Nutritional Support: Macronutrient Formulation (Assessment of Energy and Substrate Requirements)

Published 2003
Citation: J Trauma. 57(3):660-679, September 2004.

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I. Statement of the Problem

Provision of adequate calories and protein to the hypermetabolic injured patient is of paramount importance in achieving optimal outcomes for these patients. Failure to meet caloric requirements leads to erosion of lean body mass and subsequent negative nitrogen balance as the body attempts to provide sufficient energy and nitrogen to carry out vital functions. Conversely, overzealous nutritional support is associated with derangements in hepatic, pulmonary, and immunologic function and may lead to outcomes nearly as detrimental to the injured patient as malnutrition.

II. Process

A. Identification of References

References were identified from a computerized search of the National Library of Medicine for English language citations between 1973 and 2000. Keywords included: nutritional support, trauma, critically injured, head injury, spinal cord injury, paraplegia, quadriplegia, burns, energy expenditure, energy intake, enteral, parenteral, dietary proteins, dietary fats, dietary carbohydrates, protein, carbohydrate, fat, lipid, requirements, and nutrition. Studies involving laboratory animals were excluded from our review, as were studies where the patient population was exclusively or predominantly pediatric so as to avoid the effect of growth and maturation of the patient on energy and substrate requirements. The bibliographies of the selected references were reviewed for relevant articles not found in the computerized search. Literature reviews, case reports, and editorials were excluded. Seventy-three articles were identified.

B. Quality of the References

The quality assessment instrument applied to the references was developed by the Brain Trauma Foundation and subsequently adopted by the EAST Practice Management Guidelines Committee. Articles were classified as Class I, II, or III according to the following definitions (one article was classified as Class I and Class II):

Class I: A prospective, randomized clinical trial. Eighteen articles were chosen and analyzed.

Class II: A prospective, non-comparative clinical study or a retrospective analysis based on reliable data. Forty-two articles were chosen and analyzed.

Class III: A retrospective case series or database review. Thirteen articles were chosen and analyzed.

III. Recommendations

ALevel 1

There appears to be no advantage to the routine use of calorimetry to determine the caloric requirements of burn patients.

B. Level II

  1. For moderately to severely injured patients (ISS 25-30), energy requirements are estimated to be 25-30 total kcal/kg/day or 120% to 140% of predicted BEE (per Harris-Benedict equation).
  2. There appears to be no consistent relationship between ISS and measured resting energy expenditure (MREE) in trauma patients.
  3. For patients with severe head injury (GCS score <8), energy requirements may be met by replacing 140% of MREE (~30 total kcal/kg/day) in non-pharmacologically paralyzed patients and 100% of MREE (~25 kcal/kg/day) in paralyzed patients.
  4. Within the first 2 weeks after spinal cord injury, nutritional support should be delivered at 20-22 total kcal/kg/day (55% to 90% of predicted BEE by Harris-Benedict equation) for quadriplegics and 22-24 total kcal/kg/day (80% to 90% of predicted BEE by Harris-Benedict equation) for paraplegics.
  5. For patients with burns exceeding 20% to 30% TBSA, initial caloric requirements may be estimated by several available formulas.
  6. The Curreri formula (25 kcal/kg + 40kcal/TBSA burn) overestimates caloric needs of the burn patient (as estimated by calorimetry) by 25% to 50%.
  7. The Harris-Benedict formula underestimates the caloric needs of the burn patient (as estimated by calorimetry) by 25% to 50%.
  8. In patients with burns exceeding 50% TBSA, TPN supplementation of enteral feedings to achieve Curreri-predicted caloric requirements is associated with higher mortality and aberrations in T-cell function.
  9. Caloric requirements for major burns fluctuate during the hospital course but appear to follow a biphasic course with energy expenditure declining as the burn wound closes. Therefore, direct measurement of energy expenditure via calorimetry once or twice weekly may be of benefit in adjusting caloric support throughout the hospital course.
  10. Intraoperative enteral feeding of the burn patient is safe and efficacious, leads to fewer interruptions in the enteral feeding regimen, and, therefore, more successful attainment of calorie and protein goals.
  11. Approximately 1.25 grams of protein per kg body weight per day is appropriate for most injured patients.
  12. Up to 2 grams of protein per kg body weight per day is appropriate for severely burned patients.
  13. In the burn patient, energy as carbohydrate may be provided at a rate of up to 5 mg/kg/min (~25 kcal/kg/day); exceeding this limit may predispose patients to the metabolic complications associated with overfeeding. In the non-burn trauma patient, even this rate of carbohydrate delivery may be excessive.
  14. Intravenous lipid or fat intake should be carefully monitored and maintained at <30 percent of total calories. Zero fat or minimal fat administration to burned or traumatically injured patients during the acute phase of injury may minimize the susceptibility to infection and decrease length of stay.
  15. Proteins, fat, and carbohydrate requirements do not appear to vary significantly according to the route of administration, either enterally or parenterally.
  16. Fat or carbohydrate requirements do not appear to vary significantly according to the type of injury, i.e., burned versus traumatically injured.

C. Level III

  1. Provision of excess calories to trauma patients may induce hyperglycemia, excess CO2 production, fluid/electrolyte abnormalities, lipogenesis, and hepatic steatosis.
  2. Energy requirements for patients with less than 20% to 30% TBSA burns are similar to those of patients without cutaneous burns.
  3. Protein requirements in burn patients and in those with severe CNS injuries may be significantly greater than anticipated, up to 2.2 grams/kg body weight per day. However, the ability to achieve positive nitrogen balance in a given patient varies according to the phase of injury. Provision of large protein loads to elderly patients or to those with compromised hepatic, renal, or pulmonary function may lead to deleterious outcomes.

