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Consequences of Malnutrition in
Critically Ill Patients

Metabolic stress of acute illness

Indirect Calorimetry: Taking the Guess Work + Malnutrition
Out of Feeding Critically Ill Patients

= Increased healthcare costs1

Jennifer A. Wooley, MS, RD, CNSC = Higher rate of ventilator dependence2
GE Healthcare
= Longer ICU stays1
May 5, 2017
= Higher morbidity and mortality rates2

1. Reilly JJ, et al. J Parenter Enteral Nutr. 1988;12:371-376.

2. Foster GD, et al. J Am Coll Nutr. 1987;6:231-253

Pros and Cons of Predictive Equations

Pros and Cons of Indirect Calorimetry
Estimates

PROs CONs PROs CONs

• Convenient • Hundreds of equations • Accurate • Not always available

• Used more frequently and variables to • Gold standard (Newer technology now
consider integrated into ventilator)
• Inexpensive • Doesn’t have limitations
• Accuracy < 40% of equations • Not all clinicians trained in
• No consensus on how to use and interpretation
select equations • Variable insurance
• Results vary from reimbursement
clinician to clinician • Equipment is fairly costly
• No clinical trials to prove
1. Malone AM. Nutr Clin Pract. 2002;17:21-28.
2.
3.
Matarese LE, Gottschlich MM (eds). Contemporary Nutrition Support Practice: A Clinical Guide. 1998:79-98.
Reeves MM. Eur J Clin Nutr. 2003;57:1530-1535.
1.
2.
Reid CL. Proc Nutr Soc. 2004;63:467-472.
Reeves MM. Eur J Clin Nutr. 2003;57:1530-1535.
that it directly improves
3.
4.
Flancbaum L, et al. Am J Clin Nutr. 1999;69:461-466.
McClave S. Nutr Clin Pract. 1992;7:207-221.
patient outcomes
5. McClave SA, et al. J Clin Gastroenterol. 2001;33:14-19.

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What is Indirect Calorimetry (IC)? Metabolism

• Calculation of heat production by measuring Metabolism, measured in calories, is the biochemical

pulmonary gas exchange process of combining nutrients with oxygen to release
• Measurements of inspired and expired O2 and the energy needed for the body to function
CO2
• Determination of: C6H12O6 + 6O2 6CO2 + 6H20 ATP
 Resting Energy Expenditure (REE) (ENERGY)
 Respiratory Quotient (RQ)

More simply stated, resting metabolism is the

number of calories that the body burns while at rest.

1. McClave S. Nutr Clin Pract. 1992;7:207-221.

2. McClave SA, et al. J Clin Gastroenterol. 2001;33:14-19.
3. Branson RD. Resp Care. 1990;35:640-659.

Calculations for IC Equipment Options for IC

RESTING ENERGY EXPENDITURE • Metabolic cart

REE (Kcal/d) = [(VO2 x 3.94) + (VCO2 x 1.11)] x 1,440 min/day • Handheld device
• Indirect calorimetry module built in to a
RESPIRATORY QUOTIENT mechanical ventilator
VCO2 (carbon dioxide production)
RQ =
VO2 (oxygen consumption)

1. McClave S. Nutr Clin Pract. 1992;7:207-221.

2. McClave SA, et al. J Clin Gastroenterol. 2001;33:14-19.
Branson RD, Johannigman JA. Nutr Clin Pract. 2004;19:622-636.
3. Branson RD. Resp Care. 1990;35:640-659.

