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SCI: Caloric and Protein Needs in Acute and Rehabilitation Phases (2007)

Citation:

Barco KT, Smith RA, Peerless JR, Plaisier BR, Chima CS. Energy expenditure assessment and validation after acute spinal cord injury. Nutrition in Clinical Practice. 2002;17:309-313.

PubMed ID: 16215006
 
Study Design:
Longitudinal Study
Class:
C - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To determine the applicability of the Harris Benedict equation in predicting energy requirements after acute SCI.
  • To evaluate the accuracy of a 30-min energy expenditure measurement to determine 24-hr requirements.
Inclusion Criteria:
Patients admitted to the surgical intensive care unit with respiratory dysfunction requiring extended mechanical ventilation after isolated SCI (tetraplegia, with lesions between C1 and C7).
Exclusion Criteria:
  • Closed head injury
  • Renal or hepatic dysfunction
  • < 18 years of age
  • Air leaks from chest tubes or endotracheal tubes
Description of Study Protocol:

Recruitment

Patients admitted to the surgical intensive care unit after isolated SCI.

 Design

Comparison of 24-h measured resting and total energy expenditure with calculations (modified Harris Benedict equation) at 1, 2, 3 and 4 weeks post injury in a group of ventilator dependent tetraplegic SCI patients.

Blinding used (if applicable)

Not applicable.

Intervention (if applicable)

Nutrition support based on predicted energy expenditure (HBEE): Harris Benedict equation modified to include an increment of 10% (activity factor for bedrest) and a 20% injury factor.  Admission wt and ht used in equation, and protein goal was estimated at 2 g/kg admission body weight.  Predicted equation not altered during the 4 week study period

Statistical Analysis

  • One-way repeat measures analysis variance to compare serial data and all pairwise multiple comparison procedures (Tukey test)
  • Pearson product moment test to determine correlation coefficients
Data Collection Summary:

Timing of Measurements

 1, 2, 3, and 4 weeks after injury

Dependent Variables

  • Measured energy expenditure (MTEE and MREE): Indirect calorimetry using the Puritan Bennett 7250 Metabolic Monitor (integrated with the 7200ae ventilator, measured for a 24-hr period between postinjury days 3 to 5, and weekly thereafter.
  • Respiratory Quotient: Puritan Bennett 7250 Metabolic Monitor
  • Calculated nitrogen balance: Formula Nin - (Nout+ 4)

Independent Variables

  • SCI level of injury within the C range

 Control Variables

  • Prealbumin (PAB)
  • UUN

 

Description of Actual Data Sample:

Initial N: 11 males with tetraplegia and ventilator-dependent

Attrition (final N): 11

Age: mean range 32 ± 8 yrs

Ethnicity: not reported

Other relevant demographics: Healthy and well nourished before injury

Anthropometrics : Mean admission weight: 86.9 kg (range 63.5 to 130)

Location: Surgical intensive care unit, MetroHealth Medical Center, Cleveland, OH

 

Summary of Results:

 

Variables

Week 1

(mean±SD)

n = 11

Week 2

(mean±SD)

n = 10

Week 3

(mean±SD)

n = 10

Week 4

(mean±SD)

n=7

Statistical Significance

Mean MTEE (kcal/d)

2468±449 2592±408 2425±434

2629±458

NS

Mean MREE (kcal/d)

2461±402 2628±381 2391±508

 2647±425

NS

RQ

0.80±0.09 0.84±0.05 0.87±0.07

 0.89±0.06

NS

Mean MTEE/HBEE (%) 96 100 95 95  
Mean MREE/MTEE (%) 102 101 98 98  

 Other Findings

  • Mean body weight decreased by 9% over the study period
  • Patients received approximately 2/3 of MTEE and calculated protein requirements during the first 2 weeks, which improved to 100% or more by weeks 3 and 4
  • UUN excretion was elevated at > 22 g/d during the 4 week period
  • Nitrogen balance remained negative over the study period
  • There was a positive trend in mean PAB (wk 1 = 13.7 mg/dl; wk 4 = 31.3 mg/dl)

 

Author Conclusion:

While there is a strong correlation between the modified Harris Benedict equation and 24-hr measured total energy expenditure, serial metabolic monitoring is recommended, when available, to account for individual variation.

A resting energy expenditure measurement is adequate to determine daily calorie requirements

Visceral protein synthesis can be achieved despite a negative nitrogen balance

Further metabolic studies on this patient population that include correlation of energy requirements with the level of SCI in the acute phase are indicated.

The present study confirms that SCI patients with complete lesions have increased energy requirements after injury

Funding Source:
Reviewer Comments:
  • Small sample size
  • Subjects do not reflect the larger SCI population (those not on ventilators, or not in the acute phase of SCI)
  • Some loss of subject follow-up during the 4 weeks. 
  • While subjects experienced negative nitrogen balance throughout the study, changes in body compartments were not assessed so the assumption (based on nitrogen balance) that patients lost lean body mass cannot be verified.
  • Predicted energy expenditure (HBEE) was not altered during the 4-week study period to reflect changes in body weight, as changes in body compartments couldn't be measured
  • All subjects were intolerant of gastric feedings intermittently during the first 2 weeks postinjury, and during this time received approximately 2/3 of MTEE and calculated protein requirements.  During the last 2 weeks they received 100% of MTEE and calculated protein requirements.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
  1. Was the research question clearly stated? Yes
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
  1.3. Were the target population and setting specified? Yes
  2. Was the selection of study subjects/patients free from bias? ???
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? N/A
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? ???
  2.3. Were health, demographics, and other characteristics of subjects described? ???
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
  3. Were study groups comparable? N/A
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
  4. Was method of handling withdrawals described? No
4. Was method of handling withdrawals described? No
  4.1. Were follow-up methods described and the same for all groups? ???
  4.1. Were follow-up methods described and the same for all groups? ???
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) No
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? No
  4.4. Were reasons for withdrawals similar across groups? ???
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
  5. Was blinding used to prevent introduction of bias? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
  6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? ???
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? ???
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? ???
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? ???
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? No
  6.6. Were extra or unplanned treatments described? No
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
  7. Were outcomes clearly defined and the measurements valid and reliable? Yes
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  7.7. Were the measurements conducted consistently across groups? N/A
  7.7. Were the measurements conducted consistently across groups? N/A
  8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
  9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
  10. Is bias due to study's funding or sponsorship unlikely? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? ???
  10.1. Were sources of funding and investigators' affiliations described? ???
  10.2. Was the study free from apparent conflict of interest? Yes
  10.2. Was the study free from apparent conflict of interest? Yes