Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient

Optimizing Recovery in Elderly Patients: Anabolic Benefits of Glucose Supplementation during the Rehydration Period

BACKGROUND

Since many acutely admitted older adults display signs of dehydration, treatment using balanced crystalloids is an important part of medical care. Additionally, many of these patients suffer from chronic malnutrition. We speculated that the early addition of glucose might ameliorate the hospital-related drop of caloric intake and modify their catabolic status.

METHODS

We included patients 78 years and older, admitted acutely for non-traumatic illnesses. The patients were randomized into either receiving balanced crystalloid (PlasmaLyte; group P) or balanced crystalloid enriched with 100 g of glucose per liter (group G). The information about fluid balance and levels of minerals were collected longitudinally.

RESULTS

In the G group, a significantly higher proportion of patients developed signs of refeeding syndrome, i.e., drops in phosphates, potassium and/or magnesium when compared to group P (83.3 vs. 16.7%, p < 0.01). The drop in phosphate levels was the most pronounced. The urinalysis showed no differences in the levels of these minerals in the urine, suggesting their uptake into the cells. There were no differences in the in-hospital mortality or in the 1-year mortality.

CONCLUSION

The short-term administration of balanced crystalloids with glucose induced an anabolic shift of electrolytes in acutely admitted older adults.

Clinically ill patients' experiences of early mobilisation after liver transplantation: a qualitative study using Pender's health promotion model

The aim of this study is to explore the factors influencing early mobilisation behaviours and patients' needs in critically ill patients after liver transplantation (LT). This interview study used phenomenological research, and Pender's health promotion model (HPM) was used to construct the interview guide. With the use of purposeful sampling, a total of 19 critically ill patients who experienced early mobilisation after LT were recruited at three tertiary hospitals in Beijing from August to November 2022. Data were collected through semi-structured interviews and analysed using Colaizzi's seven-step method. Nine themes were categorised into the three domains of Pender's HPM. The first domain was individual characteristics and experiences: (1) symptoms of end-stage liver disease limiting premobility behaviours and (2) previous treatment experience affecting understanding of early mobilisation after LT. The second domain was behaviour-specific cognition and affect: (3) coexistence of benefits and concerns in early mobilisation after LT, (4) barriers to early mobilisation after LT, (5) high self-efficacy in early mobilisation after LT, (6) individual differences in early mobilisation and (7) support and encouragement from family, wardmates and medical staff. The final domain was behavioural outcomes: (8) the need for sufficient staff, a quiet environment, safety, goals, guidance and family participation and (9) a strong willingness to comply with early mobilisation plans. The three areas and nine themes extracted in this study are helpful for the long-term development of early mobilisation in patients after LT.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Short-Term Outcomes of the First-Session Prone Position in Patients With Severe Coronavirus Disease 2019: A Retrospective Chart Review

Introduction Prone positioning during ventilation is recommended for patients with severe coronavirus disease 2019 (COVID-19). However, the efficacy of first-session prone positioning in improving short-term outcomes remains unclear. Therefore, we aimed to investigate the impact of the rate of change in partial pressure of oxygen/fraction of inspired oxygen (P/F) ratio before and after initial prone positioning on activities of daily living (ADL) and outcomes at discharge. Methods In this retrospective chart review, 22 patients with severe COVID-19 who required ventilator management between April and September 2021 were analyzed. Patients with an improvement in the P/F ratio (after initial prone positioning, compared to that before the session) by > 16mHg and < 16mmHg were defined as responders and non-responders, respectively. Results Compared with non-responders, responders had a significantly shorter ventilator duration, a higher Barthel Index at discharge, and a higher proportion of discharged patients. There was a significant between-group difference in chronic respiratory comorbidities, with one case (7.7%) among responders and six cases (66.7%) among non-responders. Conclusions This study is the first of its kind to investigate short-term outcomes in patients with COVID-19 requiring ventilator management after initial prone positioning. After initial prone positioning, responders had higher P/F ratios as well as improved ADLs and outcomes at discharge.

Comparison of continuous versus intermittent enteral feeding in critically ill patients: a systematic review and meta-analysis

Background

The enteral route is commonly utilised to support the nutritional requirements of critically ill patients. However, there is paucity of data guiding clinicians regarding the appropriate method of delivering the prescribed dose. Continuous enteral feeding is commonly used; however, a bolus or intermittent method of administration may provide several advantages such as minimising interruptions. The purpose of this meta-analysis is to compare a continuous versus an intermittent or bolus enteral nutrition administration method.

