Caloric Debt in Critically-Ill

Trauma Patients

Chaitan K. Narsule, M.D.

May 30, 2007

Trauma Hypermetabolism

Increased basal metabolic rate

Increased catecholamine and cortisol secretion

Increased gluconeogenesis and muscle

proteolysis

Increased glucagon secretion and decreased

insulin secretion

Negative nitrogen balance

Critically-Ill Trauma Patients Can Be

Deprived of Adequate Nutrition

Ongoing resuscitation

Use of vasopressor or paralytic medications

Optimism for early recovery from injuries

Optimism for extubation

Critically-Ill Trauma Patients Can Be

Deprived of Adequate Nutrition

Sudden changes in respiratory or mental status

Operations or bedside procedures

Radiological studies or VIR intervention

Difficulty in gaining or maintaining enteral access

Does nutrition affect the clinical

outcome of critically ill patients?

Negative Impact of Hypocaloric Feeding and

Energy Balance on Clinical Outcome in ICU

Patients

48 surgical ICU patients

Enteral feeding 3.1±2.2 days after admission

Energy balance measured and complications

recorded

Villet et al. Clinical Nutrition. 2005;24:502-509

Negative Impact of Hypocaloric Feeding and

Energy Balance on Clinical Outcome in ICU

Patients

Villet et al. Clinical Nutrition. 2005;24:502-509

Effects of Early Enteral Feeding on the

Outcome of Critically-Ill Mechanically

Ventilated Patients

Artinian et al. Chest. 2006;129:960-967.

Characteristics

(N = 4,049)

Early Feeding

2,537 (63%)

Late Feeding

1,512 (37%)

p =

ICU mortality 458 (18.1) 323 (21.4) 0.01

Hospital mortality 727 (28.7) 511 (33.9) 0.001

VAP 284 (11.2) 143 (9.5) 0.08

ICU length of stay, d 10.9±8.1 10.2±7.7 0.01

# of vent-free days 17.0±9.0 16.8±9.9 0.54

Quantifying Malnutrition in the ICU

Nutritional indices

Weight

Protein indicators of malnutrition (albumin,

transferrin)

Anthropometric determinations (i.e. skin-fold

measurements)

Caloric Debt

Energy Balance =

Energy Target – Energy Delivery

Caloric Debt =

Energy Balance/Energy Target

Hypothesis

Critically-ill trauma patients have a caloric

debt of more than 50% during the initial 10

days of hospitalization.

Caloric debt accumulates, despite efforts to

optimize nutritional support, in preventable

circumstances.

Outcomes

Primary

The caloric debt of critically-ill trauma patients

during the first ten ICU days

Secondary Goals

The identification of factors

contributing to the caloric debt

Design

Respective review of trauma patients admitted from ER to TICU of Rhode Island Hospital

January 1 – April 30, 2007

Length of stay in ICU ≥ 10 days

All mechanisms of trauma included

Patients were excluded from study if:

Hospitalized at outside institution for >24 hrs

Transferred out of trauma ICU for >24 hrs

Deemed to be “floor level” while hospitalized in trauma ICU

Calories from lipid-based medications not considered

Data Collection

Mechanism of trauma

Injuries and ISS

Height and weight

Daily Energy Expenditure Measurement (HBE/Cart/Swann)

Type, amount, and route of nutrition

Reasons for delaying or interrupting nutrition

# days on ventilatory support

# days on vasopressors

# aspiration events

Mortality

Chart review

Progress notes

Flow sheets

Nursing records

Interview of nursing and support staff

Review of radiology through Centricity

Caloric Debt

Energy Target = Daily Energy Expenditure

x 10 days

Energy Delivery = Daily calories over 10-day

period

Caloric Debt = (Energy Target – Energy

Delivery)/Energy Target

Results

Total patients 34

Men 28 (82%)

Women 6 (18%)

