Estimating energy requirements in burned children: a new approach derived from measurements of resting energy expenditure13 Michael
I Goran,
Lyle
Broemeling,
ABSTRACI’
We examined
ergy
expenditure
(REE)
dren.
Predicted
area
(r2
basal and
0.76).
Days
postburn
for 21%,
and
accounted
body
REE above PBEE. was PBEE (REE
=
did
the
not
activity
used was
X PBEE);
X PBEE,
which
(1 .55
X PBEE)
to 2 X PBEE.
95%
of other
When
the
measurements
of energy
valid
approach
to estimating
Nutr
199 1;54:35-40.
KEY
WORDS
our
variables
data
lower
than
for larger
The energy
energy
presented
expenditure,
balance
energy
success and
represent
the
Energy
requirements
mination
of total
reported
that
tune,
indirect
calorimetry,
The veston
most
and
energy
expendi-
Unit March
excisional port was
Introduction that
aggressive
and
mortality
However,
it is also
evident
that
excessive
energy
intake
cannot
nutritional after
in severely
completely
support
severe
burn
stressed overcome
has
to achieve energy patients with large ular
used
patients, the
equations
is reason overestimate
balance in burned burns. This beliefhas
used
are
not
based
to believe energy children, arisen
on
by these loss. In fact, conventional
maintain
(4, 5). The
constant by the
J C/in Nutr
fact
body that
body
l991;54:35-40.
weight weight
Printed
maintenance in USA.
by deter(6)
recently with
the
children
to formulate
requirements.
8). The
been the
equations are acpatients receiving recommendations is not
is complia suitable
© 1991 American
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
majority
of the
Society
From
from
TX,
weight, hospital
Basal
energy
basal
The
energy
via
enteral
Evansville, mixtures. The University
followed. (85
independent
expenditure,
of 127
observations variables body
surface
of BSA with 3#{176} burn injury (% BSA burned), and days
expenditure
Unit,
supde-
analysis
children
percentage admission
on admission
with
Nutritional previously
Board, were
1985
uniformly
was
retrospective
in females).
age, on
the Metabolism
Review
in 56 burned
were
intake
at the GalMarch
Isocal (Mead-Johnson, or, milk-Isocal
Galveston,
43 observations
treated
of energy
was generated
injury
between
described (7). to the equations
Institutional
Branch,
REE
for burn Institute
patients.were
were either milk, (Mead-Johnson),
to predict
by observation
of energy
situation
treated
equations of Harris and Benedict from height and weight (10). The
particularly in because the pop-
measurements
energy requirements recommended tually necessary to avoid weight markedly less energy intake than
We
be
catabo-
as determined
burned
Burns
as previously according
of REE
postburn.
that currently requirements
1
Am
All ofthe
Medical
area (BSA), as estimated
protein
expenditure. The basis for success of these equations has generally weight maintenance (3, 4). However, it is unclear whether
cated
1989.
measurements in males,
injury.
catabolic response (1) and can have detrimental physiological effects (2). Consequently, it is important to accurately estimate energy requirements. There used equations significantly
be predicated
energy
were
Shriners
A database agreed
studied
standards
of Texas
morbidity
in many
ofthe
therapy standardized (4,
ethical
It is generally
would
while
(TEE).
children,
to predicting
children
fluids, which IN), Prosobee
burns
improved
because
intake
technique, is strongly correlated with resting (REE). This observation led us to examine
ofREE
approach
ideally
expenditure
in burned
labeled water expenditure
scribed
requirements,
TEE
mainly
energy
in fat synthesis continues (1).
should energy
therapy,
excess
Methods
from
Am JClin
requirements.
Nutritional
of nutritional because
expected to result predominantly lism of heavier lean body mass
equal
are derived
they
of the retention
a new
balance
X PBEE#{176}75), approximately equations
indicator of fluid
R Wolfe
commonly
burns.
achieve
and Robert
the determinants
predict
energy
J Peters,
doubly energy
described
the
to maintain
in
of REE
recently
is used,
of patients
+ (2.39
Because
only
in the elevation
addition
is significantly
that
REE
predictor
patients
especially
to ensure
with
powerful
requirement
recommendations,
required
most
surface
(% BSA burned)
variation
prediction.
energy
size
enchil-
body
significantly
burn
ofthe
of 1.2 for burn
the average
is 1.55
24%
The single
improve factor
(PBEE),
correlated and
Edward
of resting in 56 burned
expenditure
weight
1.29
N Herndon,
the determinants
127 observations
energy
(BSA), =
that
in
David
was
predicted
(9) and BSA % BSA burned
in the usual
Shriners
manner,
Burns
from
the
was calculated was estimated
Institute,
and
we made
and the De-
partments of Anesthesiology and Surgery, University of Texas Medical Branch, Galveston, TX. 2 Supported by NIH grant GM-41089 and a grant from the Shriners Hospitals. 3 Address reprint requests to RR Wolfe, Shriners Burns Institute, 610 Texas Avenue, Galveston, TX 77550. Received September 14, 1990. Accepted for publication December 5, 1990. for Clinical
Nutrition
35
36
GORAN
TABLE I Description
of data group
ET
AL
TABLE 2 Individual correlations potential predictors
analyzed1
between
Resting
energy
expenditure
and
Variable Independent Age(y)
9±5
Weight (kg) Days Postburn BSA (m2) 30 Burn size (% BSA)
32.6 25 1.06 57
Predicted BEE (Mi/d)
4.76
17.6 20 0.39 24
± ± ± ±
PBEE (Mild)1 BSA (m2) Weight (kg)
(5.6-77.6)
(0-99) (0.28-1.94) (4-98)
SD (range).
6.19 1480 n
2.58 (1.41-15.70) 616 (337-3755)
± ±
127. BSA, body surface
=
PBEE,
basal
to adjust
this
factor and
to account
carbon calorimetry
indirect
metabolic cart (Fullerton, as previously described
REE, resting
for
coverage
tempt respect
was to
made fever,
usual
clinical
was
to control infection,
around the time was to examine
dioxide-production rates by use of a Beckman
were not
performed interrupted
for standardizing antibiotics, pain
of measurement. the determinants conditions.
available in the same measurements.
patients,
repeated they
were
in the early and no at-
conditions medication,
Our rationale of measured
When
which
was
diverse
age
3 mo-21
and
burn
thropometric basal energy burned, compare
(with etc)
for this approach REE under the
measurements treated
were
as independent
REE analysis
were constructed by by using the measured
of REE as the dependent variable. The independent were the potential predictors of REE and were the measurements expenditure
observed (PBEE),
energy
multiplied
requirements,
by the
use of value
variables usual an-
in burn patients [predicted BSA, weight, age, % BSA
Harris-Benedict
with
respect
y; body injury
to anthropometric
weight
(3#{176} burns
5.6-77.6 covering
measurements
4-98%
made
variables
kg; BSA
between
(eg,
0.28-1.94
of BSA). 0 and
m2); The
data
99 d after
burn
Prediction
ofresting
Table and
energy
2 summarizes
the
between
REE
the correlation
independent
ranged weight).
