Effect of FiO2 in the measurement of VO2 and VCO2 using the E-COXV metabolic monitor

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Ferreruela, J.M. Raurich, J.A. Llompart-Pou, A. Colomar, I. Ayestarán" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Ferreruela" ] 1 => array:4 [ "nombre" => "J.M." "apellidos" => "Raurich" "email" => array:1 [ 0 => "joan.raurich@ssib.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Llompart-Pou" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Colomar" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Ayestarán" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efecto de la FiO2 sobre la medición del VO2 y la VCO2 con el monitor metabólico E-COVX" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2587 "Ancho" => 1626 "Tamanyo" => 169769 ] ] "descripcion" => array:1 [ "en" => "Graphic representation according to Bland and Altman of the percentage differences in the two consecutive values of VO2 and VCO2 of each patient measured at FiO2=0.4 with respect to the mean value of both measurements in mL/min." ] ] ] "textoCompleto" => "IntroductionThe main interest of measuring oxygen consumption (VO2) and the production of carbon dioxide (VCO2) in critical patients subjected to mechanical ventilation (MV) is to calculate energy expenditure by applying the formula of Weir.<a class="elsevierStyleCrossRef" href="#bib0140">1</a> Recent studies have shown that a calorie supply capable of compensating the losses resulting from energy expenditure shortens the duration of mechanical ventilation, reduces the nosocomial infection rate, facilitates physical recovery and reduces mortality.<a class="elsevierStyleCrossRefs" href="#bib0145">2–5</a> The measurement of VO2 and VCO2 also has other applications, however. In effect, the measurement of VO2 allows us to assess the relationship between oxygen transport and VO2<a class="elsevierStyleCrossRef" href="#bib0165">6</a> or determine the respiratory effort of a given ventilatory mode with respect to some other mode.<a class="elsevierStyleCrossRef" href="#bib0170">7</a> The measurement of VCO2 in turn allows us to measure the physiological dead space.<a class="elsevierStyleCrossRef" href="#bib0175">8</a>However, the precise measurement of VO2 and VCO2 in the critical patient subjected to mechanical ventilation poses a series of problems including the need for a fraction of inspired oxygen (FiO2) above that of room air, particularly in the acute phase of the disease; airway gas leakage due to the positive pressure of the ventilator; and the presence of water vapor in the expired gas.<a class="elsevierStyleCrossRefs" href="#bib0140">1,9–11</a> Of these problems, FiO2 is the most important, since error in the measurement of the concentrations of inspired and expired oxygen in order to determine VO2 is amplified when FiO2 is incremented.<a class="elsevierStyleCrossRef" href="#bib0195">12</a>The measurement of respiratory gas exchange in patients under mechanical ventilation has been facilitated by the development of automated systems capable of measuring VO2 and VCO2 on a breath-to-breath basis. In this regard, some studies have reported that the M-COVX and E-COVX monitors can be used in patients subjected to mechanical ventilation and with a need for high FiO2 (<0.85), with an error acceptable to clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0200">13–15</a>The present study was carried out to evaluate the effect of FiO2 upon precision in the measurement of VO2 and VCO2 using the E-COVX metabolic monitor in critical patients subjected to mechanical ventilation.Material and methodsPatientsThe study included patients admitted to the Intensive Care Unit (ICU), intubated and subjected to mechanical ventilation, who were receiving sedatives (midazolam or propofol) and/or analgesics (morphine or fentanyl) in continuous perfusion. Measurements were made of VO2 and VCO2, with the calculation of resting energy expenditure (REE). The study was carried out in the morning, with the patient under resting conditions, the headrest raised 30 degrees, and after two or more days of mechanical ventilation. All the patients were ventilated in volume control mode with FiO2≤0.4. Before indirect calorimetry measurement, we checked the pressure of the balloon of the endotracheal tube and the absence of air leakage. Indirect calorimetry measurement was carried out during the administration of enteral, parenteral or mixed nutrition, with a calorie supply of 15–30kcal/kg/day. The nutrition was administered continuously and was not interrupted, since the increase in VO2 and VCO2 is constant and with a value of about 3%.<a class="elsevierStyleCrossRef" href="#bib0215">16</a> During at least 30min before the measurements we performed no tracheal aspirations, physiotherapy, postural changes, body hygiene measures, radiological studies or catheter insertions.<a class="elsevierStyleCrossRefs" href="#bib0220">17,18</a>The following conditions were regarded as study exclusion criteria: hemodynamic instability (defined as the need to modify vasoactive drug doses or variations >20% in arterial pressure and/or heart rate); a respiratory frequency of over 35rpm; the need for FiO2>0.4; a body temperature of under 36°C or over 38°C; a sedation level as determined with the Richmond Agitation-Sedation Scale<a class="elsevierStyleCrossRef" href="#bib0230">19</a> of over −3; patients with bronchopleural fistulas; and patients subjected to renal replacement therapy.The study was approved by the hospital research committee. Since the study involved a monitoring technique, the need for informed consent was not considered necessary.E-COVX metabolic monitorThe E-COVX metabolic monitor (GE Healthcare/Datex-Ohmeda, Helsinki, Finland) is a noninvasive system equipped with a paramagnetic analyzer for oxygen, an infrared analyzer for CO2, and a pneumotachograph for measuring inspired and expired volumes. The pneumotachograph and gas sampling ports were located in a disposable connector called D-Lite sensor (GE Healthcare Finland Oy, Helsinki, Finland), placed between the heat and humidity exchanger (Edith Flex®, GE Healthcare Finland Oy, Helsinki, Finland) and the Y-piece of the ventilator circuit, in order to avoid water accumulation.<a class="elsevierStyleCrossRef" href="#bib0205">14</a> A connector with a dead space of 15ml (the manufacturer recommended a dead space of 5ml) was placed between the D-Lite sensor and the Y-piece. The purpose of this dead space was to avoid contamination of the expired gas with the continuous air flow of the ventilator, which was set to minimum (2l/min).In order to reduce systematic error in the volume measurements, the E-COVX monitor uses the Haldane transformation to calculate both VO2 and VCO2. Systematic error occurs in all the measurements and is inherent to the apparatus itself or to the measurement process. In contrast, random error is accidental, not controllable and can be reduced by increasing the sample size. The Haldane transformation consists of measuring the inspiratory volume and estimating the expiratory volume, since the latter is dependent upon the temperature (assumed to be 35°C) and humidity (assumed to be 100%) of the expired gas.The signals from the pneumotachograph and gas analyzers were synchronized in order to allow breath-to-breath gas exchange estimates. The results corresponding to VO2 and VCO2 were expressed each minute as an average of the last 60s. The measurements of VO2 and VCO2 were recorded only when the patient was metabolically stable (defined as a variation of ≤5% in 10 consecutive values).