Methods

A systematic review and meta-analysis were performed with studies identified from the PubMed, EMBASE, Cochrane Library and Web of Science databases. Studies were included if they compared a continuous with either an intermittent or bolus administration method of enteral nutrition in adult patients admitted to the intensive care unit. Study quality was assessed using the PEDro and Newcastle–Ottawa scoring systems. Review Manager was used for performing the random-effects meta-analysis on the outcomes of mortality, constipation, diarrhoea, increased gastric residuals, pneumonia, and bacterial colonisation.

Results

A total of 5546 articles were identified, and 133 were included for full text review. Fourteen were included in the final analysis. There was an increased risk of constipation with patients receiving continuous enteral nutrition (relative risk 2.24, 95% confidence interval 1.01–4.97, p = 0.05). No difference was identified in other outcome measures. No appreciable bias was identified.

Conclusion

The current meta-analysis has not identified any clinically relevant difference in most outcome measures relevant to the care of critically ill patients. However, there is a paucity of high-quality randomised controlled clinical trials to guide this decision. Therefore, clinicians may consider either dosing regimen in the context of the patient’s care requirements.

The Effect of Aging Physiology on Critical Care

Older patients experience a decline in their physiologic reserves as well as chronic low-grade inflammation named "inflammaging." Both of these contribute significantly to aging-related factors that alter the acute, subacute, and chronic response of these patients to critical illness, such as sepsis. Unfortunately, this altered response to stressors can lead to chronic critical illness followed by dismal outcomes and death. The primary goal of this review is to briefly highlight age-specific changes in physiologic systems majorly affected in critical illness, especially because it pertains to sepsis and trauma, which can lead to chronic critical illness and describe implications in clinical management.

COVID-19: Short and Long-Term Effects of Hospitalization on Muscular Weakness in the Elderly

The COVID-19 pandemic has recently been the cause of a global public health emergency. Frequently, elderly patients experience a marked loss of muscle mass and strength during hospitalization, resulting in a significant functional decline. This paper describes the impact of prolonged immobilization and current pharmacological treatments on muscular metabolism. In addition, the scientific evidence for an early strength intervention, neuromuscular electrical stimulation or the application of heat therapy during hospitalization to help prevent COVID-19 functional sequels is analyzed. This review remarks the need to: (1) determine which potential pharmacological interventions have a negative impact on muscle quality and quantity; (2) define a feasible and reliable pharmacological protocol to achieve a balance between desired and undesired medication effects in the treatment of this novel disease; (3) implement practical strategies to reduce muscle weakness during bed rest hospitalization and (4) develop a specific, early and safe protocol-based care of functional interventions for older adults affected by COVID-19 during and after hospitalization.

Effects of protein supplementation on muscle wasting disorders: A brief update of the evidence

OBJECTIVE

To examine the effects of protein supplementation on muscle mass, strength and function in individuals at risk of muscle wasting disorders.

METHODS

A narrative overview of the literature based on a PubMed search.

RESULTS

Increasing protein intake beyond the recommended dietary intake may prevent or attenuate muscle loss in people at risk of muscle wasting disorders; however, there is inconsistent evidence for any benefits on muscle strength or physical function. This is likely due to the significant heterogeneity and bias regarding baseline demographics, basal protein/energy intakes and protein supplement type, dose, timing and compliance.

CONCLUSION

Protein supplementation attenuates muscle loss in some populations at increased risk of muscle wasting, but there is no consistent evidence to support benefits on muscle strength or physical function. Further randomised controlled trials are needed that focus on whether there is an optimal type, dose and timing of protein intake, and potential interaction with other nutrients.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Malnutrition and nutritional status in critically ill patients with enteral nutrition