from The
primarily
variables.
on body
by indirect
diture, as predicted in Figure 1. The
postburn
the
ratio
% BSA
of REE
burned
are
is shown
to PBEE
during shown
REE expen-
equations,
in REE
(REE:
treatment in Figures
counted for only 2 1% and 24%, respectively, ofthe variation the elevation of REE above predicted normal. The single most powerful predictor of REE in this group
in
the
and % BSA burned
2
ac-
was
postburn
energy
thus
patients
Days
BSA, and is therefore between
basal
the Hams-Benedict
of the elevation and
and 3, respectively.
and
(r2)
coefficients
The relationship
size.
between
a reflection
days
analysis correlation
calorimetry,
from
relationships
PBEE),
The
0. 15 (% BSA burned) to 0.76 (PBEE, observed rate ofREE in burned children
dependent
as measured
expenditure
of
PBEE:
REE
=
1.29
X
(1)
PBEE
Three predicted
factor
study in burn
1.2. This
in which patients
components of energy expenditure (by use of the Harris-Benedict
sured
by indirect
calorimetry;
and
factor
of 1.2. Energy
REE by an activity expressed
as
MJ/d
and
are
TEE
Spreadsheet MA)
software or the
(Lotus
BMDP
activity
the (6).
20
factor
doubly
labeled r
are discussed: PBEE equations); REE meaderived
> 0 0
by multiplying
expenditure
accompanied
by
the
by using
either
Development
statistical
software
0 76
15
10
and intake caloric LU LU
equivalent (kcal/d) in parentheses. All statistical analyses were performed Cambridge,
was used to developed. for predicting REE
equations
activity
was derived in our recent water technique was used
5
the Lotus
Corporation, (BMDP
Inc,
Angeles).
0 0
2
4
FBEE
Results Data
from
and days postburnl. A predictive analysis the forecasting precision of the equations
To predict
Los
predicted
injury.
and
Equations for predicting stepwise-linear-regression
1-2-3
and
CA) with a face mask for gas collections (1). REE was derived by using the equa-
tion of Weir ( 1 1 ). Measurements morning. Continuous feeding
are
expenditure
of wounds.
Oxygen-consumption were measured by
were
energy
equations.
set included attempt
-0.28 0.15
area; BEE, basal energy
expenditure as predicted from the Harris-Benedict equations; energy expenditure as measured by indirect calorimetry.
no
0.73
Days posthurn % BSA burned
1.22 (1.78-8.00) (426-1914)
±
0.76 0.76 0.76
Age
I
Measured REE (Mild) (kcal/d)
healing
r2
1 138 ± 292
(kcalld)
I
variable
(0.33-21)
set
Table
1 summarizes
in 56 burned
children.
the data We treated
for 127 measurements the data
as one
entire
of REE group,
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
6
8
10
(MJ/day)
FIG 1. Relationship between resting energy sured by indirect calorimetry and basal energy dicted by the equations of Harris and Benedict
expenditure expenditure (9).
(REE) mea(PBEE) pre-
ENERGY
EXPENDITURE
IN
BURNED
TABLE Percent
3 relative
LU
37
CHILDREN
Percent
error
in predicting
resting
energy
expenditure1
Percent
of patients
relative
errort
LU % C-
0 10 25 50
LU LU
DAYS
POST
where
r2
any
0.96
=
other
when
variables
above
predicted
value
(REE/PBEE)
as a
the
is fixed
equation
at zero.
did
not
Addition
improve
of equation
measurements cent
of the
predicted value,
ofthe
energy
pre-
were REE,
with
respect
REE
within
were
±45%
in the
127
Fifty
per-
to predicted
± 17%
within
(Table
determined
basal
energy
residual
95th
random
vari-
expenditure.
oftotal
energy
Use of the activity (6) allowed derivation
requirements
percentile
was
to be
equation
factor ofan
TEE Because value
this
equation
of PBEE,
have
a TEE
1.2 from our previous publication equation to predict the average TEE: =
is the
was
percentile,
patients, our
the
less than
can
value
be derived
analysis,
the
the
for TEE
of the
value
given
the standard expenditure
of TEE by using
standard
value
one-half
the average value ofTEE and a given value of basal energy 95th
average
approximately
that
(2)
1.55 X PBEE
that
would
in equation
is exceeded
(1.55
=
X PBEE)
+ (2.39
the energy
at least
enough
value
normal
multiplied the
(3)
X PBEE#{176}75)
required energy
was
distribution,
to ensure to reach
that
a state
95%
of
of energy
The resulting value for an average patient in this study 1 ) is 9.32 MJ/d (2229 kcal/d), which is approximately to twice
the PBEE
5 displays by four
other
[9.5 1 MJ/d
the energy
(2276
kcal/d)].
requirements
equations
that would
currently
in use
be pre-
in addition
to
were prewith a burn
injury
in Figure
covering
either
30%
or 80%
BSA.
As seen
5,
our predictions are well below the lowest value. The equation designed to include 95% of patients (Eq 3) is approximately equal to the value ofequation 2 X PBEE, promulgated by Wolfe (12), which predicts energy requirements that are -20% lower than
for the
LU
those
predicted
by the
Long
equation
(13).
by 5% of the
linear
of TEE
50% of energy
our new equations 2 and 3. The energy requirements dicted for the average patient in the present study
2. If
deviation ofTEE are known, then
weighted
deviation
for a given
patients
found
predicts
receive
balance. (Table
dicted
this
of the standard
patients
equal
X PBEE#{176}75.When
5% point
Figure Prediction
1.29 X PBEE.
relative error of 127 predictions. Thus, 17% from the observed rate of resting
upper
TEE This
as a
4 as a function
show
as 1 .452
by the
and
expressed
in Figure
residuals
by using the equation
percent deviated by
of the
±30%,
3). The
predicted),
is displayed
4, these
within
were
minus
As seen in Figure
REE
was determined.
predictions
(measured
of measured
ation
for
ofthe
predictions
ofPBEE.
children
values
75%
expenditure
percent
1 in predicting
in 56 burned
measured 90%
Values
timated reliability
44.84 189.0
of
the
diction. The
30.10
90 100
t The median predictions expenditure.
the intercept into
75
BURN I
FIG 2. Elevation in REE function of days postburn.
0.41 4.42 9.34 17.08
regression.
predictions
In
was
LU
200
-
150
-
100
-
es-
2.5 r=0.24 I
LU
2.0
.. . ‘-,
LU I
..
:
I
1.0 S
I
(1’) LU
:.
