Critical Illness

CI: Calorie/Energy Needs (2007)

• Assessment
  What level of energy intake (or what caloric delivery) is associated with improvements in mortality?

  • Conclusion

    Actual energy intake of 9 to 18 kcal per kg may be associated with decreased mortality in nonobese critically ill medical patients, based on a single positive quality prospective cohort study of 187 patients.  It is important to emphasize that the calorie intake associated with decreased mortality in this study was actual intake and not goal, so that setting goal calorie level in the range of 9-18 kcal per kg will likely result in actual intake that is less than this range.  Three other smaller, possibly underpowered studies failed to show any association between energy intake and mortality in other ICU populations.

  • Grade: III
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What level of energy intake (or what caloric delivery) is associated with improvements in mortality?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Bartlett RH, Dechert RE, Mault JR, et al.  Measurement of metabolism in multiple organ failure.  Surgery 1982;92:771-779.
      • Battistella FD, Widergren JT, Anderson JT, Siepler JK, Weber JC, MacColl K. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. J Trauma 1997;43:52-58.
      •  Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: An observational study. Clinical Nutrition. 2006 25:37-44.
      • Krishnan JA, Parce PB, Martinez, Dietz GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes.  Chest 2003;124:297-305.
      • Villet S, Chiolero RL, Bollmann MD, et al.  Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.  Clin Nutr 2005;24:502-509. 
  • Search Plan and Results: CI: Energy Intake and Clinical Outcomes 2007
     
  What level of energy intake (or what caloric delivery) is associated with improvements in rate of infectious complications?

  • Conclusion
    There is fair evidence that infectious complications are increased in critically ill patients who have very low caloric intake. In one positive quality prospective cohort study, patients who received <25% of AACP energy goal had increased infection rate.
  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What level of energy intake (or what caloric delivery) is associated with improvements in rate of infectious complications?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Battistella FD, Widergren JT, Anderson JT, Siepler JK, Weber JC, MacColl K. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. J Trauma 1997;43:52-58.
      •  Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: An observational study. Clinical Nutrition. 2006 25:37-44.
      • Krishnan JA, Parce PB, Martinez, Dietz GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes.  Chest 2003;124:297-305.
      • Rubinson L, Diette GB, Xiaoyan S, et al.  Low calorie intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit.  Crit Care Med 2004;32:350-357.
      • Villet S, Chiolero RL, Bollmann MD, et al.  Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.  Clin Nutr 2005;24:502-509. 
  • Search Plan and Results: CI: Energy Intake and Clinical Outcomes 2007
     
  What level of energy intake (or what caloric delivery) is associated with improvements in length of hospital stay?

  • Conclusion
    There is fair evidence that energy intake in the ICU does not affect hospital or ICU length of stay.

     

     

                     

              

     

     

     

     

     

     

     

     

     
  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What level of energy intake (or what caloric delivery) is associated with improvements in length of hospital stay?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Battistella FD, Widergren JT, Anderson JT, Siepler JK, Weber JC, MacColl K. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. J Trauma 1997;43:52-58.
      •  Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: An observational study. Clinical Nutrition. 2006 25:37-44.
      • Hise ME, Halterman K, Gajewski BJ, Parkhurst M, Moncure M, Brown JC. Feeding practices of severely ill intensive care unit patients: an evaluation of energy sources and clinical outcomes. J Am Diet Assoc. 2007;107:458-465.
      • Kan MN, Chang HH, Sheu WF, Cheng CH, Lee BJ, Huang YC. Estimation of energy requirements for mechanically ventilated, critically ill patients using nutritional status. Crit Care. 2003;7(5):R108. 
      • Krishnan JA, Parce PB, Martinez, Dietz GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes.  Chest 2003;124:297-305.
      • Villet S, Chiolero RL, Bollmann MD, et al.  Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.  Clin Nutr 2005;24:502-509. 
  • Search Plan and Results: CI: Energy Intake and Clinical Outcomes 2007
     
  What level of energy intake (or what caloric delivery) is associated with improvements in days on mechanical ventilation?

  • Conclusion

    Energy intake may have impact on days on mechanical ventilation.  Within the first 10 days in the ICU, actual delivery of < 21 nonprotein kcals per kg by PN is associated with fewer days on mechanical ventilation.  Actual delivery of 9-18 kcals per kg by EN is also associated with fewer days on mechanical ventilation.  Further studies are needed.

  • Grade: III
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What level of energy intake (or what caloric delivery) is associated with improvements in days on mechanical ventilation?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Battistella FD, Widergren JT, Anderson JT, Siepler JK, Weber JC, MacColl K. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. J Trauma 1997;43:52-58.
      •  Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: An observational study. Clinical Nutrition. 2006 25:37-44.
      • Higgins PA, Daly BJ, Lipson AR, Guo SE. Assessing nutritional status in chronically critically ill adult patients. Am J Crit Care 2006;15(2):166-76.
      • Kan MN, Chang HH, Sheu WF, Cheng CH, Lee BJ, Huang YC. Estimation of energy requirements for mechanically ventilated, critically ill patients using nutritional status. Crit Care. 2003;7(5):R108. 
      • Krishnan JA, Parce PB, Martinez, Dietz GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes.  Chest 2003;124:297-305.
      • Villet S, Chiolero RL, Bollmann MD, et al.  Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.  Clin Nutr 2005;24:502-509. 
  • Search Plan and Results: CI: Energy Intake and Clinical Outcomes 2007
     
  What level of energy intake (or what caloric delivery) is associated with improvements in cost of medical care?

  • Conclusion
    To date, adequately powered studies have not been conducted to demonstrate that level of energy intake is associated with improvements in cost of medical care.
  • Grade: V
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Search Plan and Results: CI: Energy Intake and Clinical Outcomes 2007