Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-26T21:08:13.319Z Has data issue: false hasContentIssue false
  • English
  • Français

Energy balance in critical illness

Published online by Cambridge University Press:  08 December 2008

Lindsay D. Plank  and
Graham L. Hill
Lindsay D. Plank*
Affiliation:
Department of Surgery, University of Auckland, Auckland, New Zealand
Graham L. Hill
Affiliation:
Department of Surgery, University of Auckland, Auckland, New Zealand
*
*Corresponding author: Dr Lindsay D.Plank, fax +64 9 377 9656, email l.plank@auckland.ac.nz
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Energy balance is the difference between energy consumed and total energy expended. Over a given period of time it expresses how much the body stores of fat, carbohydrate and protein will change. For the critically-ill patient, who characteristically exhibits raised energy expenditure and proteolysis of skeletal muscle, energy balance information is valuable because underfeeding or overfeeding may compromise recovery. However, there are formidable difficulties in measuring energy balance in these patients. While energy intake can be accurately recorded in the intensive care setting, the measurement of total energy expenditure is problematic. Widely used approaches, such as direct calorimetry or doubly-labelled water, are not applicable to the critically ill patient. Energy balance was determined over periods of 5–10 d in patients in intensive care by measuring changes in the fat, protein and carbohydrate stores of the body. Changes in total body fat were positively correlated with energy balance over the 5 d study periods in patients with severe sepsis (n24, r 0.56, P=0.004) or major trauma (n 24, r 0.70, P<.0001). Fat oxidation occurred in patients whose energy intake was insufficient to achieve energy balance. Changes in body protein were independent of energy balance. These results are consistent with those of other researchers who have estimated total energy requirements from measurements of O2 consumption and CO2 production. In critically-ill patients achievement of positive non-protein energy balance or total energy balance does not prevent negative N balance. Nutritional therapy for these patients may in the future focus on glycaemic control with insulin and specialised supplements rather than on energy balance per se.

Keywords

Critical illnessEnergy balanceNutritional support
Type
Clinical Nutrition and Metabolism Group Symposium on ‘Control of energy balance in health and disease’
Information
Proceedings of the Nutrition Society , Volume 62 , Issue 2 , May 2003 , pp. 545 - 552
Copyright
Copyright © The Nutrition Society 2003

