Energy requirements for critically ill patients with COVID‐19

Abstract

Early reports suggested that predictive equations significantly underestimate the energy requirements of critically ill patients with coronavirus disease 2019 (COVID‐19) based on the results of indirect calorimetry (IC) measurements. IC is the gold standard for measuring energy expenditure in critically ill patients. However, IC is not available in many institutions. If predictive equations significantly underestimate energy requirements in severe COVID‐19, this increases the risk of underfeeding and malnutrition, which is associated with poorer clinical outcomes. As such, the purpose of this narrative review is to summarize and synthesize evidence comparing measured resting energy expenditure via IC with predicted resting energy expenditure determined via commonly used predictive equations in adult critically ill patients with COVID‐19. Five articles met the inclusion criteria for this review. Their results suggest that many critically ill patients with COVID‐19 are in a hypermetabolic state, which is underestimated by commonly used predictive equations in the intensive care unit (ICU) setting. In nonobese patients, energy expenditure appears to progressively increase over the course of ICU admission, peaking at week 3. The metabolic response pattern in patients with obesity is unclear because of conflicting findings. Based on limited evidence published thus far, the most accurate predictive equations appear to be the Penn State equations; however, they still had poor individual accuracy overall, which increases the risk of underfeeding or overfeeding and, as such, renders the equations an unsuitable alternative to IC.

Comparação dos valores de gasto energético mensurados por calorimetria indireta e os calculados por fórmula preditiva, em pacientes críticos com COVID-19

“…Em nosso estudo, pudemos verificar que houve essa diferença em relação à necessidade subestimada do cálculo da fórmula de bolso, quando comparada ao cálculo obtido através da CI. Isso vai ao encontro de outro estudo com pacientes críticos com COVID-19, onde foi identificado que a estimativa de gasto energético foi significativamente maior pela CI, quando comparada à outra equação preditiva validada para pacientes em ventilação mecânica 17 .…”

“…A primeira fase (ebb) dura cerca de 24-48h, e é caracterizada como um estado relativamente hipometabólico, com diminuição do VO 2 e do débito cardíaco. Em seguida, tem-se a fase tardia da fase aguda (flow), que pode durar até 7 dias, e é caracterizada por um estado hipermetabólico, com aumento do VO 2 e do débito cardíaco 17 . Porém, a transição das fases da doença crítica e seus intervalos de tempo pré-definidos sugeridos em literatura não parecem ser aplicáveis em pacientes com COVID-19 18 .…”

A Snapshot of the Experience of Dietitians during the COVID-19 Crisis in Five Arab Countries: Findings from a Regional Cross-Sectional Study

“…However, predictive equations can be utilized alternatively because IC is not always institutionally accessible [32]. Nevertheless, the risk of malnutrition, which is linked to poor clinical outcomes, is increased by the potential underestimation of energy requirements in severe COVID-19 patients [33].…”

Current insights in ICU nutrition: tailored nutrition

“…In approximately 56% of COVID-19 ICU patients, FI was present, and 52% of patients suffered from malnutrition. Among other factors, the hypermetabolic and prolonged catabolic state of COVID-19 patients make personalized and accurate nutrition treatment essential [38 ▪▪ ,39]. Furthermore, SARS-CoV-2 can attack the mucosal epithelium and cause gastrointestinal symptoms, increasing FI and malnutrition risk [40].…”