Nut in Clin Prac - 2023 - Murray

DOI: 10.1002/ncp.
11017
CLINICAL RESEARCH
Comparison of predictive equations and indirect

calorimetry in critical care: Does the accuracy differ by
body mass index classification?
Gretchen Murray RDN1,2 | Sheela Thomas MS, RD2 |

Timothy Dunlea RRT, RCP3 | Alberta Negri Jimenez BS, BA4 |
Daniel Eiferman MD5 | Marcia Nahikian‐Nelms PhD, RDN1 |
Kristen M. Roberts PhD, RDN1
1
School of Health and Rehabilitation
Science, The Ohio State University, Abstract
Columbus, Ohio, USA Background: Nutrition support professionals are tasked with estimating
2
Department of Nutrition Services, Ohio energy requirements for critically ill patients. Estimating energy leads to
State University Wexner Medical Center,
Columbus, Ohio, USA suboptimal feeding practices and adverse outcomes. Indirect calorimetry
3
Department of Respiratory Therapy, (IC) is the gold standard for determining energy expenditure. However,
Ohio State University Wexner Medical access is limited, so clinicians must rely on predictive equations.
Center, Columbus, Ohio, USA
Methods: A retrospective chart review of critically ill patients who underwent
4
College of Medicine, Ohio State
University Wexner Medical Center,
IC in 2019 was conducted. The Mifflin–St Jeor equation (MSJ), Penn State
Columbus, Ohio, USA University equation (PSU), and weight‐based nomograms were calculated
5
Department of Surgery, Ohio State using admission weights. Demographic, anthropometric, and IC data were
University Wexner Medical Center,
extracted from the medical record. Data were stratified by body mass index
Columbus, Ohio, USA
(BMI) classifications, and relationships between estimated energy require-
Correspondence ments and IC were compared.
Kristen M. Roberts, PhD, RDN, School of
Results: Participants (N = 326) were included. Median age was 59.2 years,
Health and Rehabilitation Science, The
Ohio State University, 306H Atwell Hall, and BMI was 30.1. The MSJ and PSU were positively correlated with
453 W 10th Ave, Columbus, OH 43210, IC in all BMI classes (all P < 0.001). Median measured energy expenditure
USA.
Email: kristen.roberts@osumc.edu
was 2004 kcal/day, which was 1.1‐fold greater than PSU, 1.2‐fold
greater than MSJ, and 1.3‐fold greater than weight‐based nomograms
Funding information (all P < 0.001).
National Center for Advancing
Translational Sciences, Grant/Award
Conclusion: Despite the significant relationships between measured and
Number: UL1TR002733 estimated energy requirements, the significant fold‐differences suggest
that using predictive equations leads to significant underfeeding, which
may result in poor clinical outcomes. Clinicians should rely on IC when
available, and increased training in the interpretation of IC is warranted.
In the absence of IC, the use of admission weight in weight‐based
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. Nutrition in Clinical Practice published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.
Nutr. Clin. Pract. 2023;1–9. wileyonlinelibrary.com/journal/ncp | 1

19412452, 0, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.11017 by Cochrane Mexico, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 | MURRAY ET AL.
nomograms could serve as a surrogate, as these calculations provided the

closest estimate to IC in participants with normal weight and overweight,
but not obesity.
KEYWORDS
adult, calorimetry, critical illness, energy requirements, obesity, overweight, predictive
equations
I N T R O D U C TI O N proteins; decreased production of albumin, prealbu-

