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Recommendations Summary

SCI: Assessment: Energy Needs in Acute and Rehabilitation Phases 2009

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    SCI: Assessment: Energy Needs in the Acute Phase

    If the patient with spinal cord injury is in the acute phase of spinal cord injury, the registered dietitian (RD) should assess energy needs by measuring energy expenditure. Patients with spinal cord injury have reduced metabolic activity due to denervated muscle. Actual energy needs are at least 10% below predicted needs. Indirect calorimetry is more accurate than estimation of energy needs in critically ill patients.

    Rating: Strong
    Conditional

    SCI: Assessment: Energy Needs in the Acute Phase using Predictive Equations

    If the patient with spinal cord injury is in the acute phase of spinal cord injury, and indirect calorimetry is not available,  the registered dietitian may consider estimating energy needs with the Harris-Benedict formula, using admission weight, an injury factor of 1.2 and an activity factor of 1.1. No research was available to compare Harris-Benedict with other predictive equations in this population. 

    Rating: Weak
    Conditional

    SCI: Assessment: Energy Needs in the Rehabilitation Phase

    If the patient with spinal cord injury is in the rehabilitation phase, the registered dietitian may estimate energy needs using 22.7kcal per kg body weight for patients with quadriplegia and 27.9kcal per kg for those with paraplegia. Patients with spinal cord injury have reduced metabolic activity due to denervated muscle.

    Rating: Weak
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • Use of predictive equations rather than measured energy expenditure may result in under- or overfeeding persons with SCI and may lead to metabolic complications with subsequent poor outcomes such as obesity, pressure ulcer development, decreased ability to perform ADLs and transfers, heart disease and diabetes
      • The weight of stabilization devices such as braces and halos should be considered when determining the body weight of persons with spinal cord injury to avoid overfeeding.

    • Conditions of Application

      Certain predictive equations were designed for application in mechanically ventilated patients.

      The AARC Clinical Practice Guidelines (1994) recommend that measurements may be indicated in patients with the following conditions:

      • Neuro trauma
      • Paralysis
      • COPD
      • Acute pancreatitis
      • Cancer with residual tumor
      • Multiple trauma
      • Amputations
      • Patients with no accurate height or weight
      • Long-term acute care (ventilator units)
      • Severe sepsis
      • Extreme obesity
      • Severely hypermetabolic or hypometabolic patients
      • Failure to wean.

      The AARC Clinical Practice Guidelines (1994) also provide recommendations for hazards and complications, limitations of the procedures and infection control.

      Hazards and Complications

      • Short-term disconnection of a patient from the ventilator for connection to an indirect calorimetry machine may result in hypoxemia, bradycardia and patient discomfort
      • Inappropriate calibration or system setup may result in erroneous results, causing incorrect patient management
      • Isolation valves in calorimeters may increase circuit resistance and cause increased work of breathing or dynamic hyperinflation
      • Inspiratory reservoirs may cause reduction in alveolar ventilation due to increased compressible volume of the breathing circuit
      • Manipulation of the vent circuit may cause leaks that may lower alveolar ventilation.

      Limitations of the Procedure

      • Leaks in the ventilator circuit, endotracheal tube cuffs or uncuffed tubes, through chest tubes or bronchopleural fistula
      • Peritoneal and hemo-dialysis procedures remove CO2 during the treatment and require a few hours after the treatment for acid-base to stabilize. Patients should not be measured during dialysis or for four hours after these dialysis treatments.
      • Inaccurate measures may be caused by:
        • Unstable O2 delivery, due to vent blender or mixing characteristics
        • FIO2 above 60%
        • Inability to separate inspired from expired gases, due to bias flow with intermittent mandatory ventilation systems
        • Anesthetic gases other than O2, CO2 and nitrogen in the system
        • Water vapor presence
        • Inappropriate calibration
        • Total circuit flow exceeding internal gas flow of calorimeter
        • Leaks within the calorimeter
        • Inadequate measurement length.

      Measures should be done by personnel trained in and with demonstrated and documented ability to calibrate, operate and maintain the calorimeter, having a general understanding of how mechanical ventilation works and recognizing calorimeter values within the normal physiologic range.

      More frequent measures may be needed in patients with rapidly changing clinical course, as recognized by hemodynamic instability, spiking fevers, immediate post-operative status and ventilator weaning.

      Infection Control

      • Use standard precautions for contamination of blood and bodily fluids
      • Appropriate use of barriers and hand washing
      • Tubing to connect expired air from ventilator to indirect calorimetry should be disposed of or cleaned between patients
      • Connections in the inspiratory limb of the circuit should be wiped clean between patients and equipment distal to the humidifier should be disposed of
      • Bacteria filters may be used to protect equipment in inspire and expired lines.

    • Potential Costs Associated with Application

      Organizational costs are associated with equipment, maintenance of equipment, time required, staff and staff training required for measurement of energy expenditure in patients with spinal cord injury.

    • Recommendation Narrative

      Caloric Needs During the Acute Phase

      • One neutral-quality narrative review found that indirect calorimetry is more accurate than predicting energy expenditure in acute-phase SCI patients (Houda, 1993)
      • One neutral-quality longitudinal study (Barco et al, 2002) found that  energy needs predicted by the Harris-Benedict equation, with an activity factor of 1.1 and an injury factor of 1.2, correlated closely with measured energy expenditure
      • One neutral-quality longitudinal study (Rodriguez et al,  1997) found that predicting energy needs with the Harris-Benedict equation, with an activity factor of 1.2 and an injury factor of 1.6, resulted in excessive overfeeding.
      • One neutral-quality case-control study concluded that a caloric intake of 1, 500kcals per day may be sufficient to prevent nutrition-related complications (Laven et al, 1989).

      Caloric Needs During the Rehabilitation Phase

      • Two case-control studies (one positive quality and one neutral quality) found that resting energy expenditure is significantly lower in SCI patients than in able-bodied subjects (Monroe et al, 1998; Buchholz et al, 2003)
      • One positive-quality cross-sectional study found that caloric requirements generally represented 45% to 90% of caloric needs as predicted by equations. The reduction in energy needs was proportional to the amount of denervated muscle. Using current body weight, stable patients were found to require 23.4kcal per kg per day; quadriplegics required 22.7kcal per kg per day and paraplegics required 27.9kcal per kg per day (Cox et al, 1985).

    • Recommendation Strength Rationale

      • Lack of generizability across study designs
      • Further research is needed to define calorie and protein needs of SCI patients
      • Conclusion statements are Grade I and III.

    • Minority Opinions

      Consensus reached.