IV. Scientific Foundation

Calorie requirements of trauma patients have been debated for years. The gold standard for determining the caloric needs of patients with traumatic injuries is to measure their energy expenditure with indirect calorimetry. By measuring oxygen consumption (VO2) and carbon dioxide production (VCO2) via indirect calorimetry, resting energy expenditure can be calculated using the abbreviated Weir equation: REE = [3.9 (VO2) + 1.1 (VCO2] x 1.44. Despite the availability of this technology, there have been few prospective, randomized clinical trials conducted specifically to determine the optimal number of calories for this patient population. The best study to date that has addressed this issue with Class I evidence compared the effect of three different parenteral nutrition regimens (hypercaloric, isocaloric, hypocaloric) on protein catabolism and nitrogen loss when protein administration was fixed at 1.7 g/kg/day.[1] Caloric needs were provided at 125% of measured resting energy expenditure (MREE) in the hypercaloric group, 100% of MREE in the isocaloric group, and 75% of MREE in the hypocaloric group. The mean ISS was 27 for all three groups, and patients with burn, spinal cord, or isolated head injuries were excluded from study enrollment. Despite significant differences in caloric provision, no significant differences were observed in nitrogen balance, 3-methylhistidine excretion, or visceral protein status among the groups. The mean MREE was approximately 28 kcal/kg/day for all patients on day 4 of the study. However, 80% (24/30) of the patients were sedated with fentanyl, and 7% (2/30) of the patients were pharmacologically paralyzed. Both of these treatment interventions have been associated with a hypometabolic response in neurologically injured patients. The only additional Class I evidence available is derived from a trial comparing the metabolic effects of a carbohydrate-based diet with a fat-based diet in critically ill patients with infections or trauma.[2] Only 2 of 12 patients were identified as having traumatic injuries. The mean MREE was approximately 26 kcal/kg/day for patients while receiving the different nutritional regimens. Demographic data describing the severity of illness or injury of the patients were not provided in the study.

Several methods have been used to estimate energy requirements of patients with traumatic injuries as an alternative to measuring actual energy requirements with indirect calorimetry. These include calculating basal energy expenditure with the Harris-Benedict energy equation (HBEE), multiplying the HBEE by an activity factor and a stress factor depending on the type of injury (i.e., blunt trauma, skeletal trauma, head trauma) and using 25 kcal/kg/day. A number of clinical trials have evaluated the accuracy of these predictive methods for estimating MREE in trauma patients. The MREE of trauma patients has been variously reported to be approximately 26 kcal/kg/day (range, 21-32 kcal/kg/day), 33 kcal/kg/day (postabsorptive state [range, 25-41 kcal/kg/day]), 37 kcal/kg/day (while receiving parenteral nutrition [range, 29-46 kcal/kg/day]), 38-48 kcal/kg/day (requiring insulin in TPN), and HBEE x 1.2 (activity factor) x

1.75 (stress factor).[3-6] One recent study noted a biphasic metabolic response to injury, with total energy expenditure (TEE) peaking during the second post-injury week at 59 kcal/kg/day, compared with only 31 kcal/kg/day during the first post-injury week.[7] Furthermore, these studies have attempted to identify a relationship between MREE and scoring systems used to evaluate the severity of disease and injury. Although some investigators [8] [9] have found no correlation (r=-0.042) between MREE and injury severity score (ISS), others[4] have reported a relatively high correlation between ISS and MREE/kg (r=0.84).

Head and spinal cord injury patients represent a subset of trauma patients with unique metabolic requirements. Most clinical trials report hypermetabolism in head-injured patients with an average increase of 40% above that predicted with HBEE.[10] The increases in energy expenditure are related to the increased oxygen consumption caused by the stress hormone flow in response to brain injury and may further be increased by hyperventilation, fever, seizures, and posturing. Patients with decerebrate or decorticate posturing have demonstrated elevations in energy expenditure at 200% to 250% of predicted energy expenditure.[11] Pharmacologic treatments have also been shown to dramatically impact energy expenditure.[10] High-dose barbiturates have been used to control increased intracranial pressures refractory to standard therapy. However, barbiturate therapy can decrease energy expenditure by as much as 40% below that predicted with HBEE.[12] Other pharmacologic interventions, such as neuromuscular blockade with pancuronium bromide, have reduced energy expenditure by 42% below predicted energy expenditure with HBEE.[11]

In contrast to trauma and head injury patients, spinal cord injury patients exhibit a decrease in energy expenditure. Within the first 3 weeks following spinal cord injury, metabolic rates 94% (range, 55% to 129%) of those predicted by HBEE have been observed.[13] An inverse relationship has been identified between the location of injury and energy expenditure. Thus, the higher the lesion, the lower the energy expenditure measurement. Nutrition support recommendations for quadriplegics are 20% to 40% below HBEE (20-22 kcal/kg/day) and 10% to 20% below HBEE for paraplegics. Recognizing the hypometabolic response in spinal cord injury patients is important because overfeeding can have adverse effects. Providing calories in excess of energy expenditure in any patient can cause: (1) impaired glucose control, (2) suppression of chemotactic/phagocytic actions of monocytes due to hyperglycemia, (3) respiratory dysfunction from excessive CO2 production, (4) lipogenesis, and (5) hepatic steatosis.

Energy requirements in the burn patient are difficult to determine because many factors impact this calculation. Early studies demonstrated a relationship between the percentage of TBSA burned and energy requirements in these patients as determined by indirect or direct calorimetry. Wilmore[14]was the first to document this relationship in his study of 20 patients with burns ranging from 7% to 84% TBSA. He further noted that this hypermetabolism appeared to be mediated by catecholamines and appeared to plateau at 60% TBSA. During that same year Curreri,[15] in a prospective study of 9 patients, derived a formula, now bearing his name, relating energy expenditure to preburn weight and the percent TBSA burned. Although subsequent studies have shown that this formula frequently overestimates actual energy requirements, it remains one of the most, if not the most, commonly used method to determine energy requirements of patients in burn centers in the United States today.[16]

Since the Curreri study, many formulas have been proposed as more accurate predictors of caloric requirements of the burned patient. The formulas tend to fall into two broad categories, formulas which include a factor for TBSA burned and those which do not. The majority of formulas in this latter category are based on calculations of basal energy expenditure (BEE) as determined by the Harris-Benedict equation, which takes into account patient age, sex, height, and weight. To the BEE are multiplied factors for the degree of stress (injury) and for the level of patient activity to arrive at an estimate for the patient’s overall caloric requirement. Many studies have compared the Curreri formula with formulas based on the Harris-Benedict­derived BEE. Turner and colleagues[17]completed such a prospective study in 35 patients with second- and third-degree burns ranging between 10% and 75% TBSA and concluded that the Harris-Benedict-derived BEE underestimated actual energy expenditure by 23%, while the Curreri formula overestimated energy expenditure by 58%. Long and coworkers[18] measured energy expenditure in 39 critically ill patients and in 20 normal volunteers, finding that energy expenditure in burned patients exceeded that predicted by the Harris-Benedict equation by 132%. They suggested that the Harris-Benedict equation be multiplied by a stress factor as well as an activity factor to arrive at a more accurate estimation of caloric requirements. In fact, the values for stress and activity factors, which he proposed nearly 20 years ago, are still widely employed today.