min, retinol‐binding protein, transferrin, and other
The intensive care unit (ICU) encompasses a nutri- negative acute‐phase reactants; and sustained inflam-
tionally complex population impacted by a surge of matory response with production of tumor necrosis
inflammatory mediators driving the metabolic shifts factor‐α, interleukin 1 (IL‐1), and IL‐6.3,11‐13 As
that occur through the ebb and flow phases of critical illness and inflammation persists, metabolism
catabolic illness. 1,2 To support the metabolic shifts, adapts from carbohydrate metabolism to continuous
nutrition support (eg, enteral and parenteral nutri- lipolysis and proteolysis. 13 Compared with healthy
tion) is commonly prescribed, and nutrition support individuals, the inflammatory and hormonal changes
professionals, often the registered dietitian nutrition- that occur during stress greatly increase the rate of
ist (RDN), are challenged to precisely estimate energy proteolysis, leading to continuous skeletal muscle
expenditure and establish a nutrition support pre- breakdown.13 As this shift in energy substrate occurs,
scription. The American Society for Parenteral and patients become hypermetabolic and catabolic, rely-
Enteral Nutrition (ASPEN) releases critical care ing on gluconeogenesis from lipolysis and proteolysis.
guidelines nearly every 5 years to provide a clinical Unmet hypermetabolic demands, with continued loss
framework for the use of nutrition support.3,4 The of fat and muscle mass, will lead to various
2016 guidelines provide direction on the appropriate- malnutrition‐associated complications. As critical
ness of using indirect calorimetry (IC) to measure illness is a dynamic process, it should be expected
energy expenditure in various populations to improve that energy requirements are also dynamic and may
estimates provided by predictive equations. 3 How- result in challenges with dosing nutrition support.
ever, the most recent 2021 guidelines do not include Predictive equations are associated with ease of
an update on the use of IC in critical care. The authors calculation, yet these equations have poor accuracy
did suggest that with the paucity of data on energy compared with IC, ranging between 40% and 75%.3 IC
needs in the ICU, a moderate, weak recommendation is the most accurate measurement of resting energy
that nutrition support dosing should fall within 12 expenditure (REE) for a critically ill patient, as IC is
and 25 kcal/kg in the first 7–10 days of an ICU based on the abbreviated Weir equation, incorporating
admission was included. Additional research has measurements of oxygen consumption and carbon
begun to explore the relationship between predictive dioxide production. Despite previous research highlight-
equations and IC in various populations, including ing the inaccuracies of predictive equations, it is of
patients in trauma, surgical, medical, and cardiac interest to understand the clinical debate on the use of
ICUs,5‐8 but the heterogeneity of metabolic derange- IC in the ICU.9‐10 A historical sample from 2007 to 2009
ments seen in critically ill patients and variable study that included 352 ICUs reported that nearly 0.5% of the
designs have left this question unanswered and under cohort received an IC measurement.14 Even with IC
debate.9,10 being available, the timing, accuracy, and ability to
This heterogeneity during times of acute illness perform a study can be impacted by the cost of
results from a hypermetabolic and catabolic environ- equipment, availability of properly trained personnel
ment that increases overall caloric needs. 2,3,11‐13 This for maintenance and interpretation (eg, respiratory
leads to increased energy mobilization by release of therapists, RDNs), and equipment appropriateness and
epinephrine, norepinephrine, and cortisol; increased calibration (eg, air leaks, anesthesia administration,
production of C‐reactive protein, ceruloplasmin, certain ventilator settings).3,5,15,16 In addition to these
plasminogen, fibrinogen, and other acute‐phase factors, many individuals may not be eligible for IC.
NUTRITION IN CLINICAL PRACTICE | 3
Furthermore, repeat measures are often needed to Study design