#{149} #{149}
2
4
PBEE
I
20
40
60
SIZE
80
#{149}#{149}#{149}
I
,: #{149}#{149}S.
#{149}.
50 0
BURN FIG function
:
#{149}#{149}.#{149}
I
0.5
0
1t2
I
0
0 I
0.0
,S.
-J
I
C-
#{149}
.1
1.5
LU LU
50
.
6
8
10
(MJ/day)
100
(% TBSA)
3. Elevation in REE above predicted value (REE/PBEE) of burn size [% total body surface burned (% TBSA)J.
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
as a
FIG 4. Residual of the predicted REE vs PBEE. The residual is the difference between the observed REE and the REE predicted by equation 1 (REE = 1.29 x predicted basal) and expressed as a percentage of the measured REE.
38
ET AL
GORAN I-
z
20
LU
::::i
LU
30%
burn
80%
burn
15
C
LU LL
>-0
0
10
LU LU’
F
5
0 LU
I-
0-
(I) LU
1 .55.PBEE
1 .55.PBEE
2.PBEE
Long
Galveston
Curreri
+
2.39.PBEEP75 FIG 5. Total energy requirements (I Mi/d = 239.2 kcal/d) for energy balance in burned children, as predicted by various equations. Energy requirements were estimated for the average patient in this study with either a 30% or an 80% burn. Requirements were estimated by using the following equations: 1.55 X PBEE, equation 2; (1.55 X PBEE) + (2.39 X PBEE#{176}75), equation 3; 2 X PBEE, reference 12; 2.52 X PBEE, Long equation (13); Galveston equation (4); Mi/d = (6.27 X BSA) + (6.27 X burn in m2), kcal/d = (1500 X BSA) + (1500 X burn in m2), Curreri equation (3); Mi/d = (0. 105 X weight) + (0. 167 X % of BSA burned), kcal/d = (25 X weight) + (40 X % of BSA burned). PBEE, basal energy expenditure predicted from Harris-Benedict equations (9); BSA, body surface area (m2); weight, body weight (kg).
The
most
important
presented
and
equations
is that
of the from burns, trative
the
burn.
difference
popular the
The
new
equations
are dependent
latter
discrepancy
in Figure
the
(4, 8) and
between
the various equations such as the 80% burn purposes
between
Galveston
the
equations
Curreri
of basal
et al (3) on the
estimations
size
derived
is particularly evident chosen as representative
with large for illus-
5.
energy
equations
recovery recovery
study
burned
represents
children.
The
dren is primarily of the elevation liably predicted
the
most
analysis
extensive
revealed
analysis
that
REE
dependent on body size, and in REE above predicted normal from the extent of burn injury.
of REE
during
this period
in burned
chil-
REE
dicted
basal
mean
of 271
size
was
was
expenditure injury
surprising
useful
state
to the recovered
ulation
such
not
other
set of equations
cifically dren
designed (14).
ments
equations
(WHO)
of energy data
greater
than
that
for children.
with those basal
WHO
3. 1 ± 7.5%
when
comparison.
The
energy
expenditure
expenditure
in children
predictions.
aged
thus
50% of BSA. and protein
Similarly, metabolism
in the many conducted
EXPENDITURE
studies in our
IN
of carbohydrate, laboratory (1, 2),
BURNED
27%
ofthe
coefficient
described
It is difficult
to assess
we never observed a significant effect of burn size in patients with a burn size > 40% of BSA. Equations estimating energy requirements based on percent burn size in patients with large
al equation
because
burns
first
fat,
are thus
not
It is unclear presence
based
on established
how much
of burn
injury
of the elevation itself
and
explained by energy expenditure effect of feeding. For example, the
entire
effect
elevation
of feeding.
expenditure
in We
REE
have
associated
ivation
of the
new
metabolic
how
in REE
much
in burn
patients effect
by using
the
the
of feeding
relationship
feel
that
physical
it is appropriate
activity
for other
increases
with
patients.
This
convalescence
of TEE to REE will generally be higher later during the initial stages. Therefore the factor overestimate
the
prediction
of TEE
from
energy
requirements
contain
a factor
actual
measurements
in burned for burn
children.
size,
Whereas
neither
ofenergy
equation
expenditure.
the
ratio
(MJ/d)
Using
from
our database,
x burn
TEE
(kcal/d)
=
(1 180 X BSA
Both coefficients than
x
derived
X burn
in this equation
are substantially
used
be explained
by Hildreth burned volume water
by the fact that
et al (4) was
children of fluid vaporization
based
size in m2)
the original
(4) lower
[kcal/d = (1800 large discrepancy
approach
on observations
described
of fluid
in
during the initial 48-h resuscitation phase. The loss was then multiplied by the energy cost of to derive
the coefficient.
This
factor
is there-
fore
inappropriate on two accounts. First, it is based only on observations made in patients treated during acute resuscitation, and second, it is not based on actual measurements of energy expenditure. and
Similarly, % BSA
when TEE was expressed in terms of body weight burned, an equation comparable to the Curreri et
al (3) equation TEE
(MJ/d)
was generated:
(0. 147
=
X weight
in kg)
+ (0.045 TEE
(kcal/d)
=
(35.2
X weight
determined
X % BSA burned)
in kg)
+ (10.8 Our experimentally
body-weight
coefficient
weight
during
the
X % BSA burned) for % BSA burned
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
requirements.
the
predictive
3 are limited.
were
dependent
The
power
of the
observation
within
and,
±17%
that
as already
ofthe
discussed,
the
interpre-
weight in burn patients is complex and may not reflection of metabolically active tissue. Second,
of body likely
that
therapy
involved,
patient,
and
to control the
a combination
(5)
is
use
presence for these
determinants
treated
offactors
our
of excisional offever
in addition
early
treated
conditions
Institute
because under
to PBEE
could
our
natural
they
are
excision
not
hormonal
status
We made aim
of
no attempt
was to examine
clinical
circumstances
laboratory conditions. Although our in a population of burn children
excision,
without
surgery,
or infection.
of REE
to controlled were developed
with
detect
likely
because any
to be appropriate
a previous
difference
report
in REE
in
from
in adults
with and without excisional surgery (19). In a recent publication, Allard et al (20) assessed the performance of a complex equation for predicting REE in burn patients, which includes factors to account for % BSA burned, treated
energy
loss
estimated
used,
2 and
50% ofpredictions
patients
in the actual Galveston equation BSA in m2) + (2200 x burn size in m2)]. This
can
those
size in m2)
in m2)
+ (845
was a retrospective
in body
measured value can be explained by a number of factors. First, the predictions of basal energy expenditure that we used were determined by the equations of Harris and Benedict (9), and as already stated, these may be inappropriate for children. Moreover, whichever equation is used, the predictions ofbasal energy expenditure are only
as opposed equations + (3.53
of the
database
equations
it is also
equations
both
are
also affect REE. These might include nutritional status of the patient at the time of REE measurement, activity ofthe subject (eg, dressing change) preceding measurement, time between measurement and most recent surgery, type of medication and
of predicting
was derived
20%
large
be an accurate et al equation
x BSA in m2)
(4.93
=
only
the
proposed
tation
we rederived equations with similar general structures to the Galveston and Current equations. When TEE is expressed in terms of BSA and m2 burn (cf, the original Galveston approach), the following was obtained: TEE
received
Despite
measurements
in the early stages of recovery. The Galveston equations (4, 8) and the Curreri (3) are probably the most commonly used means
study
changes
et
rationale
weight
in recovery than 1.2 may tend to
REE
(3). Their
and
or even
in der-
is because
so that
paper
data
(3).
