Indirect Calorimetry for Evaluation of Glucose and Lipid Metabolism in Surgical Patients on Total Parenteral Nutrition: a Pilot Study


A.I. Yaroshetskiy1, 2, S.O. Vasilieva2, N.A. Rezepov2, I.Y. Lapshina1, B.R. Gelfand1

1Pirogov Russian National Research Medical University, Moscow

2Moscow City Hospital № 67, Moscow

For correspondence: Yaroshetskiy Andrey — Head of Anesthesiology and Critical Care Department in Pirogov Russian National Research Medical University, Research Institution for Clinical Surgery Division, Moscow; e-mail:

For citation: Yaroshetskiy AI, Vasilieva SO, Rezepov NA, Lapshina IY, Gelfand BR. Indirect Calorimetry for Evaluation of Glucose and Lipid Metabolism in Surgical Patients on Total Parenteral Nutrition: a Pilot Study. Intensive Care Herald. 2016;4:12–18.

Methods of nutrient metabolism evaluation in parenteral nutrition neither validated nor published. Aim of the study was estimation of predictive value of indirect calorimetry for insulin resistance before beginning of parenteral nutrition (PN) and evaluation of nutrient assimilation during PN. Methods. We include 22 patients after abdominal surgery on total PN by «three-in-one» system under glucose control. Before start of PN we calculated resting energy expenditure (REE) by Harris—Benedict (HB) equation and measured exhaled carbon dioxide per minute (VCO2), oxygen consumption (VO2), respiratory quotient (RQ) and REE by «CCM Express» metabolograph. After 3 hours of PN we repeated measurements of VCO2, VO2 and RQ. Results. REE by HB was 1606 (1438–2020) kcal/day but REE calculated had wider range [1913 (1208–2536)] (p=1.0). REE didn’t changed significantly after 3 hours of PN [1913 (1208–2536) vs. 1956 (1374–2532), p = 0.655]. RQ increased from 0.78 (0.69–0.83) till 0.88 (0.83–0.91) (p = 0.012). In diabetes mellitus subgroup of patients (n = 4) REE measured was significantly higher than HB REE (2547 (2331–2940) vs. 1834 (1571–2022), p = 0.046). Maximal glucose level during PN and insulin dose differed significantly in diabetes mellitus patients and non-diabetes patients [14.8 (13.1–15.4) vs. 10.6 (9.1–11.5), p = 0.020 and 190 (116–210) vs. 48 (15–82), p = 0.018, respectively]. In patients with RQ less than 0.7 [0.65 (0.64–0.69)] before start of PN (n = 7) assimilation of nutrients was unpredictable — RQ at 3 hours after start of PN had wide range 0.86 (0.73–0.91) (p = 0.025). We found strong correlation between RQ before start of PN and insulin dose during PN (rho = –0.729, p = 0.005). Conclusion. RQ measurement before PN may be a simple tool for insulin resistance estimation before start of PN and probably should lead to change in composition of PN and/or PN infusion rate.

Keywords: indirect calorimetry, insulin resistance, diabetes mellitus, respiratory quotient, energy expenditure

Received: 20.10.2016


  1. Chambrier C., Laville M., Rhzioual Berrada K. et al. Insulin sensitivity of glucose and fat metabolism in severe sepsis. Clin. Sci. 2000; 99(4): 321–328.
  2. Schrezenmeir J. Rationale for specialized nutrition support for hyperglycemic patients. Clin. Nutr. 1998; 17(Suppl 2): 26–34.
  3. Pomposelli J.J., Baxter T.J. et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN 1998; 22(2): 77-81
  4. Singer P., Berger M.M., Van den Berghe G. et al. ESPEN Guidelines on parenteral nutrition: intensive care. Clin. Nutr. 2009; 28: 387–400.
  5. Gore D.C., Chinkes D.L., Hart D.W. et al. Hyperglycemia exacerbates muscle protein catabolism in burn-injured patients. Crit. Care Med. 2002; 30: 2438–2442.
  6. Biolo G. et al. Treating hyperglycemia improves skeletal muscle protein metabolism in cancer patients after major surgery. Crit Care Med 2008; 36: 1768–75.
  7. Biolo G., De Cicco M., Lorenzon S. et al. Inhibition of muscle glutamine formation in hypercatabolic patients. Clin. Sci. 2000; 99: 189–194.
  8. Hsu C.W., Sun S.F., Lin S.L., Huang H.H., Wong K.F. Moderate Glucose Control results in less negative nitrogen balances in medical ICU pts. Crit. Care. 2012, 16: R56.
  9. Somogyi M., Kirstein M. Insulin as a cause of extreme hyperglycemia and instability. Week Bull. St.-Louis M. Soc. 1938; 32: 498.
  10. Rizza R.A., Mandarino L.J., Genest J., Baker B.A., Gerich J.E. Production of insulin resistance by hyperinsulinemia in man. Diabetologia. 1985; 28: 70–75.
  11. Shanik M.H., Xu Y., Skrha J. et al. Insulin resistance and hyperinsulinemia. Is hyperinsulinemia the cart or the horse? Diabetes Care. 2008; 31(Suppl2): S262–S268.
  12. Kim S.H., Reaven G.M. Insulin resistance and hyperinsulinemia. You can’t have one without the other. Diabetes Care. 2008; 31: 1433–1438.
  13. Ярошецкий А.И., Резепов Н.А., Васильева С.О., Лапшина И.Ю., Гельфанд Б.Р. Выбор автоматизированного или «ручного» управления гликемией при проведении полного парентерального питания в хирургии: сравнительное исследование. Анналы хирургии. 2015; 2: 31–40. [Yaroshetskiy A.I., Rezepov N.A., Vasilieva S.O., Lapshina I.Ju., Gelfand B.R. Vybor avtomatizirovannogo ili ruchnogo upravlenuya glikemiei pri provedenii polnogo parenteral’nogo pitaniya v khirurgii: sravnitel’noye issledovanie.(Automatic or hand-made glucose control in total parenteral nutrition in surgery: a comparative study) Annaly Khirurgii. 2015; 2: 31–40. (In Russ)]
  14. Лейдерман И.Н., Ярошецкий А.И., Кокарев Е.А., Мазурок В.А. Парентеральное питание: вопросы и ответы. Руководство для врачей. СПб.: Онли-Пресс, 2016. [Leiderman I.N., Yaroshetskiy A.I., Kokarev E.A., Mazurok V.A. Parenteral nutrition: questions and answers. Clinical manual. Saint-Petersburg: Only-Press, 2016. (In Russ)]