However, even with these correction factors, Harris-Benedict predictions seem to perform no better than the Curreri formula. In a prospective study of 21 patients with between 21% and 81% TBSA burns, the Curreri formula overestimated actual energy expenditure by 25% to 36%, while the Harris-Benedict predictions modified by stress and activity factors, overestimated actual energy expenditure by 32% to 39%.[19] Other Harris-Benedict-derived formulas have attempted to simplify matters by simply multiplying the Harris-Benedict-derived BEE by either 1.5[20] or by a factor of 2.[21]Each of these authors claim superiority over Curreri­based predictions which, as indicated above, seem to consistently overestimate actual energy expenditure as determined by indirect calorimetry.

The other major category of energy-predicting formulas in burn patients includes those which, like the Curreri formula, are based on the patient’s TBSA and/or TBSA burned. Both Xie[22] and Allard[23]have compared their TBSA-based formulas with the Curreri formula and claim superior results, though the overall number of patients studied is quite small.

Despite the many published studies which claim superiority of a particular formula over the Curreri Formula in the prediction of energy requirements in burn patients, the Curreri Formula remains the most commonly used despite its well-documented propensity to overestimate energy requirements.[16] One would suspect, therefore, that actual determination of energy expenditure by indirect calorimetry, might be the most accurate and commonly used method of determining caloric requirements of burned patients. However, in an interesting study documenting actual burn practices in North American burn centers, Williamson[16] noted that indirect calorimetry is infrequently carried out on a routine basis, being used only occasionally or for research purposes only. More importantly, there appear to be no differences in patient outcome when calories are provided on the basis of direct measurement of energy expenditure or on the basis of a mathematical formula. In a prospective randomized study of 49 patients, patients received feedings based on the Curreri formula or on indirect calorimetry-determined energy expenditure. Despite the significant difference in the number of calories prescribed to each group, the actual number of calories received by each group were the same, and there were no differences in clinical outcomes or complications.[24] An important finding in this study was the discrepancy between the number of calories prescribed and the number of calories delivered to these burn patients. Regardless of whether the Curreri formula is used or the BEE is multiplied by an activity factor and/or a stress factor, it is frequently difficult, if not impossible, for a patient to ingest this number of calories. Indeed, in Ireton's study mentioned above,[20] patients received a caloric intake of only 81% of the calculated Curreri-predicted caloric requirement. Thus, it is perhaps advantageous that many of these formulas overestimate caloric need to compensate for the less-than-prescribed caloric load that these patients actually receive.

At the same time, however, it seems unwise to attempt to achieve these high caloric loads by supplementing enteral nutrition with TPN. In a prospective randomized study of 39 patients with TBSA burns exceeding 50%, Herndon et al.[25] demonstrated a significantly higher mortality and greater depressions in T-helper/suppressor ratios in patients receiving TPN.

Thus, the available data support the use of some formula to determine the initial caloric requirements of burned patients, recognizing that formulas may over-estimate a patient’s actual caloric need and that it is unlikely that the entire caloric load can be delivered. One common reason for the inability to deliver the prescribed caloric load in burn patients is the need to interrupt the tube feeding regimen for frequent debridement and grafting in the operating room. The Williamson survey[16] documents that most patients in North American burn centers are kept NPO for at least 6 to 8 hours before surgery. Jenkins,[26] however, demonstrated the feasibility and safety of continuing enteral feedings throughout operative procedures in a very select group of burn patients with enteral access established beyond the pylorus and airway access established via an endotracheal tube or tracheostomy. These investigators demonstrated significant caloric deficits and an increased incidence of wound infection in the unfed group compared with the group that underwent intraoperative enteral feeding.

Finally, it should be mentioned that the caloric requirements of the burn patient fluctuate over the course of burn wound healing due to closure of the burn wound and other undetermined factors. Saffle and colleagues[27] demonstrated the biphasic character of measured energy expenditures in burn patients. Energy expenditures actually rise from the time of admission through the 10th to 20th post-burn day and then decline thereafter but remain elevated at the time of discharge. This observation was confirmed by Cunningham[21] as well as by Ruten,[28] who noted a trend toward decreased energy expenditures with excision and coverage of the burn wound. Ireton-Jones,[29]however, was unable to identify a relationship between the percent of burn wound remaining open and the measured energy expenditure. Even in the absence of a demonstrated relationship between the percent of burn wound remaining open and energy expenditure, the caloric needs of the burn patient fluctuate from day to day depending on other factors such as temperature, activity level, degree of anxiety, pain control, ventilator dependency, caloric intake, the presence or absence of sepsis, and other yet-to-be defined factors. Therefore, providing the same caloric requirement over time runs the risk of overfeeding or underfeeding the burned patient. This has led some authors to recommend the use of indirect calorimetry to determine actual caloric requirements on a weekly or twice-weekly basis.[19] [30] [31]

At this time, there are insufficient data and on protein, fat, and carbohydrate requirements in traumatically injured or burned patients to provide any Level One recommendations. One major problem is the difficulty identifying specific groups of patients for study. For this reason, guidelines can only be applied broadly to patients within these two general categories. Another issue is that the current focus of nutrition and metabolic support has necessarily changed. The state of the art is such that we are less concerned with how to provide adequate quantities of macronutrients. The bulk of available evidence suggests that, with the exception of the risk of overfeeding, we currently provide patients with sufficient calories and protein to avoid the detrimental effects of malnutrition. Our attention has shifted toward manipulating a patient’s physiological and biochemical environment to his or her advantage through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses.

