Protein in the Hospital: Gaining Perspective and Moving Forward

Achieving Protein Targets in the ICU Using a Specialized High-Protein Enteral Formula: A Quality Improvement Project

BACKGROUND

To meet protein needs in critical illness (CI), guidelines suggest ≥1.2-2.5 g protein/kg/d; however, most intensive care unit (ICU) patients receive ≤0.7 g/kg/d. Higher protein enteral nutrition (EN) formulas may be part of the solution to provide prescribed protein. Our objective was to demonstrate that an EN formula with 37% protein can deliver ≥80% of prescribed protein, without overfeeding calories within the first 5 days of feeding and to describe ICU clinicians' experience.

METHODS

This quality improvement (QI) project included patients requiring exclusive EN for up to 5 days from 6 Canadian ICUs. Rationale for choosing formula, patient's BMI (kg/m² ), nutrition targets, daily protein and energy delivered, feeding interruptions, and general tolerance were recorded.

RESULTS

Forty-four of 49 patients received the formula ≥2 days. Average protein prescribed was 137.5 g/d (82.5-200) or 1.9 g/kg/d (1.5-2.5). Average protein delivered was 116.9 g/d (33.5-180) or 1.6 g/kg/d (0.4-2.4). Seventy-five percent to 83% of patients received ≥80% prescribed protein on days 2-5. Average energy prescribed was 1638.6 kcal/d (990-2500) or 17.8 kcal/kg (11-26). Average energy delivered was 1523.9 kcal/d (693.0-2557.5) or 17.3 kcal/kg/d (1.35-64.7). The formula was well tolerated with no gastrointestinal symptoms reported in 38 (86%) patients. The most common reasons to prescribe the formula were obesity and use of fat-based medications.

CONCLUSIONS

We demonstrated in a QI study that a high-protein EN formula was tolerated in a small, heterogeneous group of ICU patients and effective in meeting protein targets without overfeeding.

Are Current Protein Recommendations for the Critically Ill Adequate for Patients on VV ECMO: Experience From a High-Volume Center

BACKGROUND

The nutrition needs of patients requiring extracorporeal membrane oxygenation (ECMO) have not been established in the literature. The purpose of this study is to investigate if current protein recommendations are adequate to achieve nitrogen equilibrium in patients on venovenous ECMO (VV ECMO).

METHODS

Patients aged ≥18 years on VV ECMO admitted November 2016 through January 2018 with a documented nitrogen balance (NB) study were included. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m² ) and nonobese (BMI < 30 kg/m² ) categories for analysis.

RESULTS

After exclusions, 55 NB studies in 29 patients were analyzed. Twelve nonobese patients received a median of 2.1 g protein/kg actual body weight (ABW) (interquartile range [IQR]: 1.7-2.5), and median NB was -2.2 g/d (IQR: -7.4 to 2.8). In 17 obese patients, median protein delivery of 2 g protein/kg ideal body weight (IBW) (IQR: 1.7-2.5) achieved a median NB of -7.3 g/d (IQR: -12.6 to -2.8). Obese patients exhibited greater urinary urea nitrogen excretion than nonobese patients did (24.6 vs 17.6 g/d, P < 0.0001).

CONCLUSIONS

Obese and nonobese patients undergoing VV ECMO may require more protein than is currently recommended for critical illness. Monitoring nutrition delivery and serial NB to assess prescription adequacy should be incorporated into routine patient care. Further research is needed to confirm these findings and create specific guidelines for patients on VV ECMO.