<a class="elsevierStyleCrossRefs" href="#bib0235">20,21</a> The volumes were corrected to standard conditions of temperature, pressure and dryness.The E-COVX monitor is ready for use 5min after being turned on, and automatic calibration is performed. The system calibrations are made every 6 months according to the instructions of the manufacturer, who reports a precision of ±10% for FiO2 <0.7 and a respiratory frequency of <35rpm.Study protocolTwo groups of 30 patients each were studied sequentially and on a non-consecutive basis: in the first group, we assessed the reproducibility of the measurements of VO2 and VCO2 at FiO2=0.4, while in the second group we evaluated the effect of the changes in FiO2 upon the measurements of VO2 and VCO2. Each VO2 and VCO2 value in the study corresponded to the average of 5min.<a class="elsevierStyleCrossRefs" href="#bib0235">20,22</a>In the first group, 30min after turning on the E-COVX monitor and with the ventilator set to FiO2=0.4, we recorded body temperature and the VO2 and VCO2 values corresponding to 5min. Data recording was repeated 30min later in order to establish the reproducibility of the VO2 and VCO2 measurements at FiO2=0.4.In the second group, 30min after turning on the E-COVX monitor and with the ventilator set to FiO2=0.4, we likewise recorded body temperature and the VO2 and VCO2 values corresponding to 5min. The ventilator was then modified to FiO2=0.6, and after 30min we again recorded body temperature and the VO2 and VCO2 values corresponding to 5min. Lastly, the process was repeated at FiO2=0.8.Statistical analysisThe descriptive data included the number and percentage corresponding to categorical variables, and the mean and standard deviation or median and interquartile range (IQR) in the case of continuous variables. The Kolmogorov–Smirnov test was used to assess normal distribution of the data. We used the Student t-test or the Friedman test in application to continuous variables, and the χ2 test or the Fisher exact test in the case of categorical variables. The Bland and Altman method<a class="elsevierStyleCrossRef" href="#bib0250">23</a> was used to determine bias (mean difference between two measurements) and precision as the limits of agreement (twice the standard deviation of the difference between two measurements). Bias (or accuracy) assesses the similarity between the mean values of repeated measurements. Precision (reproducibility or variability) refers to the difference between repeated measurements and assesses the degree of dispersion. In addition, we evaluated absolute agreement between the repeated measurements of VO2 and VCO2 using the intraclass correlation coefficient (ICC) with the corresponding 95% confidence interval (95%CI). The error between two measurements was expressed as a percentage of the limits of agreement with respect to the mean value of the two measurements. A priori, an error of < 20% was considered acceptable.<a class="elsevierStyleCrossRef" href="#bib0255">24</a> Statistical significance was considered for p<0.05. The data were analyzed using the SPSS, version 19.0 statistical package (SPSS Inc., Chicago, IL, USA).ResultsThere were no demographic, clinical or metabolic activity differences (measured by indirect calorimetry) between the two groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Reproducibility of VO2 and VCO2 at FiO2=0.4There were no significant differences in body temperature, VO2 or VCO2 between the first and second indirect calorimetry measurements at FiO2=0.4 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The biases between the two measurements of VO2 and VCO2 were 1.6 and 2.1mL/min, respectively (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The precision for VO2 was 27.8 to −24.6mL/min, which represents a percentage error of 9.7 to −8.3%, versus 15.5 to −11.3mL/min for VCO2, which represents a percentage error of 7.2 to −5.2% (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The ICC (95%CI) for VO2 was 0.98 (0.95–0.99), and 0.98 (0.97–0.99) for VCO2.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Effect of the variation of FiO2 upon the measurement of VO2 and VCO2There were no significant differences in the values corresponding to body temperature, VO2 or VCO2 measured at FiO2=0.4, 0.6 and 0.8 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The bias of the VO2 values measured at FiO2=0.4 and 0.6 was −4.0mL/min, while at FiO2=0.4 and 0.8 the bias was 5.2mL/min (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The precision of the measurements of VO2 between FiO2=0.4 and 0.6 was 32.2 to −40.2mL/min, which represents a percentage error of 11.9 to −14.1%. In turn, the precision of the measurements of VO2 between FiO2=0.4 and 0.8 was 117.2 to −106.8mL/min, which represents a percentage error of 43.9 to −39.7% (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The ICC (95%CI) for VO2 measured at FiO2=0.4 and 0.6 was 0.95 (0.90–0.98), versus 0.70 (0.46–0.85) for VO2 measured at FiO2=0.4 and 0.8.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The bias of the values of VCO2 measured at FiO2=0.4 and 0.6 was −0.5mL/min, while at FiO2=0.4 and 0.8 the bias was −0.2mL/min (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The precision of the measurements of VCO2 between FiO2=0.4 and 0.6 was 19.5 to −20.5mL/min, which represents a percentage error of 9.3 to −9.9%. In turn, the precision of the measurements of VCO2 between FiO2=0.4 and 0.8 was 27.6 to −28.0mL/min, which represents a percentage error of 12.4 to −13.2% (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The ICC (95%CI) for VCO2 measured at FiO2=0.4 and 0.6 was 0.97 (0.94–0.99), versus 0.95 (0.90–0.98) for VCO2 measured at FiO2=0.4 and 0.8.DiscussionThe results of our study with the E-COVX metabolic monitor reveal good precision at FiO2=0.4 in the measurement of VO2 and VCO2. We observed no clinically significant bias in the measurements of VO2 and VCO2 over the FiO2 range of 0.4–0.8. However, precision in the measurement of VO2 increased on elevating FiO2 – the situation being clinically inadequate (>20%) with FiO2>0.6. Therefore, in clinical practice we should not use the E-COVX monitor to measure VO2 in critical patients subjected to mechanical ventilation at FiO2>0.6.The precision of the repeated measurements of VO2 at FiO2=0.4 was 10%, which is consistent with the specifications of the manufacturer, while the precision of VO2 at FiO2=0.6 was about 15%, versus 40% at FiO2=0.8. This progressive and exponential error in precision must be attributed to the increase in FiO2.<a class="elsevierStyleCrossRef" href="#bib0260">25</a> Such a lack of agreement with VO2 measured at FiO2=0.8 is reflected by the low ICC value of only 0.7, while ICC for the measurements of VCO2 always remained above 0.95, independently of the FiO2 setting.The measurement of VO2 and VCO2 in short periods of time can replace prolonged measurements, with the added advantage of reducing the physiological fluctuations.<a class="elsevierStyleCrossRefs" href="#bib0235">20,22</a> This advantage is lost as a result of the sequential design of the study; consequently, precision includes both the physiological variations of metabolism and the true error of the measurements.<a class="elsevierStyleCrossRef" href="#bib0200">13</a> However, the gradual increase in precision of the measurements of VO2 with incrementing FiO2 values, which is not seen with the measurements of VCO2, supports the idea that the increase in the precision of VO2 is due to errors in the measurement of the inspired and expired oxygen concentrations.Our results contrast with those of other studies that found the measurement of VO2 with the M-COVX monitor at FiO2 settings of up to 0.7 and 0.8 to be clinically acceptable.