A few Class I reports, randomized, prospective and adequately controlled trials, have presented “convincingly justifiable” data. However, in these instances, either the number of patients studied was too small or the particular population investigated was too specialized to warrant inclusion in this practice management guideline.

Protein requirements were largely established by reports from the early 1980s that presented dose ranges believed to be appropriate. Most of these reports are Class II studies.[6] [32-35] More recent publications have confirmed these dose ranges based on extensive research conducted by a leading investigator,[36] [37] studies of protein requirements using state-of-the-art measurements of body composition,[38] measurements of substrate metabolism and energy requirements,[39] or expert opinions based on reviews of available literature.[40] [41]

The focus of other investigations has not been on specific protein requirements, but these studies provide a reference point for the range of protein intakes that appear to be efficacious.[2] [42-45]Variations in protein requirements as a function of time after burn or injury have been acknowledged illustrating that current recommendations are only estimates of average need.[46]

The question of whether the contribution from protein should or should not be included in calculations of total caloric intake has not been specifically addressed. However, the preponderance of evidence available from detailed studies of actual energy expenditure[21] [47] or nutrient utilization,[48] [49] reviews of published reports,[50] or prospective trials[51] [52] suggest that the majority of calories should be administered as carbohydrate. Although the exact percentage of total calories needed as fat is unknown, consensus opinion suggests that 30% or less is sufficient under most circumstances. This conclusion does not obviate the need to modify carbohydrate administration to minimize CO2 production in selected instances,[47] [49] [50] but the specific range under which these modifications should occur has not been established. Some reports, though not all,[53] especially the Class I report by Battistella,[54] suggest that minimizing fat intake or altering the type of fat administered[55-57] may decrease morbidity and improve outcome or favorably alter metabolic profiles.

A few reports suggest that the specific macronutrients administered[56] [58] or the use of growth factors[45] [59-61] may favorably influence metabolic responses. However, recent preliminary reports suggest that the use of growth hormone for this purpose in critically ill patients may be associated with deleterious outcomes.

V. Summary

Multiple formulas provide an estimate of an individual patient’s energy and substrate needs. While many of these provide accurate estimates, many do not and can lead to overfeeding with all of its inherent complications. It is best to remember that these formulas provide at best only an estimate of an individual patient’s initial energy and substrate needs, and that these requirements will vary throughout the course of illness and recovery. Ongoing assessment of the appropriateness of nutritional support is crucial in avoiding under- and over-feeding.

VI. Future Investigation

It is unlikely that there is an ideal energy or substrate formula that will perform better than those currently in use. However, more reliable and easier-to-use means of measuring energy expenditure and substrate use would have significant advantages over the current state of technology with indirect calorimetry. Identification of these markers of metabolism will help in assessing a patient’s initial requirements and will help the clinician modify nutritional support throughout the course of illness and recovery. It is unlikely that prospective, randomized, double-blinded controlled trials will study the effects of the administration of different quantities of protein, fat, or carbohydrate. Our present health care environment requires a clearer delineation of the indications for nutritional or metabolic support and for unequivocal demonstrations of efficacy with regard to decreasing costs and improving outcomes. Important issues that should be examined include: 1) the nature of injury and its time course, with the goal of minimizing the effects of nutritional, especially parenteral, interventions; 2) the effects of macronutrients administration on cellular biology and organ function during critical illness; and 3) the identification of groups of patients who will benefit from the administration of specific nutrients or growth factors, who needs them, what kind, and when?

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  53. Bernier J, Jobin N, Emptoz-Bonneton A, Pugeat MM, Garrel DR. Decreased corticosteroid-binding globulin in burn patients: relationship with interleukin-6 and fat in nutritional support. Crit Care Med. 1998;26:452-460.
  54. 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;43:52-60.
  55. Alexander JW, Gottschlich MM. Nutritional immunomodulation in burn patients. Crit Care Med. 1990;18(2 Suppl):S149-S153.
  56. Brown RO, Hunt H, Mowatt-Larssen CA, Wojtysiak SL, Henningfield MF, Kudsk KA. Comparison of specialized and standard enteral formulas in trauma patients. Pharmacotherapy.1994;14:314-320.
  57. Garrel DR, Razi M, Lariviere F, et al. Improved clinical status and length of care with low-fat nutrition support in burn patients. J Parenter Enteral Nutr. 1995;19:482-491.
  58. Cerra FB, Lehmann S, Konstantinides N, et al. Improvement in immune function in ICU patients by enteral nutrition supplemented with arginine, RNA, and menhaden oil is independent of nitrogen balance. Nutrition. 1991;7:193-199.
  59. Hausmann DF, Nutz V, Rommelsheim K, Caspari R, Mosebach KO. Anabolic steroids in polytrauma patients. Influence on renal nitrogen and amino acid losses: a double-blind study. J Parenter Enteral Nutr. 1990;14:111-114.
  60. Jeevanandam M, Ali MR, Holaday NJ, Petersen SR. Adjuvant recombinant human growth hormone normalizes plasma amino acids in parenterally fed trauma patients. J Parenter Enteral Nutr. 1995;19:137-144.
  61. Jeevanandam M, Holaday NJ, Petersen SR. Integrated nutritional, hormonal, and metabolic effects of recombinant human growth hormone (rhGH) supplementation in trauma patients.Nutrition. 1996;12:777-787.
  62. Kosanovich JM, Dumler F, Horst M, Quandt C, Sargent JA, Levin NW. Use of urea kinetics in the nutritional care of the acutely ill patient. J Parenter Enteral Nutr. 1985;9:165-169.
  63. Mollinger LA, Spurr GB, el Ghatit AZ, et al. Daily energy expenditure and basal metabolic rates of patients with spinal cord injury. Arch Phys Med Rehabil. 1985;66:420-426.
  64. Swinamer DL, Grace MG, Hamilton SM, Jones R, Roberts P, King EG. Predictive equation for assessing energy expenditure in mechanically-ventilated critically ill patients. Crit Care Med.1990;18:657-661.
  65. Kolpek JH, Ott LG, Record KE, et al. Comparison of urinary urea nitrogen excretion and measured energy expenditure in spinal cord injury and non-steroid-treated head trauma patients. J Parenter Enteral Nutr. 1989;13:277-280.
  66. Dickerson RN, Guenter PA, Gennarelli TA, Dempsey DT, Mullen JL. Increased contribution of protein oxidation to energy expenditure in head-injured patients J Am Coll Nutr. 1990;9:86-88.
  67. Sedlock DA, Laventure SJ. Body composition and resting energy expenditure in long-term spinal cord injury. Paraplegia. 1990;28:448-454.
  68. Rodriquez DJ, Clevenger FW, Osler TM, Demarest GB, Fry DE. Obligatory negative nitrogen balance following spinal cord injury. J Parenter Enteral Nutr. 1991;15:319-322.
  69. Klein CJ, Wiles CE. Evaluation of nutrition care provided to patients with traumatic injuries at risk for multiple organ dysfunction syndrome. J Am Diet Assn. 1997;97:1422-1424.
  70. Bartlett RH, Allyn PA, Medley T, Wetmore N. Nutritional therapy based on positive caloric balance in burn patients. Arch Surg. 1977;112:974-980.
  71. Allard JP, Jeejheebhoy KN, Whitwell J, Pashutinski L, Peters WJ. Factors influencing energy expenditure in patients with burns. J Trauma. 1988;28:199-202.
  72. Ireton-Jones CS, Turner WW Jr., Liepa GU, Baxter CR. Equations for the estimation of energy expenditures in patients with burns with special reference to ventilatory status. J Burn Care Rehabil. 1992;13:330-333.
  73. Schumer W. Supportive therapy in burn care. J Trauma. 1979;19:897-911.
  74. Mancusi-Ungaro HR Jr, Van Way CW, McCool C. Caloric and nitrogen balances as predictors of nutritional outcome in patients with burns. J Burn Care Rehabil. 1992;13:695­702.
  75. Kuhl DA, Brown RO, Vehe KL, Boucher BA, Luther RW, Kudsk KA. Use of selected visceral protein measurements in the comparison of branched-chain amino acids with standard amino acids in parenteral nutrition support of injured patients. Surgery. 1990;107:503-510

