J. Walsh1, P. Wischmeyer2, C. S. Tiko-Okoye1, J. Molinger1, S. Howell1, S. Agarwal1, C. Vatsaas1, C. Cox1, K. Schmader1, K. L. Haines1 2Duke University Medical Center, Anesthesiology, Durham, NC, USA 1Duke University Medical Center, Trauma, Acute And Critical Care Surgery, Durham, NC, USA
Introduction: Suboptimal nutrition can exacerbate unfavorable outcomes in trauma patients, particularly among those aged 60 and over. The metabolic demands of critically ill and trauma patients are often variable compared to their uninjured counterparts, making nutritional needs complex. Many institutions opt to utilize predictive energy equations as access to and application of more accurate measuring tools like indirect calorimetry (IC) is less widespread and more labor intensive. This has led to reliance on predictive calculations, which several studies have shown inaccurately estimate caloric needs in trauma and critically ill patients. In our pilot randomized controlled trial, we explored the potential benefits of indirect calorimetry-guided nutrition recommendations as compared to standard predictive equations, particularly focusing on the older adult trauma patient population.
Methods: In this pilot randomized controlled trial, 26 older adult trauma patients were enrolled. 3:1 randomization was used for the intervention and control arms of this study. Those in the intervention arm had their metabolic requirements measured by indirect calorimetry while in the control group followed the standard of care. These requirements were compared to the results of the Mifflin St. Jeor and Harris-Benedict equations. The intervention group then received personalized targeted nutrition via our StructurED Nutrition Delivery Pathway – SeND Home. This was designed to improve resilience in older adult trauma patients. Enrolled patients were then followed after discharge and repeat interval metrics were obtained.
Results: The pilot study enrolled 26 older adult trauma patients, including 15 females (57.7%) and 11 males (42.3%). The demographic distribution comprised 1 Hispanic (3.8%) and 5 Black (19.2%) participants. 20 participants had indirect calorimetry performed. The average age of participants was 72.5 years, ranging from 61 to 94 years. The mean caloric requirement estimated by the Mifflin St. Jeor equation was 1511.46 ± 62.11 kcal/day and that of the Harris-Benedict was 1741.75 ± 105.88 kcal/day. Measured indirect calorimetry mean requirement was 2000.65 ± 117.82 kcal/day.
Conclusion: Predictive energy equations such as Mifflin St. Jeor and Harris-Benedict consistently underpredicted the metabolic demands of older trauma patients compared to measurements from indirect calorimetry. Both overfeeding and underfeeding can contribute to poor outcomes, making the accurate assessment of caloric needs essential. Institutions that have access to indirect calorimetry should prioritize its use to accurately identify the metabolic demands of older trauma patients. This will help to more effectively optimize their nutrition and minimize the risk of suboptimal outcomes. These findings advocate for broadening access to indirect calorimetry and facilitating it’s use to ensure that nutritional needs are met accurately.