Do PICU patients meet technical criteria for performing indirect calorimetry?

Background & Aims: Indirect calorimetry (IC) is considered gold standard for assessing energy needs of critically ill children as predictive equations and clinical status indicators are often unreliable. Accurate assessment of energy requirements in this vulnerable population is essential given the high risk of over or underfeeding and the consequences thereof. The proportion of patients and patient days in pediatric intensive care (PICU) for which energy expenditure (EE) can be measured using IC is currently unknown. In the current study, we aimed to quantify the daily proportion of consecutive PICU patients who met technical criteria to perform indirect calorimetry and describe the technical contraindications when criteria were not met.

Methods: Prospective, observational, single-centre study conducted in a cardiac and general PICU. All consecutive patients admitted for at least 96 h were included in the study. Variables collected for each patient included age at admission, admission diagnosis, and if technical criteria for indirect calorimetry were met. Technical criteria variables were collected within the same 2 h each morning and include: provision of supplemental oxygen, ventilator settings, endotracheal tube (ETT) leak, diagnosis of chest tube air leak, provision of external gas support (i.e. nitric oxide), and provision of extracorporeal membrane oxygenation (ECMO).

Results: 288 patients were included for a total of 3590 patient days between June 2014 and February 2015. The main reasons for admission were: surgery (cardiac and non-cardiac), respiratory distress, trauma, oncology and medicine/other. The median (interquartile range) patient age was 0.7 (0.3-4.6) years. The median length of PICU stay was 7 (5-14) days. Only 34% (95% CI, 32.4-35.5%) of patient days met technical criteria for IC. For patients less than 6 months of age, technical criteria were met on significantly fewer patient days (29%, p < 0.01). Moreover, 27% of patients did not meet technical criteria for IC on any day during their PICU stay. Most frequent reasons for why IC could not be performed included supplemental oxygen, ECMO, and ETT leak.

Conclusions: In the current study, technical criteria to perform IC in the PICU were not met for 27% of patients and were not met on 66% of patient days. Moreover, criteria were met on only 29% of days for infants 6 months and younger where children 24 months of age and older still only met criteria on 40% of patient days. This data represents a major gap in the feasibility of current recommendations for assessing energy requirements of this population. Future studies are needed to improve methods of predicting and measuring energy requirements in critically ill children who do not meet current criteria for indirect calorimetry.