Original Communication

Journal of Parenteral and Enteral

Nutrition
Continuous Indirect Calorimetry in Critically Injured Patients Volume 44 Number 5
July 2020 889–894
Reveals Significant Daily Variability and Delayed, Sustained 
C 2019 American Society for

Parenteral and Enteral Nutrition

Hypermetabolism DOI: 10.1002/jpen.1713
wileyonlinelibrary.com

Georgia Vasileiou, MD1 ; Michelle B. Mulder, MD1 ; Sinong Qian, MD1 ;

Rahul Iyengar, BS1 ; Lindsey M. Gass, RD2 ; Jonathan Parks, MD1 ;
Edward Lineen, MD1 ; Patricia Byers, MD1 ; and Daniel Dante Yeh, MD1

Abstract
Background: Previous studies have used using Indirect Calorimetry (IC) with solitary or sparse measurements of resting energy
expenditure (REE). This “snapshot” may not capture the dynamic nature of metabolic requirements. Using continuous IC, we
describe the variation of REE during the first days in the intensive care unit. Methods: Injured adults (ࣙ18 years) requiring
mechanical ventilation from March 2018 to September 2018 were enrolled. IC was initiated within 4 days of admission and
continuous REE recorded until 14 days, extubation, or death. Multiple 10-minute periods collected during steady state were used to
calculate daily REE maximum, minimum, average, and variability [(REEmax − REEmin/2)/average REE]. Results: We included 55
patients. Median age was 38 [27–58] years, 38 (69%) were male, body mass index was 28 [25–33] kg/m2 , and Acute Physiology and
Chronic Health Evaluation II was 17 [14–24]. Mechanism of injury was: blunt (n = 38, 69%), penetrating (n = 9, 16%), and burn
(n = 8, 15%). Average REE increased gradually from 1,663 kcal [1,435–2,143] to a maximum of 2,080 [1,701–2,336] on day 7, a
relative 25% increase, which was sustained through day 14. REE variability ranged 8%–13% and was not reliably predicted by fever,
tachycardia, elevated intracranial pressures, hypertension, or hypotension. Conclusion: In critically injured patients, steady-state
REE measurements display fluctuations over a 24-hour period and demonstrate a gradual rise over the first few days after injury.
Continuous REE, if available, is recommended for more precise matching of energy delivery to metabolic requirements. (JPEN J
Parenter Enteral Nutr. 2020;44:889–894)

Keywords
adult; calorimetry; outcomes research/quality; surgery; trauma

Clinical Relevancy Statement
The use of indirect calorimetry (IC) as a clinical gold
standard remains unchallenged, but continuous measure-
ment of energy expenditure has been extremely limited.
The majority of the studies published so far use single
IC measurements taken at varying times during hospital-
ization. In this study, we collected continuous calorimetry
measurements during the first 14 days of intensive care unit
admission, describe the daily variability that energy expen-
diture exhibits in critically injured patients, and describe its
relationship with clinical events.
rarely repeated; however, it has been shown that REE can
vary considerably within a 24-hour period and between
days.6,7 Thus, when short-interval measurements of REE
are extrapolated to calculate a patient’s 24-hour total energy
From the 1 Miller School of Medicine, DeWitt Daughtry Family
Department of Surgery, University of Miami, Miami, Florida, USA;
and 2 Nutrition Services, Jackson Memorial Hospital, Miami, Florida,
USA.
Financial disclosure: D. D. Yeh receives author royalties by
UpToDate. D. D. Yeh and P. Byers have separate Takeda research
grants. The rest of the authors have no financial disclosures.

Introduction Conflicts of interest: None declared.

