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Transcript of Indirect Calorimetry Final
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KATRINA MAE S. GAMPONIA,M.D.
PERIE ADORABLE-WAGAN,M.D.
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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
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Case Study
• R.C., 59/M, Filipino
• CC: difficulty of breathing
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History of Present Illness
1 day PTA
• Fever, non-productivecough, shortness of
breath, chest heaviness• Rx: ISDN – without relief
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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
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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)
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Personal and Social History
• Previous smoker 10 sticks/day x >20 years
• Occasional alcohol beverage drinker
Family History
• (+) HTN• (+) DM
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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
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Physical Examination
• Flabby abdomen, NABS, soft, non-tender, no
palpable masses
• Full pulses, (+) bilateral grade 3 pedal edema
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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
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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
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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
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Problem #3: RENAL
• Referred to nephrology• Due to increasing creatinine, underwent IJ
catheter insertion, underwent hemodialysis
• AVF creation
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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
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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
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• 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.
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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
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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
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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
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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
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COMPONENTS OF TOTAL ENERGY
EXPENDITURE
Journal of Dietician Ass of Australia 2007
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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
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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
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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
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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
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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
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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%
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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
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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
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INDIRECT CALORIMETRY
Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette,MHS, 11/09/2005
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RESPIRATORY QUOTIENT
Respiratory Quotients for Various Substrates -- RQ = VCO2 ÷ VO2
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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
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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
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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
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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
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INDICATIONS
• Neurologic trauma
• Paralysis
• Acute pancreatitis
• Cancer with residual tumor burden
• Amputations
44
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INDICATIONS
•Patients who fail to respond adequately toestimated nutritional needs
• Patients who require long-term acute care
• Extremely obese patients
45
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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
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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
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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
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TECHNICAL CONSIDERATIONS
FiO2 stability
Steady state conditions
System leak
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bl f
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Acceptable Ranges for
Indirect Calorimetry Data
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METABOLIC CONDITIONS
• HYPOMETABOLIC REE < 90%
• NORMOMETABOLIC REE 90-110%
• HYPERMETABOLIC REE > 110%
54
CALCULATION OF CALORIES
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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
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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
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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
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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
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Wooley, J. Indirect Calorimetry:
Applications in Practice, 2006
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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
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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
INDIRECT CALORIMETRY: THE
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INDIRECT CALORIMETRY: THE
MEDICAL CITY EXPERIENCE
• Method:
Retrospective
Chart review
Descriptive study
Puno and Romero
INDIRECT CALORIMETRY
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INDIRECT CALORIMETRY
THE MEDICAL CITY EXPERIENCE
INDIRECT CALORIMETRY
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INDIRECT CALORIMETRY
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
INDIRECT CALORIMETRY
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INDIRECT CALORIMETRY
THE MEDICAL CITY EXPERIENCE
INDIRECT CALORIMETRY
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INDIRECT CALORIMETRY
THE MEDICAL CITY EXPERIENCE
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.
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THE MEDICAL CITY ICU
69
45%FEMALE
55%MALE
GENDER DISTRIBUTION OF IC PATIENTS
N = 251
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THE MEDICAL CITY ICU
70
19-60 yo48%
> 61 yo52%
AGE DISTRIBUTION OF IC PATIENTS
N = 251
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71
OPD32%
ICU
21%
FLOORS47%
LOCATION OF IC PATIENTS
N = 251
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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.
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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.
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ACKNOWLEDGEMEMT
• Dra.JB Ramos
Data on Indirect Calorimetry
• Dra.Puno and Dra. Romero
Research Paper
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