Evaluation of residual urine volume after catheterization by ultrasound performed by a nurse (2025)

Indirect calorimetry in the pediatric ICU

Critical Care, 2015

Introduction: Failure to accurately estimate energy requirements may result in an impaired recovery. Overfeeding has been associated with increased carbon dioxide production, respiratory failure, hyperglycemia and fat deposits in the liver, while underfeeding can lead to malnutrition, muscle weakness and impaired immunity. Objective: This study aimed to determine the metabolic profile of infant and preschool children submitted to mechanical ventilation in the ICU. Methods: A prospective study was carried out in a pediatric ICU in Rio de Janeiro that included children aged from 1 month to 6 years submitted to mechanical ventilation from June 2013 to May 2015. Indirect calorimetry was used to obtain resting energy expenditure (REE) and oxygen consumption (VO 2) in the first 48 hours of admission. The predicted basal metabolic rate (PBMR) was calculated using the Schofield equation. The metabolic state of each patient was assigned as hypermetabolic (REE/PBMR >110%), hypometabolic (REE/PBMR <90%) or normal (REE/PBMR 90-110%). The ratio of caloric intake to REE was also calculated and ratios of >1.5 and <0.5 were classified as overfeeding and underfeeding respectively. Results: A total of 35 infants and 17 preschool children were included. The male/female ratio was 34/18. In respect of severity of sepsis, 19 patients had septic shock, 24 had sepsis, five had severe sepsis and four had systemic inflammatory response syndrome. We observed a high incidence of hypometabolism (88.5%) and a low incidence of normal metabolism (7.7%) and hypermetabolism (3.8%). A low value of VO 2 was observed in 46.1% of the patients (VO 2 ≤120 ml/minute/m 2), a normal value in 40.4% (VO 2 >120 to ≤160 ml/minute/m 2) and a high value in only 13.5% of the patients (VO 2 > 160 ml/minute/m 2). Among the 52 included patients, 18 were fasting at the moment of the examination. The ratio of caloric intake to REE for the remaining 34 patients showed 38.2% overfeeding, 11.8% underfeeding and 50.0% normal feeding. Conclusion: Predictive equations do not accurately predict REE in critically ill infants and preschool children, resulting in inadequate feeding. Although hypermetabolism and enhanced energy expenditure are the main clinical features of critical illness in adults, the majority of our patients were found to be hypometabolic which reinforces the need for a different approach between adult and pediatric critically ill patients.

Energy expenditure in critically ill children

Pediatric Critical …, 2007

In critically ill children, optimal nutritional intake can improve recovery. During stay in the pediatric intensive care unit (PICU), both underfeeding and overfeeding have to be avoided. The assessment of energy requirements is difficult during critical illness because of lack of devices to measure it. In addition, energy requirements vary during the different phases of critical illness; i.e. the acute, stable and recovery phase. Energy expenditure is affected by the illness itself, but also by the conditions of the PICU such as mechanical ventilation, sedation, fever and the lack of physical activity. During the acute phase, energy intake has to be increased gradually while not exceeding resting energy expenditure (REE). The latter may be estimated using the Schofield equation or ideally be measured using a validated indirect calorimeter. After the acute phase, energy intake has to be increased to enable recovery and growth. The aim of this review is to give an overview of the current knowledge concerning REE in critically ill children and factors that may affect REE. The principles of measurement or calculation of REE will be described. The available evidence will be synthesized and practical recommendations will be provided for guiding energy intake during the different phases of illness.

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

Intensive Care Medicine, 2013

Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children

Age ( …, 2011

The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.

A methodological and clinical approach to measured energy expenditure in the critically ill pediatric patient

Frontiers in Pediatrics

The metabolic response to injury and stress is characterized initially by a decreased energy expenditure (Ebb phase) followed by an increased metabolic expenditure (Flow phase). Indirect calorimetry is a methodology utilized to measure energy expenditure and substrate utilization by measuring gas exchange in exhaled air and urinary nitrogen. The use of indirect calorimetry in critically ill patients requires precise equipment to obtain accurate measurements. The most recent guidelines suggested that measured energy expenditure by indirect calorimetry be used to determine energy requirements. This article reviews the methodological and clinical use of indirect calorimetry in critically ill pediatric patients.

Adequate feeding and the usefulness of the respiratory quotient in critically ill children

Nutrition, 2005

Objective: We determined incidences of underfeeding and overfeeding in children who were admitted to a multidisciplinary tertiary pediatric intensive care and evaluated the usefulness of the respiratory quotient (RQ) obtained from indirect calorimetry to assess feeding adequacy. Methods: Children 18 y and younger who fulfilled the criteria for indirect calorimetry entered our prospective, observational study and were studied until day 14. Actual energy intake was recorded, compared with required energy intake (measured energy expenditure plus 10%), and classified as underfeeding (Ͻ90% of required), adequate feeding (90% to 110% of required), or overfeeding (Ͼ110% of required). We also evaluated the adequacy of a measured RQ lower than 0.85 to identify underfeeding, and an RQ higher than 1.0 to identify overfeeding. Results: Ninety-eight children underwent 195 calorimetric measurements. Underfeeding, adequate feeding, and overfeeding occurred on 21%, 10%, and 69% of days, respectively. An RQ lower than 0.85 to identify underfeeding showed low sensitivity (63%), high specificity (89%), and high negative predictive value (90%). An RQ higher than 1.0 to indicate overfeeding showed poor sensitivity (21%), but a high specificity (97%) and a high positive predictive value (93%). Food composition, notably high-carbohydrate intake, was responsible for an RQ exceeding 1.0 in the overfed group. Conclusion: Children admitted to the intensive care unit receive adequate feeding on only 10% of measurement days during the first 2 wk of admission. The usefulness of RQ to monitor feeding adequacy is limited to identifying (carbohydrate) overfeeding and excluding underfeeding.