in the Curreri
20 d of recovery in nine burn patients. Change in body weight was plotted against actual dietary intake, expressed as a
between
REE and TEE. This factor (1.2) was determined experimentally in a limited number of patients by using the doubly labeled water technique to measure TEE (6). Although this factor was derived in a patient group studied in the latter stages of recovery,
we
supportive
intake
et al equation
for the factors
energy
thermic
for the
no
in the original ofdietary
in the Curreri
the basis
percentage of ideal caloric intake calculated by the Curreni formula. Even the original data presented by Curreri et a! (3) argue against the validity of the equation because patients receiving significantly less energy intake than prescribed by the equation nonetheless maintained body weight. The only patient who lost
be potentially
by
accounted
the thermic
equations
is due to the
can
associated with the thermic Allard et al (18) accounted for
indirectly
with
processes.
provided analysis
39
CHILDREN
intake,
PBEE,
complex
equation
not
that
clear
temperature,
is cumbersome
significant
power
energy
requirements
PBEE.
If we had included
et al (20) in our analysis,
by the the
and
days
to use and is added
consideration
postburn.
furthermore
to the
This
it is
predictions
of factors
other
of than
the additional factors used by Allard r2 ofour predictive equation would
have decreased. In addition to the problems of formulating a good equation, it must be realized that there is a certain amount of variation in REE that is not explained by body size or body composition even in normal volunteers (2 1, 22). It is of further concern that the error assessment presented in Table 3 does not include the error in predicting TEE from REE. From our previous experiment in a limited number of patients in whom both REE and TEE were measured (6), equation 2 functioned poorly in predicting TEE even though there was a significant correlation between TEE and REE. In summary, the most reliable estimates of energy requirements are obtained by actual measurements of REE on an in-
40
GORAN
dividual basis in conjunction which is 1.2 in the convalescent of REE that
is not
if energy
patients
will
to their
feasible, receive
desirable
to
x PBEE
to energy
paper
twice
an amount
In severely
stressed of energy
energy
according
this will be sufficient
the
support
the
PBEE,
patients
intake who it may
to
equation
to maintain
all equal
are unable
excess, the
notion
virtually
of energy
side effects
provide
because
in this
at about
at least
expenditure. potential
close
the data
is provided
to tolerate
with an appropriate activity factor, burned child (6). If measurement
be more 1.55
most patients
U
balance.
We are grateful to Manu Dessai who allowed us ments ofresting energy expenditure in patients under we thank Tom Rutan, James Richardson, and the staffofthe Shriners Burns Institute for performing calorimetry measurements.
to perform measurehis cane. In addition, Respiratory Therapy some ofthe indirect
References 1. iahoor F, Desai M, Herndon DN, Wolfe RR. Dynamics ofthe protein metabolic response to burn injury. Metabolism 1988;37:330-7. 2. Wolfe RR. Nutrition and metabolism in burns. Crit Care Med l986;7: 19-63.
3. Curreri PW, Richmond D, Marvin i, Baxter CR. Dietary requirements of patients with major burns. i Am Diet Assoc 1974;65: 415-7. 4. Hildreth MA, Herndon DN, Desai MH, Duke MA. Caloric needs of adolescent patients with burns. i Burn Cane Rehabil 1989;l00: 523-6. 5. Cunningham ii, Lydon MK, Russell WE. Calorie and protein provision from severe burns in infancy and young children. Am i Clin Nutr l990;51:553-7. 6. Goran MI, Peters El, Herndon DN, Wolfe RR. Total energy cxpenditure in burned children using the doubly labeled water technique. Am J Physiol l990;259:E576-85. 7. Herndon DN, Curreri PW, Abston 5, Rutan TC, Barrow RE. Treatment ofburns. Curr Probl Surg 1987;2:347-97.
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
ET
AL
8. Hildreth MA, Carvajhal HF. Caloric requirements in burned children: a simple formula to estimate daily caloric requirements. i Burn Care Rehabil l982;3:78-80. 9. Harris iA, Benedict FG. A biometric study of basal metabolism in man. Washington, DC: Carnegie Institute of Washington, 1919. (Publication no. 279.) 10. Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight are known. Arch Intern Med 19 16; 17:863-7 1. I 1. Weir deJB. New methods for calculating metabolic rate with special reference to protein metabolism. J Physiol l949;l09:l-9. 12. Wolfe RR. Caloric requirements of the burned patient. i Trauma 198 1;2 l(suppl):7 12-4. 13. Long C. Energy expenditure of major burns. i Trauma 1979;19: 904-6. 14. World Health Organization. Energy and protein requirements. WHO Tech Rep 5cr 1985:724. 15. Wilmore DW, Long JM, Mason AD, Streen AW, Pruitt BA Jr. Catecholamines: mediator of the hypermetabolic response to thermal injury. Ann Surg 1974;l80:653-69. 16. Caldwell FT ir, Bowser BH, Crabtree JH. The effect of occlusive dressings on the energy metabolism of severely burned children. Ann Surg 198 l;193:579-9l. 17. Bradham GB. Direct measurement oftotal metabolism ofa burned child. Arch Surg l972;105:4l0-3. 18. Allard JP, ieejheebhoy KN, Whitwell J, Pashutinski L, Peters Wi. Factors influencing energy expenditure in patients with burns. i Trauma l988;28: 199-202. 19. Rutan TC, Herndon DN, Van Osten T, Abston S. Metabolic rate alterations in early excision and grafting versus conservative treatment. J Trauma l986;26:l40-2. 20. Allard iP, Pichard C, Hoshino E, et al. Validation ofa new formula for calculating the energy requirements of burn patients. JPEN 1990;14:l 15-8.
21.
22.
Fontain ER, Savard A, Trembly iP, Despres E, Poehlman ET, Bouchard C. Resting metabolic rate in monozygotic and dyzygotic twins. Acta Genet Med Gemellol (Roma) I985;34:4 1-7. Ravussin E, Lillioja S, Anderson TE, Christin L, Bogardus C. Dcterminants of 24-hour energy expenditure in man. Methods and results using a respiratory chamber. i Gin Invest 1986;78:1568-78.
