Indirect Calorimetry and the GE Engstrom Carestation. Jorge E. Rodriguez BSRC, RRT

Transcription

1 Jorge E. Rodriguez BSRC, RRT

2 Indirect tcl Calorimetry and the GE To obtain the most accurate metabolic data from Indirect Calorimetry, one must: Evaluate the patient. Obtain consistent, Steady State data. Analyze and correlate lt the data to the patient s t situation. ti

3 Patient Evaluation A stable patient is paramount for metabolic measurement! Only when the patient is in a resting Steady State will the metabolic measurement of Indirect Calorimetry reflect patient metabolism. Hemodynamics Stable BP MAP of 65 mmhg or greater (adequate perfusion of tissues) HR less than 130 No cardiac arrhythmias

4 Ventilator Settings FiO2 70% RR 35 PEEP 10 What is the ventilator mode/strategy? What is the work of breathing? Adjust Bias Flow, Patient trigger, Rise time, and End flow for patient comfort if needed. Accurate weight and height entered in gas exchange menu. At least 1 hour is needed after parameter change for metabolic measurement.

5 There can be no leaks present in the ventilator circuit, lungs (pneumothorax), tracheostomy or endotracheal cuff, or chest tube present during Indirect Calorimetry. Any exhaled gas not measured can result in erroneous data. Reviewing laboratory data can help to understand the patient s current state. WBC, RBC, Hgb, Platelet, Albumin, Prealbumin, CRP, etc.

6 Chest X Ray Atelectasis, Pleural Effusion, Consolidation, Pneumothorax, Pulmonary Edema, Pneumonia, ARDS? Lung Compliance Evaluate Static Compliance measurement.

7 Identifying the best time for metabolic measurement The patient is not to be disturbed during metabolic measurement! If the patient is stimulated, it may take up to 30 minutes to return to resting state (usually 2-10 min). Coordinate with the Nurse, RT, and/or MD to allow the patient to rest at the time of metabolic measurement. An ideal time for metabolic measurement is after clinical personnel has completed their morning/afternoon patient assessment. Discuss the level of sedation and pain medication with the nurse to ensure patient comfort during measurement.

8 Metabolic measurement should not be considered during the following and should take place minutes after any stress has been placed on the body: Spontaneous Breathing Trial Bronchoscopy, BAL Nebulizer treatment, IPV, CPT, etc. Patient mobilization, Bath, Physical Therapy Placement of Arterial Lines, PICC Lines, CVC Lines Lumbar puncture, biopsies, i drain/tube placement CT Scan, MRI, Interventional Radiology Agitation

9 Hemodialysis and metabolic measurement Intermittent hemodialysis removes CO₂ from the blood that would normally be exhaled by the lungs and would not be measured via Indirect Calorimetry. Slow Low Efficiency Dialysis (SLED), Continuous Renal Replacement Therapy (CRRT), and Continuous Venovenous Dialysis (CVVHD) use slow filtration rates for long periods of time. These types of dialysis can decrease body temperature and therefore decrease VO₂ by up to 20%. Indirect Calorimetry can be performed 3-4 hours after Intermittent Hemodialysis has finished or when slow, continuous dialysis has been discontinued. Transfusion of blood products and metabolic measurement Indirect Calorimetry can be performed 3-4 hours after Packed Red Blood Cell Indirect Calorimetry can be performed 3-4 hours after Packed Red Blood Cell (PRBC), Platelet, Fresh Frozen Plasma (FFP), White Blood Cells (WBC), etc.

10 Advantages of using the Engstrom Carestation for metabolic measurement Quick and easy set up of the gas module and sample lines eliminate the need for a separate metabolic cart. Gas sampling proximal to ETT or Trach that reduces errors caused by bias flow and end expiratory sampling. Continuous metabolic measurement that provides recorded data up to 3 days in as little as 1 minute intervals and allows for trending.

11 Preparing for metabolic measurement Inspect D-Fend tubing/sensor for condensation and/or occlusion. If needed, replace with new tubing/sensor. Place D-Fend sensor so that it rests at a 45 upwards angle to reduce the amount of condensation collecting in the tubing. Empty the water trap and if necessary, replace with a new water trap to ensure accurate measurement. CO module should be inserted in the module bay and reading accurate CO₂ module should be inserted in the module bay and reading accurate CO₂, VCO₂, and VO₂. Allow 30 minutes for module to warm up and read accurately.

12 Preparing for metabolic measurement Check to ensure the patient s correct height and last known Dry Weight have been entered in the Patient Setup menu. Select EE/RQ from the screen menu to display in the digital field for observation and consistency.

13 Preparing for metabolic measurement From the trends menu, you can view EE/RQ, VO₂/VCO₂, VO₂/kg/min and VCO₂/kg/min, or Ve to observe consistency in breathing pattern and metabolic measurement.