<a class="elsevierStyleCrossRefs" href="#bib0200">13–15</a> These studies are based on the notion that the E-COVX monitor measures VO2 and VCO2 on a breath-to-breath basis for 5min, which would be the equivalent to about 100 measurements (5min at 20rpm). According to the theoretical study of Ultman and Bursztein,<a class="elsevierStyleCrossRef" href="#bib0195">12</a> random error in the measurement of VO2 would be gradually reduced by incrementing the number of measurements. Accordingly, precision is considered to be ±10% when FiO2<0.65, versus ±15% when FiO2 >0.65 and <0.85.<a class="elsevierStyleCrossRef" href="#bib0260">25</a>The results of our study referred to the precision of the measurement of VO2 are consistent with the idea that any error in the measurement of oxygen concentration in the inspired and expired gas is amplified when FiO2 is increased.<a class="elsevierStyleCrossRefs" href="#bib0180">9,11</a> An error of 1% in the measurement of FiO2, at FiO2=0.4, results in an error of 15% in the measurement of VO2. At FiO2=0.8 or higher, the same error of 1% results in an error of ≥100%, and because of this we did not perform measurements with FiO2>0.8. On the other hand, the measurement of REE in patients subjected to mechanical ventilation at FiO2>0.6 remains difficult and should not be made. As expected, the precision in the measurement of VCO2 showed minimum changes with increments of FiO2.<a class="elsevierStyleCrossRef" href="#bib0195">12</a>The mean respiratory quotient (RQ=0.72) observed in our series of patients was lower than expected. The RQ in patients subjected to mechanical ventilation under the effects of sedoanalgesia and with enteral, parenteral or mixed nutrition including carbohydrates (50%), lipids (30%) and proteins (20%), should be between 0.8 and 0.9. The most likely explanation for the low RQ would be systematic error in measuring VCO2. In this sense, Meyer et al.<a class="elsevierStyleCrossRef" href="#bib0265">26</a> recorded a VCO2 value with the M-COVX monitor of under 17.6% with respect to the Deltatrac II system. The low RQ could also be due to overestimation of VO2, but this would give rise to a high REE value which we did not observe, since in the formula of Weir for calculating REE, the VO2 multiplying factor is 3.9, versus 1.1 in the case of VCO2.<a class="elsevierStyleCrossRef" href="#bib0140">1</a> The mean REE of our 60 patients was similar to that recorded in other studies in patients with similar demographic characteristics using other measurement methods.<a class="elsevierStyleCrossRefs" href="#bib0160">5,27</a>The underestimation of VCO2 has little impact upon measurement of the REE, but precludes the correct interpretation of RQ in assessing the metabolic substrates. Furthermore, it disables calculation of the physiological dead space. A possible source of systematic error is the continuous flow of the ventilator (Engström Carestation), which could dilute the expired gas. However, and despite increasing the dead space between the D-Lite and the ventilator to 15ml (the recommended value being 5ml), we observed no increase in RQ.The main limitation of our study, apart from its sequential design, is the fact that the measurements of VO2 and VCO2 were not compared with another indirect calorimetry method, such as the Douglas bag, particularly for checking the values of VCO2.In conclusion, the E-COVX metabolic monitor measures VO2 in critical patients subjected to mechanical ventilation with clinically acceptable precision to a FiO2 setting of 0.6. The measurement of VCO2 is not affected by FiO2.AuthorshipMireia Ferreruela: data collection, preparation and review of the manuscript.Joan Maria Raurich: literature search, data collection, study design, data analysis, preparation and final review of the manuscript.Juan Antonio Llompart-Pou: preparation and final review of the manuscript.Asunción Colomar: data collection, preparation and review of the manuscript.Ignacio Ayestarán: data collection, preparation and review of the manuscript.Conflicts of interestThe authors declare that they have no conflicts of interest in this study." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres933230" "titulo" => "Abstract" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients or participants" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Variables of main interest" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec907589" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres933231" "titulo" => "Resumen" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Pacientes o participantes" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Variables de interés principales" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec907590" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "E-COVX metabolic monitor" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Study protocol" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Reproducibility of VO and VCO at FiO = 0.4" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Effect of the variation of FiO upon the measurement of VO and VCO" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Authorship" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-14" "fechaAceptado" => "2016-12-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec907589" "palabras" => array:6 [ 0 => "Oxygen consumption" 1 => "Carbon dioxide" 2 => "Pulmonary gas exchange" 3 => "Mechanical ventilation" 4 => "Critical illness" 5 => "Reproducibility of results" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec907590" "palabras" => array:6 [ 0 => "Consumo de oxígeno" 1 => "Dióxido de carbono" 2 => "Intercambio pulmonar de gases" 3 => "Ventilación mecánica" 4 => "Paciente crítico" 5 => "Reproducibilidad de resultados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveWe evaluated the effect of changes in FiO2 on the bias and accuracy of the determination of oxygen consumption (V⋅O2) and carbon dioxide production (V⋅CO2) using the E-COVX monitor in patients with mechanical ventilation. DesignDescriptive of concordance. SettingIntensive Care Unit. Patients or participantsPatients with mechanical ventilation. InterventionsWe measured V⋅O2 and V⋅CO2 using the E-COVX monitor. Values recorded were the average in 5min. Two groups of 30 patients. We analyzed: 1) the reproducibility in the measurement of V⋅O2 and V⋅CO2 at FiO2 0.4, and 2) the effect of the changes in FiO2 on the measurement of V⋅O2 and V⋅CO2. Statistical analysis was performed using Bland and Altman test. Variables of main interestBias and accuracy. Results1) FiO2 0.4 reproducibility: The bias in the measurement of V⋅O2 and V⋅CO2 was 1.6 and 2.1mL/min, respectively, and accuracy was 9.7 to −8.3% and 7.2 to −5.2%, respectively, and 2) effect of FiO2 on V⋅O2: The bias of V⋅O2 measured at FiO2 0.4 and 0.6 was −4.0mL/min and FiO2 0.4 and 0.8 was 5.2mL/min. Accuracy between FiO2 0.4 and 0.6 was 11.9 to −14.1%, and between FiO2 0.4 and 0.8 was 43.9 to −39.7%. ConclusionsThe E-COVX monitor evaluates V⋅O2 and V⋅CO2 in critical patients with mechanical ventilation with a clinically acceptable accuracy until FiO2 0.6." "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients or participants" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Variables of main interest" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoValorar el efecto de la FiO2 sobre el sesgo y la precisión en la medición del consumo de oxígeno (V⋅O2) y la producción de dióxido de carbono (V⋅CO2) con el monitor E-COVX en pacientes con ventilación mecánica. DiseñoDescriptivo de concordancia. ÁmbitoUnidad de Cuidados Intensivos. Pacientes o participantesPacientes con ventilación mecánica. IntervencionesSe midieron el V⋅O2 y la V⋅CO2 con el monitor E-COVX. Los valores de V⋅O2 y V⋅CO2 fueron el promedio de 5min. Dos grupos de 30 pacientes. Se analizó: 1) la reproducibilidad de la medición del V⋅O2 y la V⋅CO2 con una FiO2 de 0,4, y 2) el efecto de los cambios en la FiO2 sobre el V⋅O2 y la V⋅CO2. Análisis estadístico por el método de Bland y Altman. Variables de interés principalesSesgo y precisión. Resultados1) Reproducibilidad a una FiO2 de 0,4: los sesgos en la medición del V⋅O2 y la V⋅CO2 fueron de 1,6 y 2,1mL/min, respectivamente, y los errores en la precisión fueron de 9,7 a −8,3% y de 7,2 a −5,2%, respectivamente, y 2) efecto de la FiO2 sobre el V⋅O2: el sesgo del V⋅O2 medido a una FiO2 de 0,4 y 0,6 fue de −4,0mL/min y a FiO2 de 0,4 y 0,8, de 5,2mL/min. La precisión entre FiO2 de 0,4 y 0,6 fue de 11,9 a −14,1%, y entre FiO2 de 0,4 y 0,8, de 43,9 a −39,7%. ConclusionesEl monitor E-COVX mide el V⋅O2 y la V⋅CO2 en pacientes críticos con ventilación mecánica con un sesgo y una precisión clínicamente aceptables hasta una FiO2 de 0,6." "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Pacientes o participantes" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Variables de interés principales" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ferreruela M, Raurich JM, Llompart-Pou JA, Colomar A, Ayestarán I. Efecto de la FiO2 sobre la medición del VO2 y la VCO2 con el monitor metabólico E-COVX. Med Intensiva. 