understand the metabolic changes that occur over the
course of an ICU admission. The aim of this cross‐sectional, retrospective chart review
The Penn State University equation (PSU), was to identify the relationship between energy (kilocalories)
Mifflin–St Jeor equation (MSJ), and weight‐based estimated using predictive equations and measurements
nomograms are some commonly used predictive taken by IC. It was hypothesized that predictive equation
equations reported in the literature. The PSU and results would be significantly different from IC measure-
weight‐based nomograms are often used as a substitu- ments regardless of BMI classification. Clinical character-
tion for IC. Although the MSJ is an accurate predictor istics extracted from the electronic medical record (EMR)
of energy expenditure in healthy adults and not included age, admission weight, BMI, body temperature
hospitalized patients, it has not been shown to be less closest to IC measurement, use of enteral and parenteral
accurate than equations more commonly used in the nutrition, and ICU length of stay. This protocol was reviewed
hospital setting.3 Each of these equations includes the and approved through IRB #2021E0812.
use of a body weight (eg, actual, ideal) as a constituent
to estimate energy needs. Some of these equations are
likely better than others at predicting energy require- IC
ments as body mass index (BMI; defined as weight [kg]
divided by height squared [m2]) changes. Therefore, it Institutional standard‐of‐care protocol to determine
is critical that the accuracy of predictive equations, eligibility for IC measurement in the critically ill
compared to IC, be stratified by BMI class to highlight population was followed:
which predictive equation may not be acceptable in
specific BMI categories. This information will add to • Ventilator settings are as follows:
the current body of literature to enhance clinical o fraction of inspired oxygen ≤0.6;
guidelines for use of IC as a tool for dosing nutrition o positive end‐expiratory pressure ≤12 mm H2O; and
support. Therefore, the aims of this project were (1) to o total respiratory rate <35 breaths per minute (bpm).
determine the relationship between commonly used • There is no endotracheal tube or tracheostomy tube
predictive equations and measured energy expenditure cuff leak or chest tube air leak.
through use of IC, (2) to investigate the magnitude of • Patient is at goal tube feed or parenteral nutrition rate
difference between predicted and measured energy for >12 h.
expenditure, and (3) to look at these relationships • Patient is in a quiet environment.
stratified by BMI class. • Patient has not received general anesthesia in the
past 12 h.
• Patient has not received intermittent hemodialysis in
METHODS the past 4–6 h (can still use IC in setting of continuous
renal replacement therapy or continuous veno‐venous
Study population hemodialysis).
• Patient does not have hypothermia.
Within a large academic medical center, a conve- • Patient is not actively seizing or shivering.
nience sample of critically ill adult patients requiring • Patient has not received burn dressing changes or
mechanical ventilation were evaluated for inclusion painful procedures in the pasthour.
and exclusion criteria. Patients who were admitted in • Patient is not on extracorporeal membrane oxygenation.
2019 and underwent a measurement of energy • Patient's ventilator has not been changed 30 min
expenditure using the Carescape R860 ventilator with before or during the study.
E‐sCOVX module (General Electric) for IC were • No patient contact or routine nursing care is permitted
enrolled. This gas module is connected to every during the study.
ventilator. To initiate the study, a sample line is
placed within the ventilator circuit at the patient All patients were prescreened to ensure clinical elig-
connection. The module collects the inhaled and ibility. Although multiple participants received multiple IC
exhaled gases from the ventilator circuit and is studies during their hospital stay, only their initial IC study
analyzed to measure the REE. Patients were excluded was included in this analysis. Timing of IC within hospital
if they were <18 years of age, in prison, or pregnant or stay varied on patient's hospital course and individual
did not meet the quality parameters for the IC study dietitian practice in recommending or ordering IC. Measure-
discussed in the IC methodology. ments were taken when 10 min of a steady state was
4 | MURRAY ET AL.
achieved, typically overnight. Steady state was defined as computed to evaluate the relationship between predicted and
volume of oxygen consumption coefficient of variance measured energy expenditure. Significance for correlations
(VO2CV) and volume of carbon dioxide consumption was defined at P < 0.01 and was two‐tailed. A related‐
coefficient of variance (VCO2CV) ≤5%, and an average samples Wilcoxon signed rank test was used to evaluate the
physiological respiratory quotient of 0.67 to 1.3 was achieved. relationship between predicted and measured energy
All patients were at goal tube feeding or parenteral nutrition expenditure. The cutoff for significance was set at P < 0.05.
for >12 h unless planned extubation occurred before 12 h IBM SPSS Statistics version 27 was used for all statistical
and IC was still requested. analysis.
Predictive equations RESUL TS
Extracted admission weights were used to calculate Study population

estimated energy requirements for each participant using
the MSJ, PSU, and 2016 ASPEN guidelines or other Following a review of inclusion and exclusion criteria
weight‐based nomogram equations (see Table 1). The (Figure 1), 326 participants were included in the
2010 PSU was used for participants with a BMI > 30 and presented analysis. The median age was 59.2 years with
age >60 years, whereas the 2003b equation was used for 44.2% of the population being female (Table 2). Median
participants with a BMI < 30 or with both a BMI > 30 and BMI was 30.1 with 24% being within the normal‐weight
age <60 years. Minute ventilation used in the PSU was BMI classification and >70% being within the overweight
estimated via respiratory rate and tidal volume. or obese categories. Median length of ICU admission was
20 days, and length of hospital admission was 27 days.
Statistical methods
Predicted and measured energy
Continuous variables were expressed as a median and expenditure within the total cohort
interquartile range for nonnormally distributed variables.
Categorical variables were expressed as a percentage Significant correlations were identified between MSJ
(ratio). Data were assessed for the entire cohort and by and PSU and IC (Spearman correlation = 0.637 and
BMI classification. Spearman correlation coefficient was 0.689, respectively [P < 0.001]), whereas weight‐based
TABLE 1 Predictive equations of EERs.