Tables

Assessment of Energy and Substrate Requirements for the Trauma Patient

Table 1: Energy Requirements in Trauma Patients

First AuthorYearData ClassPatient Type and Number (n)Conclusion

Frankenfield [1]

1997

I

Blunt and penetrating trauma n = 30

Prospective, randomized study evaluating the effect of energy balance on nitrogen balance in multiple trauma patients (ISS>25). Achievement of energy balance (NPC or total) failed to decrease catabolic rate or nitrogen loss at a fixed protein intake of 1.7 g/kg/day.

Schneeweiss [2]

1992

I

Polytrauma n = 12

Prospective, randomized, cross-over study comparing fat-based versus CHO-based enteral nutrition in 12 critically-ill patients. Only 2/12 patients were trauma patients. Approximately 35% of enteral CHO was stored as glycogen, and 50% to 60% of energy needs were met by fat oxidation. MREE ~ 26 kcal/kg/day.

Iapichino [5]

1982

II

Trauma n = 19

Maximum protein sparing effect reached when caloric intake was equal to 130% MEE (~38-48 kcal/kg/day). Increased doses of insulin were used with TPN.

Paauw [6]

1984

II

Blunt trauma (n=8) Total patients n=119

Caloric intake of 25 kcal/kg/day(~ MREE ) ~ 7% of patients were trauma

Dempsey [12]

1985

II

Head injury n = 10

Patients with severe head trauma without barbiturate therapy exhibit an average REE 26% above predicted by HBEE.

Kosanovich [62]

 

1985

 

II

 

Trauma (n=8) Surgery (n=11)

 

Prospective, nonrandomized observational study. Increased caloric intake from 27.8 to 34.2 kcal/kg/day on fixed protein of 1.27 g/kg/day decreased the protein catabolic rate. Only 42% of patients were trauma patients.

Mollinger [63]

1985

II

Spinal cord jury n = 48

20% to 30% below REE for quadriplegics and 12% to 15% below REE for paraplegics; however, patients were 3.8 to 8.6 years from injury.

Clifton [11]

1986

II

Head injury n = 57

The authors recommend use of a nomogram to estimate REE at the bedside of comatose patients.

Swinamer [64]

1987

II

Critically Ill Patients n = 112 (52 trauma patients)

Mean MREE was 47% above predicted energy expenditure based on HBEE.

Kolpek [65]

1989

II

Spinal cord injury and head trauma n = 14

44% below BEE (22 kcal/kg/day) for spinal cord injury patients during the first week after injury versus 144% x BEE (35 kcal/kg/day) for head trauma patients during first week. Protein losses for both groups were between 1.3 and 1.4 g/kg/day

Shaw [9]

1989

II

Blunt trauma n = 43

The use of TPN in trauma patients results in an increase in glucose oxidation and decreased fat oxidation and attenuation of protein synthesis. Recommend regimen of 2000-2500 kcal/day and 1.7 g protein/kg/day.

Dickerson [66]

1990

II

Head trauma n = 6

Protein requirements are accentuated in excess of kcal needs in head-injured patients. UUN excretion of 16.5 g/day.

Jeevanandam [4]

1990

II

Blunt trauma n = 9

Prospective, nonrandomized observational study REE = 33.4 to 37.7 kcal/kg/day for trauma patients with mean ISS = 34. Daily protein losses ~ 1.34 g/kg/day. Also found traumatic injury increased rate of fat mobilization.

Sedlock [67]

 

1990

 

II

 

Paraplegics n = 4

~21kcal/kg/day for MREE of four paraplegics with a mean of 7.4 years post injury

Rodriguez [68]

1991

II

Spinal cord injury n = 30

Nonrandomized, prospective comparative trial. Nitrogen losses are obligatory in spinal cord injury patients. Recommend protein at 2 g/kg IBW/day due to losses.

Rodriguez [3]

1995

II

Multisystem trauma (no des-cription of bluntvs penetrating) n = 35

Prospective, observational study. Demonstrated no correlation between ISS and MREE. Suggested correlation between predicted and MREE.

