Nutrition Challenges in Polytrauma Patients. New Trends in Energy Expenditure Measurements

Central European Journal of Clinical Research Volume 2, Issue 1, Pages 51-57 DOI: 10.2478/cejcr-2019-0008

MINI-REVIEW

Nutrition challenges in polytrauma patients. New trends in energy expenditure measurements

Barbara Kołakowska1 1 Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland

Correspondence to: Barbara Kołakowska Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland E-mail: [email protected]

Conflicts of interests Nothing to declare

Acknowledgements None.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for profit sectors.

Keywords: sepsis; nutrition; biomarkers; indirect calorimetry.

These authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. Central Eur J Clin Res 2019;2(1):51-57 ______Received: 01.04.2019, Accepted: 10.04.2019, Published: 13.04.2019

Copyright © 2018 Central European Journal of Clinical Research. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. tients lost their energy because of intensified catabolism, due to neuroendocrine changes Abstract and inflammatory reactions, which may worsen already existing malnutrition. Patients hospitalized in Intensive Care Units (ICU) are in severe general condition Background and they need specialized care, rehabilitation and proper nutrition to improve their condition The goal of nutrition support therapy and recover as soon as possible. Therefore, is to avoid catabolic response for critically ill it is very important that nutrition consists of all patients, which causes several complications, necessary elements that will cover their dai- weaken the metabolic response to shock, pre- ly demand for nutrients. However, malnutrition vent the injuries caused by free oxygen radicals among ICU patients is very common. According and favorably modulate the immune response to statistics, up to 50% is malnourished. It en- (1–3) . At present, in clinical practice few meth- hances average length of stay, risk of infection, ods find application and out of them the most prolongs ventilator days, delays wound healing beneficial seems to be early enteral nutrition and translates into an increased hospital cost. (EN) (4,5). It reduces disease severity, risk of It may end in multi-organ failure, what in con- infections, septic complications, modulates sequence increases mortality. Polytrauma pa- systemic immune response, maintains gut in-

51 Nutrition challenges in polytrauma patients tegrity and has a favorable impact on patient’s function and then ROS are realesed (16–18). outcome. Some meta-analysis show that early Improvement in mitochondrial respiration plays enteral nutrition, provided within 24 hours of an important role, because it is suggested to be intensive care unit admission, significantly de- associated with the recovery of organ function creases mortality in critically ill patients. How- in patients, who survive sepsis (13). ever, sometimes enteral nutrition is impossible When patient is not fasted, but met- or insufficient to provide appropriate demand on abolic response develops due to sepsis etc., nutrients. In that case, parenteral nutrition (PN) we are dealing with stress starvation. It leads should be included. Also, patients, who cannot to many changes which consist of increase of tolerate EN or there are contraindications to use metabolism, acceleration of protein catabolism, it, should receive the parenteral nutrition (PN), if increase of glucose circulation, exacerbation of they are not expected to be on normal nutrition sodium and water retention, reduction of albu- within 3 or 4 days. It is recommended to use min concentration in plasma and and increased both methods at the same time, because using secretion of catabolic hormones in combination PN alone may cause hyperglycemia, hepatocel- of insulin resistance. The balance between ele- lular injury and immunosuppression, which may vated level