2017;41:461–467." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2587 "Ancho" => 1626 "Tamanyo" => 169769 ] ] "descripcion" => array:1 [ "en" => "Graphic representation according to Bland and Altman of the percentage differences in the two consecutive values of VO2 and VCO2 of each patient measured at FiO2=0.4 with respect to the mean value of both measurements in mL/min." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2537 "Ancho" => 3355 "Tamanyo" => 352132 ] ] "descripcion" => array:1 [ "en" => "Graphic representation according to Bland and Altman of the percentage differences in the two consecutive values of VO2 and VCO2 of each patient measured at FiO2=0.4 and 0.6 and at FiO2=0.4 and 0.8 with respect to the mean value of both measurements in mL/min." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SD: standard deviation; REE: resting energy expenditure; RQ: respiratory quotient." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 (n=30) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 (n=30) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age in years, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight in kg, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81±19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83±19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height in cm, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">171±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">169±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index in kg/m2, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.6±4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.7±5.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Type of patient, n (%)</td><td class="td" title="table-entry " align="char" valign="top">0.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trauma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (30.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (46.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (60.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Indirect calorimetry, mean±SD</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temperature, °C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36.5±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36.6±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">REE, kcal/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.917±396 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.907±396 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">REE, kcal/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.4±5.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23.5±4.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">REE, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">116±20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">116±21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.93 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.71±0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.72±0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577168.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical characteristics, and indirect calorimetry results of the two groups of patients." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FiO2: fraction of inspired oxygen; VO2: oxygen consumption; VCO2: production of carbon dioxide.Data expressed as mean±standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">First measurement FiO2 0.4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Second measurement FiO2 0.4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difference first – second measurement  \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temperature, °C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.5±1.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.5±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VO2, mL/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">284±60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">283±61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.6±13.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VCO2, mL/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">202±42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">200±40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.1±6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577169.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Reproducibility of the measurements of VO2 and VCO2 at FiO2=0.4." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FiO2: fraction of inspired oxygen; VO2: oxygen consumption; VCO2: production of carbon dioxide.Data expressed as mean±standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO2 0.4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO2 0.6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO2 0.8 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difference 0.6–0.4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difference 0.8–0.4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temperature, °C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.6±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.6±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.6±0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VO2, mL/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">283±60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">279±58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">288±83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−4.0±18.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2±56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VCO2, mL/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201±41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201±42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201±47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.5±9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.2±13.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.88 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577167.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Bias and precision of the measurement of VO2 and VCO2 at FiO2=0.4, 0.6 and 0.8." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New methods for calculating metabolic rate with special reference to protein metabolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.B. 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Effect of FiO2 in the measurement of VO2 and VCO2 using the E-COXV metabolic monitor

Efecto de la FiO2 sobre la medición del VO2 y la VCO2 con el monitor metabólico E-COVX

M. Ferreruela, J.M. Raurich

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joan.raurich@ssib.es

Corresponding author.