Klein [69]

1997

II

Trauma (no description of blunt vs penetrat­ing) n = 8

Study which evaluated the quality of nutrition provided to trauma patients at risk for MODS. Endpoints included dietitian documentation, percent kcal/protein goals met based on HBEE.

Uehara [7]

1999

II

Trauma patients with ISS > 16 (median ISS=33.5) n = 24

Derived TEE in 12 trauma patients by measuring energy intake and changes in total body fat, protein, and glycogen. Authors noted a significant rise in TEE, which averaged 31 kcal/kg/day during the first week but peaked at 59 kcal/kg/day during the second week. Based on this, authors recommend multiplying the HBEE by factors of 1.4 and 2.5, respectively for the first two post-injury weeks.

Brain Trauma Foundation [10]

2000

III

Head injury (REVIEW)

Replace 140% of REE in non-paralyzed patients and 100% of REE in paralyzed patients receiving enteral or parenteral nutrition containing at least 15% of kcal as protein by the day 7 post-injury.

ISS, Injury Severity Score; NPC, non-protein calories; CHO, carbohydrate; MREE, measured resting energy expenditure; REE, resting energy expenditure; TPN, total parenteral nutrition; HBEE, Harris-Benedict energy equation; BEE, basal energy expenditure; UUN, urinary urea nitrogen; MODS, multiple organ dysfunction syndrome; TEE, total energy expenditure; IBW, ideal body weight

Assessment of Energy and Substrate Requirements for the Trauma Patient

Table 2. Energy Requirements in Burn Patients

First AuthorYearClassConclusions

Ruten [28]

1986

I

Prospective, randomized study of 13 patients with burns >45% TBSA. One group had burn excised within 72 hours and covered with autograft or allograft. Second group treated with hydrotherapy and dressings. No significant difference in REE at any time up to 30 days post-burn but trend toward decreased REE with excision. Small number of patients, and groups were not comparable.

Herndon [25]

1989

I

Prospective, randomized study of 39 patients with >50% TBSA burns. Sixteen patients received intravenous supplementation of enteral nutrition to achieve Curreri formula-predicted requirements. Supplemented group had significantly higher mortality and greater depressions in T-helper/suppressor ratios. Patient groups questionably comparable.

Saffle [24]

1990

I

Prospective, randomized study of 49 patients with 25% to 79% TBSA burns. Patients received feedings based on Curreri formula or on indirect calorimetry. Curreri-based caloric goals exceeded MEE by 43%. Caloric goals for calorimetry patients were MEE X 1.2 (activity factor). Caloric intakes were the same for both groups. No differences in outcomes or complications.

Jenkins [26]

1994

I

Prospective, randomized study of 80 patients with >10% TBSA burns. 40 patients fed peri­operatively; remainder had feedings held pre-, intra- and immediately postoperatively. No aspiration occurred in either group. Same LOS, mortality, and percent pneumonia. Unfed group had significant caloric deficit, increased incidence of wound infection, and required more albumin supplementation.

Curreri [15]

 

1974

 

II

 

Prospective study of nine patients with TBSA burn between 40% and 73%. Used regression analysis to determine equation for caloric requirements using pre-burn weight, weight at 20 days post-burn, and actual caloric intake over the 20-day period. Formula derived: Caloric intake = 25 kcal/kg + 40 kcal/percent burn (Curreri formula).

Wilmore [14]

1974

II

Classic paper relating increased burn wound size to increased energy expenditure.Prospective study of 20 patients with 7% to 84% TBSA burns and four unburned control patients. Noted hypermetabolism to be modified by ambient temperature and infection and to be mediated by catecholamines. Increase in energy expenditure is maximal with ~60% TBSA burn.

Bartlett [70]

1977

II

Prospective study of indirect calorimetry in 15 patients with 20% to 70% TBSA burns. Indirect calorimetry performed once or twice daily until burn wound coverage. Oxygen consumption and caloric expenditure was 1.5 to 2 times normal and was consistent hour-to­hour and day-to-day. MEE correlated best with the extent of full thickness burn.

Long [18]

1979

II

Measured energy expenditure in 39 sepsis/trauma/burn patients and 20 normal volunteers. Energy expenditure of burn patients exceeded that predicted by the HBEE equation by 132%. Developed equation: Caloric expenditure = HBEE X stress factor X activity factor. Values for stress and activity factors are given and are still in use today.

Saffle [27]

1985

II

Prospective study of indirect calorimetry in 29 patients with 3% to 80% TBSA burns. Actual MEE was only 76% of Curreri-predicted requirements and was 1.47 times the Harris­Benedict-predicted requirement. Neither formula addresses biphasic character of actual MEE, which rises from admission through day 10-20, then declines but still remains elevated at discharge.

Turner [17]

1985

II

Prospective study of 35 patients with 10% to 75% second/third degree TBSA burns. Calculated energy expenditure predicted by the HBEE underestimated actual energy expenditure by 23%. Curreri-derived energy requirements overestimated actual energy expenditure by 58%. In patients with TBSA >20%, HBEE was a more accurate predictor of actual energy expenditure.

Ireton [20]

 

1986

 

II

 

Prospective study of indirect calorimetry in 17 patients with 26% to 79% TBSA burns. Each patient had indirect calorimetry only once between post-burn day 2 and 26. Actual MEE best estimated by HBEE X 1.5. Curreri formula overestimated MEE by a factor of 1.53, and HBEE underestimated MEE by 0.72. Mean caloric intake was only 81% of Curreri formula, indicating difficulties attaining this goal.

Ireton-Jones [29]

1987

II

Prospective study of 20 patients with 31% to 74% second/third degree TBSA burns. Serial MEE and UUN excretion determined as wounds were reduced to <15% TBSA with healing and grafting. No correlation between percent open wound and MEE or UUN excretion. Also poor correlation between MEE and caloric requirement as predicted by Curreri formula, even modified for reduced burn size.

Schane [19]

1987

II

Prospective study of 21 patients with 21% to 81% TBSA burns. Curreri-formula-derived energy requirements overestimated actual MEE by 25% to 36%. Harris-Benedict predictions modified by stress and activity factors overestimated actual MEE by 32% to 39%. CEE and HBEE were good estimates of maximal MEE. Serial determinations of MEE are recommended.

