KATRINA MAE S. GAMPONIA,M.D. PERIE ADORABLE-WAGAN,M.D.

OBJECTIVES
1. Discuss the bodys 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

Case Study
R.C., 59/M, Filipino CC: difficulty of breathing

History of Present Illness

Fever, non-productive cough, shortness of breath, chest heaviness Rx: ISDN without relief

1 day PTA

Review of Systems
HEENT: No headache, no dizziness, no seizures, no blurring of vision, no tinnitus, no hearing loss, no nose bleeding, 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, no hematuria Musculoskeletal: no joint pains

Past Medical History

(-) asthma, allergies (+) 2 vessel CAD s/p coronary angiogram (2008), advised PCI (+) Congestive heart failure secondary to ischemic heart disease (+) 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)

Personal and Social History

Previous smoker 10 sticks/day x >20 years Occasional alcohol beverage drinker

Family History
(+) HTN (+) DM

Physical Examination
Conscious, coherent, stretcher-borne, in respiratory distress 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

Physical Examination
Flabby abdomen, NABS, soft, non-tender, no palpable masses Full pulses, (+) bilateral grade 3 pedal edema

Assessment
Acute pulmonary congestion secondary to congestive heart failure with acute LV dysfunction Congestive heart failure, functional class IV, secondary to ischemic 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 diabetes mellitus and hypertensive nephrosclerosis

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

Problem # 2: RESPIRATORY
Initial CXR cardiomegaly with pulmonary congestive changes, intercurrent pneumonia cannot be ruled out Intubated patient, started on Ampicillin-sulbactam ETA GSCS Klebsiella pneumoniae, antibiotics shifted to Ceftriaxone Rpt ETA GSCS Stenotrophomonas maltophilia, Ceftriaxone shifted to Levofloxacin 2x self extubation Indirect calorimetry 5th HD Weaning eventually started, antibiotics completed

Problem #3: RENAL

Referred to nephrology Due to increasing creatinine, underwent IJ catheter insertion, underwent hemodialysis AVF creation

INDIRECT CALORIMETRY RESULTS

REE RQ VO2 VCO2 1928 kcal/day 0.73 3.1 ml/kg/min .207 L/min

DIET: 1800 kcal Nutren Diabetes, 2:1 concentration, continuous at 38 ml/hour

INTRODUCTION
Overall approach to managing critically ill patients
Assessment and monitoring metabolic changes and determining caloric 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

 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 status influences patient prognosis underscores the importance of preventing, detecting, and treating malnutrition.

Physiologic Characteristics of Hypometabolic and Hypermetabolic State

Metabolic characteristics and nutritional needs of hypermetabolic patients who are stressed from injury, infection, or chronic inflammatory illness differ from those of hypometabolic patients who are unstressed but chronically starved

Physiologic characteristics

Hypometabolic, Nonstressed Patient

Hypermetabolic, Stressed Patient

Metabolic rate, O2 If the metabolic rate (energy requirement) is not matched by energy intake, weight loss consumption results, slowly in hypometabolism and quickly in hypermetabolism
Cytokines, catecholamines, glucagon, cortisol, insulin Proteolysis, gluconeogenesis Ureagenesis, urea excretion

Fat catabolism, fatty acid Relative utilization Adaptation to starvation Normal

Absolute

Abnormal

Physiologic characteristics Cytokines, catecholamines, glucagon, cortisol, insulin Proteolysis, gluconeogenesis

Hypometabolic, Nonstressed Patient

Hypermetabolic, Stressed Patient

- 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

Estimating Nutrional Requirements and Determining Caloric Needs

Nutritional assessment can be viewed as a triad of assessment techniques incorporating anthropometric measurements, screening of biochemical indices, and predicting/measuring energy expenditure
Anthropometrics Ideal body weight Triceps skin fold measurements Arm circumference Biochemical Indices Predicting/Measuring EE Creatinine-heights index Equations Lymphocytes count Trasnferrin and albumin levels Calorimetry Indirect calorimetry

COMPONENTS OF TOTAL ENERGY EXPENDITURE

Journal of Dietician Ass of Australia 2007

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 burn from 1000 to 3000 Kcal per day just to maintain normal body functions. This varies hugely with disease

Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette, 25 MHS, 11/09/2005

DIRECT CALORIMETRY
measures heat exchange between body and the environment Place patient in thermally sealed room and measure how much they warm the air in the room.