, J.A. Llompart-Pou, A. Colomar, I. Ayestarán

Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain

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parenteral or mixed nutrition&#44; with a calorie supply of 15&#8211;30<span class="elsevierStyleHsp" style=""></span>kcal&#47;kg&#47;day&#46; The nutrition was administered continuously and was not interrupted&#44; since the increase in VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> is constant and with a value of about 3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> During at least 30<span class="elsevierStyleHsp" style=""></span>min before the measurements we performed no tracheal aspirations&#44; physiotherapy&#44; postural changes&#44; body hygiene measures&#44; radiological studies or catheter insertions&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The following conditions were regarded as study exclusion criteria&#58; hemodynamic instability &#40;defined as the need to modify vasoactive drug doses or variations &#62;20&#37; in arterial pressure and&#47;or heart rate&#41;&#59; a respiratory frequency of over 35<span class="elsevierStyleHsp" style=""></span>rpm&#59; the need for FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#59; a body temperature of under 36<span class="elsevierStyleHsp" style=""></span>&#176;<span class="elsevierStyleSmallCaps">C</span> or over 38<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; a sedation level as determined with the Richmond Agitation-Sedation Scale<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> of over &#8722;3&#59; patients with bronchopleural fistulas&#59; and patients subjected to renal replacement therapy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was approved by the hospital research committee&#46; Since the study involved a monitoring technique&#44; the need for informed consent was not considered necessary&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">E-COVX metabolic monitor</span><p id="par0040" class="elsevierStylePara elsevierViewall">The E-COVX metabolic monitor &#40;GE Healthcare&#47;Datex-Ohmeda&#44; Helsinki&#44; Finland&#41; is a noninvasive system equipped with a paramagnetic analyzer for oxygen&#44; an infrared analyzer for CO<span class="elsevierStyleInf">2</span>&#44; and a pneumotachograph for measuring inspired and expired volumes&#46; The pneumotachograph and gas sampling ports were located in a disposable connector called D-Lite sensor &#40;GE Healthcare Finland Oy&#44; Helsinki&#44; Finland&#41;&#44; placed between the heat and humidity exchanger &#40;Edith Flex<span class="elsevierStyleSup">&#174;</span>&#44; GE Healthcare Finland Oy&#44; Helsinki&#44; Finland&#41; and the Y-piece of the ventilator circuit&#44; in order to avoid water accumulation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> A connector with a dead space of 15<span class="elsevierStyleHsp" style=""></span>ml &#40;the manufacturer recommended a dead space of 5<span class="elsevierStyleHsp" style=""></span>ml&#41; was placed between the D-Lite sensor and the Y-piece&#46; The purpose of this dead space was to avoid contamination of the expired gas with the continuous air flow of the ventilator&#44; which was set to minimum &#40;2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In order to reduce systematic error in the volume measurements&#44; the E-COVX monitor uses the Haldane transformation to calculate both VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span>&#46; Systematic error occurs in all the measurements and is inherent to the apparatus itself or to the measurement process&#46; In contrast&#44; random error is accidental&#44; not controllable and can be reduced by increasing the sample size&#46; The Haldane transformation consists of measuring the inspiratory volume and estimating the expiratory volume&#44; since the latter is dependent upon the temperature &#40;assumed to be 35<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and humidity &#40;assumed to be 100&#37;&#41; of the expired gas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The signals from the pneumotachograph and gas analyzers were synchronized in order to allow breath-to-breath gas exchange estimates&#46; The results corresponding to VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> were expressed each minute as an average of the last 60<span class="elsevierStyleHsp" style=""></span>s&#46; The measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> were recorded only when the patient was metabolically stable &#40;defined as a variation of &#8804;5&#37; in 10 consecutive values&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">20&#44;21</span></a> The volumes were corrected to standard conditions of temperature&#44; pressure and dryness&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The E-COVX monitor is ready for use 5<span class="elsevierStyleHsp" style=""></span>min after being turned on&#44; and automatic calibration is performed&#46; The system calibrations are made every 6 months according to the instructions of the manufacturer&#44; who reports a precision of &#177;10&#37; for FiO<span class="elsevierStyleInf">2</span> &#60;0&#46;7 and a respiratory frequency of &#60;35<span class="elsevierStyleHsp" style=""></span>rpm&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Study protocol</span><p id="par0060" class="elsevierStylePara elsevierViewall">Two groups of 30 patients each were studied sequentially and on a non-consecutive basis&#58; in the first group&#44; we assessed the reproducibility of the measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; while in the second group we evaluated the effect of the changes in FiO<span class="elsevierStyleInf">2</span> upon the measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span>&#46; Each VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> value in the study corresponded to the average of 5<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">20&#44;22</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the first group&#44; 30<span class="elsevierStyleHsp" style=""></span>min after turning on the E-COVX monitor and with the ventilator set to FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; we recorded body temperature and the VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> values corresponding to 5<span class="elsevierStyleHsp" style=""></span>min&#46; Data recording was repeated 30<span class="elsevierStyleHsp" style=""></span>min later in order to establish the reproducibility of the VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> measurements at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the second group&#44; 30<span class="elsevierStyleHsp" style=""></span>min after turning on the E-COVX monitor and with the ventilator set to FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; we likewise recorded body temperature and the VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> values corresponding to 5<span class="elsevierStyleHsp" style=""></span>min&#46; The ventilator was then modified to FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;6&#44; and after 30<span class="elsevierStyleHsp" style=""></span>min we again recorded body temperature and the VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> values corresponding to 5<span class="elsevierStyleHsp" style=""></span>min&#46; Lastly&#44; the process was repeated at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">The descriptive data included the number and percentage corresponding to categorical variables&#44; and the mean and standard deviation or median and interquartile range &#40;IQR&#41; in the case of continuous variables&#46; The Kolmogorov&#8211;Smirnov test was used to assess normal distribution of the data&#46; We used the Student <span class="elsevierStyleItalic">t</span>-test or the Friedman test in application to continuous variables&#44; and the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test or the Fisher exact test in the case of categorical variables&#46; The Bland and Altman method<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> was used to determine bias &#40;mean difference between two measurements&#41; and precision as the limits of agreement &#40;twice the standard deviation of the difference between two measurements&#41;&#46; Bias &#40;or accuracy&#41; assesses the similarity between the mean values of repeated measurements&#46; Precision &#40;reproducibility or variability&#41; refers to the difference between repeated measurements and assesses the degree of dispersion&#46; In addition&#44; we evaluated absolute agreement between the repeated measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> using the intraclass correlation coefficient &#40;ICC&#41; with the corresponding 95&#37; confidence interval &#40;95&#37;CI&#41;&#46; The error between two measurements was expressed as a percentage of the limits of agreement with respect to the mean value of the two measurements&#46; <span class="elsevierStyleItalic">A priori</span>&#44; an error of &#60; 20&#37; was considered