Allard [71]

1988

II

Prospective study of indirect calorimetry in 23 patients with 7% to 90% TBSA burns. Curreri formula overestimated MEE by 52%, and HBEE underestimated MEE by 29%. Energy expenditure increased from 6.5% to 34.1% above HBEE with feeding, suggesting that 25% of the caloric intake is used to increase MEE.

Cunningham [21]

1989

II

Prospective study of indirect calorimetry in 122 patients with 2% to 98% TBSA burns. Actual MEE best estimated by 2 X HBEE, not by Currrei formula, BEE X activity factor X injury factor, or 2000 X TBSA. Confirms biphasic MEE noted by Saffle (27). TBSA burns <30% are associated with MEEs which are difficult to differentiate from normal variability in MEE.

Allard [23]

1990

II

Prospective study of 10 patients with 30% to 90% TBSA burns. Compares actual MEE with energy requirements predicted by the Curreri and the Toronto formulas and twice the HBEE formula. Best approximation of actual MEE was Toronto formula, which uses TBSA burned, caloric intake of prior 24 hours, number of days post-burn, temperature, and HBEE.

Ireton-Jones [72]

 

1992

 

II

 

Developed equations predicting energy expenditures based on 200 patients with a variety of diagnoses including burns. Tested equation on 100 patients and observed a high correlation with MEE. Factors predictive of energy expenditure included age, sex, ventilator dependency, weight, presence of obesity, trauma, or burns. Burn size, however, was not a predictive factor.

Xie [22]

1993

II

Prospective study of 75 patients with 5% to 98% TBSA burns. Compares new formula [1000 X m2 (surface area) + 25 X %TBSA] to Curreri formula and to [2000 X m2], [2 x BMR] and [20 X Kg + 70 X %TBSA]. Data suggest Chinese formula more closely approximates actual MEE.

Khorram-Sefat [31]

1999

II

Resting energy expenditure determined in 27 patients, daily for the first post-burn week and twice a week thereafter. Patients grouped according to predicted mortality (<20%, 20% to 80%, and >80%), and REE patterns in the three groups were compared. REE similar in all groups for first 20 days (~50% above HBEE). After this, REE declined in patients with predicted mortality <80%; however, it continued to be elevated up to the 45th day in patients with predicted mortality >80%. Finding no clear relationship between REE and TBSA burn during the first 15 days post-burn, the authors conclude that the only reliable way to calculate the caloric needs of burn patients is to perform indirect calorimetry. If this is not feasible, a caloric load of no more than 50% to 60% above HBEE is recommended.

Schumer [73]

1979

III

Expert panel discussion of the metabolic effects of burn injury and some of the treatment strategies required to overcome them. Despite being written almost 20 years ago, this report is still quite applicable to current discussions of burn nutrition.

Williamson [16]

1989

III

Interesting study documenting actual burn nutrition practices at North American burn centers. Most centers use a Curreri-based formula to determine energy requirements. Centers that use metabolic carts do so only occasionally or for research purposes. Most centers keep patients NPO at least 6 to 8 hours before surgery.

Mancusi-Ungaro [74]

1992

III

Retrospective study of 12 patients with 7% to 82.5% TBSA burns. Measured caloric balance (calories consumed minus calories expended as determined by weekly calorimetry). Positive caloric balance correlated with good patient and nutritional outcomes and was easier to determine than nitrogen balance. Caloric expenditure did not correlate with burn size.

Waymack [30]

 

1992

 

III

 

Recommends weekly or preferentially twice-weekly measurement of resting metabolic energy expenditures using indirect calorimetry for patients with severe burns.

TBSA, total body surface area; REE, resting energy expenditure; MEE, measured energy expenditure; LOS, length of stay; HBEE, Harris-Benedict energy equation; UUN, urinary urea nitrogen; CEE, Curreri formula derived energy requirements; BEE, basal energy expenditure, BMR, basal metabolic rate; NPO, nothing by mouth

Assessment of Energy and Substrate Requirements for the Trauma Patient

Table 3. Macronutrient Requirements in Trauma And Burn Patients

First AuthorYearData ClassPatient Type and Number (n)Conclusion

Moore [42]

1986

I

ATI >15 N = 75

Protein intake estimated from body weights was 1.5 - 2.0 g/kg body weight/day

Hausmann [59]

1990

I

Polytrauma N =20

Nandrolone decanoate improved nitrogen balance by reducing nitrogen excretion and 3-methylhistidine and renal amino acid losses.

Kuhl [75]

1990

I

Polytrauma N =20

Nitrogen balance, IGF-1, fibronectin, and prealbumin levels measured in patients randomized to receive standard (21% branched chain amino acids) or enriched formula (46% branched chain amino acids). No differences in these variables were detected.

Cerra [58]

1991

I

Critically ill N = 20

Enteral diets supplemented with arginine, fish oil, and RNA stimulated in vitrolymphocyte proliferative responses and reduced 3-methyl histidine excretion but had no observed beneficial effects at follow-up 6 and 12 months.

Brown [56]

1994

I

Trauma N = 41

An enteral formula enriched with arginine, linolenic acid, beta carotene, and hydrolyzed protein led to a decreased incidence of infection and better nitrogen balance.

Petersen [45]

1994

I

Trauma

Protein given as 1.6 g/kg body weight/day. Recombinant human growth hormone increased the efficiency of protein synthesis.

Garrel [57]

 

1995

 

I

 

Burns N =43

Three groups: control (35% fat), low (15% fat), low fat (15%) plus fish oil. Low fat nutritional support decreases infectious morbidity and LOS. Fat composition did not matter.

Jeevanadam [60]

1995

I

Trauma, ISS = 31 N =20

Recombinant human growth hormone plus TPN in the period immediately after traumatic injury improves nitrogen retention (less negative) and normalizes plasma amino acid levels.

Jeevanadam [48]

1995

I

Polytrauma N =10

Amino acids as 20% of energy needs, CHO as 50%, and lipids as 30%. A medium-chain triglyceride/long-chain triglyceride mixture may be better for trauma patients because the formula allows more rapid and efficient fuel use.