Population Equation Details
MSJ
Male EER = (0.99 × weight) + (6.25 × height) – (4.92 × age) + 5 Admission weight in kilograms, height
in centimeters, age in years
Female EER = (0.99 × weight) + (6.25 × height) – (4.92 × age) − 161
Penn State University
2010: BMI > 30 and age > 60 EER = MSJ(0.71) + Ve(64) + Tmax(85) – 3085 Ve = minute ventilation in L/min
years
2003b: BMI < 30 or BMI > 30 EER = MSJ(0.96) + Ve(31) + Tmax(167) − 6212 Tmax = maximum temperature (°C)
and age < 60 years within 24 h of IC study
Weight‐based nomograms
Underweight (BMI < 18.5) EER = 35 kcal/kg Using actual body weight in kilograms
Normal weight EER = 30 kcal/kg
(BMI = 18.5–24.9)
Overweight (BMI = 25.0–29.9) EER = 25 kcal/kg
Obese class I (BMI 30.0–49.9) EER = 11 kcal/kg
Obese class II (BMI ≥ 50.0) EER = 22 kcal/IBW Using IBW as determined through the
Hamwi equation
Abbreviations: BMI, body mass index; EER, estimated energy requirement; IBW, ideal body weight; IC, indirect calorimetry; MSJ, Mifflin–St Jeor.
FIGURE 1 Study flow diagram. EMR, electronic medical record.
nomograms were not correlated with IC (Spearman of nearly twofold in both obese classes (all P < 0.001).
correlation = 0.053 [P = 0.343]) (Table 3). When compar- However, for underweight, normal weight, and over-
ing estimated energy requirements with measured weight, using a weight‐based nomogram did not differ
energy expenditure, all equations resulted in significantly from using IC (P = 0.301, 0.107, and 0.861, respectively).
different energy requirements (all P < 0.001; Table 4). Similarly, the obese class II showcases that MSJ and PSU
Measured energy expenditure was 1.22‐fold greater than results do not differ from IC results (P = 0.176 and 0.347,
that calculated by MSJ, 1.12‐fold greater than that respectively).
calculated by PSU, and 1.35‐fold greater than that
calculated by weight‐based nomograms.
D I S C U S S IO N
Predicted and measured energy In this retrospective, cross‐sectional study, we exam-

expenditure stratified by BMI class ined the relationship between commonly used predic-
tive equations and the “gold standard” of IC in a critical
The relationship between predictive equations and IC care population. With the newer technology of IC as a
varies based on BMI class. The underweight classification component of some mechanical ventilation systems,
showed a significant relationship between MSJ and PSU there has been an increase in interest regarding the true
with IC, yet no relationship was identified for the weight‐ accuracy of predictive equations compared to IC.6‐8,17‐20
based nomogram used (Table 3). For all other BMI Given the challenges with implementing IC into
classes, there was a significant correlation identified. clinical practice and controversy over the necessity of
Despite the degree of correlation between predictive this measurement for dosing nutrition support in the
equations and IC, when energy expenditure was strati- critically ill, there is ongoing debate among healthcare
fied by BMI class, the difference in energy expenditure professionals regarding the need for this technology.9,10
was evident. The MSJ and PSU results were significantly Our study highlights two key discussion points to add
different from IC results in the normal‐weight, over- to this debate, in addition to providing additional
weight, and obese class I groups (all P < 0.001; Table 4). evidence of the inaccuracies of predictive equations
Weight‐based nomograms were also significantly differ- from a large sample size of patients admitted to the
ent in the obese classes I and II, with a striking difference ICU. First, we confirm that there is a strong correlation
6 | MURRAY ET AL.
TABLE 2 Clinical characteristics of the full cohort of patients. T A B L E 3 Correlations between measured and estimated
Characteristics Full cohort (N = 326) energy expenditure.
Height, median (IQR), cm 170.2 (161.8–177.8) Spearman