BACKGROUND & OBJECTIVE: The prevention of malnutrition is an important factor in the survival of critically ill patients with enteral nutrition. The present study aims to assess the nutritional status and its association with some blood-related markers in critically ill patients with enteral nutrition during hospitalization in the intensive care units (ICUs). METHODS: Totally, 110 patients participated in this study from the time of admission to discharge at five ICUs. The patients’ nutritional status was assessed by subjective global assessment (SGA), Acute Physiology and Chronic Health Evaluation and Albumin, Total Iron Binding Capacity (TIBC), Hemoglobin (Hb), Hematocrit (HCT), Ferritin, and Feas biochemical indices and anthropometric parameters. RESULTS: Malnutrition prevalence increased significantly on the day of discharge (83.6%) compared to the day of admission (41.8%), according to SGA (P < 0.001). Hb, HCT, serum Fe decreased and ferritin, also TIBC were increased during hospitalization in ICU. The malnutrition risk predictors based on the logistic regression were low levels of Hb (OR = 0.6), HCT (OR = 0.9), Fe (OR = 0.9), Albumin (OR = 0.3) and High Ferritin level (OR = 1.006) on the admission day. Anemia of inflammation (AI) was observed during ICU stay. CONCLUSION: This study demonstrated that malnutrition is an increasing phenomenon in the ICU patients and the delay in patient’s enteral feeding had a direct influence in the prevalence of malnutrition on discharge day.

Protein Requirements during Hypocaloric Nutrition for the Older Patient With Critical Illness and Obesity: An Approach to Clinical Practice

Current guidelines recommend a hypocaloric, high protein nutrition regimen for patients with obesity and critical illness. The impact of advancing age presents with unique challenges in which a greater protein intake is required to overcome the anabolic resistance associated with aging in the face of presumed decreased renal function. The primary objective of this review is to provide an overview of the impact of obesity and advancing age on protein requirements for patients with critical illness and review the scientific evidence supporting the rationale for hypocaloric, high protein nutrition for this subpopulation, as well as provide some practical suggestions for their clinical management.

Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies

Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.

Protein metabolism and requirements in the ICU

The critically ill patient is highly catabolic, loosing significant amounts of protein and muscle. This proteolysis may induce a loss of 20% of the muscle mass in 10 days of hospitalization. Muscle loss may be assessed measuring urinary nitrogen excretion, muscle mass by ultrasound, bioimpedance, computerized tomography or MRI. To reduce the negative nitrogen balance, protein can be administrated enterally, or parenterally through amino acids as a part of parenteral nutrition. ESPEN guidelines recommend to administer 1.3 g/kg/day of protein to critically ill patients but this recommendation should be adapted according to clinical conditions. Elderly, obese, trauma, burn, acute kidney injury patients should receive larger amount of protein.

Macronutrients in Parenteral Nutrition: Amino Acids

The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with significant clinical benefits. Several industrial PN mixtures are available so that nutrition specialists can choose the product closest to the patient's needs. In selected cases, there is the possibility of personalizing compounded mixtures in a hospital pharmacy that completely meets the individual nutritional needs of PN patients. This narrative review deals with the AA solutions used in PN mixtures. The physiology, the methods to calculate the AA needs, and the AA and energy requirements suggested by scientific guidelines for each patient type are also reported.

Narrowing the Protein Deficit Gap in Critically Ill Patients Using a Very High-Protein Enteral Formula

BACKGROUND

Protein deficits have been associated with longer intensive care unit (ICU) stays and increased mortality. Current view suggests if protein goals are met, meeting full energy targets may be less important and prevent deleterious effects of overfeeding. We proposed a very-high protein (VHP) enteral nutrition (EN) formula could provide adequate protein, without overfeeding energy, in the first week of critical illness.

METHODS

This was a retrospective study of medical/surgical ICU patients receiving EN exclusively for ≥5 days during the first week of ICU admission. Twenty participants received standard EN; 20 participants received the VHP-EN formula (1 kcal/mL, 37% protein). Protein and energy prescribed/received, gastrointestinal tolerance, and feeding interruptions were examined.

RESULTS

Forty ICU patients [average Acute Physiology and Chronic Health Evaluation II score of 20.1] were included. Protein prescribed and received was significantly higher in the VHP group vs the standard EN group (135.5 g/d ± 22.9 vs 111.4 g/d ± 25; P = .003 and 112.2 g/d ± 27.8 vs 81.7 g/d ± 16.7, respectively; P = .002). Energy prescribed and received was similar between groups (1696 kcal/d ± 402 vs 1893 kcal/d ± 341, respectively; P = .101 and 1520 kcal/d ± 346 vs 1506 ± 380 kcal/d; P = .901). There were no differences in EN tolerance (P = .065) or feeding interruptions (P = .336).