of catabolic hormones and reduced be very harmful for patients in severe condition function of insulin as well as an influence of (6–8). anabolic hormones on metabolism of proteins, carbohydrates and fats is significantly changed. Metabolism during sepsis Due to this, the nutrition in patients with diag- nosed sepsis should be well- balanced and in- In sepsis, the recognition of foreign an- cluding all necessary elements in appropriate tigens leads to inflammatory response at the doses. Choosing the right method of nutrition place of infection. The essence of these com- plays a significant role in patient’s therapy. The plex reactions is to produce pro-inflammatory biggest application has enteral nutrition (EN). It factors like TNF- alfa, interleukin 1, interleukin is well-tolerated way of feeding and it causes 6, interleukin 12, and interleukin 15, which re- the least complications. It should be always the sults in inflammatory cascade, leading to limita- first choice for the clinictians starting nutrition tion and then destruction of the infectious place. in patients in severe condition, if there are no Many factors, including organism’s response contrindiactions for that method like: (1) Diseas- and products made by pathogens, may be very es associated with ileus: multiple trauma with adverse on the course of inflammatory reaction, significant retroperitoneal hematoma and peri- which results in multi-organ failure or dissemi- tonitis; (2) Intestinal obstruction; (3) Active gas- nated intravascular coagulation (DIC). Simulta- trointestinal hemorrhage; (4) Hemodynamic in- neously, the anti-inflammatory processes with stability – it can worsen ischemia and may lead participation of cytokines like interleukin 4, in- to necrosis and bacterial overgrowth. If these terleukin 10, interleukin 13 are taking places (9– conditions occur, we must take parenteral nu- 11). Also the level of tumor growth factor beta trition under consideration. However, there are (TGF-beta) and cortisol are increased. With ad- some situations in which we cannot use the PN. vantage of anti-inflammatory factors, especial- The contraindications are: (1) The possibility of ly in polytrauma patients, may occur immunity gastrointestinal feeding, (2) Irreversibly decere- impairment or deepening in severity of sepsis breate patients, (3) Lack of specific therapeu- (8,12–15). tic goal, (4) Severe cardiovascular instability or Sepsis-induced organ dysfunction metabolic derangements (19,20). has been suggested to be at least in part due Energy Expenditure measurements to mitochondrial dysfunction. This condition is methods caused by oxidative stress (OS), which may re- Considering estimation of energy ex- sult in failure of energy production. The patho- penditure (EE), there are 3 available options: genesis of mitochondrial damage is recognized direct calorimetry (DC), indirect calorimetry (IC) as a complex series of events. Both nitric oxide and predictive equations and formulas elabo- (NO) and oxigen free radicals (ROS) combined rated on basis of above measurements. Direct with the release of a variety of exacerbating in- calorimetry is practically not used in clinical flammatory mediators can act to directly or indi- practice anymore, as requires special big and rectly influence mitochondrial function and en- thermally isolated chambers (to put patient in- ergy production. It is hard to define whether the side in order to capture and measure total body self-amplifying cycle of ROS generation and mi- heat output) and is very burdensome for pa- tochondrial damage occurs with mitochondrial tients and physicians; cost of measurement is dysfunction leading to oxidative stress and more also very high. Indirect calorimetry is gaining mitochondrial impairment as the primary event, more and more clinical confidence and usage or if oxidative stress initiates mitochondrial dys- and is strongly recommended (if only available)