correlation P value
Weight, median (IQR), kg 39.8 (31.3–51)
Underweight (BMI < 18.5) (n = 19)
Age, median (IQR), years 59.2 (44.8–68.7)
Mifflin–St Jeor 0.535 0.033a
Female sex, n (%) 144 (44.2)
Penn State University 0.832 <0.001a
BMI, median (IQR) 30.1 (24.0–38.0)
Weight‐based nomogram 0.315 0.235
BMI, n (%) (35 kcal/kg)
Underweight (<18.5) 16 (4.9) Normal weight (BMI 18.5–24.9) (n = 77)
Normal weight (18.5–24.9) 77 (23.6) Mifflin–St Jeor 0.431 <0.001a
Overweight (25.0–29.9) 66 (20.2) Penn State University 0.496 <0.001a
Obese class I (≥30.0–49.9) 136 (41.7) Weight‐based nomogram 0.414 <0.001a
Obese class II (≥50.0) 31 (9.5) (30 kcal/kg)
Hospital LOS, median (IQR), days 27.0 (17–40) Overweight (BMI 25.0–29.9) (n = 67)
ICU LOS, median (IQR), days 20.0 (13–32) Mifflin–St Jeor 0.593 <0.001a
ICU type, n (%) Penn State University 0.608 <0.001a
Surgical 143 (43.8) Weight‐based nomogram 0.494 <0.001a

(25 kcal/kg)
Neurological 83 (25.5)
Obese class I (BMI 30.0−49.9) (n = 136)
Medical 89 (27.3)
Mifflin–St Jeor 0.597 <0.001a
Oncology 11 (3.4)
Nutrition support, n (%)
2016 ASPEN guidelines 0.515 <0.001a
PN 38 (11.7) (11 kcal/kg)
EN 291 (89.3) Obese class II (BMI ≥ 50.0) (n = 31)
PN and EN 6 (1.8) Mifflin–St Jeor 0.783 <0.001a
Abbreviations: BMI, body mass index; EN, enteral nutrition; ICU, intensive Penn State University 0.837 <0.001a
care unit; IQR, interquartile range; LOS, length of stay; PN, parenteral
nutrition. 2016 ASPEN guidelines (22 kcal 0.526 0.002a
per kilogram of IBW)
Total cohort (N = 326)
between IC measurement and predictive equation Mifflin–St Jeor 0.637 <0.001a
results; however, the magnitude of difference between
median estimates of energy expenditure and IC was
Weight‐based nomogram 0.053 0.343
significant, suggesting a lack of efficacy for the use of
these equations when IC is available. Second, we have Abbreviations: ASPEN, American Society for Parenteral and Enteral
identified specific BMI classes for which predictive Nutrition; BMI, body mass index; IBW, ideal body weight.
a
Statistically significant (P < 0.05).
equations may be acceptable in clinical practice, and
we examined the use of weight‐based nomograms for
obesity compared with other predictive equations.3
These data suggest that IC is superior for those with a Previous study findings regarding the inaccuracy of
BMI between 30 and 49.9 because predictive equations predictive equations were confirmed.6‐8,17‐20 However,
and the weight‐based nomograms for obesity were because few studies have examined these relationships when
ineffective at accurately estimating energy require- stratified by BMI class,6 we were able to identify when IC
ments compared with IC. Conversely, the PSU and was consistent with predictive equations. The relationship
weight‐based nomograms in nonobese populations between predicitive equation and IC measurements of
were more accurate in those with underweight, and energy expenditure is essential to understand so that hospital
the MSJ and PSU were more accurate in those with a systems can complete a needs assessment to inform
BMI of ≥50. decisions to incorporate IC technology into critical care.
TABLE 4 Estimated and measured EE differences stratified by weight class.