I Goran,
Lyle
Broemeling,
ABSTRACI’
We examined
ergy
expenditure
(REE)
dren.
Predicted
area
(r2
basal and
0.76).
Days
postburn
for 21%,
and
accounted
body
REE above PBEE. was PBEE (REE
=
did
the
not
activity
used was
X PBEE);
X PBEE,
which
(1 .55
X PBEE)
to 2 X PBEE.
95%
of other
When
the
measurements
of energy
valid
approach
to estimating
Nutr
199 1;54:35-40.
KEY
WORDS
our
variables
data
lower
than
for larger
The energy
energy
presented
expenditure,
balance
energy
success and
represent
the
Energy
requirements
mination
of total
reported
that
tune,
indirect
calorimetry,
The veston
most
and
energy
expendi-
Unit March
excisional port was
Introduction that
aggressive
and
mortality
However,
it is also
evident
that
excessive
energy
intake
cannot
nutritional after
in severely
completely
support
severe
burn
stressed overcome
has
to achieve energy patients with large ular
used
patients, the
equations
is reason overestimate
balance in burned burns. This beliefhas
used
are
not
based
to believe energy children, arisen
on
by these loss. In fact, conventional
maintain
(4, 5). The
constant by the
J C/in Nutr
fact
body that
body
l991;54:35-40.
weight weight
Printed
maintenance in USA.
by deter(6)
recently with
the
children
to formulate
requirements.
8). The
been the
equations are acpatients receiving recommendations is not
is complia suitable
© 1991 American
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
majority
of the
Society
From
from
TX,
weight, hospital
Basal
energy
basal
The
energy
via
enteral
Evansville, mixtures. The University
followed. (85
independent
expenditure,
of 127
observations variables body
surface
of BSA with 3#{176} burn injury (% BSA burned), and days
expenditure
Unit,
supde-
analysis
children
percentage admission
on admission
with
Nutritional previously
Board, were
1985
uniformly
was
retrospective
in females).
age, on
the Metabolism
Review
in 56 burned
were
intake
at the GalMarch
Isocal (Mead-Johnson, or, milk-Isocal
Galveston,
43 observations
treated
of energy
was generated
injury
between
described (7). to the equations
Institutional
Branch,
REE
for burn Institute
patients.were
were either milk, (Mead-Johnson),
to predict
by observation
of energy
situation
treated
equations of Harris and Benedict from height and weight (10). The
particularly in because the pop-
measurements
energy requirements recommended tually necessary to avoid weight markedly less energy intake than
We
be
catabo-
as determined
burned
Burns
as previously according
of REE
postburn.
that currently requirements
1
Am
All ofthe
Medical
area (BSA), as estimated
protein
expenditure. The basis for success of these equations has generally weight maintenance (3, 4). However, it is unclear whether
cated
1989.
measurements in males,
injury.
catabolic response (1) and can have detrimental physiological effects (2). Consequently, it is important to accurately estimate energy requirements. There used equations significantly
be predicated
energy
were
Shriners
A database agreed
studied
standards
of Texas
morbidity
in many
ofthe
therapy standardized (4,
ethical
It is generally
would
while
(TEE).
children,
to predicting
children
fluids, which IN), Prosobee
burns
improved
because
intake
technique, is strongly correlated with resting (REE). This observation led us to examine
ofREE
approach
ideally
expenditure
in burned
labeled water expenditure
scribed
requirements,
TEE
mainly
energy
in fat synthesis continues (1).
should energy
therapy,
excess
Methods
from
Am JClin
requirements.
Nutritional
of nutritional because
expected to result predominantly lism of heavier lean body mass
equal
are derived
they
of the retention
a new
balance
X PBEE#{176}75), approximately equations
indicator of fluid
R Wolfe
commonly
burns.
achieve
and Robert
the determinants
predict
energy
J Peters,
doubly energy
described
the
to maintain
in
of REE
recently
is used,
of patients
+ (2.39
Because
only
in the elevation
addition
is significantly
that
REE
predictor
patients
especially
to ensure
with
powerful
requirement
recommendations,
required
most
surface
(% BSA burned)
variation
prediction.
energy
size
enchil-
body
significantly
burn
ofthe
of 1.2 for burn
the average
is 1.55
24%
The single
improve factor
(PBEE),
correlated and
Edward
of resting in 56 burned
expenditure
weight
1.29
N Herndon,
the determinants
127 observations
energy
(BSA), =
that
in
David
was
predicted
(9) and BSA % BSA burned
in the usual
Shriners
manner,
Burns
from
the
was calculated was estimated
Institute,
and
we made
and the De-
partments of Anesthesiology and Surgery, University of Texas Medical Branch, Galveston, TX. 2 Supported by NIH grant GM-41089 and a grant from the Shriners Hospitals. 3 Address reprint requests to RR Wolfe, Shriners Burns Institute, 610 Texas Avenue, Galveston, TX 77550. Received September 14, 1990. Accepted for publication December 5, 1990. for Clinical
Nutrition
35
36
GORAN
TABLE I Description
of data group
ET
AL
TABLE 2 Individual correlations potential predictors
analyzed1
between
Resting
energy
expenditure
and
Variable Independent Age(y)
9±5
Weight (kg) Days Postburn BSA (m2) 30 Burn size (% BSA)
32.6 25 1.06 57
Predicted BEE (Mi/d)
4.76
17.6 20 0.39 24
± ± ± ±
PBEE (Mild)1 BSA (m2) Weight (kg)
(5.6-77.6)
(0-99) (0.28-1.94) (4-98)
SD (range).
6.19 1480 n
2.58 (1.41-15.70) 616 (337-3755)
± ±
127. BSA, body surface
=
PBEE,
basal
to adjust
this
factor and
to account
carbon calorimetry
indirect
metabolic cart (Fullerton, as previously described
REE, resting
for
coverage
tempt respect
was to
made fever,
usual
clinical
was
to control infection,
around the time was to examine
dioxide-production rates by use of a Beckman
were not
performed interrupted
for standardizing antibiotics, pain
of measurement. the determinants conditions.
available in the same measurements.
patients,
repeated they
were
in the early and no at-
conditions medication,
Our rationale of measured
When
which
was
diverse
age
3 mo-21
and
burn
thropometric basal energy burned, compare
(with etc)
for this approach REE under the
measurements treated
were
as independent
REE analysis
were constructed by by using the measured
of REE as the dependent variable. The independent were the potential predictors of REE and were the measurements expenditure
observed (PBEE),
energy
multiplied
requirements,
by the
use of value
variables usual an-
in burn patients [predicted BSA, weight, age, % BSA
Harris-Benedict
with
respect
y; body injury
to anthropometric
weight
(3#{176} burns
5.6-77.6 covering
measurements
4-98%
made
variables
kg; BSA
between
(eg,
0.28-1.94
of BSA). 0 and
m2); The
data
99 d after
burn
Prediction
ofresting
Table and
energy
2 summarizes
the
between
REE
the correlation
independent
ranged weight).
