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Caloric Debt in Critically-Ill
Trauma Patients
Chaitan K. Narsule, M.D.
May 30, 2007
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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
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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
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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
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Does nutrition affect the clinical
outcome of critically ill patients?
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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
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Negative Impact of Hypocaloric Feeding and
Energy Balance on Clinical Outcome in ICU
Patients
Villet et al. Clinical Nutrition. 2005;24:502-509
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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
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Quantifying Malnutrition in the ICU
Nutritional indices
Weight
Protein indicators of malnutrition (albumin,
transferrin)
Anthropometric determinations (i.e. skin-fold
measurements)
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Caloric Debt
Energy Balance =
Energy Target – Energy Delivery
Caloric Debt =
Energy Balance/Energy Target
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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.
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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
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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
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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
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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
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Results
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Total patients 34
Men 28 (82%)
Women 6 (18%)
Age 44 18
ISS 22 10
Daily Energy Expenditure 2366 386
Patient Characteristics
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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%)
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Mechanism of Injury
2
18
8
3
12
Ped vs. Car
MVA/MCA
Fall
Burn
Penetrating
Other
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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
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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
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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
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Caloric Debt
Caloric Debt, 10 days 73 18%
Caloric Debt, 1st 5 days 87 13%
Caloric Debt, 2nd 5 days 59 26%
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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%
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Caloric Debt Based on Use of
Vasopressors
Caloric Debt = 75±13%
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Reasons for Delayed or Interrupted
Nutritional Support
Total days affected = 197
(+30)
Nutrition was
delayed = 145
Nutrition was
interrupted = 52 (+30)
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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
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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
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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
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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
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Discussion
Caloric debt larger than expected
Features unique to evaluating energy balance
during the first 10 days of an ICU
hospitalization
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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
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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.
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Acknowledgements
Dr. David Harrington
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Caloric Debt in Critically-Ill
Trauma Patients
Chaitan K. Narsule, M.D.
May 30, 2007