References

Adam, S & Batson, S (1997) A study of problems associated with the delivery of enteral feed in critically-ill patients in five ICUs in the UK. Intensive Care Medicine 23, 261–266Google Scholar
American, Society, for, Parenteral and, Enteral, Nutrition, Board, of Directors (1995) Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition 17, 1SA–52SA Suppl.Google Scholar
Bollmann, MD, Berger, MM, Revelly, JP, Cayeux, MC Chiolero (2001) Impact of energy balance on clinical outcome in ICU patients–preliminary results. Clinical Nutrition 20 3 Suppl. 3Google Scholar
Brandi, LS, Bertolini, R, Calafà, M (1997) Indirect calorimetry in critically-ill patients: clinical applications and practical advice. Nutrition 13, 349–358Google Scholar
Bursztein, S, Saphar, P, Singer, P & Elwyn, D (1989) A mathematical analysis of indirect calorimetry measurements in acutely ill patients. American Journal of Clinical Nutrition 50, 227–230Google Scholar
Chioléro, RL, Bracco, D & Revelly, D (1993) Does indirect calorimetry reflect energy expenditure in the critically-ill patient. In Metabolic Support of the Critically-ill patient, pp 95–118 [Wilmore, DW Carpentier, YA, editors]. Berlin: Springer.CrossRefGoogle Scholar
Coward, WA (1988) The doubly-labelled water ( 2 H 2 18 O) method. Proceedings of the Nutrition Society 47, 209–218Google Scholar
Cuthbertson, DP (1942) Post-shock metabolic response. Lancet i, 433–437Google Scholar
Ebener, C, Kramhöller, H, Eder, F, Röckelein, W & Jauch, JW (2001) Enteral nutrition in critically ill surgical patients: do we meet caloric requirements in daily routine?. Clinical Nutrition 20, 54 Suppl. 3Google Scholar
Flakoll, PJ, Hill, JO & Abumrad, NN (1993) Acute hyperglycemia enhances proteolysis in normal man. American Journal of Physiology 265, E715–E721Google Scholar
Franch-Arcas, G, Plank, LD, Monk, DN, Gupta, R, Maher, K, Gillanders, L & Hill, GL (1994) A new method for the estimation of the components of energy expenditure in patients with major trauma. American Journal of Physiology 267, E1002–E1009Google ScholarPubMed
Frankenfield, DC, Smith, JS & Cooney, RN (1997) Accelerated nitrogen loss after traumatic injury is not attenuated by achievement of energy balance. Journal of Parenteral and Enteral Nutrition 21, 324–329Google Scholar
Frankenfield, DC, Wiles, CE, III, Bagley, S, Siegel JH (1994) Relationships between resting and total energy expenditure in injured and septic patients. Critical Care Medicine 22, 1796–1804CrossRefGoogle ScholarPubMed
Heyland, DK (1998) Nutritional support in the critically-ill patients. A critical review of the evidence. Critical Care Clinics 14, 423–440Google Scholar
Hill, AG (2000) Initiators and propagators of the metabolic response to injury. World Journal of Surgery 24, 624–629CrossRefGoogle ScholarPubMed
Ishibashi, N, Plank, LD, Sando, K & Hill, GL (1998) Optimal protein requirements during the first 2 weeks after the onset of critical illness. Critical Care Medicine 26, 1529–1535CrossRefGoogle ScholarPubMed
Jebb, SA & Prentice, AM (1997) Assessment of human energy balance. Journal of Endocrinology 155, 183–185Google Scholar
Jebb, SA, Prentice, AM, Goldberg, GR, Murgatroyd, PR & Coward, WA (1996) Changes in macronutrient balance during over- and under-feeding assessed by 12-d continuous wholebody calorimetry. American Journal of Clinical Nutrition 64, 259–266Google Scholar
Jeejeebhoy, KN (2001) Total parenteral nutrition: potion or poison?. American Journal of Clinical Nutrition 74, 160–163Google Scholar
Kirkland, LL (1999) Factors impeding enteral tube feedings. Critical Care Medicine 27, 1383–1384CrossRefGoogle ScholarPubMed
Klein, S, Peters, EJ, Shangraw, RE & Wolfe, RR (1991) Lipolytic response to metabolic stress in critically-ill patients. Critical Care Medicine 19, 776–779Google Scholar
Klein, CJ, Stanek, GS & Wiles, CE (1998) Overfeeding macronutrients to critically ill adults: metabolic complications. Journal of the American Dietetic Association 98, 795–806CrossRefGoogle ScholarPubMed
Koea, JB, Wolfe, RR & Shaw, JHF (1995) Total energy expenditure during total parenteral nutrition: ambulatory patients at home versus patients with sepsis in surgical intensive care. Surgery 118, 54–62Google Scholar