Energy expenditure and components evaluation Nutrition Hosp 2011;26(3):430-440

Metabolic measurements using indirect calorimetry During Mechanical Ventilation2004 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 GUIDELINE

28

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

HARRIS-BENEDICT EQUATION
Men 66 + {13.7 x wt (kg)} + {5 x ht (cm)} {6.8 x age (yrs)} Women 655 + {9.6 x wt (kg)} + {1.8 x ht (cm)} {4.7 x age (yrs)}

Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette, MHS, 11/09/2005

30

PREDICTIVE EQUATIONS VS IC
Pt Diagnosis H-B
Kcal/day Indirect Calorimetry Kcal/day Variance Kcal/day

%
error

1
2 3 4

Obstructive Jaundice
Liver Transplant Liver Transplantcryptogenic cirrhosis Pneumonectomy, pneumonia, bronch fistula Crohns diseasesubtotal colectomy

1098
1496 1855 1255

2199
1531 2421 2695

- 1101
- 35 - 566 - 1440

50%
2% 23% 53%

1091

820

+ 271

33%

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

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

INDIRECT CALORIMETRY

Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Terry L. Forrette, MHS, 11/09/2005

RESPIRATORY QUOTIENT

Respiratory Quotients for Various Substrates -- RQ = VCO2 VO2

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

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 UN measurements

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

INDICATIONS
Severe sepsis

Multiple 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

INDICATIONS
Neurologic trauma Paralysis Acute pancreatitis Cancer with residual tumor burden Amputations

44

INDICATIONS
Patients who fail to respond adequately to estimated nutritional needs Patients who require long-term acute care Extremely obese patients

45

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

Conditions for Conducting a Study

Continous approach Minimum of 12 hours Continous basis Obtain an accurate reflection of Total energy expenditure that would include periods of rest, sleep and activity Intermittent approach Selection of time period Resting measurement of energy expenditure can be obtained

CONDITIONS FOR STUDY

Ventilated 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 TV settings on mech vent Suctioning not allowed 30 mins before

49

TECHNICAL CONSIDERATIONS
FiO2 stability Steady state conditions System leak

Acceptable Ranges for Indirect Calorimetry Data

METABOLIC CONDITIONS
HYPOMETABOLIC REE < 90%

NORMOMETABOLIC REE 90-110% HYPERMETABOLIC REE > 110%

54

CALCULATION OF CALORIES BASED ON STRESS

FEVER
BEE x 1.1 (for each C rise above normal Temp) BEE x 1.2 BEE x 1.4 BEE x 1.6
55

STRESS MILD MODERATE SEVERE

SAARC J ANEST 2008; 1 (2): 135-141

CALCULATION OF CALORIES BASED ON ACTIVITY

ON VENTILATOR UNCONSCIOUS AWAKE ON BED SITTING ON CHAIR BEE x 0.85 BEE x 1.0 BEE x 1.1 BEE x 1.2

56

CALCULATION OF CALORIES BASED ON STRESS

MINOR SURGERY TRAUMA SEPSIS SEVERE BURNS BEE x 1.2 BEE x 1.3 BEE x 1.6 BEE x 2.1

57

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 primary substrates for metabolism 0.67-1.3 Non-steady state conditions
J. Greenwood VCH ICU

Wooley, J. Indirect Calorimetry: Applications in Practice, 2006

Indirect Calorimtery: The Medical City Experience (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 MEDICAL CITY EXPERIENCE

Objectives: The purpose of this study is to describe the patients who have undergone Indirect Calorimetry while admitted at The Medical City from January 2008 to January 2009. Subjects: 19 years old and above admitted 84 subjects 5 excluded
Puno and Romero

INDIRECT CALORIMETRY: THE MEDICAL CITY EXPERIENCE

Method: Retrospective Chart review Descriptive study

Puno and Romero

INDIRECT CALORIMETRY THE MEDICAL CITY EXPERIENCE

INDIRECT CALORIMETRY THE MEDICAL CITY EXPERIENCE

CASES PER ORGAN SYSTEM
Pulmonary Rheumatology Gastroenterology Endocrine & Metabolism Oncology Infectious disease

# of cases =91
45 1 3 11 8 12

Percentage (%)
50.54 1.1 3.29 12.09 8.8 13.19

Cardiology
Neurology Nephrology

7
2 1

7.69
2.2 1.1

Puno and Romero

INDIRECT CALORIMETRY THE MEDICAL CITY EXPERIENCE

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.

THE MEDICAL CITY ICU

GENDER DISTRIBUTION OF IC PATIENTS

45% 55%FEMALE MALE

N = 251

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THE MEDICAL CITY ICU

AGE DISTRIBUTION OF IC PATIENTS

> 61 yo 52%

19-60 yo 48%

N = 251

70

LOCATION OF IC PATIENTS

OPD 32% FLOORS 47%

ICU 21%

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 and problems associated with overfeeding patients, especially those who require mechanical ventilation. Usefulness in determining dietary needs and as a tool for ventilator management and diagnosing cardiopulmonary failure.

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ACKNOWLEDGEMEMT
Dra.JB Ramos Data on Indirect Calorimetry Dra.Puno and Dra. Romero Research Paper