Age 44 18

ISS 22 10

Daily Energy Expenditure 2366 386

Patient Characteristics

Patient Characteristics

# patients vented 31 (91%)

Average # days on ventilator 8.2

# patients on pressors 9 (27%)

Average # days on pressors 3.4

Aspiration events 0

Mortality 2 (6%)

Mechanism of Injury

2

18

8

3

12

Ped vs. Car

MVA/MCA

Fall

Burn

Penetrating

Other

4

6

8

5

2

6

1 1 1

5-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50

Injury Severity Score

Type and Route of Nutrition Initiated

9

10

4

1

1

6

21

NGT/OGT

NDT

NDT in stomach

TPN

TPN & NGT

PO

NJT

PEG-J

Days Until Initiation of Nutrition

Days until initiation of nutrition 4.7 2.3

NDT (10) 4.5

NGT/OGT (9) 4.8

NDT in stomach (4) 4.25

TPN (1) 5

TPN & NGT (1) 9

PO (6) 4

NJT (2) 4.5

PEG-J (1) 7

Caloric Debt

Caloric Debt, 10 days 73 18%

Caloric Debt, 1st 5 days 87 13%

Caloric Debt, 2nd 5 days 59 26%

Caloric Debt Based on Type and

Route of Nutrition Initiated

NDT (10) 75.89%

NGT/OGT (9) 71.51%

NDT in stomach (4) 63.78%

TPN (1) 64.10%

TPN & NGT (1) 89.60%

PO (6) 75.15%

NJT (2) 73.65%

PEG-J (1) 78.40%

Caloric Debt Based on Use of

Vasopressors

Caloric Debt = 75±13%

Reasons for Delayed or Interrupted

Nutritional Support

Total days affected = 197

(+30)

Nutrition was

delayed = 145

Nutrition was

interrupted = 52 (+30)

Reasons for Delaying Nutrition

# of days %

On vasopressor or paralytic medications 25 12.7

Plan to extubate, unsuccessful 19 9.6

Plan for OR or bedside procedure 16 8.1

Difficulty in gaining enteral access 15 7.6

No identifiable reason 13 6.6

Ongoing resuscitation 11 5.6

Withheld for medical reasons 10 5.1

For radiological study or VIR intervention 8 4.1

Reasons for Delaying Nutrition

# of days %

Change in respiratory or mental status,

requiring intubation 8 4.1

Change in respiratory or mental status 8 4.1

Withheld for withdrawal of life support

discussions 4 2.0

Plan to extubate, successful 2 1.0

NPO for speech and swallow evaluation 2 1.0

Open abdomen with plan for closure 2 1.0

PEG-J placement 1 0.5

Awaiting operative plan from consultants 1 0.5

Reasons for Interrupting Nutrition

# of days %

High gastric residuals 30 --

Plan for OR or bedside procedure 12 6.1

Difficulty in gaining or maintaining enteral access,

requiring intervention 7 3.6

On vasopressor or paralytic medications 6 3.0

Change in respiratory or mental status 4 2.0

For radiological study or VIR intervention 4 2.0

Plan to extubate, successful 4 2.0

Reasons for Interrupting Nutrition

# of days %

NPO for speech and swallow evaluation 4 2.0

Plan to extubate, unsuccessful 3 1.5

Plan for OR, cancelled due to scheduling 2 1.0

Plan for OR, cancelled for medical reasons 2 1.0

PEG-J placement 2 1.0

Withheld for medical reasons 2 1.0

Discussion

Caloric debt larger than expected

Features unique to evaluating energy balance

during the first 10 days of an ICU

hospitalization

Discussion

Areas for potential change:

Early initiation of nutrition

Use of TPN in patients treated with vasopressor or paralytic medications

Continuous enteral feeding of patients up to one-hour before operation

Conclusions

The caloric debt among critically-ill trauma

patients is enormous.

Nutrition should be addressed early in order to

prevent the accumulation of a large caloric debt.

Acknowledgements

Dr. David Harrington

Caloric Debt in Critically-Ill

Trauma Patients

Chaitan K. Narsule, M.D.

May 30, 2007