住院病人熱量需求如何應用 公式計算 - 最新文獻之建議

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1 住院病人熱量需求如何應用 公式計算 - 最新文獻之建議 1

2 Outline Common Equations for Calculation of Metabolic Rate Harris-Benedict equation Mifflin St Jeor equation Penn State equation Examples of estimating energy needs Discussion 2

3 p B JPEN. 2011;35:564 3

4 2 3 Resting energy expenditure (REE) has been used to describe BEE in a post-absorptive state. In sedentary healthy subjects, REE accounts for about two-thirds of TEE. JPEN. 2013;37:706 4

5 Livingston EH,2005 Frankenfield DC, 2003 JPEN. 2011;35:565 5

6 Muscle mass accounts for 43% of the fat-free mass but only 16% of the resting metabolic rate (15 kcal/kg tissue). The brain, heart, liver, and kidney represent only 7% of the fat-free mass but 80% of the resting metabolic rate (468 kcal/kg tissue). The remaining fat-free mass (50% of the total, representing bone and extracellular water and protein) accounts for no more than 4% of the resting metabolic rate (<1 kcal/kg tissue). JPEN. 2011;35:565 6

7 Harris-Benedict equation 臨床營養學,2005 實用重症營養治療手冊,2012 7

8 Harris-Benedict equation The Harris-Benedict equation has been used as the basis for predicting resting metabolic rate in healthy people. It has been recognized that the Harris-Benedict equation tends to overestimate the resting metabolic rate (as far back as 1928, Benedict was calling attention to this fact). The reference equations in which stress multipliers are used (most often Harris-Benedict) are not as accurate as the disease-specific equations that do not use stress multipliers. JPEN. 2011;35:

9 Mifflin St Jeor equation 9

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11 Mifflin St Jeor equation Men: Wt(10) + Ht(6.25) Age(5) + 5 Women: Wt(10) + Ht(6.25) Age(5) 161 Weight is in kilograms Height is in centimeters Age is in years 11

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13 (54) (76) (83) (47) 13

14 The Mifflin standard provided an accurate estimate of actual RMR in the largest percentage of individuals. 14

15 Resting metabolic rate to be overestimated by the Harris-Benedict equation in men with BMI >50. 15

16 Using adjusted body weight in the Harris-Benedict equation - 100% incidence of underestimation of resting metabolic rate in subjects with BMI >

17 Critically Ill During the first days after the onset of critical illness, the risk of overfeeding is probably higher, when the endogenous non-inhibitable production of calories (mainly endogenous glucose production) matches 50% 75%. JPEN. 2013;37:705 17

18 JPEN. 2013;37:706 18

19 Recommended requirements use in ICU P 19

20 Sample validated requirement equations used in ICU 20

21 Penn State equation 21

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25 Hypermetabolism, if defined as an elevation in resting metabolic rate of at least 10% above healthy resting, begins at a body temperature of about 37.0 C. JPEN. 2011;35:567 25

26 The Mifflin equation, resting metabolic rate can be accurately predicted in about 80% of nonobese and overweight people (body mass index <30 kg/m 2 ) about 70% of obese people. (BMI >=30 kg/m 2 ) Because the Mifflin equation was designed for healthy people, it was tested alone and in a modified version by multiplying it by 1.25 to account for illness hypermetabolism. H JPEN. 2013;37:362 26

27 Penn State equation PSU = Mifflin(0.96) + Tmax(167) + Ve(31) 6212 Tmax is maximum body temperature in the previous 24 hours Ve is minute ventilation at the time of measurement, read from the ventilator, not the calorimeter B The accuracy of the predictive equations can be influenced by other variables including some support techniques (eg, renal replacement therapies) and some medications that modify metabolism (eg, β-blockers, sedative agents, or catecholamines) or body temperature. JPEN. 2013;37:707 27

28 CIU(Clinical Investigation Unit): Resting Metabolic Rate Predictive Equations for Non-obese Critically Ill Adults If indirect calorimetry is not available, RD should use the Penn State University [PSU(2003b)] equation in non-obese, critically ill mechanically-ventilated adults. Research indicates that this equation has the best prediction accuracy in non-obese patients. Rating: Fair 22 studies evaluating predictive equations provide evidence for the Following: 4 equations were precise and unbiased in the non-obese patients. These equations and their accuracy rates in patients less than 60 years and those 60 years or older, respectively, were: PSU(2003b) (69%, 77%); Brandi equation (61%, 61%), MSJE x 1.25 (54%, 54%) and Faisy equation (65%, 37%) ADA Evidence Analysis Library

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32 Penn State equation (modified for BMI 30 and age 60 years) PSU = Mifflin(0.96) + Tmax(167) + Ve(31) 6212 PSU(m) =Mifflin(0.71) + Tmax(85) + Ve(64) 3085 Tmax is maximum body temperature in the previous 24 hours Ve is minute ventilation at the time of measurement, read from the ventilator, not the calorimeter 32