acceptable&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The data were analyzed using the SPSS&#44; version 19&#46;0 statistical package &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">There were no demographic&#44; clinical or metabolic activity differences &#40;measured by indirect calorimetry&#41; between the two groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Reproducibility of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4</span><p id="par0085" class="elsevierStylePara elsevierViewall">There were no significant differences in body temperature&#44; VO<span class="elsevierStyleInf">2</span> or VCO<span class="elsevierStyleInf">2</span> between the first and second indirect calorimetry measurements at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The biases between the two measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> were 1&#46;6 and 2&#46;1<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The precision for VO<span class="elsevierStyleInf">2</span> was 27&#46;8 to &#8722;24&#46;6<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; which represents a percentage error of 9&#46;7 to &#8722;8&#46;3&#37;&#44; versus 15&#46;5 to &#8722;11&#46;3<span class="elsevierStyleHsp" style=""></span>mL&#47;min for VCO<span class="elsevierStyleInf">2</span>&#44; which represents a percentage error of 7&#46;2 to &#8722;5&#46;2&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The ICC &#40;95&#37;CI&#41; for VO<span class="elsevierStyleInf">2</span> was 0&#46;98 &#40;0&#46;95&#8211;0&#46;99&#41;&#44; and 0&#46;98 &#40;0&#46;97&#8211;0&#46;99&#41; for VCO<span class="elsevierStyleInf">2</span>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Effect of the variation of FiO<span class="elsevierStyleInf">2</span> upon the measurement of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span></span><p id="par0090" class="elsevierStylePara elsevierViewall">There were no significant differences in the values corresponding to body temperature&#44; VO<span class="elsevierStyleInf">2</span> or VCO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; 0&#46;6 and 0&#46;8 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The bias of the VO<span class="elsevierStyleInf">2</span> values measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 was &#8722;4&#46;0<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; while at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8 the bias was 5&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;min &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The precision of the measurements of VO<span class="elsevierStyleInf">2</span> between FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 was 32&#46;2 to &#8722;40&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; which represents a percentage error of 11&#46;9 to &#8722;14&#46;1&#37;&#46; In turn&#44; the precision of the measurements of VO<span class="elsevierStyleInf">2</span> between FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8 was 117&#46;2 to &#8722;106&#46;8<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; which represents a percentage error of 43&#46;9 to &#8722;39&#46;7&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The ICC &#40;95&#37;CI&#41; for VO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 was 0&#46;95 &#40;0&#46;90&#8211;0&#46;98&#41;&#44; versus 0&#46;70 &#40;0&#46;46&#8211;0&#46;85&#41; for VO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The bias of the values of VCO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 was &#8722;0&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; while at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8 the bias was &#8722;0&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;min &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The precision of the measurements of VCO<span class="elsevierStyleInf">2</span> between FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 was 19&#46;5 to &#8722;20&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; which represents a percentage error of 9&#46;3 to &#8722;9&#46;9&#37;&#46; In turn&#44; the precision of the measurements of VCO<span class="elsevierStyleInf">2</span> between FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8 was 27&#46;6 to &#8722;28&#46;0<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; which represents a percentage error of 12&#46;4 to &#8722;13&#46;2&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The ICC &#40;95&#37;CI&#41; for VCO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 was 0&#46;97 &#40;0&#46;94&#8211;0&#46;99&#41;&#44; versus 0&#46;95 &#40;0&#46;90&#8211;0&#46;98&#41; for VCO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The results of our study with the E-COVX metabolic monitor reveal good precision at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 in the measurement of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span>&#46; We observed no clinically significant bias in the measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> over the FiO<span class="elsevierStyleInf">2</span> range of 0&#46;4&#8211;0&#46;8&#46; However&#44; precision in the measurement of VO<span class="elsevierStyleInf">2</span> increased on elevating FiO<span class="elsevierStyleInf">2</span> &#8211; the situation being clinically inadequate &#40;&#62;20&#37;&#41; with FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;6&#46; Therefore&#44; in clinical practice we should not use the E-COVX monitor to measure VO<span class="elsevierStyleInf">2</span> in critical patients subjected to mechanical ventilation at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;6&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The precision of the repeated measurements of VO<span class="elsevierStyleInf">2</span> at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 was 10&#37;&#44; which is consistent with the specifications of the manufacturer&#44; while the precision of VO<span class="elsevierStyleInf">2</span> at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;6 was about 15&#37;&#44; versus 40&#37; at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#46; This progressive and exponential error in precision must be attributed to the increase in FiO<span class="elsevierStyleInf">2</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> Such a lack of agreement with VO<span class="elsevierStyleInf">2</span> measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8 is reflected by the low ICC value of only 0&#46;7&#44; while ICC for the measurements of VCO<span class="elsevierStyleInf">2</span> always remained above 0&#46;95&#44; independently of the FiO<span class="elsevierStyleInf">2</span> setting&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The measurement of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> in short periods of time can replace prolonged measurements&#44; with the added advantage of reducing the physiological fluctuations&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">20&#44;22</span></a> This advantage is lost as a result of the sequential design of the study&#59; consequently&#44; precision includes both the physiological variations of metabolism and the true error of the measurements&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> However&#44; the gradual increase in precision of the measurements of VO<span class="elsevierStyleInf">2</span> with incrementing FiO<span class="elsevierStyleInf">2</span> values&#44; which is not seen with the measurements of VCO<span class="elsevierStyleInf">2</span>&#44; supports the idea that the increase in the precision of VO<span class="elsevierStyleInf">2</span> is due to errors in the measurement of the inspired and expired oxygen concentrations&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Our results contrast with those of other studies that found the measurement of VO<span class="elsevierStyleInf">2</span> with the M-COVX monitor at FiO<span class="elsevierStyleInf">2</span> settings of up to 0&#46;7 and 0&#46;8 to be clinically acceptable&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">13&#8211;15</span></a> These studies are based on the notion that the E-COVX monitor measures VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> on a breath-to-breath basis for 5<span class="elsevierStyleHsp" style=""></span>min&#44; which would be the equivalent to about 100 measurements &#40;5<span class="elsevierStyleHsp" style=""></span>min at 20<span class="elsevierStyleHsp" style=""></span>rpm&#41;&#46; According to the theoretical study of Ultman and Bursztein&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> random error in the measurement of VO<span class="elsevierStyleInf">2</span> would be gradually reduced by incrementing the number of measurements&#46; Accordingly&#44; precision is considered to be &#177;10&#37; when FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;65&#44; versus &#177;15&#37; when FiO<span class="elsevierStyleInf">2</span> &#62;0&#46;65 and &#60;0&#46;85&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The