Received for publication March 14, 2019; accepted for publication
Indirect calorimetry (IC) remains the gold standard for August 28, 2019.
measuring resting energy expenditure (REE) in critically This article originally appeared online on October 10, 2019.
ill patients.1 In practice, IC is used to assess the metabolic
Corresponding Author:
response to various states, such as burns,2,3 head injury,4 and Georgia Vasileiou, MD, University of Miami, 1800 NW 10th Ave,
fever,5 to design energy-provision regimens. In the literature, T-215, Miami, FL 33136, USA.
most REE measurements are performed only once or only Email: georgia.vas@gmail.com
890
expenditure (TEE), significant error can result in over- or
undernourishment of hospitalized patients. As a result, it is
suggested that measurements should be taken during steady
state.8-10
Critically injured patients experience significant changes
in clinical status and metabolic requirements over the course
of hospitalization in response to medical/nursing care or
complications. Considering patients with highly variable
hospital courses, optimal care may depend upon repeated
IC measurements throughout a patient’s entire stay.11,12
Therefore, in trauma, a single 24-hour IC measurement may
not adequately capture the dynamic nature of a patient’s
metabolic requirements. However, there are limited data
among trauma patients of continuous IC measurements
beyond a 24-hour period. In this study, we sought to
continuously measure the IC of trauma patients in the
intensive care unit (ICU) over the initial 2-week period
to examine the within-day and between-day variations of
REE. We hypothesized that the metabolic requirements of
trauma ICU patients would change considerably during
early hospitalization.
Methods
Following approval from our institutional review board, we
prospectively enrolled injured adults (age ࣙ 18 years) that
were admitted in the trauma ICU and required mechanical
ventilation from March 1, 2018, to November 15, 2018.
The requirement to obtain informed consent was waived.
Patients were excluded if they were transferred from other
institutions, pregnant, or prisoners.
IC was initiated as soon as possible within 4 days of ICU
admission. We used CARESCAPE R-860 ventilators (GE
Healthcare, Madison, WI, USA) that have the ability to
record continuous IC measurements using a gas-sampling
module, E-sCOVX or E-COVX (GE Healthcare/Datex-
Ohmeda, Helsinki, Finland). Data collected included de-
mographics (age, sex, weight, body mass index [BMI], and
baseline nutrition status as documented by the registered
dietitian [RD]), injury characteristics (injury mechanism,
underlying injuries, Acute Physiology and Chronic Health
Evaluation [APACHE] II score, and surgery within 24 hours
and after 24 hours), medications, ventilator settings, labo-
ratory values, and energy/protein prescription and delivery.
There is 1 full-time RD assigned to the trauma ICU, and the
vast majority of initial nutrition assessments and follow-up
assessments were performed by that 1 RD. As recommended
by American Society for Parenteral and Enteral Nutrition
(ASPEN), the RD used measurements from the IC to guide
energy prescriptions if those measurements were confirmed
to be taken at steady state and were relatively consistent
within a single day. However, in times when large variations
were apparent, the RD reverted to using the formula of
25–30 kcal/kg. Propofol is commonly used in our ICU for
Journal of Parenteral and Enteral Nutrition 44(5)
sedation. It is the customary practice of the ICU dietitians
to review the average amount of propofol received and
deduct the propofol energy from the energy targets during
reassessments. Therefore, we did not include propofol en-
ergy in our deficits, as it would have been double-counted.
Multiple 10-minute periods were collected daily during
steady state (coefficient of variation ࣘ 5% for both
oxygen consumption (VO2 ) and carbon dioxide production
(VCO2 )) and were used to calculate REE daily maximum,
REE daily minimum, REE daily average, and REE
variability [(REEmax − REEmin/2)/average REE]. The
CARESCAPE R-860 collects metabolic information in
a continuous fashion, and these data are stored for up
to 24 hours. Every day, the previous day’s record was
reviewed for any 10-minute steady-state time periods (as
defined above). A minimum of 4 periods of 10 minutes
were chosen, and attempts were made to select time periods
dispersed throughout the day. Variability calculation was
based on all 10-minute periods recorded for that day, and
the number of periods used to calculated variability was
dependent upon the number of recorded 10-minute periods
for that day. For the maximum and minimum REE values
that were collected, we recorded clinical events occurring at
that time (fever > 38.5°C, intracranial pressure > 15 mmHg,
heart rate > 120 beats/min, systolic blood pressure [BP]
> 140 mmHg or < 90 mmHg, and other changes such
as hypothermia and tachypnea). Data were not collected
during extracorporeal membrane oxygenation, when there
was a chest-tube air leak > 10% of tidal volume, when
the patients were being ventilated with FiO2 > 60%, when
the patients were on intermittent hemodialysis (iHD), and
for 4 hours after iHD. However, during continuous renal
replacement therapy, REE data were normally collected.
Data were recorded for up to 14 consecutive days or until
transfer out from the ICU, extubation, or death, whichever
occurred first. Per the manufacturer’s suggestion, the gas
modules were calibrated every 3 months because of their
use for research purposes.
Based upon parametric or nonparametric distribution,
the mean ± SD or median (interquartile range) was re-
ported, respectively. Statistical tests were performed using
Stata for Windows, Version 14.0 (StataCorp LLC, College
Station, TX, USA).
Results
Fifty-five patients were included in the final analysis. The
median age was 38 [27–58] years, 38 (69%) were male, BMI
was 28 [25–33] kg/m2 , and APACHE II score was 17 [14–
24]. The most common mechanism of injury was blunt
(n = 38, 69%), followed by penetrating (n = 9, 16%) and
burn (n = 8, 15%) (Table 1).
Measurements were initiated a median of 1 [0–1] day
following ICU admission. On day 1 of measurements,
Vasileiou et al 891