Livesey, G & Elia, M (1988) Estimation of energy expenditure, net carbohydrate utilization, and net fat oxidation and synthesis by indirect calorimetry: evaluation of error with special reference to the detailed composition of foods. American Journal of Clinical Nutrition 47, 608–628Google Scholar
Long, CL, Kinney, JM & Geiger, JW (1976) Nonsuppressibility of gluconeogenesis by glucose in septic patients. Metabolism 25, 193–200CrossRefGoogle Scholar
McClave, SA, Sexton, LK, Spain, DA, Adams, JL, Owens, NA, Sullins, MB, Blandford, BS & Snider, HL (1999) Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Critical Care Medicine 27, 1252–1256CrossRefGoogle ScholarPubMed
McCowen, KC, Friel, C, Sternberg, J, Chan, S, Forse, RA, Burke, PA & Bistrian, BR (2000) Hypocaloric total parenteral nutrition: Effectiveness in prevention of hyperglycemia and infectious complications–A randomized clinical trial. Critical Care Medicine 28, 3606–3611CrossRefGoogle ScholarPubMed
McCowen, KC, Malhotra, A & Bistrian, BR (2001) Stress-induced hyperglycemia. Critical Care Clinics 17, 107–124CrossRefGoogle ScholarPubMed
Monk, DN, Plank, LD, Franch-Arcas, G, Finn, PJ, Streat, SJ & Hill, GL (1996) Sequential changes in the metabolic response in critically injured patients during the first 25 days after blunt trauma. Annals of Surgery 223, 395–405CrossRefGoogle ScholarPubMed
Patino, JF, de, Pimiento, SE, Vergara, A, Savino, P, Rodriguez, M, Escallon J (1999) Hypocaloric support in the critically ill. World Journal of Surgery 23, 553–559CrossRefGoogle ScholarPubMed
Plank, LD, Connolly, AB & Hill, GL (1998) Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis. Annals of Surgery 228, 146–158Google Scholar
Plank, LD & Hill, GL (2000) Sequential metabolic changes following induction of systemic inflammatory response in patients with severe sepsis or major blunt trauma. World Journal of Surgery 24, 630–638Google Scholar
Reid, CL & Campbell, IT (2001) High energy deficits in MODS patients are associated with prolonged ICU length of stay but not mortality. Clinical Nutrition 20, 52 Suppl. 3Google Scholar
Shangraw, RE, Jahoor, F, Miyoshi, H, Neff, WA, Stuart, CA, Herndon, DN & Wolfe, RR (1989) Differentiation between septic and postburn insulin resistance. Metabolism 38, 983–989Google Scholar
Shaw, JHF, Wildbore, M & Wolfe, RR (1987) Whole body protein kinetics in severely septic patients. Annals of Surgery 205, 288–294Google Scholar
Smyrnios, NA, Curley, FJ & Shaker, KG (1997) Accuracy of 30-minute indirect calorimetry studies in predicting 24-hour energy expenditure in mechanically ventilated, critically-ill patients. Journal of Parenteral and Enteral Nutrition 21, 168–174CrossRefGoogle ScholarPubMed
Speakman, JR (1990) Principles, problems and a paradox with the measurement of energy expenditure of free-living subjects using doubly-labelled water. Statistics in Medicine 9, 1365–1380CrossRefGoogle Scholar
Streat, SJ, Beddoe, AH & Hill, GL (1987) Aggressive nutritional support does not prevent protein loss despite fat gain in septic intensive care patients. Journal of Trauma 27, 262–266Google Scholar
Uehara, M, Plank, LD & Hill, GL (1999) Components of energy expenditure in patients with severe sepsis and major trauma: a basis for clinical care. Critical Care Medicine 2, 1295–1302Google Scholar
Van, den, Berghe, G, Wouters, P, Weekers, F, Verwaest, C, Bruyninckx, F, Schetz, M, Vlasselaers, D, Ferdinande, P, Lauwers, P & Bouillon, R (2001) Intensive insulin therapy in critically-ill patients. New England Journal of Medicine 345, 1353–1367Google Scholar
Weissman, C, Kemper, M, Elwyn, DH, Askanazi, J, Hyman, AI & Kinney, JM (1986) The energy expenditure of the mechanically ventilated critically-ill patient. An analysis. Chest 89, 254–259CrossRefGoogle ScholarPubMed
Wolfe, RR (1996) Herman Award Lecture, 1996: Relation of metabolic studies to clinical nutrition–the example of burn injury. American Journal of Clinical Nutrition 64, 800–808Google Scholar
Wolfe, RR (1997) Substrate utilization/insulin resistance in sepsis/trauma. Baillière's Clinical Endocrinology and Metabolism 11, 645–657Google Scholar
Wolfe, RR & Martini, WZ (2000) Changes in intermediary metabolism in severe surgical illness. World Journal of Surgery 24, 639–647Google Scholar
Zaloga, GP & Roberts, P (1994) Permissive underfeeding. New Horizons 2, 257–263Google Scholar