CONCLUSIONS

Use of a VHP formula in ICU patients resulted in higher protein intakes without overfeeding energy or use of modular protein in the first 5 days of exclusive EN.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Medical Nutrition Therapy in Critically Ill Patients Treated on Intensive and Intermediate Care Units: A Literature Review

Medical nutrition therapy in critically ill patients remains challenging, not only because of the pronounced stress response with a higher risk for complications, but also due to their heterogeneity evolving from different phases of illness. The present review aims to address current knowledge and guidelines in order to summarize how they can be best implemented into daily clinical practice. Further studies are urgently needed to answer such important questions as best timing, route, dose, and composition of medical nutrition therapy for critically ill patients and to determine how to assess and to adapt to patients’ individual needs.

Regulation of mitochondrial quality following repeated bouts of hindlimb unloading

Muscle disuse impairs muscle quality and is associated with increased mortality. Little is known regarding additive effects of multiple bouts of disuse, which is a common occurrence in patients experiencing multiple surgeries. Mitochondrial quality is vital to muscle health and quality; however, to date mitochondrial quality control has not been investigated following multiple bouts of disuse. Therefore, the purpose of this study was to investigate mitochondrial quality controllers during multiple bouts of disuse by hindlimb unloading. Male rats (n ∼ 8/group) were assigned to the following groups: hindlimb unloading for 28 days, hindlimb unloading with 56 days of reloading, 2 bouts of hindlimb unloading separated by a recovery phase of 56 days of reloading, 2 bouts of hindlimb unloading and recovery after each disuse, or control animals with no unloading. At designated time points, tissues were collected for messenger RNA and protein analysis of mitochondrial quality. Measures of mitochondrial biogenesis, such as proliferator-activated receptor gamma coactivator 1 alpha, decreased 30%-40% with unloading with no differences noted between unloading conditions. Measures of mitochondrial translation were 40%-50% lower in unloading conditions, with no differences noted between bouts of unloading. Measures of mitophagy were 40%-50% lower with reloading, with no differences noted between reloading conditions. In conclusion, disuse causes alterations in measures of mitochondrial quality; however, multiple bouts of disuse does not appear to have additive effects. Novelty Disuse atrophy causes multiple alterations to mitochondrial quality control. With sufficient recovery most detriments to mitochondrial quality control are fixed. In general, multiple bouts of disuse do not produce additive effects.

Contraction and nutrition interaction promotes anabolism in cachectic muscle

PURPOSE OF REVIEW

Cachexia is a disease-related multifactorial syndrome characterized by inflammation, massive muscle protein catabolism and carbohydrate and lipid metabolism disorder.Several studies tried to define the impact of either nutrition or physical exercise (single approach strategy) or their combination (multimodal approach strategy) on prevention and/or treatment of muscle wasting in cachectic patients.

RECENT FINDINGS

Single approach strategies (i.e. nutrition or physical exercise) have the potential of preventing and improving features of the cachexia syndrome possibly with a differential impact according to the underlying disease. Limited information is available on the beneficial effect of multimodal approach strategies.

SUMMARY

Multimodal approaches appear to be more effective than those based on single interventions in physiological condition and in cachectic patients with COPD or chronic kidney disease. Further studies, however, are required in cachexia induced by heart failure, cancer and critical illness.

Achieving protein targets without energy overfeeding in critically ill patients: A prospective feasibility study

BACKGROUND & AIMS

High protein delivery during early critical illness is associated with lower mortality, while energy overfeeding is associated with higher mortality. Protein-to-energy ratios of traditional enteral formulae are sometimes too low to reach protein targets without energy overfeeding. This prospective feasibility study aimed to evaluate the ability of a new enteral formula with a high protein-to-energy ratio to achieve the desired protein target while avoiding energy overfeeding.

METHODS

Mechanically ventilated non-septic patients received the high protein-to-energy ratio nutrition during the first 4 days of ICU stay (n = 20). Nutritional prescription was 90% of measured energy expenditure. Primary endpoint was the percentage of patients reaching a protein target of ≥1.2 g/kg ideal body weight on day 4. Other endpoints included a comparison of nutritional intake to matched historic controls and the response of plasma amino acid concentrations. Safety endpoints were gastro-intestinal tolerance and plasma urea concentrations.

RESULTS

Nineteen (95%) patients reached the protein intake target of ≥1.2 g/kg ideal body weight on day 4, compared to 65% in historic controls (p = 0.024). Mean plasma concentrations of all essential amino acids increased significantly from baseline to day 4. Predefined gastro-intestinal tolerance was good, but unexplained foul smelling diarrhoea occurred in two patients. In one patient plasma urea increased unrelated to acute kidney injury.