Estimated EE, median IC EE, median (IQR),
(IQR), kcal/day kcal/day P value
Underweight (BMI < 18.5) (n = 16)
Mifflin–St Jeor 1187 (939–1300) 1373 (1041–1841) 0.044a
Penn State University 1372 (1009–1665) 0.756
Weight‐based nomogram 1565 (1388–1945) 0.301
Normal weight (BMI 18.5–24.9) (n = 77)
Mifflin–St Jeor 1425 (1188–1571) 1810 (1432–2226) <0.001a
Penn State University 1593 (1308–1834) <0.001a
Overweight (BMI 25.0–29.9) (n = 66)
Mifflin–St Jeor 1519 (1294–1742) 2025 (1579–2448) <0.001a
Obese class I (BMI ≥ 30.0−49.9) (n = 136)
Mifflin–St Jeor 1817 (1563–2036) 2132 (1803–2577) <0.001a
Weight‐based nomogram 1178 (1025–1311) <0.001a
Obese class II (BMI ≥ 50) (n = 31)
Mifflin–St Jeor 2273 (1941–2764) 2583 (1904–2991) 0.176
Penn State University 2121 (1939–2945) 0.347
Total cohort (N = 326)
Mifflin–St Jeor 1639 (1383–1890) 2004 (1610–2488) <0.001a
Abbreviations: BMI, body mass index; EE, energy expenditure; IC, indirect calorimetry; IQR, interquartile range.
a
Statistically significant (P < 0.05).
Zusman et al depict the lack of correlation between predicted Historically, permissive underfeeding was a strategy to
and measured energy expenditure in their cohort of 1440 decrease adiposity and the adipocyte inflammatory response
patients, for whom their evaluation of eight different associated with the production of interleukins, specifically
predictive equations similarly found that no predictive IL‐6. Based on expert consensus, guidelines suggest feeding a
equation results were >50% in agreement with IC measure- patient with obesity at 65%–70% of the REE as measured by
ments.17 Ratzlaff et al added to understanding these IC, although this is based on the findings in a few original
inaccuracies in predicted verse measured energy expendi- research papers.21‐25 To understand the impact of hypoca-
ture with similar findings related to the underestimation of loric feeding in the population with obesity, we must
energy expenditure when using the PSU.18 Neither of these understand current practices in institutions with respiratory
papers investigate the relationship between weight classes, therapy and nutrition expertise that use IC in daily practice.
nor do they investigate weight‐based nomograms for obesity. To the best of our knowledge, this is the only study to date
Because these guidelines are highlighted by others and are that compares REE from energy equations to IC measure-
suggested for use in the ICU owing to their simplistic ment stratified by all BMI classes and that uses BMI‐targeted
calculations, comparison to IC is warranted.10 weight‐based nomograms to estimate energy expenditure in
It is also important to characterize these results as they patients with obesity. Da Silva Oliveria et al classified
relate to the consequences of inaccurate energy delivery. their data into underweight, normal‐weight, and overweight
8 | MURRAY ET AL.
categories, but they omitted individuals with a BMI ≥ 30, equations and IC. These data provide insight to clinicians
which limits the breadth of understanding because many and hospital systems for decisions on purchasing IC
critically ill patients fall within this BMI classification.3,6 equipment for incorporation into clinical practice.
When reviewing those patients with a BMI ≥ 30, our results
show that use of the weight‐based nomograms for obesity A U T H O R C O N TR I B U T I O N S
resulted in feeding at 50%–55% of target IC measurements or Sheela Thomas, Daniel Eiferman, Marcia Nahikian‐
a deficit of 954–1284 kcal/day, which may result in too rapid Nelms, and Kristen M. Roberts equally contributed to
of a weight loss and might compromise lean body mass. the conception and design of the research; Gretchen
Pressoir et al support this with their findings that highlight Murray, Sheela Thomas, Timothy Dunlea, Alberta Negri
that obese patients were at the greatest risk of malnutrition Jimenez, and Kristen M. Roberts contributed to the
and unintentional weight loss.26 Additionally, the implica- acquisition of the data; Gretchen Murray, Sheela
tions for wound healing in the surgical patient with obesity Thomas, Marcia Nahikian‐Nelms, and Kristen M. Rob-
are still largely unknown. With an increased risk of hospital‐ erts contributed to the analysis of the data and
acquired malnutrition in the setting of hypermetabolism interpretation of the data. All authors drafted the
combined with current practices that feed drastically below manuscript, critically revised the manuscript, agree to
