Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation

Abstract

To assess energy balance in very sick medical patients requiring prolonged acute mechanical ventilation and its possible impact on outcome, we conducted an observational study of the first 14 d of intensive care unit (ICU) stay in thirty-eight consecutive adult patients intubated at least 7 d. Exclusive enteral nutrition (EN) was started within 24 h of ICU admission and progressively increased, in absence of gastrointestinal intolerance, to the recommended energy of 125·5 kJ/kg per d. Calculated energy balance was defined as energy delivered 2 resting energy expenditure estimated by a predictive method based on static and dynamic biometric parameters. Mean energy balance was 25439 (SEM 222) kJ per d. EN was interrupted 23 % of the time and situations limiting feeding administration reached 64 % of survey time. ICU mortality was 72 %. Non-survivors had higher mean energy deficit than ICU survivors (P¼ 0·004). Multivariate analysis identified mean energy deficit as independently associated with ICU death (P¼0·02). Higher ICU mortality was observed with higher energy deficit (P¼ 0·003 comparing quartiles). Using receiver operating characteristic curve analysis, the best deficit threshold for predicting ICU mortality was 5021 kJ per d. Kaplan -Meier analysis showed that patients with mean energy deficit^5021 kJ per d had a higher ICU mortality rate than patients with lower mean energy deficit after the 14th ICU day (P¼ 0·01). The study suggests that large negative energy balance seems to be an independent determinant of ICU mortality in a very sick medical population requiring prolonged acute mechanical ventilation, especially when energy deficit exceeds 5021 kJ per d. Energy balance: Enteral nutrition: Acute prolonged mechanical ventilation: OutcomeNutritional support is based on the assumption that critically ill patients are prone to develop malnutrition, especially protein-energy deficit, this condition being associated with morbidity and mortality (1 -5) . Indeed, protein-energy deficit seems common in intensive care units (ICU), occurring in 43 -88 % of critically ill patients (6,7) . Underfeeding has been reported as associated with an increased rate of infection, poor wound healing, reduced respiratory muscle mass, delayed weaning from mechanical ventilation, increased length of ICU stay and increased health care costs (1,8 -13) . Perturbations of the normal metabolic response to starvation with hyperglycaemia, high lactate level, hypertriglyceridaemia and high NEFA concentrations due to insulin resistance characterize the hypermetabolic state of the critically injured patients (2,14,15) . Energy deficit results from a combination of hypermetabolism and reduced intake due to frequent interruptions in feedings because of gastrointestinal intolerance, diagnostic and therapeutic procedures (16 -18) . In intubated and mechanically ventilated patients, the great variability of resting energy expenditure (REE) and nutrient delivery compared to prescription, partly due to frequent use of sedatives, analgesic...

Enteral nutrition is associated with improved outcome in patients with severe sepsis

“…In contrast, previous observation al studies suggested a better outcome with increased caloric and protein intake owing to the early supplemental or pre dominant use of PN in critically ill pa tients [1,10,13,27,32,35]. In the major ity of these studies, only a limited num ber of severely septic patients were includ ed.…”

“…The advantage of the one nutrition type is thereby regarded as the disadvantage of the other, as both have inherent risks of under or overfeed ing. On the one hand, large energy deficits resulting from a low caloric intake dur ing EN may lead to increased infectious complications and a longer intensive care unit (ICU) stay [10,13,35]. On the other hand, PN is associated with nutritional ex cess leading to hyperglycemia, increased meta bolic stress, and infectious morbi dity [9,28].…”

Energy expenditure: how much does it matter in infant and pediatric chronic disorders?

“…Cumulative energy deficits are associated with loss of muscle mass, poor wound healing, increased risk of infections, increased morbidity, and a higher risk of mortality in critically ill adults (24,25). Both energy and protein deficits are undesirable.…”

Terapia nutricional enteral em politraumatizados sob ventilação mecânica e oferta energética

“…O estudo de Faisy et al 25 demonstrou uma associação entre o balanço energético negativo e a mortalidade em UTI de pacientes gravemente doentes que permaneceram por tempo prolongado sob VM enquanto recebiam nutrição enteral exclusiva. No estudo realizado por Kan et al 10 , os pacientes que receberam uma alimentação inadequada para suprir a demanda energética dependeram por mais tempo da VM.…”