Table 1. Patients’ Demographics and Clinical Characteristics. common “finding” was that no corresponding clinical event
was identified.
Patients’ Characteristics N = 55

Age [IQR] 38 [27–58] Discussion

Male (%) 38 (69)
BMI [IQR] 28 [25–33] Based on continuous IC measurements, we report that the
APACHE II [IQR] 17 [14–24] REE fluctuates widely during the first few days following
ISS 26 [17–34] injury in trauma ICU patients requiring mechanical ven-
Mechanism of injury (%) tilation. We defined daily REE variability as [(REEmax −
• Blunt 38 (69) REEmin/2)/average REE], and it is apparent that within
• Penetrating 9 (16) a 24-hour period, 1 single measurement of REE during
• Burn 8 (15)
steady state might not represent a patient’s average daily
ICU LOS [IQR] 21 [10–44]
Hospital LOS [IQR] 31 [16–59] metabolic status or energy needs during the first 14 days.
Ventilator days [IQR] 19 [6–37] At the end of the 14-day period, there were 12 males and
28 ventilator-free days [IQR] 4 [0–22] 5 females remaining intubated, a similar male-to-female
Hospital mortality (%) 9 (16) ratio as on the first day of measurements. Therefore, it
is unlikely that the changes in the recorded median REE
APACHE II, Acute Physiology and Chronic Health Evaluation II;
values can be attributed to more males finishing the 14-day
BMI, body mass index; ICU, intensive care unit; IQR, interquartile
range; ISS, injury severity score; LOS, length of stay. study period. All of our measurements were values recorded
from 10-minute intervals with ࣘ5% coefficient of variation,
the group median for the daily average REE was 1,663 which is a stricter measure of steady state than the one
[1,435–2,143] kcal, and by the seventh day, it had increased that McClave et al suggested (<10% coefficient of variation
to 2,080 [1,701–2,336] kcal, a 25% increase, which was for 5 minutes).10 The 2016 ASPEN/Society of Critical Care
relatively sustained through the 14th day (Figure 1). For Medicine guidelines recommend IC measurements twice a
every day of the 14-day period, the clinical events associated week, when available. Our data suggest that this might not
with the recorded REE maximum and REE minimum are be sufficiently accurate, especially on the first days following
shown on Tables 2 and 3. The calculated REE variability trauma, when variability can be increased, and various
ranged between 8% and 13% (Figure 2). In particular, with steady-state measurements can vary widely.
the exception of the first day of measurements, variability Previous studies have demonstrated the effect that many
was measured to be ࣙ10% for the rest of the days. Tables 2 factors have on a patient’s REE, and consequently, these
and 3 show that there are some clinical events that can daily variations in the clinical picture will affect the average
elevate or reduce REE without affecting the steady state. REE, as evidenced by the calculated REE variability.13-15
However, for every REE minimum and nearly every REE Although the numbers are small, we noted that occa-
maximum in the first 14 days of measurements, the most sionally the maximum REE value was recorded at times

Figure 1. Average REE in the early post-injury period. REE, resting energy expenditure. [Correction added on July 10, 2020 after
first online publication: the axis labeling in the figure was modified.]
892 Journal of Parenteral and Enteral Nutrition 44(5)

Table 2. Clinical Events in the First Week of Measurements.