14 Use Spirometry and FRC measurement to further evaluate the patient s pulmonary status.

15 Preparing for metabolic measurement Laptop loaded with OhmedaCom Research Tool software is connected to the ti via Ethernet t cord. Records breath by breath ventilator data, including metabolic measurement. Download min of consistent Steady State data and assess for accuracy. Ventilator data is transferred to an Excel spreadsheet and a graph can be made representing EE/RQ.

16 EView A portable device that attaches to the back of the ventilator screen, allowing capture of all output data from the ventilator. Up to 7 days worth of data can be collected in breath by breath measurements and downloaded to a flash drive or SD card. This enables the clinician to evaluate the data and can help form specific treatment plans. Eview can be disconnected d and used with another GE ventilator.

17 Indirect tcl Calorimetry and the GE Ghjazali, B IC Graph measured EE (kcal/day) 0.60 measured RQ Kcal Time

18 Indirect tcl Calorimetry and the GE Dudley IC Graph measured EE (kcal/day) measured RQ Time Kcal

19 Predictive equations and A.S.P.E.N. guidelines: Predictive Equations Ireton Jones, Penn State, Swinamer, and Frankenfield equations use the patient s weight (kg), height (cm), age (yrs), activity level, stress factors, temp, minute ventilation for an estimated EE. These equations have been shown to correlate poorly with Indirect Calorimetry, which is considered the gold standard for determining resting energy expenditure. A.S.P.E.N. Nutritional Guidelines Based on patient s IBW kcal/kg for obese patients, (BMI 30) kcal/kg for most patients, (BMI 30) kcal/kg for underweight patients, (BMI 17)

20 What is the patient s current nutritional status and what will be the expected RQ? Is the patient NPO? If so, for how long? Is the patient receiving tube feeding, TPN, both? How long has the patient been receiving the current nutrition? Is nutrition support at the patient s goal? Are there any additional kcal from other sources? D5/D10, Propofol? Does the measured metabolic data correlate with the patient s current nutritional intake and situation?

21 Hypocaloric feeding of the critically ill obese patient Provides nutrition support without exacerbating the acute stress response of released stress related hormones causing hyperglycemia and elevated serum triglyceride levels. Must provide adequate amount of dietary protein. Benefits Improved glycemic control. Decreased ICU length of stay. Decreased ventilator days. Decreased infection rate. Avoid overfeeding and pulmonary complications. Fat weight loss.

22 Example: Male patient, 59 years old, 180 cm, 98 kg (IBW is 77.6 kg), BMI 30.2 He is sedated (Versed, Fentanyl), mechanically ventilated (day 3), with the following settings: BiLevel Mode, FiO2 50%, Peep High 12 / Peep Low 5, Pressure Support 10, set RR 12 total RR 12 Intubated for respiratory distress, worsening x ray (pneumonia), and possible sepsis. Current Nutrition: NPO, D5 in 0.9% Normal Saline at 50 ml/hr ( providing 204 kcal/day ).

23 Estimated needs using Harris Benedict Equation Using Actual Body Weight and stress factor added for infection 2,577 kcal/day Estimated needs using Mifflin St. Jeor Equation Using Actual Body Weight and stress factor added for infection 2,450 kcal/day Estimated needs via A.S.P.E.N. Guidelines Using Ideal Body Weight with no stress factors added 25 kcal/kg, 1940 kcal/day.

24 Indirect Calorimetry for this patient: The patient was resting and sedated d during metabolic measurement. Hemodynamically stable. No large variations in Ve, Vt, RR, VO2, VCO2 which resulted in Steady State. Indirect Calorimetry results using 25 minutes of consistent C y g 5 data shows an average EE of 2340 kcal/day and RQ of 0.70

25 Analysis of Metabolic Measurement: Once minutes of Steady State data has been obtained, it is important to analyze the data and correlate the metabolic measurement to the patient s medical/nutritional status. Is the EE accurate for this patient, at this time, and under the current conditions? Does the RQ match the patient s current nutritional status, and substrate utilized? If necessary, compare recently obtained data to previously recorded data or data collected at a later time. Collaborate with Clinical Nutrition staff to identify patient s expected energy requirements, and compare to the measured.

26 Indirect tcl Calorimetry and the GE Trouble Shooting: Check D-Fend Tubing/Water Trap, and replace if needed. Reset CO₂ module by pulling out of module bay and re-inserting after 30 seconds, allow to warm up and zero. If necessary, remove CO₂ module and replace with new module. Allow 30 minutes for the new module to warm up and assess measurements. Check system for leaks (Vent Circuit, ETT/Trach cuff leak, Chest Tube, Pneumothorax, etc.) Evaluate patient HR, BP, O₂ Sat, RR and Ve to ensure stability. Check ventilator settings to rule out recent changes in parameters. Check for changes in sedation and/or pain medication.

27 The End! Questions? Contact: