Preventing Underfeeding and Overfeeding: A Clinician's Guide to the Acquisition and Implementation of Indirect...

In critically ill patients, indirect calorimetry (IC) is the gold standard to determine energy needs, as the use of predictive equations can result in underfeeding or overfeeding. The aim of this quality improvement (QI) initiative was to describe the rationale for and implementation of a process to target energy provision according to IC measurements in a tertiary academic medical center pediatric intensive care unit (PICU).

To justify the purchase of an indirect calorimeter for clinical use, a needs assessment was conducted, followed by a training and implementation period. PICU patients were selected for IC according to published guidelines. Measured energy expenditure was compared with predicted energy expenditure and the provided energy prescription. The dietitians assessed IC results and adjusted energy prescriptions, if indicated.

Thirty-five total tests were completed with 24 patients. Sixty-nine percent of measurements resulted in energy delivery adjustments. Fifteen (47%) energy prescriptions decreased by a mean of 27% ± 11%, and 7 (22%) increased by a mean of 17% ± 15%. Staff and patient/guardians accommodated the use of IC, and PICU dietitian recommendations for IC tests and to adjust nutrition regimens were universally implemented.

Data to support the procurement of IC are vital to promote best practice to measure energy expenditure. Critically ill pediatric patients exhibit metabolic alterations that cannot be predicted by standard equations. Our QI initiative demonstrated the implementation and application of IC in the critically ill population and the ability to target energy provision to prevent energy imbalances.