Evaluation of Calorie and Protein Intakes and Clinical Outcomes in Critically Ill Patients: Cross- sectional study

Background: Critically ill patients admitted to the intensive care unit (ICU) are often hyper-metabolic and hyper-catabolic and at risk of malnutrition. This study aimed to evaluate the amount of energy and protein intake and its correlation with the required amount in critically ill patients. Method: Seventy patients with critical conditions who were admitted to ICU were eligible (age ≥18 years and over a 3-day stay in ICU). Basic characteristics, medical history, and laboratory test results were extracted from the patients&#39; medical records. Anthropometric indices and APACHE II questionnaire were assessed by an expert nurse. The calorie and protein requirement of patients were considered 25 kcal/kg/day and 1.2 g/kg/day, respectively. Result: Mean age in the target population was 57.69 ± 20.81 years, and 48.6% were men. The mean actual energy intake was significantly lower than the requirement (531.27 ±365.40 vs. 1583.77 ± 329.36 Kcal/day, P˂0.001). The mean actual protein intak...

Nutritional stabilization in paediatric intensive care unit: A Literature Review

The Professional Medical Journal

The subject of nutrition in intensive care is being discussed among the pediatric intensivists since long. The nutritional supplementation plays a vital role in treatment of pediatric intensive care patients. In recent past, due to technological advances the pathophysiology of critical diseases is being better understood so better nutritional strategies are being implemented in critical care units. As a result the prognosis of intensive care patients is improving resulting in decreased length of stay and less number of deaths of these patients. The metabolic stress in sick patients is an important factor to be considered while calculating the nutritional requirements of patients. The body’s physiological mechanisms in the event of stress due to critical illness, need to be understood to make nutritional assessment of pediatric critical patients. The purpose of the current review is to recognize the recent nutritional supplementation guidelines of pediatric critical patients and to d...

Resting energy expenditure in critically ill patients: Evaluation methods and clinical applications

Revista da Associacao Medica Brasileira (1992), 2016

Patients on intensive care present systemic, metabolic, and hormonal alterations that may adversely affect their nutritional condition and lead to fast and important depletion of lean mass and malnutrition. Several factors and medical conditions can influence the energy expenditure (EE) of critically ill patients, such as age, gender, surgery, serious infections, medications, ventilation modality, and organ dysfunction. Clinical conditions that can present with EE change include acute kidney injury, a complex disorder commonly seen in critically ill patients with manifestations that can range from minimum elevations in serum creatinine to renal failure requiring dialysis. The nutritional needs of this population are therefore complex, and determining the resting energy expenditure is essential to adjust the nutritional supply and to plan a proper diet, ensuring that energy requirements are met and avoiding complications associated with overfeeding and underfeeding. Several evaluatio...

Indirect Calorimetry as an Instrument of Research to Identify the Effect of Hypermetabolism in Critical Patients’ Prognosis

Cureus, 2021

Background: Energy expenditure (EE) evaluation in Intensive Care Unit (ICU) patients can be very challenging. Critical illness is characterized by great variability in EE, which is influenced by the disease itself and the effects of treatment. Indirect calorimetry (IC) is currently the gold standard to measure EE in Intensive Care Unit (ICU) patients. However, calorimeters are not widely available, and predictive formulas (PF) are still commonly used, leading to under or overfeeding and deleterious consequences. Important metabolic changes occur and catabolism becomes prominent in critically ill patients. Both hyper and hypometabolism can be observed, but hypermetabolic patients appear to have higher mortality rates compared to metabolically normal patients. This study aimed to assess hypermetabolism incidence and compare clinical outcomes between hypermetabolic and normometabolic patients in ICU. Methods: A single-center, retrospective, and observational study was conducted in the ICU of the Hospital do Divino Espírito Santo in Ponta Delgada, between August 2018 and February 2021. Only invasively mechanically ventilated patients were included. Resting energy expenditure (REE) was predicted by 25 kcal/kg/day formula to obtain predicted resting energy expenditure (PREE), and REE was measured by IC to obtain measured resting energy expenditure (MREE). According to their metabolic state (PREE/MREE), patients were divided into hypermetabolic (≥1.3) and normometabolic (<1.3). To determine the limits of agreement between PREE and MREE, we performed a Bland-Altman (BA) analysis. Baseline characteristics, severity criteria, nutritional status, and main diagnosis on admission were compared. The primary outcome considered was 30-day mortality. Other outcomes such as the ICU length of stay (LOS), in-hospital LOS, and length of invasive ventilation were also evaluated. Results: Among the 80 ICU patients included in the final analysis, 67 patients were normometabolic (83.4%). Patients admitted due to pneumonia were more hypermetabolic, 8 (61.5%) vs. 10 (14.9%); p<0.001. Hypermetabolism was found also in patients admitted due to sepsis/septic shock, 7 (53.8%) vs. 16 (23.9%); p=0.029. Hypermetabolic patients had lower body mass index (22.5 [interquartile range (