Assessing resting energy expenditure in overweight and obese adolescents in a clinical setting: validity of a handheld indirect calorimeter.

BACKGROUND: Accurately determining energy requirements is key for nutritional management of pediatric obesity. Recently, a portable handheld indirect calorimeter, MedGem (MG) has become available to measure resting energy expenditure (REE). Our work aims to determine the clinical validity and usefulness of MG to measure REE in overweight and obese adolescents. METHODS: Thirty-nine overweight and obese adolescents (16 male (M): 23 female (F), 15.2 ± 1.9 y, BMI percentile: 98.6 ± 2.2%) and 15 normal weight adolescents (7M: 8F, age 15.2 ± 2.0 y, BMI percentile: 39.2 ± 20.9%) participated. REE was measured with both MG and standard indirect calorimeter (VMax) in random order. RESULTS: MG REE (1,600 ± 372 kcal/d) was lower than VMax REE (1,727 ± 327 kcal/) in the overweight and obese adolescents. Bland Altman analysis (MG -VMax) showed a mean bias of -127 kcal/d (95% CI = -72 to -182 kcal/d, P < 0.001), and a proportional bias existed such that lower measured REE by VMax was underestimated by MG, and higher measured REE by VMax were overestimated by MG. CONCLUSION: MG systematically underestimates REE in the overweight and adolescent population, thus the MG portable indirect calorimeter is not recommended for routine use. Considering that it is a systematic underestimation of REE, MG may be clinically acceptable, only if used with caution.

Disparities between two common data sources on hospital nurse staffing.

PURPOSE: To compare nurse staffing measures derived from two widely used data sources: the American Hospital Association (AHA) Annual Survey of Hospitals and the California Office for Statewide Health Planning and Development (OSHPD). DESIGN: Descriptive cross-sectional study with measures of nurse staffing level and skill mix constructed from each database for 372 nonfederal, acute care hospitals in California. METHODS: Discrepancies in nurse staffing estimates between the two databases were examined. Relationships of nurse staffing with risk-adjusted patient outcomes (decubitus ulcer, failure to rescue, and mortality) were assessed through multivariate analyses and compared for nursing measures derived from the two databases. FINDINGS: For small, rural, or nonteaching hospitals, AHA reported substantially higher registered nurse (RN) hours per patient day than did OSHPD. RN proportion among licensed nurses matched most closely in the two databases. RN hours per patient day derived from both databases showed significant inverse relationships with decubitus ulcer and mortality, and the association was stronger for the measure based on the OSHPD data. RN proportion derived from the OSHPD data was significantly associated with all three patient outcomes, but the AHA measure had a significant relationship only with decubitus ulcer. CONCLUSIONS: Compared with the AHA survey, the OSHPD data on hospital nurse staffing appear to be more complete and also were more closely associated with patient outcomes. Efforts to refine the AHA survey as a national database for nurse staffing will significantly enhance the capacity for monitoring nurse workforce and its effect on quality of care.

Optimizing sedation and analgesia in mechanically ventilated patients--an evidence-based approach.

Critically ill, mechanically ventilated patients experience pain and anxiety related to a number of factors, including underlying disease processes, invasive procedures, therapeutic devices, immobility, and even routine nursing care such as turning and positioning. Failure to provide adequate analgesia and sedation has been shown to have detrimental physiological consequences, including an increase in sympathetic nervous activity and ventilator dyssynchrony (Young, Knudsen, Hilton & Reves, 2000). Over-sedation has also given rise to concerns related to prolongation of mechanical ventilation, intensive care unit (ICU) length of stay, and cost. The challenge for the ICU team is to provide comfort while avoiding the consequences of both over- and under-sedation. New strategies show promise and focus on a team approach for the management of sedation and analgesia in critically ill, mechanically ventilated patients. These strategies include the use of sedation protocols, which incorporate nurse-driven dose titration directives, sedation scoring systems, and daily interruption of sedative infusions. This article provides a review of three recent studies evaluating these new approaches to the administration of sedation and analgesia in the adult ICU.