from The
primarily
variables.
on body
by indirect
diture, as predicted in Figure 1. The
postburn
the
ratio
% BSA
of REE
burned
are
is shown
to PBEE
during shown
REE expen-
equations,
in REE
(REE:
treatment in Figures
counted for only 2 1% and 24%, respectively, ofthe variation the elevation of REE above predicted normal. The single most powerful predictor of REE in this group
in
the
and % BSA burned
2
ac-
was
postburn
energy
thus
patients
Days
BSA, and is therefore between
basal
the Hams-Benedict
of the elevation and
and 3, respectively.
and
(r2)
coefficients
The relationship
size.
between
a reflection
days
analysis correlation
calorimetry,
from
relationships
PBEE),
The
0. 15 (% BSA burned) to 0.76 (PBEE, observed rate ofREE in burned children
dependent
as measured
expenditure
of
PBEE:
REE
=
1.29
X
(1)
PBEE
Three predicted
factor
study in burn
1.2. This
in which patients
components of energy expenditure (by use of the Harris-Benedict
sured
by indirect
calorimetry;
and
factor
of 1.2. Energy
REE by an activity expressed
as
MJ/d
and
are
TEE
Spreadsheet MA)
software or the
(Lotus
BMDP
activity
the (6).
20
factor
doubly
labeled r
are discussed: PBEE equations); REE meaderived
> 0 0
by multiplying
expenditure
accompanied
by
the
by using
either
Development
statistical
software
0 76
15
10
and intake caloric LU LU
equivalent (kcal/d) in parentheses. All statistical analyses were performed Cambridge,
was used to developed. for predicting REE
equations
activity
was derived in our recent water technique was used
5
the Lotus
Corporation, (BMDP
Inc,
Angeles).
0 0
2
4
FBEE
Results Data
from
and days postburnl. A predictive analysis the forecasting precision of the equations
To predict
Los
predicted
injury.
and
Equations for predicting stepwise-linear-regression
1-2-3
and
CA) with a face mask for gas collections (1). REE was derived by using the equa-
tion of Weir ( 1 1 ). Measurements morning. Continuous feeding
are
expenditure
of wounds.
Oxygen-consumption were measured by
were
energy
equations.
set included attempt
-0.28 0.15
area; BEE, basal energy
expenditure as predicted from the Harris-Benedict equations; energy expenditure as measured by indirect calorimetry.
no
0.73
Days posthurn % BSA burned
1.22 (1.78-8.00) (426-1914)
±
0.76 0.76 0.76
Age
I
Measured REE (Mild) (kcal/d)
healing
r2
1 138 ± 292
(kcalld)
I
variable
(0.33-21)
set
Table
1 summarizes
in 56 burned
children.
the data We treated
for 127 measurements the data
as one
entire
of REE group,
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
6
8
10
(MJ/day)
FIG 1. Relationship between resting energy sured by indirect calorimetry and basal energy dicted by the equations of Harris and Benedict
expenditure expenditure (9).
(REE) mea(PBEE) pre-
ENERGY
EXPENDITURE
IN
BURNED
TABLE Percent
3 relative
LU
37
CHILDREN
Percent
error
in predicting
resting
energy
expenditure1
Percent
of patients
relative
errort
LU % C-
0 10 25 50
LU LU
DAYS
POST
where
r2
any
0.96
=
other
when
variables
above
predicted
value
(REE/PBEE)
as a
the
is fixed
equation
at zero.
did
not
Addition
improve
of equation
measurements cent
of the
predicted value,
ofthe
energy
pre-
were REE,
with
respect
REE
within
were
±45%
in the
127
Fifty
per-
to predicted
± 17%
within
(Table
determined
basal
energy
residual
95th
random
vari-
expenditure.
oftotal
energy
Use of the activity (6) allowed derivation
requirements
percentile
was
to be
equation
factor ofan
TEE Because value
this
equation
of PBEE,
have
a TEE
1.2 from our previous publication equation to predict the average TEE: =
is the
was
percentile,
patients, our
the
less than
can
value
be derived
analysis,
the
the
for TEE
of the
value
given
the standard expenditure
of TEE by using
standard
value
one-half
the average value ofTEE and a given value of basal energy 95th
average
approximately
that
(2)
1.55 X PBEE
that
would
in equation
is exceeded
(1.55
=
X PBEE)
+ (2.39
the energy
at least
enough
value
normal
multiplied the
(3)
X PBEE#{176}75)
required energy
was
distribution,
to ensure to reach
that
a state
95%
of
of energy
The resulting value for an average patient in this study 1 ) is 9.32 MJ/d (2229 kcal/d), which is approximately to twice
the PBEE
5 displays by four
other
[9.5 1 MJ/d
the energy
(2276
kcal/d)].
requirements
equations
that would
currently
in use
be pre-
in addition
to
were prewith a burn
injury
in Figure
covering
either
30%
or 80%
BSA.
As seen
5,
our predictions are well below the lowest value. The equation designed to include 95% of patients (Eq 3) is approximately equal to the value ofequation 2 X PBEE, promulgated by Wolfe (12), which predicts energy requirements that are -20% lower than
for the
LU
those
predicted
by the
Long
equation
(13).
by 5% of the
linear
of TEE
50% of energy
our new equations 2 and 3. The energy requirements dicted for the average patient in the present study
2. If
deviation ofTEE are known, then
weighted
deviation
for a given
patients
found
predicts
receive
balance. (Table
dicted
this
of the standard
patients
equal
X PBEE#{176}75.When
5% point
Figure Prediction
1.29 X PBEE.
relative error of 127 predictions. Thus, 17% from the observed rate of resting
upper
TEE This
as a
4 as a function
show
as 1 .452
by the
and
expressed
in Figure
residuals
by using the equation
percent deviated by
of the
±30%,
3). The
predicted),
is displayed
4, these
within
were
minus
As seen in Figure
REE
was determined.
predictions
(measured
of measured
ation
for
ofthe
predictions
ofPBEE.
children
values
75%
expenditure
percent
1 in predicting
in 56 burned
measured 90%
Values
timated reliability
44.84 189.0
of
the
diction. The
30.10
90 100
t The median predictions expenditure.
the intercept into
75
BURN I
FIG 2. Elevation in REE function of days postburn.
0.41 4.42 9.34 17.08
regression.
predictions
In
was
LU
200
-
150
-
100
-
es-
2.5 r=0.24 I
LU
2.0
.. . ‘-,
LU I
..
:
I
1.0 S
I
(1’) LU
:.
#{149} #{149}
2
4
PBEE
I
20
40
60
SIZE
80
#{149}#{149}#{149}
I
,: #{149}#{149}S.