Jeevanadam [61]

1996

I

Trauma, ISS = 31 N = 20

Less negative nitrogen balance, increased whole-body protein synthesis, increased efficiency of protein synthesis, increased plasma glucose levels, and enhanced lipolysis in patients treated with recombinant human growth hormone.

Battistella [54]

1997

I

Polytrauma N = 57

Patients receiving TPN, who received the same amino acid and CHO dose, randomized to receive standard fat emulsion or to have fat withheld for 10 days. IV fat increased the susceptibility to infection, prolonged pulmonary dysfunction, and delayed recovery (question if secondary to underfeeding or fat).

Frankenfield [1]

1997

I

Trauma, excluding burns, spinal cord injuries, and isolated brain injuries N =30

Randomized, prospective study of patients to three groups: 1) CHO + lipid = MEE; 2) CHO, lipid, + protein = MEE; and 3) CHO + lipid = 50% of MEE. Protein = 1.7 g/kg body weight/day. Achieving energy balance did not decrease the catabolic rate or nitrogen loss.

Bernier [53]

1998

I

Burns > 20% TBSA; n = 37

Low-fat feeding with or without fish oil did not change IL-6 production.

Iapichino [5]

1982

II

Trauma N =19

Caloric intake of 130% of energy needs provided maximal protein sparing effect. Amino acids should be provided as 20% of energy requirements.

Kagan [51]

1982

II

Burns: 1%-10%, 11%-30% and 31%-60% TBSA n = 18

Calorie:nitrogen ratios of 150:1 may not provide adequate nitrogen to achieve equilibrium.

Matsuda [52]

1983

II

Burns n = 52

Calorie:nitrogen ratios of 150:1 OK for patients with BSA less than 10%. Patients with > 10% wounds need ratios of approximately 100:1.

Nordenstrom [34]

1983

II

Mixture of trauma and septic patients n = 23

Nitrogen sparing effects of lipid-and glucose-based systems are similar. Factors other than nitrogen balance should be used to decide which system to use.

Wolfe [35]

1983

II

Burns (average 70% TBSA) n = 6

Protein intake was 1.4 to 2.2 g protein/kg body weight/day With the higher dose, there was additional increase in protein synthesis, but nitrogen excretion was decreased.

Twyman [33]

1985

II

Head Injuries n = 21

Data indicate that protein requirements are higher in head-injured patients at approximately 2.2 g/kg body weight/day.

Cunningham [21]

1989

II

Burns n = 122

For burns exceeding 30% TBSA, 2 X the resting metabolic rate most closely approximated the measured energy expenditure. Cal:nitrogen ratio of 150:1 preferred.

Jeevanadam [39]

1990

II

Trauma n = 8

Prospective study suggesting that 0.35 g nitrogen or ~2.2 g protein/kg body weight/day required to minimize loss of lean body mass.

Larsson [46]

 

1990

 

II

 

Burns or fracture of >2 long bones n = 39

Nitrogen requirements vary over time. 0.20 g nitrogen/kg body weight/day or 1.25 g protein/kg body weight/day is optimal.

Jeevanadam [47]

1992

II

Trauma, ISS 32±2 n = 18

Study suggests that intravenous glucose should be given at a rate that does not exceed the REE.

Eyer [43]

1993

II

Blunt trauma, ISS 10; n = 38

Purpose of this randomized controlled study was to evaluate metabolic responses to early enteral feeding (unaltered) but protein was set at 1.5 g/kg body weight/day.

Guenst [49]

1994

II

Mixed patient Population n = 140

Use indirect calorimetry to measure energy expenditure or give total calories up to 140% of the BEE with glucose infusions = 4 mg/kg body weight/minute. Fat can be given as 40% to 60% of calories.

Chuntrasakul [44]

1998

II

Trauma, burns and cancer (ISS 24, average % TBSA burned 48); n = 26

Goal of study was not to determine CHO, protein or fat requirements but energy provided as 35-50 kcal/kg body weight/day and protein at 1.5-2.5 g/kg body weight/day.

Homsy [32]

1983

III

Critically ill and marasmic patients (REVIEW)

30-40 kcal and 1.5 g protein/kg body weight/day recommended.

Alexander [55]

1990

III

Burns (REVIEW)

Authors suggest that optimal enteral diet provides 20% energy from whey, 2% from arginine, 0.5% from histidine and cysteine, with lipids as 15% of non-protein calories. Lipid should be 50% fish oil and 50% safflower oil. This diet is believed to improve outcome (decreased wound infections, hospital stays, and death).

Tredget [50]

1992

III

Burns (REVIEW)

CHOs are an important fuel source for burned patients. The theoretical maximum is 5-6 mg/kg body weight/minute.

Wolfe [37]

1997

III

Critically ill (REVIEW)

Review by leading researcher in the field suggests that carbohydrates should be the predominant source of non-protein calories.

Ishibashi [38]

1998

III

Immediately post-trauma or severely septic patients (ISS 16); n = 23

Retrospective study that used very sophisticated techniques. 1.2 g protein/kg pre-illness weight is optimal amount.

DeBiasse [40]

1994

III

Critically ill including burns and trauma patients (REVIEW)

Authors suggest that 70% of energy should be provided as CHO, 30% or less as lipid, and 1.5 to 2 g protein/kg body weight/day (the latter for burn patients).

Wolfe [36]

1996

III

Critical ill including burns and trauma patients (REVIEW)

Non-protein energy should be provided largely as CHO. Protein should be set at 1.5 g/kg body weight/day.

Pomposelli [41]

1994

III

Critically Ill (REVIEW)

Protein should be provided between 1.5-2 g/kg body weight/day. Calories should be limited to the patient's energy expenditure.

ATI, abdominal trauma index; RNA, , ribonucleic acid; LOS, length of stay TPN, total parenteral nutrition, CHO, carbohydrate; ISS; Injury Severity Score; IV, intravenous; MEE, measured energy expenditure; IL-6, interleukin 6; TBSA, total body surface area; REE, resting energy expenditure; BEE, basal energy expenditure

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