The effect of cisatracurium infusion on the energy expenditure of critically ill patients: an observational cohort study

Abstract

Background: Both overfeeding and underfeeding of intensive care unit (ICU) patients are associated with worse outcomes. A reliable estimation of the energy expenditure (EE) of ICU patients may help to avoid these phenomena. Several factors that influence EE have been studied previously. However, the effect of neuromuscular blocking agents on EE, which conceptually would lower EE, has not been extensively investigated. Methods: We studied a cohort of adult critically ill patients requiring invasive mechanical ventilation and treatment with continuous infusion of cisatracurium for at least 12 h. The study aimed to quantify the effect of cisatracurium infusion on EE (primary endpoint). EE was estimated based on ventilator-derived VCO 2 (EE in kcal/day = VCO 2 × 8.19). A subgroup analysis of septic and non-septic patients was performed. Furthermore, the effects of body temperature and sepsis on EE were evaluated. A secondary endpoint was hypercaloric feeding (> 110% of EE) after cisatracurium infusion. Results: In total, 122 patients were included. Mean EE before cisatracurium infusion was 1974 kcal/day and 1888 kcal/day after cisatracurium infusion. Multivariable analysis showed a significantly lower EE after cisatracurium infusion (MD − 132.0 kcal (95% CI − 212.0 to − 52.0; p = 0.001) in all patients. This difference was statistically significant in both sepsis and non-sepsis patients (p = 0.036 and p = 0.011). Non-sepsis patients had lower EE than sepsis patients (MD − 120.6 kcal; 95% CI − 200.5 to − 40.8, p = 0.003). Body temperature and EE were positively correlated (Spearman's rho = 0.486, p < 0.001). Hypercaloric feeding was observed in 7 patients. Conclusions: Our data suggest that continuous infusion of cisatracurium in mechanically ventilated ICU patients is associated with a significant reduction in EE, although the magnitude of the effect is small. Sepsis and higher body temperature are associated with increased EE. Cisatracurium infusion is associated with overfeeding in only a minority of patients and therefore, in most patients, no reductions in caloric prescription are necessary.

Point‐Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit

“…We found observed changes in mREE do not demonstrate a significant relationship to organ failure severity and are only minorly affected by prone positioning/paralysis, as over the study period the use of these therapies was not significantly different. This is consistent with previously published data showing that paralysis appears to have only a minor effect on mREE 39 . Our data strongly suggest that personalization of nutrition delivery via routine, longitudinal IC use 1,34 should be considered as the new standard of care to accurately assess EE, help guide nutrition therapy in COVID‐19 (and, likely, other ICU patients), and improve patient care overall.…”

Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19

“…To our knowledge, this is the first description of longitudinal mREE in a COVID-19 ICU population. The COVID-19 metabolic phenotype may be unique from previously described ICU models of metabolic response [2], with a more prolonged hypermetabolic phase that may be independent of severity of organ failure and, as previously published, may only be minorly affected by interventions such as paralysis [6]. Further, it is one of the largest single-ICU diagnosis cohorts with longitudinal IC measures for 21 days.…”

Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations

“…Sedatives and analgesics may cause reductions in VO 2 and REE [ 4 , 13 ]. Neuromuscular blocking agents also affect the EE, although the effect is small [ 8 , 24 , 28 , 77 , 78 ]. A recent study with continuous infusion of cisatracurium showed a significant reduction in EE measured with the VCO 2 method, although the clinical relevance is presumed to be minor, and in most patients no reductions in caloric prescription are necessary [ 78 ].…”

“…Neuromuscular blocking agents also affect the EE, although the effect is small [ 8 , 24 , 28 , 77 , 78 ]. A recent study with continuous infusion of cisatracurium showed a significant reduction in EE measured with the VCO 2 method, although the clinical relevance is presumed to be minor, and in most patients no reductions in caloric prescription are necessary [ 78 ]. Furthermore, the administration of vasopressors increases REE, whereas specific β-blockers are contradictory reported to decrease REE [ 8 , 35 , 77 , 79 ].…”

“…Body temperature variations of more than 1 °C before IC measurement, make results less reliable [ 28 , 68 , 78 ]. Some authors report an increase in REE caused by fever, whereas therapeutic hypothermia is associated with a decrease in REE; however, not all studies report similar findings [ 81 ].…”