#{149}.
50 0
BURN FIG function
:
#{149}#{149}.#{149}
I
0.5
0
1t2
I
0
0 I
0.0
,S.
-J
I
C-
#{149}
.1
1.5
LU LU
50
.
6
8
10
(MJ/day)
100
(% TBSA)
3. Elevation in REE above predicted value (REE/PBEE) of burn size [% total body surface burned (% TBSA)J.
Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/35/4691060 by guest on 24 April 2018
as a
FIG 4. Residual of the predicted REE vs PBEE. The residual is the difference between the observed REE and the REE predicted by equation 1 (REE = 1.29 x predicted basal) and expressed as a percentage of the measured REE.
38
ET AL
GORAN I-
z
20
LU
::::i
LU
30%
burn
80%
burn
15
C
LU LL
>-0
0
10
LU LU’
F
5
0 LU
I-
0-
(I) LU
1 .55.PBEE
1 .55.PBEE
2.PBEE
Long
Galveston
Curreri
+
2.39.PBEEP75 FIG 5. Total energy requirements (I Mi/d = 239.2 kcal/d) for energy balance in burned children, as predicted by various equations. Energy requirements were estimated for the average patient in this study with either a 30% or an 80% burn. Requirements were estimated by using the following equations: 1.55 X PBEE, equation 2; (1.55 X PBEE) + (2.39 X PBEE#{176}75), equation 3; 2 X PBEE, reference 12; 2.52 X PBEE, Long equation (13); Galveston equation (4); Mi/d = (6.27 X BSA) + (6.27 X burn in m2), kcal/d = (1500 X BSA) + (1500 X burn in m2), Curreri equation (3); Mi/d = (0. 105 X weight) + (0. 167 X % of BSA burned), kcal/d = (25 X weight) + (40 X % of BSA burned). PBEE, basal energy expenditure predicted from Harris-Benedict equations (9); BSA, body surface area (m2); weight, body weight (kg).
The
most
important
presented
and
equations
is that
of the from burns, trative
the
burn.
difference
popular the
The
new
equations
are dependent
latter
discrepancy
in Figure
the
(4, 8) and
between
the various equations such as the 80% burn purposes
between
Galveston
the
equations
Curreri
of basal
et al (3) on the
estimations
size
derived
is particularly evident chosen as representative
with large for illus-
5.
energy
equations
recovery recovery
study
burned
represents
children.
The
dren is primarily of the elevation liably predicted
the
most
analysis
extensive
revealed
analysis
that
REE
dependent on body size, and in REE above predicted normal from the extent of burn injury.
of REE
during
this period
in burned
chil-
REE
dicted
basal
mean
of 271
size
was
was
expenditure injury
surprising
useful
state
to the recovered
ulation
such
not
other
set of equations
cifically dren
designed (14).
ments
equations
(WHO)
of energy data
greater
than
that
for children.
with those basal
WHO
3. 1 ± 7.5%
when
comparison.
The
energy
expenditure
expenditure
in children
predictions.
aged
thus
50% of BSA. and protein
Similarly, metabolism
in the many conducted
EXPENDITURE
studies in our
IN
of carbohydrate, laboratory (1, 2),
BURNED
27%
ofthe
coefficient
described
It is difficult
to assess
we never observed a significant effect of burn size in patients with a burn size > 40% of BSA. Equations estimating energy requirements based on percent burn size in patients with large
al equation
because
burns
first
fat,
are thus
not
It is unclear presence
based
on established
how much
of burn
injury
of the elevation itself
and
explained by energy expenditure effect of feeding. For example, the
entire
effect
elevation
of feeding.
expenditure
in We
REE
have
associated
ivation
of the
new
metabolic
how
in REE
much
in burn
patients effect
by using
the
the
of feeding
relationship
feel
that
physical
it is appropriate
activity
for other
increases
with
patients.
This
convalescence
of TEE to REE will generally be higher later during the initial stages. Therefore the factor overestimate
the
prediction
of TEE
from
energy
requirements
contain
a factor
actual
measurements
in burned for burn
children.
size,
Whereas
neither
ofenergy
equation
expenditure.
the
ratio
(MJ/d)
Using
from
our database,
x burn
TEE
(kcal/d)
=
(1 180 X BSA
Both coefficients than
x
derived
X burn
in this equation
are substantially
used
be explained
by Hildreth burned volume water
by the fact that
et al (4) was
children of fluid vaporization
based
size in m2)
the original
(4) lower
[kcal/d = (1800 large discrepancy
approach
on observations
described
of fluid
in
during the initial 48-h resuscitation phase. The loss was then multiplied by the energy cost of to derive
the coefficient.
This
factor
is there-
fore
inappropriate on two accounts. First, it is based only on observations made in patients treated during acute resuscitation, and second, it is not based on actual measurements of energy expenditure. and
Similarly, % BSA
when TEE was expressed in terms of body weight burned, an equation comparable to the Curreri et
al (3) equation TEE
(MJ/d)
was generated:
(0. 147
=
X weight
in kg)
+ (0.045 TEE
(kcal/d)
=
(35.2
X weight
determined
X % BSA burned)
in kg)
+ (10.8 Our experimentally
body-weight
coefficient
weight
during
the
X % BSA burned) for % BSA burned
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requirements.
the
predictive
3 are limited.
were
dependent
The
power
of the
observation
within
and,
±17%
that
as already
ofthe
discussed,
the
interpre-
weight in burn patients is complex and may not reflection of metabolically active tissue. Second,
of body likely
that
therapy
involved,
patient,
and
to control the
a combination
(5)
is
use
presence for these
determinants
treated
offactors
our
of excisional offever
in addition
early
treated
conditions
Institute
because under
to PBEE
could
our
natural
they
are
excision
not
hormonal
status
We made aim
of
no attempt
was to examine
clinical
circumstances
laboratory conditions. Although our in a population of burn children
excision,
without
surgery,
or infection.
of REE
to controlled were developed
with
detect
likely
because any
to be appropriate
a previous
difference
report
in REE
in
from
in adults
with and without excisional surgery (19). In a recent publication, Allard et al (20) assessed the performance of a complex equation for predicting REE in burn patients, which includes factors to account for % BSA burned, treated
energy
loss
estimated
used,
2 and
50% ofpredictions
patients
in the actual Galveston equation BSA in m2) + (2200 x burn size in m2)]. This
can
those
size in m2)
in m2)
+ (845
was a retrospective
in body
measured value can be explained by a number of factors. First, the predictions of basal energy expenditure that we used were determined by the equations of Harris and Benedict (9), and as already stated, these may be inappropriate for children. Moreover, whichever equation is used, the predictions ofbasal energy expenditure are only
as opposed equations + (3.53
of the
database
equations
it is also
equations
both
are
also affect REE. These might include nutritional status of the patient at the time of REE measurement, activity ofthe subject (eg, dressing change) preceding measurement, time between measurement and most recent surgery, type of medication and
of predicting
was derived
20%
large
be an accurate et al equation
x BSA in m2)
(4.93
=
only
the
proposed
tation
we rederived equations with similar general structures to the Galveston and Current equations. When TEE is expressed in terms of BSA and m2 burn (cf, the original Galveston approach), the following was obtained: TEE
received
Despite
measurements
in the early stages of recovery. The Galveston equations (4, 8) and the Curreri (3) are probably the most commonly used means
study
changes
et
rationale
weight
in recovery than 1.2 may tend to
REE
(3). Their
and
or even
in der-
is because
so that
paper
data
(3).
