB Ramos

Data on Indirect Calorimetry

• Dra.Puno and Dra. Romero

Research Paper



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Indirect Calorimetry Final