EE: Body Positions in Critically Ill 2013
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.
EE: RMR Measurements in the Usual Body Position in Critically Ill
The registered dietitian nutritionist (RDN) should conduct indirect calorimetry measurements in the critically ill patient who is in the semi-recumbent posture (standard position in the ICU). However, it is acceptable to measure the patient in the non-semi-recumbent position, if that is their usual body position. Limited research reports that posture can affect the accuracy of the measurement of resting metabolic rate (RMR) in some critically ill patients.
EE: RMR Measurements After Changes in Usual Body Position in Critically Ill
In critically ill patients, if the patient's usual body position changes temporarily, the RDN should wait until the patient is moved back into the usual body position in order to perform indirect calorimetry. If the patient's usual body position changes to a new permanent position (e.g., change in head of bed elevation), the RDN should conduct a new indirect calorimetry measurement. See Rest Period Duration for Measuring RMR. Limited research reports that posture can affect the accuracy of the measurement of resting metabolic rate (RMR) in some critically ill patients.
Risks/Harms of Implementing This Recommendation
There are no potential risks or harms associated with the application of this recommendation.
Conditions of Application
- The RDN should inquire with the interdisciplinary team to determine if the patient's position is temporary or permanent
- Moving the patient only for the measurement of indirect calorimetry may increase the risk of injury, pain and negative health outcomes to patients (PHAMA, 2010).
Potential Costs Associated with Application
There are no obvious costs that may be associated with the application of this recommendation.
Only one study was included in the evidence analysis to support the recommendations:
- One positive-quality before-and-after study (Brandi et al, 1996) provides limited evidence that posture can affect measurement of RMR in some critically ill patients. One study reported that energy expenditure was significantly greater in the supine position than in the 30-degree head of bed elevation post-operatively, possibly attributed to increased work of breathing because these patients were not mechanically ventilated.
- Further research is necessary to determine if there are differences between sitting upright and lying semi-recumbent in intubated vs. non-intubated patients
- No new studies were identified in the update of this question.
Recommendation Strength Rationale
Conclusion statement is Grade III.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Is there a difference in accuracy of RMR measurements related to the effects of different body positions in the critically ill population?
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and American Dietetic Association (ADA): standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in nutrition support
- Task Force of A.S.P.E.N; American Dietetic Association Dietitians in Nutrition Support Dietetic Practice Group, Russell M, Stieber M, Brantley S, Freeman AM, Lefton J, Malone AM, Roberts S, Skates J, Young LS; A.S.P.E.N. Board of Directors; ADA Quality Management Committee. Nutr Clin Pract. 2007 Oct; 22 (5): 558-586.
- PHAMA Patient Handling and Movement Assessments: A White Paper. Prepared by the 2010 Health Guidelines Revision Committee Specialty Subcommittee on Patient Movement: Martin H. Cohen, Gaius G. Nelson, David A. Green, Robert Leib, Mary W. Matz, et al. Carla M. Bordon, editor. 2010. Accessed online 1/23/2012: http://www.fgiguidelines.org/pdfs/FGI_PHAMA_whitepaper_042810.pdf.