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The Classic Indirect Calorimeter Handheld and Table Top Indirect Calorimeters



Indirect Calorimetry Module within Mechanical

Ventilator

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SCCM and ASPEN 2016 Guidelines for the Provision and

When is IC Helpful? Assessment of Nutrition Support Therapy
in the Critically Ill Patient

• When you cannot accurately estimate 1. A3a: IC should be used to determine energy
caloric requirements requirements when available
• When predictive equations produce an 2. C3: Provide at least 80% of estimated or calculated goal
inadequate clinical response in a patient energy and protein within 48-72 hours over the 1st week
of hospitalization
• When clinical signs suggest under- or over- 3. I1: Pulmonary failure – High fat low carbohydrate
feeding formulations designed to manipulate RQ and decrease
CO2 production are not recommended for use
4. M4b: Burn – IC should be used to assess energy needs
with weekly repeated measures
1.
2.
Foster GD, et al. J Am Coll Nutr. 1987;6:231-253.
Malone AM. Nutr Clin Pract. 2002;17:21-28.
5. Q5: Obesity – Target energy requirements should be
3. Brandi LS, et al. Nutrition. 1997;13:349-358.
4. Porter C. J Am Diet Assoc. 1996;96:49-54, 57 measured by IC. Feed at 65-70% of target
McClave SA et al. J Parenter Enteral Nutr 2016;40(2):1-53

Factors Affecting the Accuracy of Estimates Consequences of Under- or Overfeeding

• Multiple trauma • Use of paralytic agents or • Underfeeding1,2

• Neurological trauma sedation
• Impairs regeneration of respiratory epithelium
• Burns • Post-operative organ
• Multi-system organ failure transplantation • Contributes to muscle weakness and respiratory
• Sepsis • Large or multiple open dysfunction
wounds • Overfeeding2-5
• Systemic inflammatory • Malnutrition with altered
response syndrome body composition • Worsens metabolic stress
• Acute or chronic • Underweight • Increases the work of breathing
respiratory distress • Obesity
syndrome (can lengthen ventilator dependence)
• Limb amputation
• Peripheral edema
• Ascites 1. Askanazi J, et. al. Crit Care Med. 1982;10:163-172.
2. Kan M, et al. J Crit Care. 2003;7:108-115.
3. McClave SA. J Resp Care Pract. 1997;10:57-8,60,62-64.
4. Dark DS, et al. Chest. 1985;88:141-143.
5. Porter C. J Am Diet Assoc. 1996;96:49-54, 57.
Reprinted from Nutrition in Clinical Practice. 2003;18-434-439: American Society for Parenteral and Enteral Nutrition with permission from the
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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How to Conduct IC Measurements Achieving a Steady State is Key

• Intermittent
• Steady state conditions:
• Continuous
• McClave Definition:
• 5 minutes with 5 % CV in vO2, vCO2
“Snapshot” studies of ≤ 30 minutes are more
common than continuous monitoring. • 10 minutes with 10% CV in vO2, vCO2
• Results reflect a steady state for at least
5 consecutive minutes (or follow your unit’s protocols)
Results are extrapolated to a 24-hour day
• CV = co-efficient of variation

McClave SA, et al. J Parenter Enteral Nutr. 2003;27:21-26.

What to do if You don’t Achieve Steady State? Physiologic Issues that can Affect Results

Altered Gases Cause

• Compare predicted VCO2 and VO2 to measured
Elevated VCO2  Metabolic acidosis  Hyperventilation
levels  Hypermetabolism  Overfeeding
Decreased VCO2  Metabolic alkalosis  Hypoventilation
• Normal Adult VCO2 = 2 - 3 ml/kg/minute  Hypometabolism  Gluconeogenesis
 Starvation/ketosis  Underfeeding
Elevated VO2  Sepsis  Hypermetabolism
• Normal Adult VO2 = 3 - 4 ml/kg/minute 

Hyperthermia  Blood transfusions
Shivering/agitation/excessive movement
 Increased minute ventilation
 Hemodialysis (within 4 hr of treatment)
• Note: use the most appropriate reference  Overfeeding

weight for these calculations Decreased VO2  Hypothermia  Fasting/starvation

 Hypothyroidism  Advanced age
 Paralysis  General anesthesia
 Heavy sedation  Coma/deep sleep

Reprinted with permission from A.S.P.E.N.: Use of indirect calorimetry in critically ill patients. In: Merritt R, ed. The A.S.P.E.N. Nutrition Support
Practice Manual. 2nd ed. 2006:277-280.