results of our study referred to the precision of the measurement of VO<span class="elsevierStyleInf">2</span> are consistent with the idea that any error in the measurement of oxygen concentration in the inspired and expired gas is amplified when FiO<span class="elsevierStyleInf">2</span> is increased&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">9&#44;11</span></a> An error of 1&#37; in the measurement of FiO<span class="elsevierStyleInf">2</span>&#44; at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; results in an error of 15&#37; in the measurement of VO<span class="elsevierStyleInf">2</span>&#46; At FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8 or higher&#44; the same error of 1&#37; results in an error of &#8805;100&#37;&#44; and because of this we did not perform measurements with FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#46; On the other hand&#44; the measurement of REE in patients subjected to mechanical ventilation at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;6 remains difficult and should not be made&#46; As expected&#44; the precision in the measurement of VCO<span class="elsevierStyleInf">2</span> showed minimum changes with increments of FiO<span class="elsevierStyleInf">2</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The mean respiratory quotient &#40;RQ<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;72&#41; observed in our series of patients was lower than expected&#46; The RQ in patients subjected to mechanical ventilation under the effects of sedoanalgesia and with enteral&#44; parenteral or mixed nutrition including carbohydrates &#40;50&#37;&#41;&#44; lipids &#40;30&#37;&#41; and proteins &#40;20&#37;&#41;&#44; should be between 0&#46;8 and 0&#46;9&#46; The most likely explanation for the low RQ would be systematic error in measuring VCO<span class="elsevierStyleInf">2</span>&#46; In this sense&#44; Meyer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> recorded a VCO<span class="elsevierStyleInf">2</span> value with the M-COVX monitor of under 17&#46;6&#37; with respect to the Deltatrac II system&#46; The low RQ could also be due to overestimation of VO<span class="elsevierStyleInf">2</span>&#44; but this would give rise to a high REE value which we did not observe&#44; since in the formula of Weir for calculating REE&#44; the VO<span class="elsevierStyleInf">2</span> multiplying factor is 3&#46;9&#44; versus 1&#46;1 in the case of VCO<span class="elsevierStyleInf">2</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> The mean REE of our 60 patients was similar to that recorded in other studies in patients with similar demographic characteristics using other measurement methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The underestimation of VCO<span class="elsevierStyleInf">2</span> has little impact upon measurement of the REE&#44; but precludes the correct interpretation of RQ in assessing the metabolic substrates&#46; Furthermore&#44; it disables calculation of the physiological dead space&#46; A possible source of systematic error is the continuous flow of the ventilator &#40;Engstr&#246;m Carestation&#41;&#44; which could dilute the expired gas&#46; However&#44; and despite increasing the dead space between the D-Lite and the ventilator to 15<span class="elsevierStyleHsp" style=""></span>ml &#40;the recommended value being 5<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; we observed no increase in RQ&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The main limitation of our study&#44; apart from its sequential design&#44; is the fact that the measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> were not compared with another indirect calorimetry method&#44; such as the Douglas bag&#44; particularly for checking the values of VCO<span class="elsevierStyleInf">2</span>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion&#44; the E-COVX metabolic monitor measures VO<span class="elsevierStyleInf">2</span> in critical patients subjected to mechanical ventilation with clinically acceptable precision to a FiO<span class="elsevierStyleInf">2</span> setting of 0&#46;6&#46; The measurement of VCO<span class="elsevierStyleInf">2</span> is not affected by FiO<span class="elsevierStyleInf">2</span>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Authorship</span><p id="par0150" class="elsevierStylePara elsevierViewall">Mireia Ferreruela&#58; data collection&#44; preparation and review of the manuscript&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Joan Maria Raurich&#58; literature search&#44; data collection&#44; study design&#44; data analysis&#44; preparation and final review of the manuscript&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Juan Antonio Llompart-Pou&#58; preparation and final review of the manuscript&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Asunci&#243;n Colomar&#58; data collection&#44; preparation and review of the manuscript&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Ignacio Ayestar&#225;n&#58; data collection&#44; preparation and review of the manuscript&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest in this study&#46;</p></span></span>"
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              "titulo" => "Reproducibility of VO and VCO at FiO &#61; 0&#46;4"
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              "titulo" => "Effect of the variation of FiO upon the measurement of VO and VCO"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We evaluated the effect of changes in FiO<span class="elsevierStyleInf">2</span> on the bias and accuracy of the determination of oxygen consumption &#40;V&#8901;O2&#41; and carbon dioxide production &#40;V&#8901;CO2&#41; using the E-COVX monitor in patients with mechanical ventilation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descriptive of concordance&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intensive Care Unit&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients or participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients with mechanical ventilation&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We measured V&#8901;O2 and V&#8901;CO2 using the E-COVX monitor&#46; Values recorded were the average in 5<span class="elsevierStyleHsp" style=""></span>min&#46; Two groups of 30 patients&#46; We analyzed&#58; 1&#41; the reproducibility in the measurement of V&#8901;O2 and V&#8901;CO2 at FiO<span class="elsevierStyleInf">2</span> 0&#46;4&#44; and 2&#41; the effect of the changes in FiO<span class="elsevierStyleInf">2</span> on the measurement of V&#8901;O2 and V&#8901;CO2&#46; Statistical analysis was performed using Bland and Altman test&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables of main interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Bias and accuracy&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">1&#41; FiO<span class="elsevierStyleInf">2</span> 0&#46;4 reproducibility&#58; The bias in the measurement of V&#8901;O2 and V&#8901;CO2 was 1&#46;6 and 2&#46;1<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; respectively&#44; and accuracy was 9&#46;7 to &#8722;8&#46;3&#37; and 7&#46;2 to &#8722;5&#46;2&#37;&#44; respectively&#44; and 2&#41; effect of FiO<span class="elsevierStyleInf">2</span> on V&#8901;O2&#58; The bias of V&#8901;O2 measured at FiO<span class="elsevierStyleInf">2</span> 0&#46;4 and 0&#46;6 was &#8722;4&#46;0<span class="elsevierStyleHsp" style=""></span>mL&#47;min and FiO<span class="elsevierStyleInf">2</span> 0&#46;4 and 0&#46;8 was 5&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; Accuracy between FiO<span class="elsevierStyleInf">2</span> 0&#46;4 and 0&#46;6 was 11&#46;9 to &#8722;14&#46;1&#37;&#44; and between FiO<span class="elsevierStyleInf">2</span> 0&#46;4 and 0&#46;8 was 43&#46;9 to &#8722;39&#46;7&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The E-COVX monitor evaluates V&#8901;O2 and V&#8901;CO2 in critical patients with mechanical ventilation with a clinically acceptable accuracy until FiO<span class="elsevierStyleInf">2</span> 0&#46;6&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Valorar el efecto de la FiO<span class="elsevierStyleInf">2</span> sobre el sesgo y la precisi&#243;n en la medici&#243;n del consumo de ox&#237;geno &#40;V&#8901;O2&#41; y la producci&#243;n de di&#243;xido de carbono &#40;V&#8901;CO2&#41; con el monitor E-COVX en pacientes con ventilaci&#243;n mec&#225;nica&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Descriptivo de concordancia&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Unidad de Cuidados Intensivos&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes o participantes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pacientes con ventilaci&#243;n mec&#225;nica&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se midieron el V&#8901;O2 y la V&#8901;CO2 con el monitor E-COVX&#46; Los valores de V&#8901;O2 y V&#8901;CO2 fueron el promedio de 5<span class="elsevierStyleHsp" style=""></span>min&#46; Dos grupos de 30 pacientes&#46; Se