Response to Berger and Pichard and Heyland et al

Protein nutrition and exercise survival kit for critically ill

PURPOSE OF REVIEW

Protein delivery as well as exercise of critically ill in clinical practice is still a highly debated issue. Here we discuss only the most recent updates in the literature concerning protein nutrition and exercise of the critically ill.

RECENT FINDINGS

By lack of randomized controlled trial (RCTs) in protein nutrition we discuss four post-hoc analyses of nutrition studies and one experimental study in mice. Studies mainly confirm some insights that protein and energy effects are separate and that the trajectory of the patient in the ICU might change these effects. Exercise has been studied much more extensively with RCTs in the last year, although also here the differences between patient groups and timing of intervention might play their roles. Overall the effects of protein nutrition and exercise appear to be beneficial. However, studies into the differential effects of protein nutrition and/or exercise, and optimization of their combined use, have not been performed yet and are on the research agenda.

SUMMARY

Optimal protein nutrition, optimal exercise intervention as well as the optimal combination of nutrition, and exercise may help to improve long-term physical performance outcome in the critically ill patients.

Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis

BACKGROUND

There is conflicting evidence about the relationship between the dose of enteral caloric intake and survival in critically ill patients. The objective of this systematic review and meta-analysis is to compare the effect of lower versus higher dose of enteral caloric intake in adult critically ill patients on outcome.

METHODS

We reviewed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through November 2015. We included randomized and quasi-randomized studies in which there was a significant difference in the caloric intake in adult critically ill patients, including trials in which caloric restriction was the primary intervention (caloric restriction trials) and those with other interventions (non-caloric restriction trials). Two reviewers independently extracted data on study characteristics, caloric intake, and outcomes with hospital mortality being the primary outcome.

RESULTS

Twenty-one trials mostly with moderate bias risk were included (2365 patients in the lower caloric intake group and 2352 patients in the higher caloric group). Lower compared with higher caloric intake was not associated with difference in hospital mortality (risk ratio (RR) 0.953; 95 % confidence interval (CI) 0.838-1.083), ICU mortality (RR 0.885; 95 % CI 0.751-1.042), total nosocomial infections (RR 0.982; 95 % CI 0.878-1.077), mechanical ventilation duration, or length of ICU or hospital stay. Blood stream infections (11 trials; RR 0.718; 95 % CI 0.519-0.994) and incident renal replacement therapy (five trials; RR 0.711; 95 % CI 0.545-0.928) were lower with lower caloric intake. The associations between lower compared with higher caloric intake and primary and secondary outcomes, including pneumonia, were not different between caloric restriction and non-caloric restriction trials, except for the hospital stay which was longer with lower caloric intake in the caloric restriction trials.

CONCLUSIONS

We found no association between the dose of caloric intake in adult critically ill patients and hospital mortality. Lower caloric intake was associated with lower risk of blood stream infections and incident renal replacement therapy (five trials only). The heterogeneity in the design, feeding route and timing and caloric dose among the included trials could limit our interpretation. Further studies are needed to clarify our findings.