CONCLUSIONS

In selected non-septic patients tolerating enteral nutrition, recommended protein targets can be achieved without energy overfeeding using a new high protein-to-energy ratio enteral nutrition.

Nutrition in the ICU: new trends versus old-fashioned standard enteral feeding?

PURPOSE OF REVIEW

The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings.

RECENT FINDINGS

Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results.

SUMMARY

Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.

Current perspective for tube feeding in the elderly: from identifying malnutrition to providing of enteral nutrition

With the number of individuals older than 65 years expected to rise significantly over the next few decades, dramatic changes to our society and health care system will need to take place to meet their needs. Age-related changes in muscle mass and body composition along with medical comorbidities including stroke, dementia, and depression place elderly adults at high risk for developing malnutrition and frailty. This loss of function and decline in muscle mass (ie, sarcopenia) can be associated with reduced mobility and ability to perform the task of daily living, placing the elderly at an increased risk for falls, fractures, and subsequent institutionalization, leading to a decline in the quality of life and increased mortality. There are a number of modifiable factors that can mitigate some of the muscle loss elderly experience especially when hospitalized. Due to this, it is paramount for providers to understand the pathophysiology behind malnutrition and sarcopenia, be able to assess risk factors for malnutrition, and provide appropriate nutrition support. The present review describes the pathophysiology of malnutrition, identifies contributing factors to this condition, discusses tools to assess nutritional status, and proposes key strategies for optimizing enteral nutrition therapy for the elderly.

Current Practices and Priority Issues Regarding Nutritional Assessment and Patient Satisfaction with Hospital Menus

Purpose: Patient satisfaction with hospital food enhances consumption and adequate intake of nutrients required for recovery from illness/injury and maintenance of health; accordingly, the nutrient content of the menu must balance patient preferences. This study of Ontario hospital foodservice departments collected data on current practices of analyzing the nutritional adequacy and assessing patient satisfaction with menus, and it explored perceptions of priority issues.

Methods: Foodservice managers/directors from 57 of 140 (41%) hospitals responded to cross-sectional in-depth telephone interviews. Deductive analysis of responses to open-ended questions supplemented quantitative data from closed-ended questions.

Results: The hospitals without long-term care facilities (LTCFs) assessed regular (58%), therapeutic (53%), and texture-modified (47%) menus for nutritional adequacy. This differed from hospitals governing LTCFs where there was a higher frequency of assessment of regular (75%), therapeutic (75%), and textured-modified (66%) menus. Most departments (86%–94%) obtained patient satisfaction feedback at the departmental/corporate levels. Many identified budget and labour issues as priorities rather than assessing menus for nutritional adequacy and patient satisfaction.

Conclusions: Hospital menus were not consistently assessed for nutritional adequacy and patient satisfaction; common assessment methodologies and standards were absent. Compliance standards seem to increase the frequency of menu assessment as demonstrated by hospitals governing LTCFs.

Protein in the Hospital: Gaining Perspective and Moving Forward

Provision of adequate protein is crucial for optimizing outcomes in hospitalized patients. However, the methodologies upon which current recommendations are based have limitations, and little is known about true requirements in any clinical population. In this tutorial, we aim to give clinicians an understanding of how current protein recommendations were developed, an appreciation for the limitations of these recommendations, and an overview of more sophisticated approaches that can be applied to better define protein requirements. A broader perspective of the challenges and opportunities in determining clinical protein requirements can help clinicians think critically about the individualized nutrition care they provide to their patients with the goal of administering adequate protein to optimize outcomes.

Experimental and Outcome-Based Approaches to Protein Requirements in the Intensive Care Unit

Insight into protein requirements of intensive care unit (ICU) patients is urgently needed, but at present, it is unrealistic to define protein requirements for different diagnostic groups of critical illness or at different stages of illness. No large randomized controlled trials have randomized protein delivery, adequately addressed energy intake, and evaluated relevant clinical outcomes. As a pragmatic approach, experimental studies have focused on protein requirements of heterogeneous ICU patients. Data are scarce and the absolute value of protein requirements therefore is an approximation. Experimental studies indicate a protein requirement of >1.2 g/kg protein, which is supported by several outcome-based observational studies. Protein intake levels of up to 2.0-2.5 g/kg appear to be safe. A higher level of personalized treatment, within 1.2 and 2.5 g/kg, must involve identification of patients with low muscle protein mass that might benefit most from adequate protein nutrition in the ICU.