52 Nutrition challenges in polytrauma patients by all published guidelines with the most actual in 1919 based on the results deriving from the ESPEN (www.espen.org) guidelines on the top group of 333 healthy patients (female, male and (21–23). newborns), just after awakening, mentally and Traditional method for estimating en- physically relaxed, 12-14 hours after last meal, ergy expenditure (EE) is the use of predictive stable ambient temperature, normal body tem- equations: they are easy to use, equation used perature (24,25). How these conditions corre- differs by patient, clinical scenario, and clinician spond with seriously ill patient in ICU, which is preference, but only 14-32% of patients receive usually sedated, getting NMBs, ventilated, un- accurate nutritional regimens. Over past 100 der/overfeeded, having SIRS increasing oxygen years, 200 different mathematic equations and demand, tissue perfusion failures, dysfunctional formulas were elaborated and published, but liver etc. These are main factors impacting neg- currently, Harris-Benedict formula seems to be atively accuracy of EE estimation using predic- one of the most commonly used. This was de- tive equations and making them inefficient and veloped by two physicians: Harris and Benedict not recommended (Table 1).

Table 1. Factors impacting negatively accuracy of EE estimation using predictive equations Bearing in mind all limitations and • Sepsis; weaknesses of direct calorimetry and predictive • Systemic inflammatory response syndrome equations in daily clinical practice and proper (SIRS); estimation of patient EE, indirect calorimetry is • Acute respiratory distress syndrome (ARDS); perceived as golden standard and highly rec- • Use of paralytic agents or sedation; ommended by all published guidelines (26). • Post-operative organ transplantation; Instead of measuring the heat output • Large or multiple open wounds; of the body (like in direct calorimetry measure- • Malnutrition with altered body composition ment) indirect calorimetry calculates the to- o Underweight; tal Energy Expenditure (EE) and Respiratory o Obesity; Quotient (RQ) by measuring Respiratory Gas o Limb amputation; Exchange i.e. the consumption (or uptake) of o Peripheral edema; O2 (VO2) and production (or elimination) of o Ascites; CO2 (VCO2) which are the result of oxidization There are different devices for gas ex- (burning) of food and nutrients to generate en- change and indirect calorimetry measurement ergy for the human body. We know exactly what available on the market, but one of the most is the amount of consumed O2 and produced commonly used is technology invented and de- CO2 in process of metabolism of fats, carbohy- livered by GE Healthcare (GE Healthcare, Hel- drates and proteins; we also know, how much sinki, Finland). Since 1975, when first compact energy is released during metabolism of these capnometer was launched, through Deltatrac substrates. Therefore, measuring O2 consump- (1986), which is still positioned and perceived tion and CO2 production, we are capable to as golden standard and reference device for estimate real energy expenditure. Indirect calo- gas exchange measurement, to last versions of rimetry measurement is continuous and non-in- miniaturized respiratory gas modules that can vasive procedure, that can be applied for adult be used in ventilators, cardiomonitors and even and pediatric patients (27–30). anesthesia units. GE Healthcare (GE Health- Clinical indications for routine indirect care, Helsinki, Finland), is worldwide leader in calorimetry measurement are represented by: gas exchange measurement and has delivered • Multiple trauma; more 400 000 modules to healthcare providers • Neurological trauma; over last years (31–34). • Burns; Using GE technology and solutions (GE • Multi-system organ failure; Healthcare, Helsinki, Finland), gas exchange 53 Nutrition challenges in polytrauma patients measurement is very easy and non-invasive or concentration via paramagnetic sensor and CO2 time consuming; it doesn’t require any special concentration via infrared sensor; gas module skills or knowledge and can be easily performed can be inserted either to GE Healthcare venti- by each member of ICU staff. Following ele- lator (GE Healthcare, Helsinki, Finland) or GE ments and accessories are needed to perform Healthcare cardiomonitor (GE Healthcare, Hel- measurement: sinki, Finland) (Figure 1). • Gas module E-sCOVX (GE Health- • D-lite/Pedi-lite gas sampler and flow care, Helsinki, Finland), which is measuring O2 sensor

Figure 1. E-SCOVX gas sample module (GE Healthcare, Helsinki, Finland) Following parameters are measured CO2 produced. Any leaks with indirect calorimetry: • in the ventilator circuit or • Respiratory quotient (RQ) = VCO2/ • around the artificial airway (endotra- VO2, physiological range between 0,7 and 1,3, cheal or tracheostomy tube) • Energy expenditure (EE), Weir equa- • parenchymal leaks in the lung from fis- tion: tulas, pneumothorax or chest drains etc. EE adult (kcal/day) = 5.5x VO2 (ml/min) will affect the measurement. For this + 1.76x VCO2 (ml/min) - 1.99 x UN (g/day) reason, measuring a patient ventilated in NIV EE ped (kcal/day) = 5.5x VO2 (ml/min) (noninvasive mode) via a mask or other NIV + 1.76x VCO2 (ml/min). interface is not advisable. Leaks should be The fact that this method is indirect in- probed prior to IC measurements and eliminat- troduces several limitations which need to be ed as much as possible (21,37). well understood by the physician who will use the provided data as well as by the clinicians 2. Blood filtration who will help generate such data. Every clinician using Indirect Calorimetry should under- For the same reason as above, Indirect stand and account for its limitations, before re- Calorimetry may provide inaccurate data during porting and interpreting results. hemodialysis or peritoneal dialysis. The limitations of Indirect Calorimetry stem from both human physiology and the way 3. N2O and other gas mixtures Energy Expenditure (EE) and Respiratory Quo- tient (RQ) are measured (32,35,36). Indirect Calorimetry cannot be performed in the presence of N2O. Please note 1. Leaks that the elimination of N2O from the body and also from diffusion is not immediate and patients Indirect Calorimetry uses measured should not be measured during or immediately VO2 and VCO2 (minute volumes of consumed after anesthesia involving N2O. O2 and produced CO2) to calculate Energy Ex- In general, Indirect Calorimetry mea- penditure (EE) and Respiratory Quotient (RQ). surements should not be performed if there are In order to have a representative result the de- any other gases apart from Air/O2 are present vice must measure all the O2 consumed and all at the airway (38).

54 Nutrition challenges in polytrauma patients

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