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Situations Where VCO2 May Be Elevated Situations Where VCO2 May Be Decreased

• Metabolic acidosis • Metabolic alkalosis

• Hyperventilation • Hypoventilation
• Hypermetabolism • Hypometabolism
• Overfeeding • Gluconeogenesis
• Starvation/ketosis
• Underfeeding

 RQ
 RQ

Situations Where VO2 May Be Elevated Situations Where VO2 May Be Decreased

• Sepsis • Paralysis • Hypothermia

• Hypermetabolism • Coma • Fasting
• Hyperthermia
• General anesthesia • Starvation
• Shivering / agitation / pain / excessive movement
• Increased minute ventilation
• Sedation • Hypothyroidism
• Overfeeding • Analgesics • Sleep
• Muscle relaxants • Advanced age

 REE  REE

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Recommendations to Improve IC Measurements: Recommendations to Improve IC Measurements:

Patient  Equipment  Environment Patient  Equipment  Environment

• Do measurements in a quiet, thermoneutral environment • IC measurements may not be valid within:

• Rest patient in supine position > 30 min. prior to the study • 8 to 12 hrs of general anesthesia
• Do the study ~ 1 hr after an intermittent feeding if • 90 minutes of changes in ventilatory settings
thermogenesis is included in the REE; 4 hr after the
• 3 to 4 hrs of hemodialysis
feeding if it is not
• 1 hr of any painful procedures
• Ensure that the rate and composition of continuously
infused nutrients is stable at least 12 hr prior to the study

Adapted from Nutrition in Clinical Practice. 2003;18-434-439: American Society for Parenteral and Enteral Nutrition with permission from the Adapted from Nutrition in Clinical Practice. 2003;18-434-439: American Society for Parenteral and Enteral Nutrition with permission from the
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

Technical Issues that can Affect Results

Interpretation of the Measured REE

• Keep FiO2 constant during the measurement • In general, feed critically ill patients 100% REE
• Mechanical ventilation with FiO2 > 60 without adding activity or stress factors
• Mechanical ventilation with PEEP > 12 cm H2O
• Hyper/hypoventilation (alters the body’s CO2 stores)
• Provide sufficient protein (1.5-2.0 gm/kg)
• Leak(s) in the sampling system
• Moisture in the system can affect the oxygen analyzer
• Continuous system flow > 0 L/min during exhalation • Re-evaluate REE when indicated
• Inability to collect all expiratory flow

Reprinted from Nutrition in Clinical Practice. 2003;18-434-439: American Society for Parenteral and Enteral Nutrition with permission from the
McClave SA,et al. JPEN 27:16-20, 2003
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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Interpretation of RQ Designing a Nutrition Regimen

• Historically used to determine substrate utilization.1 • Consider the phase of the patient’s response to
CAUTION: This varies by patient and condition2 metabolic stress
• Stress response • Stress phase, or ebb phase (12 – 24 hr.)
• Underlying pulmonary disease • Catabolic phase, or flow phase (7 – 10 days)
• Acid/base abnormalities • Anabolic phase (variable time, may last for months)
• Pharmacologic agents • Adjust nutritional support according to phase of
• RECOMMENDATION: Use RQ to validate test results metabolic stress
and to gauge whether RQ is within normal biological • In all phases, provide a balanced mix of protein:carbs:fat
range (0.67 to 1.3)3-7 at approximately 20%: 50%: 30%
1. Matarese LE. J Am Diet Assoc. 1997;10(suppl2):S154-S160.
2. Merritt R, ed. The A.S.P.E.N. Nutrition Support Practice Manual. 2nd ed. 2006:277-280.
3. McClave S. Nutr Clin Pract. 1992;7:207-221.
4. Branson RD. Resp Care. 1990;35:640-659.
1. Cerra FB. Surgery. 1987;101:1-14.
5. Branson RD. Nutr Clin Pract. 2004;19:622-636.
2. McClave SA. New Horizons. 1994;2:139-146.
6. Holdy KE. Nutr Clin Pract. 2004;19:447-454.
3. Wooley JA. Support Line. 2003;25:3-7.
7. McClave SA, et al. J Parenter Enteral Nutr. 2003;27:21-26.