33 CIU: Resting Metabolic Rate Predictive Equations for Obese Critically Ill Adults If indirect calorimetry is not available, for obese patients 60 years or older, the PSU(2010) equation should be used. Research indicates that these equations have the best prediction accuracy. Rating: Fair The PSU(2003b) and PSU(2010) predictive equations were designed for mechanically-ventilated patients 8 studies comparing measured RMR with RMR predicted by several equations in critically ill patients with obesity provide evidence for the following : The Penn State equation [PSU(2003b)] worked best and predicted RMR with 70%accuracy in obese patients. For a subset of obese critically ill patients 60 years old or older, a modified Penn State equation [PSU(2010)] predicted RMR with 74%accuracy. All other predictive equations tested had lower accuracy rates. ADA Evidence Analysis Library

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35 N=55 N=56 35

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38 That error is usually an underestimation (ie, actual resting metabolic rate is higher ) 38

39 Modification of the Penn State equation - body mass index <21 kg/m 2 Resting metabolic rate (kcal/d) = Mifflin(0.76)+ Tcurr(86) + HR(2) + Ve(45) 3102 HR: heart rate at the time of study (beats/min) Tcurr: current body temperature Compared with the morbidly obese group, Heart rate and current body temperature are more predictive of resting metabolic rate than is maximum body temperature in the underweight group. 39

40 範例 -Body mass index 21~30 kg/m 2 Engström Carestation 編號 1 2 診 斷 Pneumonia ESRD Lung ca S/P OP 年齡 性別 身高 體重 BMI Tmax Ve HR Tcurr 88 女 女 編號 25cal /kg 30cal/ kg Harris Harris 1.25 Ireton- Jones Mifflin Mifflin 1.25 Penn State (1) Penn State (2) Penn State (3) HD-IC non HD-IC

41 範例 -Body mass index >30 kg/m 2 and age 60 years 編號診斷年齡性別身高體重 BMI Tmax Ve HR Tcurr 3 Ileus S/P OP 61 女 SAH 75 女 編號 25cal/kg 30cal/kg Harris Harris 1.25 Ireton- Jones Mifflin Mifflin 1.25 Penn State (1) Penn State (2) Penn State (3)

42 範例 -Body mass index <21 kg/m 2 編號診斷年齡性別身高體重 BMI Tmax Ve HR Tcurr 5 Pneumonia 85 男 Pneumonia 87 女 編號 25cal/kg 30cal/kg Harris Harris 1.25 Ireton- Jones Mifflin Mifflin 1.25 Penn State (1) Penn State (2) Penn State (3)

43 VE (minute ventilation) Exp. minute volume : the volume of gas exhaled per minute 43

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45 Summary Individualise. Use validated equations, in the absence of indirect calorimetry. The Mifflin equation was designed for healthy people, it was tested alone and in a modified version by multiplying it by 1.25 to account for illness hypermetabolism. The Registered Dietitian (RD) should use the Penn State University [PSU(2003b)] equation in critically ill mechanically-ventilated. For obese patients 60 years or older, the PSU(2010) equation should be used. Prediction of resting metabolic rate in patients BMI <21 kg/m 2 was problematic with all tested equations. A modification of the Penn State equation(2013) is suggested but has not been validated. 45

46 References 1. Frankenfield DC, Ashcraft CM. Estimating energy needs in nutrition support patients. JPEN J Parenter Enteral Nutr. 2011;35: Mifflin MD, St Jeor ST, Hill LA, Scott BJ, Daugherty SA. A new predictive equation for resting energy expenditure in healthy individuals. Am J Clin Nutr. 1990; Frankenfield DC 1, Rowe WA, Smith JS, Cooney RN. Validation of several established equations for resting metabolic rate in obese and nonobese people. J Am Diet Assoc Sep;103(9): Fraipont V, Preiser JC. Energy estimation and measurement in critically ill patients. JPEN J Parenter Enteral Nutr. 2013;37: Frankenfield DC, Coleman A, Alam S, Cooney RN. Analysis of estimation methods for resting metabolic rate in critically ill adults. JPEN J Parenter Enteral Nutr. 2009;33: Frankenfield D. Validation of an equation for resting metabolic rate in older obese, critically ill patients. JPEN J Parenter Enteral Nutr ;35: Frankenfield DC, Ashcraft CM, Galvan DA. Prediction of resting metabolic rate in critically ill patients at the extremes of body mass index. JPEN J Parenter Enteral Nutr. 2013;37: ADA Evidence Analysis Library. Printed on: 12/01/13 - from: uth=1 46

47 Thanks for your attention! 47