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

(N = 55) (N = 55) (N = 53) (N = 42) (N = 36) (N = 34) (N = 32)

Clinical events during the recorded REE maximuma

No changes (%) 25 (45) 22 (40) 21 (40) 14 (33) 10 (28) 13 (38) 12 (50)
Fever (T > 38.5°C) (%) 8 (15) 9 (16) 9 (17) 7 (17) 6 (17) 5 (15) 7 (22)
ICP > 15 mmHg (%) 5 (9) 5 (9) 5 (9) 5 (12) 4 (11) 1 (3) 1 (3)
Tachycardia (HR > 120) (%) 12 (22) 13 (24) 14 (26) 7 (17) 5 (14) 6 (18) 4 (13)
Hypertension (SBP > 140 mmHg) (%) 15 (27) 16 (29) 13 (25) 18 (43) 16 (44) 12 (35) 13 (41)
Hypotension (SBP < 90 mmHg) (%) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (3) 0 (0)
Other (%) 1 (2) 1 (2) 2 (4) 5 (12) 2 (6) 2 (6) 1 (3)
Clinical events during the recorded REE minimuma
No changes (%) 31 (56) 28 (51) 30 (57) 19 (45) 16 (44) 18 (53) 19 (59)
Fever (T > 38.5°C) (%) 6 (11) 6 (11) 4 (8) 4 (10) 3 (8) 4 (12) 3 (9)
ICP > 15 mmHg (%) 3 (5) 5 (9) 4 (8) 5 (12) 3 (8) 1 (3) 1 (3)
Tachycardia (HR > 120) (%) 9 (16) 7 (13) 4 (8) 4 (10) 2 (6) 2 (6) 2 (6)
Hypertension (SBP > 140 mmHg) (%) 12 (22) 11 (20) 9 (17) 14 (33) 12 (33) 9 (26) 10 (31)
Hypotension (SBP < 90 mmHg) (%) 0 (0) 1 (2) 1 (2) 1 (2) 0 (0) 1 (3) 1 (3)
Other (%) 1 (2) 3 (5) 9 (17) 5 (12) 4 (11) 2 (6) 1 (3)

HR, heart rate; ICP, intracranial pressure; REE, resting energy expenditure; SBP, systolic blood pressure; T, temperature.
a Percentages add up to >100% because multiple clinical events could have been recorded simultaneously.

Table 3. Clinical Events in the Second Week of Measurements.

Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14

(N = 29) (N = 27) (N = 25) (N = 23) (N = 20) (N = 19) (N = 17)

Clinical events during the recorded REE maximuma

No changes (%) 13 (45) 15 (56) 14 (56) 12 (52) 11 (55) 11 (58) 6 (35)
Fever (T > 38.5°C) (%) 7 (24) 4 (15) 3 (12) 1 (4) 1 (5) 2 (11) 3 (18)
ICP > 15 mmHg (%) 1 (3) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Tachycardia (HR > 120) (%) 4 (14) 3 (11) 2 (8) 6 (26) 5 (25) 2 (11) 1 (6)
Hypertension (SBP > 140 mmHg) (%) 8 (28) 7 (26) 7 (28) 6 (26) 7 (35) 6 (32) 6 (35)
Hypotension (SBP < 90 mmHg) (%) 0 (0) 1 (4) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Other (%) 1 (3) 1 (4) 1 (4) 1 (4) 0 (0) 0 (0) 2 (12)
Clinical events during the recorded REE minimuma
No changes (%) 19 (66) 19 (70) 16 (64) 16 (70) 13 (65) 14 (74) 9 (53)
Fever (T > 38.5°C) (%) 2 (7) 1 (4) 1 (4) 1 (4) 0 (0) 2 (11) 3 (18)
ICP > 15 mmHg (%) 1 (3) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Tachycardia (HR > 120) (%) 1 (3) 2 (7) 3 (12) 3 (13) 1 (5) 1 (5) 2 (12)
Hypertension (SBP > 140 mmHg) (%) 3 (10) 3 (11) 5 (20) 4 (17) 4 (20) 1 (5) 3 (18)
Hypotension (SBP < 90 mmHg) (%) 1 (3) 2 (7) 1 (4) 0 (0) 0 (0) 0 (0) 0 (0)
Other (%) 2 (7) 1 (4) 1 (4) 0 (0) 2 (10) 1 (5) 1 (6)

HR, heart rate; ICP, intracranial pressure; REE, resting energy expenditure; SBP, systolic blood pressure; T, temperature.
a Percentages add up to >100% because multiple clinical events could have been recorded simultaneously.

