Indirect Calorimetry and the GE Indirect …

1 7/1/20111 Indirect Calorimetry and the GE Engstrom CarestationJorge E. RodriguezBSRC, RRTI ndirect Calorimetry and the GE Engstrom Carestation To obtain the most accurate metabolic data from Indirect Calorimetry , one must:y Evaluate the patient. Obtain consistent, Steady State data. Analyze and correlate the data to the patient s Calorimetry and the GE Engstrom Carestation Patient Evaluation A stable patient is paramount for metabolic measurement! Only when the patient is in a resting Steady State will the metabolicwhen 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 arrhythmiasIndirect Calorimetry and the GE Engstrom Carestation Ventilator Settings FiO2 70% RR 35 RR 35 PEEP 10 What is the ventilator mode/strategy?

2 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 Calorimetry and the GE Engstrom Carestation 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, Calorimetry and the GE Engstrom Carestation Chest X Ray Atelectasis, Pleural Effusion, Consolidation, Pneumothorax, Pulmonary Edema, Pneumonia, ARDS ?

3 Lung Compliance Evaluate Static Compliance Calorimetry and the GE Engstrom Carestation 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 210is 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 Calorimetry and the GE Engstrom Carestation Metabolic measurement should not be considered during the following and should take place 30-90 minutes after any stress has been placed on the body:StBthiTil Spontaneous Breathing Trial Bronchoscopy, BAL Nebulizer treatment, IPV, CPT, etc.)

4 Patient mobilization, Bath, Physical Therapy Placement of Arterial Lines, PICC Lines, CVC Lines Lumbar puncture, biopsies, drain/tube placement CT Scan, MRI, Interventional Radiology AgitationIndirect Calorimetry and the GE Engstrom Carestation Hemodialysis and metabolic measurement Intermittent hemodialysis removes CO 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 longand Continuous Venovenous Dialysis (CVVHD) use slow filtration rates for long periods of time. These types of dialysis can decrease body temperature and therefore decrease VO 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.

5 Transfusion of blood products and metabolic measurement Indirect Calorimetry can be performed 3-4 hours after Packed Red Blood Cell (PRBC), Platelet, Fresh Frozen Plasma (FFP), White Blood Cells (WBC), Calorimetry and the GE Engstrom Carestation Advantages of using the Engstrom Carestation for metabolic measurementQik dtfth 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 Calorimetry and the GE Engstrom Carestation Preparing for metabolic measurement Inspect D-Fend tubing/sensor for condensation and/or occlusion.

6 If needed replace with new tubing/sensor Place D-Fend sensor so that itneeded, 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 CO , VCO , and VO . Allow 30 minutes for module to warm up and read Calorimetry and the GE Engstrom Carestation Preparing for metabolic measurement Check to ensure the patient s correct height and last known Dry Weight height and last known Dry Weight have been entered in the Patient Setup menu. Select EE/RQfrom the screen menu to display in the digital field for observation and Calorimetry and the GE Engstrom Carestation Preparing for metabolic measurement From the trends menu, you can view EE/RQ,VO /VCO ,VO /kg/min andEE/RQ, VO /VCO , VO /kg/min and VCO /kg/min, or Veto observe consistency in breathing pattern and metabolic Calorimetry and the GE Engstrom Carestation Use Spirometry and FRC measurement to further evaluate the patient s pulmonary Calorimetry and the GE Engstrom Carestation Preparing for metabolic measurement Laptop loaded with OhmedaCom Research Tool software is connected to the Engstrom Carestation via Ethernet cord.

7 Records breath by breath ventilator data, including metabolic measurement. Download 15-20 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 Calorimetry and the GE Engstrom Carestation EView A portable device that attaches to the back of the ventilator screen, allowing capture of all foutput 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 and used with another GE Calorimetry and the GE Engstrom , B IC Graph , Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011.

8 Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..Tue, Apr 12, 2011 ..KcalTimemeasured EE (kcal/day)measured RQ Indirect Calorimetry and the GE Engstrom IC Graph , Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010.

9 Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..Wed, Mar 10, 2010 ..TimeKcalmeasured EE (kcal/day)measured RQ 7/1/20114 Indirect Calorimetry and the GE Engstrom CarestationPredictive equations and guidelines: Predictive Equations Ireton Jones, Penn State, Swinamer, and Frankenfield equations use the patient s weight (kg) height (cm) age (yrs) activity leveluse 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.

10 Nutritional Guidelines Based on patient s IBW 20-25 kcal/kg for obese patients, (BMI 30) 25-30 kcal/kg for most patients, (BMI 30) 30-35 kcal/kg for underweight patients, (BMI 17) Indirect Calorimetry and the GE Engstrom Carestation What is the patient s current nutritional status and what will be the expected RQ? Is the patient NPO? If so, for how long?g 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? Indirect Calorimetry and the GE Engstrom Carestation 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.