energy requirements, it is imperative to understand how be fully accountable for ensuring the integrity and
feeding practices and outcomes such as morbidity, mortality, accuracy of the work, and read and approved the final
and hospital length of stay are impacted in subsets of ICU manuscript.
populations.27
Despite this study contributing to the body of C O NF L I C T O F I N T E R E S T S TA T E M E N T
literature in this area, there are a few limitations to The authors declare no conflict of interest.
discuss. Collecting data retrospectively imposes chal-
lenges for interpretation. The extraction of body weight ORC ID
data from the EMR is inferior to prospective collection. Kristen M. Roberts http://orcid.org/0000-0001-
Without the context of hydration status, body weight 5619-990X
can be inaccurately recorded in the EMR. Therefore, the
extracted weights may contribute to inaccuracies in REFER ENCES
predicting energy expenditure. To minimize the impact 1. Ridley EJ, Tierney A, King S, et al. Measured energy
of positive fluid balance, we selected admission body expenditure compared with best‐practice recommendations
weights for this study. Although this weight may have for obese, critically ill patients—a prospective observational
study. JPEN J Parenter Enteral Nutr. 2020;44(6):1144‐1149.
changed by the time of IC measurement, many
2. Foley N, Marshall S, Pikul J, Salter K, Teasell R. Hyper-
clinicians use admission weights in their calculations
metabolism following moderate to severe traumatic acute
as standard of practice for their calculations. This study brain injury: a systematic review. J Neurotrauma. 2008;25(12):
did not explore nutrition support prescriptions, but the 1415‐1431.
nutrition support prescriptions were assumed to be 3. McClave SA, Taylor BE, Martindale RG, et al; Society of
determined on the basis of IC measurements. Exploring Critical Care Medicine; American Society for Parenteral and
nutrition support prescriptions of the population with Enteral Nutrition. Guidelines for the provision and assessment
obesity would add to this discussion to see whether of nutrition support therapy in the adult critically ill patient.
clinicians were prescribing nutrition support at target JPEN J Parenter Enteral Nutr. 2016;40(2):159‐211.
IC measurements or at 65%–70% based on ASPEN/ 4. Compher C, Bingham AL, McCall M, et al. Guidelines for the
provision of nutrition support therapy in the adult critically ill
Society of Critical Care Medicine (SCCM) 2016 critical
patient: The American Society for Parenteral and Enteral
care guidelines. However, the effects on outcomes were Nutrition. JPEN J Parenter Enteral Nutr. 2022;46(1):12‐41.
not identified and are the targets of future investiga- 5. Grguric L, Musillo L, DiGiacomo JC, Munnangi S. Throwing
tions. This will enhance the understanding of decision‐ darts in ICU: how close are we in estimating energy
making based on the availability of IC within an requirements? Trauma Surg Acute Care Open. 2020;5(1):
institution. e000493.
6. Oliveira ACS, Oliveira CC, Jesus MT, et al. Comparison of
equations to predict energy requirements with indirect
calorimetry in hospitalized patients. JPEN J Parenter Enteral
CONCLUSION Nutr. 2021;45(7):1491‐1497.
7. Vasileiou G, Qian S, Iyengar R, et al. Use of predictive
In conclusion, to our knowledge, we present the largest equations for energy prescription results in inaccurate
cohort to date for which IC data were extracted by BMI estimation in trauma patients. Nutr Clin Pract. 2020;35(5):
class to evaluate the relationship between predictive 927‐932.
8. Lee SJ, Lee HJ, Jung YJ, Han M, Lee SG, Hong SK. 20. Tah PC, Lee ZY, Poh BK, et al. A single‐center prospective
Comparison of measured energy expenditure using indirect observational study comparing resting energy expenditure
calorimetry vs predictive equations for liver transplant in different phases of critical illness: indirect calorimetry
recipients. JPEN J Parenter Enteral Nutr. 2021;45(4):761‐767. versus predictive equations. Crit Care Med. 2020;48(5):
9. Wischmeyer PE, Molinger J, Haines K. Point‐counterpoint: e380‐e390.
indirect calorimetry is essential for optimal nutrition therapy 21. Choban P, Burge J, Scales D, Flancbaum L. Hypoenergetic
in the intensive care unit. Nutr Clin Pract. 2021;36(2):275‐281. nutrition support in hospitalized obese patients: a simplified