when clinical events that are expected to elevate metabolic
requirements occurred, such as fever, elevated BP, and
tachycardia. Similarly, at times when the minimum REE was
recorded, events expected to decrease REE were noted, such
as reduced BP or hypothermia, which was the most common
event reported as “other.” However, for both REE minimum
and REE maximum, the most common “finding” was no
corresponding clinical event.
Vermeij et al studied the day-to-day variability of TEE in
critically ill surgical patients.7 In that study, they found that
the differences in TEE between days were not significant,
although they argued that in the individual patient, this
variability may become significant. However, this study was
limited by its wide range of days when measurements were
initiated and by the small amount of patients that completed
7 days of measurements. They initiated measurements on
day 6 of ICU admission, and less than half of their patients
had measurements for >3 days. When comparing their
results with our findings, the biggest increase in the daily
average REE that we measured was within the first 7 days
Vasileiou et al
Figure 2. REE variability in the early post-injury period. REE variability = [(REEmax − REEmin/2)/average REE]. REE, resting
energy expenditure. [Correction added on July 10, 2020 after first online publication: the axis labeling in the figure was modified.]
of measurements, when REE rose from a median 1,663 to
2,080 kcal, a 20% increase during early hospitalization days.
In our study, no measurements were initiated after 4 days
of ICU admission, since we were interested in capturing the
early postinjury energy requirements and their progress over
time. Thus, day-to-day variability can change significantly,
especially in the early days post injury.
Limitations
The study has several limitations that need to be addressed.
First, we included only 55 patients, a relatively small sample
size, precluding strong conclusions. External replication
by others would strengthen our conclusions. Additionally,
the exclusion of all patients other than injured patients
decreases the generalizability of this study. It would be
interesting to see whether the increased variability of REE
can be seen in other patient populations as well, but this was
beyond the scope of this study. Raurich et al attempted to
describe the differences of REE in various types of lesions,
including trauma, but failed to identify differences between
medical, surgical, and trauma patients. However, that study
was limited by its retrospective nature and the wide range
of days within which the measurements were obtained.16
Second, despite our efforts to collect continuous 24-hour
data, there were sometimes interruptions, some of them
avoidable. For instance, in many patients, following a neb-
ulizer treatment, the nebulizer mode was left on for several
hours, and the ventilator would not collect IC data until
the nebulizer was manually switched off, and then IC mea-
surements could resume. Despite these sporadic, random
interruptions, in most patients we were still able to collect
multiple data points throughout each study day. Third, we
893
did not account exactly for the amount of propofol energy,
as this is accounted for by the ICU dietitian when adjusting
the energy target. Because this was a purely observational
study, we did not wish to disrupt the usual practice of the
ICU clinicians. Although this may have led to some impre-
cision in the calculation of the energy deficits, we believe this
is a small margin of error, as it is commonly interrupted
for reasons including frequent neurologic examinations in
brain-injured patients, return trips to the operating room,
hypotension, or bradycardia. Another potential limitation
of our study is that we did not specifically document every
single ventilator setting change, though we did record the
ventilator settings at the start of each day. It is possible that a
measurement taken shortly after a ventilator setting change
may be inaccurate, though it should be emphasized that all
REE recordings entered into the database were taken during
a 10-minute period of steady state, with <5% variation in
VCO2 and VO2 . Additionally, we did not specifically record
every single change in the tube feeding rate, and it is possible
that changes in continuous feeding may affect the metabolic
rate. However, a recent study suggests that the thermic effect
of food is negligible in an ICU setting when patients are re-
ceiving continuous tube feeding.17 Despite these limitations,
this study provides meaningful insight into the progression
of REE in critically injured patients during the first 2 weeks
of recovery and confirms that, on average, the hyperme-
tabolic state is sustained, though individual variability can
be high. Although many consider IC to be the gold standard
for determining the metabolic requirements in critically ill