analiz&#243;&#58; 1&#41; la reproducibilidad de la medici&#243;n del V&#8901;O2 y la V&#8901;CO2 con una FiO<span class="elsevierStyleInf">2</span> de 0&#44;4&#44; y 2&#41; el efecto de los cambios en la FiO<span class="elsevierStyleInf">2</span> sobre el V&#8901;O2 y la V&#8901;CO2&#46; An&#225;lisis estad&#237;stico por el m&#233;todo de Bland y Altman&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s principales</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Sesgo y precisi&#243;n&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">1&#41; Reproducibilidad a una FiO<span class="elsevierStyleInf">2</span> de 0&#44;4&#58; los sesgos en la medici&#243;n del V&#8901;O2 y la V&#8901;CO2 fueron de 1&#44;6 y 2&#44;1<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; respectivamente&#44; y los errores en la precisi&#243;n fueron de 9&#44;7 a &#8722;8&#44;3&#37; y de 7&#44;2 a &#8722;5&#44;2&#37;&#44; respectivamente&#44; y 2&#41; efecto de la FiO<span class="elsevierStyleInf">2</span> sobre el V&#8901;O2&#58; el sesgo del V&#8901;O2 medido a una FiO<span class="elsevierStyleInf">2</span> de 0&#44;4 y 0&#44;6 fue de &#8722;4&#44;0<span class="elsevierStyleHsp" style=""></span>mL&#47;min y a FiO<span class="elsevierStyleInf">2</span> de 0&#44;4 y 0&#44;8&#44; de 5&#44;2<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; La precisi&#243;n entre FiO<span class="elsevierStyleInf">2</span> de 0&#44;4 y 0&#44;6 fue de 11&#44;9 a &#8722;14&#44;1&#37;&#44; y entre FiO<span class="elsevierStyleInf">2</span> de 0&#44;4 y 0&#44;8&#44; de 43&#44;9 a &#8722;39&#44;7&#37;&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El monitor E-COVX mide el V&#8901;O2 y la V&#8901;CO2 en pacientes cr&#237;ticos con ventilaci&#243;n mec&#225;nica con un sesgo y una precisi&#243;n cl&#237;nicamente aceptables hasta una FiO<span class="elsevierStyleInf">2</span> de 0&#44;6&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ferreruela M&#44; Raurich JM&#44; Llompart-Pou JA&#44; Colomar A&#44; Ayestar&#225;n I&#46; Efecto de la FiO<span class="elsevierStyleInf">2</span> sobre la medici&#243;n del VO<span class="elsevierStyleInf">2</span> y la VCO<span class="elsevierStyleInf">2</span> con el monitor metab&#243;lico E-COVX&#46; Med Intensiva&#46; 2017&#59;41&#58;461&#8211;467&#46;</p>"
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Graphic representation according to Bland and Altman of the percentage differences in the two consecutive values of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> of each patient measured at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;6 and at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4 and 0&#46;8 with respect to the mean value of both measurements in mL&#47;min&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; REE&#58; resting energy expenditure&#59; RQ&#58; respiratory quotient&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male sex&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age in years&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Weight in kg&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Height in cm&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">171<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">169<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Body mass index in kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Type of patient&#44; n &#40;&#37;&#41;</span></td><td class="td" title="table-entry  " align="char" valign="top">0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Trauma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;30&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;46&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;60&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Indirect calorimetry&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Temperature&#44; &#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>REE&#44; kcal&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;917<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;907<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>REE&#44; kcal&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>REE&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">116<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">116<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;71<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics&#44; and indirect calorimetry results of the two groups of patients&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at2"
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          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">FiO<span class="elsevierStyleInf">2</span>&#58; fraction of inspired oxygen&#59; VO<span class="elsevierStyleInf">2</span>&#58; oxygen consumption&#59; VCO<span class="elsevierStyleInf">2</span>&#58; production of carbon dioxide&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Data expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">First measurement<br>FiO<span class="elsevierStyleInf">2</span> 0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Second measurement<br>FiO<span class="elsevierStyleInf">2</span> 0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difference first &#8211; second measurement<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temperature&#44; &#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VO<span class="elsevierStyleInf">2</span>&#44; mL&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">284<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">283<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VCO<span class="elsevierStyleInf">2</span>&#44; mL&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">202<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">200<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Reproducibility of the measurements of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#46;</p>"
        ]
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      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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            "identificador" => "at3"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">FiO<span class="elsevierStyleInf">2</span>&#58; fraction of inspired oxygen&#59; VO<span class="elsevierStyleInf">2</span>&#58; oxygen consumption&#59; VCO<span class="elsevierStyleInf">2</span>&#58; production of carbon dioxide&#46;</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Data expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>47&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Bias and precision of the measurement of VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span> at FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; 0&#46;6 and 0&#46;8&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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                  "host" => array:1 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;L&#46; Vincent"
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                  "contribucion" => array:1 [
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2017.08.007

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Year/Month	Html	Pdf	Total

2024 November	12	10	22
2024 October	122	63	185
2024 September	160	43	203
2024 August	153	53	206
2024 July	139	44	183
2024 June	147	77	224
2024 May	138	55	193
2024 April	147	48	195
2024 March	146	36	182
2024 February	112	36	148
2024 January	139	40	179
2023 December	97	46	143
2023 November	119	65	184
2023 October	132	66	198
2023 September	111	45	156
2023 August	117	24	141
2023 July	120	36	156
2023 June	92	26	118
2023 May	115	38	153
2023 April	104	25	129
2023 March	222	53	275
2023 February	149	39	188
2023 January	102	56	158
2022 December	159	53	212
2022 November	187	35	222
2022 October	169	74	243
2022 September	158	50	208
2022 August	150	59	209
2022 July	114	59	173
2022 June	124	42	166
2022 May	168	53	221
2022 April	198	55	253
2022 March	201	83	284
2022 February	235	51	286
2022 January	200	43	243
2021 December	168	58	226
2021 November	179	59	238
2021 October	200	88	288
2021 September	112	45	157
2021 August	109	42	151
2021 July	64	43	107
2021 June	77	39	116
2021 May	105	65	170
2021 April	291	128	419
2021 March	183	55	238
2021 February	183	44	227
2021 January	159	25	184
2020 December	144	20	164
2020 November	152	22	174
2020 October	105	37	142
2020 September	102	27	129
2020 August	77	27	104
2020 July	73	24	97
2020 June	95	23	118
2020 May	96	44	140
2020 April	101	26	127
2020 March	60	33	93
2020 February	194	94	288
2020 January	103	29	132
2019 December	108	22	130
2019 November	304	60	364
2019 October	139	23	162
2019 September	96	28	124
2019 August	59	31	90
2019 July	52	23	75
2019 June	50	22	72
2019 May	96	39	135
2019 April	52	21	73
2019 March	63	36	99
2019 February	62	32	94
2019 January	55	43	98
2018 December	56	62	118
2018 November	120	45	165
2018 October	134	25	159
2018 September	54	15	69
2018 August	36	8	44
2018 July	38	22	60
2018 June	46	15	61
2018 May	24	6	30
2018 April	30	12	42
2018 March	38	6	44

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