Is Indirect Calorimetry a Necessity or a Luxury in the Pediatric Intensive Care Unit?

Kyle, Ursula G.; Arriaza, Ana; Esposito, Monica; Coss‐Bu, Jorge A.

doi:10.1177/0148607111415108

Cited by 36 publications

(30 citation statements)

References 23 publications

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“…Four patients were admitted after an elective procedure; the remaining patients were admitted as a result of an acute illness or injury. Twelve (27.3 %) patients presented severe (4) or moderate (8) malnutrition. All patients survived.…”

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confidence: 99%

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Unpredictable combination of metabolic and feeding patterns in malnourished critically ill children: the malnutrition–energy assessment question

et al. 2013

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Dear Editor, Advances in paediatric critical care have resulted in the increased survival of chronically ill patients. In many units, such patients represent [50 % of the workload and are often malnourished [1]. Prediction of energy expenditure (PEE) equations are simple alternatives to the gold standard of assessing resting energy expenditure (REE) by indirect calorimetry (IC). However, recent work has suggested that PEE equations fail to adequately predict REE. New paediatric intensive care unit (PICU)-oriented equations have been found to be no better than well-established tools, such as the Schofield-HW equation [2]. We have compared PICU-specialized and commonly used PEE equations with REE using a new modular metabolic monitor (E-COVX) in well-nourished and malnourished critically ill children. The E-COVX compact metabolic module has the advantage of not being influenced by uneventful open endotracheal suctioning [3]. It is suitable for repeated 30-min measurements in well-sedated mechanically ventilated children with stable respiratory patterns in a variety of ventilation modes [4]. We hypothesized that IC using the E-COVX would show that energy expenditure is unpredictable in malnourished children and that replacing REE with any PEE equation, including the new PICU-oriented equations, might not be applicable for estimating energy expenditure in patients suffering from malnutrition during a critical illness. The Ethics Committee of the Institutional Review Board approved this study, and parents or guardians of the children gave informed, written consent.Mechanically ventilated critically ill children, consecutively admitted to the PICU of the University Hospital, Heraklion, Crete, were enrolled in the study. Thirty consecutive 1-min gas exchange measurements (VO 2 and VCO 2 ) were taken and the respiratory quotient (RQ) and REE were calculated for each patient (results were blinded from the attending physician). The nutritional status was evaluated for the presence of proteinenergy malnutrition as defined by Waterlow [5]. The PEE was estimated and basal metabolic rate (PBMR) was predicted using the common Harris-Benedict, Schofield-HW, Seashore, Fleisch, CaldwellKennedy and Henrys formulas, as well as equations specifically developed for the PICU by White and by Meyer [2]. Patients were classified as hypermetabolic, normometabolic and hypometabolic when the REE was [110, 90-110 and \90 % of the Schofield-PBMR, respectively, and as overfed, adequately fed and underfed when the caloric intake was [110, 80-110 and \80 % of the REE, respectively.Forty-four patients (28 boys, 16 girls) were studied (total measurements 1,320). Four patients were admitted after an elective procedure; the remaining patients were admitted as a result of an acute illness or injury. Twelve (27.3 %) patients presented severe (4) or moderate (8) malnutrition. All patients survived.The REE did not differ between patients according to a body temperature of \37.1°C (1,068 ± 460 kcal/ day) or C37.1°C (824 ± 217 kcal/ day) or with a Ramsey s...

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confidence: 99%

“…Accordingly, while nutritional risk continues to be unrecognized and undertreated in clinical practice, malnourished patients have been shown to be candidates for IC per A.S.P.E.N. (American Society for Parenteral and Enteral Nutrition) guidelines [8].…”

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confidence: 99%

Unpredictable combination of metabolic and feeding patterns in malnourished critically ill children: the malnutrition–energy assessment question

et al. 2013

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“…True energy needs can only be determined by measuring energy expenditure with IC. This is confirmed in a recent Journal of Parenteral and Enteral Nutrition ( JPEN ) Original Communication by Kyle et al 12 As of yet, we have not yet been able to quantify hospital outcomes with caloric deficit. Furthermore, we have no means to measure the impact of over‐ or underfeeding in the PICU.…”

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confidence: 71%

Resting Energy Expenditure After Fontan Surgery in Children With Single‐Ventricle Heart Defects

Larsen

2012

J Parenter Enteral Nutr

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“…In addition, the stage of an infant's recovery post–cardiac surgery has been shown to affect energy requirements. The study by Kyle et al of 150 PICU patients (6.7 ± 5.6 y) found that though resting energy expenditure preoperatively was significantly greater than that of healthy, age‐matched control infants, infants 6 months post–corrective cardiac surgery had the same resting energy expenditure as the controls 5 . In addition, they reported that hypermetabolic patients (assessed using clinician expertise based on diagnosis and clinical status) and patients on mechanical ventilation were the most frequent indicators for patients requiring indirect calorimetry to estimate resting energy expenditure to optimize nutrition repletion 5 …”

Section: Energy Needs Of the Postoperative Cardiac Surgery Childmentioning

confidence: 95%

“…The criteria were based on the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) 2009 clinical guidelines for nutrition support of the critically ill child 5 . In the context of the PICU, optimal energy (interchangeable with “nutrition” in this review) repletion is important because a fifth of pediatric critically ill patients have been reported as malnourished upon admission to the hospital 1 …”

Section: Introductionmentioning

confidence: 99%

Nutrition Support of the Postoperative Cardiac Surgery Child

2013

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There may be a correlation in critically ill children between the accuracy of estimated energy requirement and infection, mortality, and length of stay. Historically, energy needs were estimated using predictive equations with stress factor adjustments. The purpose of this review is to evaluate the evidence for indirect calorimetry, predictive equations, and other clinical indicators (ie, patient outcomes) to estimate energy requirements of the postoperative, critically ill, cardiac infant. Consistent with current guidelines, indirect calorimetry provides the best estimate of energy requirements for critically ill children. Predictive equations are unreliable, either over- or underestimate energy requirements, and do not take into account the metabolic changes that occur in the postoperative cardiac infant. To address the changing metabolic state throughout the course of illness, clinicians need to individualize recommendations by implementing frequent indirect calorimetry measurements at bedside. Actual energy delivery to the postoperative cardiac surgery child in the pediatric intensive care unit (PICU) can be further hindered by many procedural and patient barriers. The provision of appropriate caloric requirements may help clinicians correct the metabolic state and promote recovery and anabolism. Therefore, optimizing nutrition intake of the postoperative, cardiac surgical child requires a paradigm shift toward individualized nutrition prescription, in the context of a PICU-specific feeding algorithm.

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Is Indirect Calorimetry a Necessity or a Luxury in the Pediatric Intensive Care Unit?

Cited by 36 publications

References 23 publications

Unpredictable combination of metabolic and feeding patterns in malnourished critically ill children: the malnutrition–energy assessment question

Unpredictable combination of metabolic and feeding patterns in malnourished critically ill children: the malnutrition–energy assessment question

Resting Energy Expenditure After Fontan Surgery in Children With Single‐Ventricle Heart Defects

Nutrition Support of the Postoperative Cardiac Surgery Child

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