patients, we report that a solitary measurement or sparse
measurements may not be accurate. We recommend that
steady-state measurements be examined at least daily in
the first 14 days after injury and even more frequently, if
feasible.
894
Conclusion
In critically ill injured patients, intermittent REE measure-
ments obtained during “steady state” still display a wide
fluctuation over a 24-hour period and demonstrate a grad-
ual rise over the first few days after injury. Various clinical
events may be associated with those fluctuations and are not
necessarily predictive of higher or lower metabolic require-
ments. Isolated REE measurements may not accurately
reflect the true metabolic requirements (especially during
early hospitalization), and continuous REE measurements,
if available, are recommended for capturing the variations
of metabolism as they occur on a day-to-day basis and their
relation to patients’ clinical course.
Statement of Authorship
G. Vasileiou and D. D. Yeh equally contributed to the con-
ception and design of the research; P. Byers contributed to
the design of the research; G. Vasileiou, M. B. Mulder, S.
Qian, R. Iyengar, and L. M. Gass contributed to the acqui-
sition and analysis of the data; G. Vasileiou, D. D. Yeh, P.
Byers, E. Lineen, and J. Parks contributed to the interpre-
tation of the data; and G. Vasileiou and D. D. Yeh drafted
the manuscript. All authors critically revised the manuscript,
agree to be fully accountable for ensuring the integrity and
accuracy of the work, and read and approved the final
manuscript.
References
1. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the
provision and assessment of nutrition support therapy in the adult
critically ill patient: Society of Critical Care Medicine (SCCM) and
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
2. Rutan TC, Herndon DN, Van Osten T, Abston S. Metabolic rate
alterations in early excision and grafting versus conservative treatment.
J Trauma. 1986;26(2):140-142.
3. Stanojcic M, Abdullahi A, Rehou S, Parousis A, Jeschke MG.
Pathophysiological response to burn injury in adults. Ann Surg.
2018;267(3):576-584.
Journal of Parenteral and Enteral Nutrition 44(5)
4. Bruder N, Lassegue D, Pelissier D, Graziani N, François G. Energy
expenditure and withdrawal of sedation in severe head-injured patients.
Crit Care Med. 1994;22(7):1114-1119.
5. Frankenfield DC, Smith JS, Jr., Cooney RN, Blosser SA, Sarson
GY. Relative association of fever and injury with hypermetabolism in
critically ill patients. Injury. 1997;28(9-10):617-621.
6. Swinamer DL, Phang PT, Jones RL, Grace M, King EG. Twenty-
four hour energy expenditure in critically ill patients. Crit Care Med.
1987;15(7):637-643.
7. Vermeij CG, Feenstra BW, van Lanschot JJ, Bruining HA. Day-to-day
variability of energy expenditure in critically ill surgical patients. Crit
Care Med. 1989;17(7):623-626.
8. Zijlstra N, ten Dam SM, Hulshof PJ, Ram C, Hiemstra G, de Roos
NM. 24-Hour indirect calorimetry in mechanically ventilated critically
ill patients. Nutr Clin Pract. 2007;22(2):250-255.
9. Smyrnios NA, Curley FJ, Shaker KG. Accuracy of 30-minute indi-
rect calorimetry studies in predicting 24-hour energy expenditure in
mechanically ventilated, critically ill patients. JPEN J Parenter Enteral
Nutr. 1997;21(3):168-174.
10. McClave SA, Spain DA, Skolnick JL, et al. Achievement of steady
state optimizes results when performing indirect calorimetry. JPEN J
Parenter Enteral Nutr. 2003;27(1):16-20.
11. Monk DN, Plank LD, Franch-Arcas G, Finn PJ, Streat SJ, Hill GL. Se-
quential changes in the metabolic response in critically injured patients
during the first 25 days after blunt trauma. Ann Surg. 1996;223(4):395-
405.
12. Plank LD, Connolly AB, Hill GL. Sequential changes in the metabolic
response in severely septic patients during the first 23 days after the
onset of peritonitis. Ann Surg. 1998;228(2):146-158.
13. Bruder N, Raynal M, Pellissier D, Courtinat C, François G. Influence
of body temperature, with or without sedation, on energy expenditure
in severe head-injured patients. Crit Care Med. 1998;26(3):568-572.
14. Boulanger BR, Nayman R, McLean RF, Phillips E, Rizoli SB. What
are the clinical determinants of early energy expenditure in critically
injured adults? J Trauma. 1994;37(6):969-974.
15. Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS,
Metabolic response to injury and illness: estimation of energy and
protein needs from indirect calorimetry and nitrogen balance. JPEN
J Parenter Enteral Nutr. 1979;3(6):452-456.
16. Raurich JM, Ibáñez J, Marsé P, Riera M, Homar X. Resting energy
expenditure during mechanical ventilation and its relationship with the
type of lesion. JPEN J Parenter Enteral Nutr. 2007;31(1):58-62.
17. Frankenfield DC. Impact of feeding on resting metabolic rate and
gas exchange in critically ill patients. JPEN J Parenter Enteral Nutr.
2019;43(2):226-233.