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Beyond the limits of indirect calorimetry

European Journal of Clinical Nutrition volume 77, pages 925–926 (2023)Cite this article

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Predictive equations are often inaccurate [1] and therefore indirect calorimetry has been recognized as the gold standard for evaluating the energy requirements of critically ill patients [2]. Significant technological improvement has been achieved in recent years [3], however, the list of limitations and contraindications for the use of indirect calorimetry remains mostly unchanged [4]. In recent years, some of these contraindications and limitations have been re-evaluated and the use of IC has been found to be acceptable in extra corporeal systems and in continuous renal replacement therapy, in particular [5]. Handling the loss of CO2 from the circuit could have been challenging but has been demonstrated to affect the final evaluation of energy expenditure by less than 5%. During extra corporeal membrane oxygenation (ECMO), this challenge is more significant. First there is no gold standard for ECMO patients and most of the studies existing compared results to predictive equations. Several teams have studied small groups of patients on veno-venous ECMO [6,7,8]). Results showed substantial variability. This may be related to level of awareness, sedation and paralysis, use of vasopressors, temperature (active cooling in specific cases) and presence of sepsis [6]. Technically, in the Wollersheim setup [6], conventional IC is performed and extended by calculating O2 uptake and CO2 elimination through the difference in gas content before and after the filter and the extracorporeal life support (ECLS) blood flow. Practically, results of the blood gas analysis are inserted into the model of Dash and Bassingthwaighte, which is a mathematical model that calculates O2 and CO2 concentrations in the blood [9]. D ˙VO2 and D ˙VCO2 can be determined by multiplying the difference of O2 (DcO2) and CO2 concentrations (DcCO2), in volume percentages, with the volumetric blood flow in the ECMO-circuit (˙Vblood). In the de Waele study [7], gas sampling and flow measurements were obtained with a metabolic cart at the ECMO side. Breath‐by‐breath technology was used. In 7 ICU children connected to ECMO and ventilated with FIO2 < 0.6 [8], VO2 and VCO2 from the mechanical ventilator (Native Lung Measurement) and VO2 and VCO2 from the ECMO oxygenator (ECMO Lung) were obtained. The VO2 total was obtained by adding the VO2 native lung to the VO2 ECMO lung. The VCO2 total was the VCO2 native lung combined with the VCO2 ECMO lung. The VO2 total and VCO2 total were then placed in the modified Weir equation to calculate REE in Kcal/day: REE (Kcal/day) = ([3.9 × VO2 total] + [1.1 × VCO2 total]) × 1.44. in this study too, large variability was noted.

Tatucu-Babet et al. [10] in this journal, found that measuring EE in patients receiving veno arterial (VA) ECMO using a modified indirect calorimetry protocol was also feasible, and pushed further the limits of feasibility of IC. Using a mathematical model, the O2 and CO2 content pre- and post- the ECMO membrane were determined and VO2 and VCO2 calculated. The energy expenditure results were not significantly lower than the non ECMO ICU patients, but again only 21 patients were included.

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Authors and Affiliations

  1. Herzlia Medical Center intensive care unit and Reichman University, Herzlia, Israel

    Pierre Singer

  2. Beilinson Medical Center, Institute for Nutrition Research, Petah Tiqwa, Israel

    Liran Statlender

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  1. Pierre Singer
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PS and LS contributed both to the redaction of this comment.

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Correspondence to Pierre Singer.

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Singer, P., Statlender, L. Beyond the limits of indirect calorimetry. Eur J Clin Nutr 77, 925–926 (2023). https://doi.org/10.1038/s41430-023-01319-2

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