in the Curreri
20 d of recovery in nine burn patients. Change in body weight was plotted against actual dietary intake, expressed as a
between
REE and TEE. This factor (1.2) was determined experimentally in a limited number of patients by using the doubly labeled water technique to measure TEE (6). Although this factor was derived in a patient group studied in the latter stages of recovery,
we
supportive
intake
et al equation
for the factors
energy
thermic
for the
no
in the original ofdietary
in the Curreri
the basis
percentage of ideal caloric intake calculated by the Curreni formula. Even the original data presented by Curreri et a! (3) argue against the validity of the equation because patients receiving significantly less energy intake than prescribed by the equation nonetheless maintained body weight. The only patient who lost
be potentially
by
accounted
the thermic
equations
is due to the
can
associated with the thermic Allard et al (18) accounted for
indirectly
with
processes.
provided analysis
39
CHILDREN
intake,
PBEE,
complex
equation
not
that
clear
temperature,
is cumbersome
significant
power
energy
requirements
PBEE.
If we had included
et al (20) in our analysis,
by the the
and
days
to use and is added
consideration
postburn.
furthermore
to the
This
it is
predictions
of factors
other
of than
the additional factors used by Allard r2 ofour predictive equation would
have decreased. In addition to the problems of formulating a good equation, it must be realized that there is a certain amount of variation in REE that is not explained by body size or body composition even in normal volunteers (2 1, 22). It is of further concern that the error assessment presented in Table 3 does not include the error in predicting TEE from REE. From our previous experiment in a limited number of patients in whom both REE and TEE were measured (6), equation 2 functioned poorly in predicting TEE even though there was a significant correlation between TEE and REE. In summary, the most reliable estimates of energy requirements are obtained by actual measurements of REE on an in-
40
GORAN
dividual basis in conjunction which is 1.2 in the convalescent of REE that
is not
if energy
patients
will
to their
feasible, receive
desirable
to
x PBEE
to energy
paper
twice
an amount
In severely
stressed of energy
energy
according
this will be sufficient
the
support
the
PBEE,
patients
intake who it may
to
equation
to maintain
all equal
are unable
excess, the
notion
virtually
of energy
side effects
provide
because
in this
at about
at least
expenditure. potential
close
the data
is provided
to tolerate
with an appropriate activity factor, burned child (6). If measurement
be more 1.55
most patients
U
balance.
We are grateful to Manu Dessai who allowed us ments ofresting energy expenditure in patients under we thank Tom Rutan, James Richardson, and the staffofthe Shriners Burns Institute for performing calorimetry measurements.
to perform measurehis cane. In addition, Respiratory Therapy some ofthe indirect
References 1. iahoor F, Desai M, Herndon DN, Wolfe RR. Dynamics ofthe protein metabolic response to burn injury. Metabolism 1988;37:330-7. 2. Wolfe RR. Nutrition and metabolism in burns. Crit Care Med l986;7: 19-63.
3. Curreri PW, Richmond D, Marvin i, Baxter CR. Dietary requirements of patients with major burns. i Am Diet Assoc 1974;65: 415-7. 4. Hildreth MA, Herndon DN, Desai MH, Duke MA. Caloric needs of adolescent patients with burns. i Burn Cane Rehabil 1989;l00: 523-6. 5. Cunningham ii, Lydon MK, Russell WE. Calorie and protein provision from severe burns in infancy and young children. Am i Clin Nutr l990;51:553-7. 6. Goran MI, Peters El, Herndon DN, Wolfe RR. Total energy cxpenditure in burned children using the doubly labeled water technique. Am J Physiol l990;259:E576-85. 7. Herndon DN, Curreri PW, Abston 5, Rutan TC, Barrow RE. Treatment ofburns. Curr Probl Surg 1987;2:347-97.
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ET
AL
8. Hildreth MA, Carvajhal HF. Caloric requirements in burned children: a simple formula to estimate daily caloric requirements. i Burn Care Rehabil l982;3:78-80. 9. Harris iA, Benedict FG. A biometric study of basal metabolism in man. Washington, DC: Carnegie Institute of Washington, 1919. (Publication no. 279.) 10. Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight are known. Arch Intern Med 19 16; 17:863-7 1. I 1. Weir deJB. New methods for calculating metabolic rate with special reference to protein metabolism. J Physiol l949;l09:l-9. 12. Wolfe RR. Caloric requirements of the burned patient. i Trauma 198 1;2 l(suppl):7 12-4. 13. Long C. Energy expenditure of major burns. i Trauma 1979;19: 904-6. 14. World Health Organization. Energy and protein requirements. WHO Tech Rep 5cr 1985:724. 15. Wilmore DW, Long JM, Mason AD, Streen AW, Pruitt BA Jr. Catecholamines: mediator of the hypermetabolic response to thermal injury. Ann Surg 1974;l80:653-69. 16. Caldwell FT ir, Bowser BH, Crabtree JH. The effect of occlusive dressings on the energy metabolism of severely burned children. Ann Surg 198 l;193:579-9l. 17. Bradham GB. Direct measurement oftotal metabolism ofa burned child. Arch Surg l972;105:4l0-3. 18. Allard JP, ieejheebhoy KN, Whitwell J, Pashutinski L, Peters Wi. Factors influencing energy expenditure in patients with burns. i Trauma l988;28: 199-202. 19. Rutan TC, Herndon DN, Van Osten T, Abston S. Metabolic rate alterations in early excision and grafting versus conservative treatment. J Trauma l986;26:l40-2. 20. Allard iP, Pichard C, Hoshino E, et al. Validation ofa new formula for calculating the energy requirements of burn patients. JPEN 1990;14:l 15-8.
21.
22.
Fontain ER, Savard A, Trembly iP, Despres E, Poehlman ET, Bouchard C. Resting metabolic rate in monozygotic and dyzygotic twins. Acta Genet Med Gemellol (Roma) I985;34:4 1-7. Ravussin E, Lillioja S, Anderson TE, Christin L, Bogardus C. Dcterminants of 24-hour energy expenditure in man. Methods and results using a respiratory chamber. i Gin Invest 1986;78:1568-78.
