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Energy Expenditure

EE: Scope of Guideline (2013)

Guideline Scope Characteristics

Below you will find a list of characteristics that describe the Scope of this Guideline.

Disease/Condition(s)

The Guideline is intended to be used by the registered dietitian nutritionist (RDN) and other trained health professionals involved in the nutritional care of the critically ill. The recommendations are intended to provide healthcare practitioners with guidance and direction based on the current scientific evidence for measuring resting metabolic rate (RMR) in the critically ill population in order to promote positive clinical outcomes.

The Guideline assumes that the practitioner conducting RMR measurements is trained on the specific indirect calorimetry device used in the facility and has achieved technical competency. In addition, it is assumed that the practitioner is familiar with the facility's protocol and privileges for measuring RMR. 

Guideline Category

Technology Assessment

Clinical Specialty

Critical Care, Nutrition

Intended Users

Registered Dietitians, Advanced Practice Nurses, Allied Health Personnel, Nurses, Physician Assistants, Physicians, Respiratory Care Practitioners, Students

Guideline Objective(s)

Overall Objective

  • To provide practice guidelines for measuring RMR in the critically ill patient to improve accuracy of the indirect calorimetry measurement.

Specific Objectives

  • To define evidence-based recommendations for the measurement of RMR, using indirect calorimetry by RDNs in collaboration with other healthcare providers
  • To guide practice decisions that integrate medical and nutritional elements
  • To reduce variations in measurement practices among RDNs
  • To provide the RDN with evidence-based practice recommendations to adjust the medical nutrition therapy (MNT) or recommend other therapies to achieve positive outcomes
  • To promote optimal nutrition support within cost constraints of the healthcare environment.  

Target Population

Pre-school Child (2 to 5 years), Child (6 to 12 years), Adolescent (13 to 18 years), Adult (19 to 44 years), Middle Age (45 to 64 years), Aged (65 to 79 years), Male, Female

Target Population Description

Critically ill patients requiring or eligible for nutrition support in the intensive care unit (ICU).

Medical and surgical conditions where this guideline may apply include:

  • Sepsis and systemic inflammatory response syndrome (SIRS)
  • Trauma
  • Neurological injury such as traumatic brain injury, stroke, ALS, etc.
  • Pancreatitis
  • Respiratory failure
  • Multi-organ failure
  • Surgery
  • Amputations
  • Extreme obesity, underweight, or unusual stature
  • Failure to wean from mechanical ventilation
  • Paralysis.

The evidence for the guideline did not include or specifically examine populations that were exclusively patients with burns, although many of the principles may apply. Some of the principles may apply to pediatric populations, but the evidence in this patient group was limited in the current project.

Future Research Needs

Additional research is needed in the critically ill population to: 

Confirm:

  • The length of rest period needed prior to measurement of RMR and to determine the minimum time to recover after routine ICU care, taking sedation level into account. (The potential for sedation to shorten the rest period has not been studied.)
  • The effect of time of day (diurnal variation) on metabolic rate in patients who are spontaneously breathing, in the fasted state or being intermittently fed
  • The thermic effect of continuous feeding.

Determine:

  • If there are differences between sitting upright and lying semi-recumbent at 30 degrees in intubated vs. non-intubated patients
  • If there are differences in RMR measurement accuracy between different types of gas collection devices
  • The effect of sedation on diurnal variation in RMR 
  • The effect of time of day (diurnal variation) on RMR, as well as TEE
  • The effect of diurnal variation in patients who are not mechanically ventilated while receiving continuous feedings
  • The room conditions (temperature, noise level, humidity and lighting) required for accurate RMR measurement in the critically ill (non-burn) population
  • The range of thermoneutrality
  • If there is a thermic effect of bolus or intermittent feeding
  • The accuracy of RQ to detect RMR measurement error.

Interventions and Practices Considered

The Evidence-Based Nutrition Practice Guideline for Measuring Resting Metabolic Rate (RMR) in the Critically Ill is based on the Academy of Nutrition and Dietetic's Nutrition Care Process and Model, which involves the following steps. Terms relevant to the treatment of critically ill patients come from the International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Fourth Edition.

  • Nutrition Assessment
  • Nutrition Diagnosis
  • Nutrition Intervention
  • Nutrition Monitoring and Evaluation.

This guideline addresses topics that correspond to the following areas of the Nutrition Care Process. Please refer to the algorithm in this guideline for a more detailed view of the recommendations and their application within the Nutrition Care Process.

I. Referral to a Registered Dietitian Nutritionist
II. Medical Nutrition Therapy

A. Nutrition Assessment

Click here to view the complete list of nutrition assessment terms from International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process, Fourth Edition.

B. Nutrition Diagnosis

Click here to view the complete list of nutrition diagnoses-related terms from International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process, Fourth Edition. 

C. Nutrition Intervention (Planning and Implementation)

Individualized nutrition prescription is based on current reference standards and dietary guidelines and the patient/client’s health condition and nutrition diagnosis:

  • Formula/solution 
  • Nutritional needs of patient
  • Medical status
  • Current clinical status
  • Total energy estimated needs
  • Methods for estimating needs.

Click here to view the complete list of nutrition intervention terms from International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process, Fourth Edition.

D. Monitoring and Evaluation

Monitoring and evaluation are critical components in reassessing the adequacy and success of the nutrition support intervention.

Click here to view the complete list of nutrition monitoring and evaluation terms from International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process, Fourth Edition.