10. McClave SA, Omer E. Point‐counterpoint: indirect calorimetry method for clinical application. Am J Clin Nutr. 1997;66(3):
is not necessary for optimal nutrition therapy in critical 546‐550.
illness. Nutr Clin Pract. 2021;36(2):268‐274. 22. Dickerson RN, Boschert KJ, Kudsk KA, Brown RO. Hypoca-
11. Ehlting C, Wolf SD, Bode JG. Acute‐phase protein synthesis: a loric enteral tube feeding in critically ill obese patients.
key feature of innate immune functions of the liver. Biol Nutrition. 2002;18(3):241‐246.
Chem. 2021;402(9):1129‐1145. 23. Dickerson RN, Medling TL, Smith AC, et al. Hypocaloric,
12. Davis CJ, Sowa D, Keim KS, Kinnare K, Peterson S. The use of high‐protein nutrition therapy in older vs younger
prealbumin and C‐reactive protein for monitoring nutrition critically ill patients with obesity. JPEN J Parenter
support in adult patients receiving enteral nutrition in an urban Enteral Nutr. 2013;37(3):342‐351.
medical center. JPEN J Parenter Enteral Nutr. 2012;36(2):197‐204. 24. Zauner A, Schneeweiss B, Kneidinger N, Lindner G,
13. Lheureux O, Preiser JC. Role of nutrition support in Zauner C. Weight‐adjusted resting energy expenditure is
inflammatory conditions. Nutr Clin Pract. 2017;32(3):310‐317. not constant in critically ill patients. Intensive Care Med.
14. Heyland DK, Cahill N, Day AG. Optimal amount of calories 2006;32(3):428‐434.
for critically ill patients: depends on how you slice the cake!
25. Alves VGF, da Rocha EEM, Gonzalez MC, da Fonseca RBV,
Crit Care Med. 2011;39(12):2619‐2626.
Silva MHN, Chiesa CA. Assessement of resting energy
15. Schlein KM, Coulter SP. Best practices for determining resting
expenditure of obese patients: comparison of indirect calorim-
energy expenditure in critically ill adults. Nutr Clin Pract.
etry with formulae. Clin Nutr. 2009;28(3):299‐304.
2014;29(1):44‐55.
26. Pressoir M, Desné S, Berchery D, et al. Prevalence, risk
16. Singer P, Singer J. Clinical guide for the use of metabolic carts:
factors and clinical implications of malnutrition in French
Indirect calorimetry—no longer the orphan of energy estima-
Comprehensive Cancer Centres. Br J Cancer. 2010;102(6):
tion. Nutr Clin Pract. 2016;31(1):30‐38.
966‐971.
17. Zusman O, Kagan I, Bendavid I, Theilla M, Cohen J, Singer P.
27. McClave SA, Martindale RG, Kiraly L. The use of indirect
Predictive equations versus measured energy expenditure by
calorimetry in the intensive care unit. Curr Opin Clin Nutr
indirect calorimetry: a retrospective validation. Clin Nutr.
Metab Care. 2013;16(2):202‐208.
2019;38(3):1206‐1210.
18. Ratzlaff R, Nowak D, Gordillo D, et al. Mechanically
ventilated, cardiothoracic surgical patients have significantly
different energy requirements comparing indirect calorimetry How to cite this article: Murray G, Thomas S,
and the Penn State equations. JPEN J Parenter Enteral Nutr. Dunlea T, et al. Comparison of predictive
2016;40(7):959‐965. equations and indirect calorimetry in critical care:
19. Tatucu‐Babet OA, Ridley EJ, Tierney AC. Prevalence of
does the accuracy differ by body mass index
underprescription or overprescription of energy needs in
critically ill mechanically ventilated adults as determined by
classification? Nutr Clin Pract. 2023;1‐9.
indirect calorimetry: a systematic literature review. JPEN doi:10.1002/ncp.11017
J Parenter Enteral Nutr. 2016;40(2):212‐225.

Nut in Clin Prac - 2023 - Murray

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nut in Clin Prac - 2023 - Murray

Uploaded by

Copyright:

Available Formats

DOI: 10.1002/ncp.

Comparison of predictive equations and indirect

Gretchen Murray RDN1,2 | Sheela Thomas MS, RD2 |

Nutr. Clin. Pract. 2023;1–9. wileyonlinelibrary.com/journal/ncp | 1

nomograms could serve as a surrogate, as these calculations provided the

I N T R O D U C TI O N proteins; decreased production of albumin, prealbu-

Furthermore, repeat measures are often needed to Study design

Predictive equations RESUL TS

Extracted admission weights were used to calculate Study population

TABLE 1 Predictive equations of EERs.

FIGURE 1 Study flow diagram. EMR, electronic medical record.

Predicted and measured energy In this retrospective, cross‐sectional study, we exam-

Height, median (IQR), cm 170.2 (161.8–177.8) Spearman

ICU type, n (%) Penn State University 0.608 <0.001a

Surgical 143 (43.8) Weight‐based nomogram 0.494 <0.001a

TABLE 4 Estimated and measured EE differences stratified by weight class.

You might also like