Hypercatabolism ≠ Hypermetabolism

Uehara M, Plank LD, Hill GL. Crit Care Med. 1999;27:1295-1302

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Energy Considerations for Each Phase of the

Stress Response Interpretation of the Measured REE

• Stress and catabolic • Anabolic phase • In general, feed critically ill patients
phases = metabolic • Marked rise in energy 100% REE without adding activity or
support requirements
stress factors
• Preserve lean body • Focus on nutrition
mass without repletion and recovery • Provide sufficient protein (1.5-2.0
overfeeding • Patients may be fed gm/kg)
• High protein feedings up to 130% of their • Re-evaluate REE when indicated
<100% of REE measured REE
Measure energy expenditure in ventilated patients requiring
• Ongoing aggressive an ICU stay of > 5 days who need nutrition intervention
protein delivery
• Anticipated ICU LOS < 5 days – IC once/week
• Anticipated ICU LOS > 7 days – IC 2-3 times/week
1. Cerra FB, et al. Chest. 1997;111:769-778.
2. Malone AM. Nutr Clin Pract. 2002;17:21-28.
3. McClave SA, et al. J Parenter Enteral Nutr. 2003;27:16-20.
4. Wooley JA. Support Line. 2003;25:3-7.
McClave SA,et al. JPEN 27:16-20, 2003
Singer P., Singer J. Nutr Clin Pract. 2016;31(1):30-38

Patient Case The Patient’s Nutrition Status

• 44 y.o. female
• Ht: 5’8”
• Diagnosis: Necrotizing Fasciitis
• PMH: • Wt: 188kg BMI: 63!
• HTN • Sedentary; in usual state of
• Asthma
health until admission
• Hypothyroidism
• Morbid obesity
• PSH:
• Appendectomy
• Hysterectomy
• Oophorectomy

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What is the Patient’s Predicted Energy

Review of Clinical Course
Expenditure?

• Sepsis w/ respiratory failure • HBE (BEE x 1.3-1.6) 2156-2653 kcals/d

• OR: Right BKA • Swinamer 2955 kcals/d
• IJEE(v) 2196 kcals/d
• Post-operative complications:
• 20-25 kcal/kg 1900-2375 kcals/d
 C. Diff diarrhea
• Mifflin-St. Jeor 2559 kcals/d
 Poor wound healing
 UTI

Is this patient is a good candidate

Indirect Calorimetry Studies
for IC?

• YES! • Hospital Day #8 1st study: Valid

 REE 2259 calories/day; RQ 0.83
• Sepsis
• Obesity
• Altered body surface area secondary to BKA • Hospital Day #15 2nd study: Valid
• Respiratory failure  REE 2730 calories/day; RQ 0.83
• Hypermetabolism
• Wound healing

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Trends in Measured REE Potential Benefits of Using IC

• Prevention of over- or
3500
underfeeding
3000 RMR • Reduced resource utilization
HBE x 1.6
2500 & associated cost savings
IJEE
2000
25 kcal/kg • Improved outcomes
MIFFLIN
• Fewer days on mechanical
1500 Swinamer ventilation
• Shorter ICU LOS
1000
Week 1 Week 2 Week 3 Week 4

Summary

• Indirect calorimetry (IC) is the gold standard for

determining energy expenditure in critically ill patients
• IC is objective and accurate
• The REE does not need to be adjusted by stress or
activity factors
• Use the RQ primarily to validate test results
• IC is a valuable tool for
• monitoring patient response to metabolic stress
• monitoring nutrition interventions
• optimizing nutrition

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