The Effect of High Protein and Mobility-Based Rehabilitation on Clinical Outcomes in Survivors of Critical Illness

Managing the Chronically Ventilated Critically Ill Population

Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.

The effect of protein provision and exercise therapy on patient-reported and clinical outcomes in intensive care unit survivors: A systematic review

BACKGROUND

Intensive care unit (ICU) survivors deal with long-term health problems, which negatively affect their quality of life (QoL). Nutritional and exercise intervention could prevent the decline of muscle mass and physical functioning which occurs during critical illness. Despite the growing amount of research, robust evidence is lacking.

METHODS

For this systematic review, Embase, PubMed and Cochrane Central Register of Controlled Trials databases were searched. The effect of protein provision (PP) or combined protein and exercise therapy (CPE) during or after ICU admission on QoL, physical functioning, muscle health, protein/energy intake and mortality was assessed compared to standard care.

RESULTS

Four thousand nine hundred and fifty-seven records were identified. After screening, data were extracted for 15 articles (9 randomised controlled trials and 6 non-randomised studies). Two studies reported improvements in muscle mass, of which one found higher independency in activities of daily living. No significant effect was found on QoL. Overall, protein targets were seldom met and often below recommendations.

CONCLUSION

Evidence for the effect of PP or CPE on patient-reported outcomes in ICU survivors is limited due to study heterogeneity and lack of high-quality studies. Future research and clinical practice should focus on adequate protein delivery with exercise interventions to improve long-term outcomes.

Novel protocol combining physical and nutrition therapies, Intensive Goal-directed REhabilitation with Electrical muscle stimulation and Nutrition (IGREEN) care bundle

Background

Although the combination of rehabilitation and nutrition may be important for the prevention of intensive care unit (ICU)-acquired weakness, a protocolized intervention of this combination has not yet been reported. We herein developed an original combined protocol and evaluated its efficacy.

Methods

In this single-center historical control study, we enrolled adult patients admitted to the ICU. Patients in the control group received standard care, while those in the intervention group received the protocol-based intervention. The ICU mobility scale was used to set goals for early mobilization and a neuromuscular electrical stimulation was employed when patients were unable to stand. The nutritional status was assessed for nutritional therapy, and target calorie delivery was set at 20 or 30 kcal/kg/day and target protein delivery at 1.8 g/kg/day in the intervention group. The primary endpoint was a decrease in femoral muscle volume in 10 days assessed by computed tomography.

Results

Forty-five patients in the control group and 56 in the intervention group were included in the analysis. Femoral muscle volume loss was significantly lower in the intervention group (11.6 vs 14.5%, p = 0.03). The absolute risk difference was 2.9% (95% CI 0.1–5.6%). Early mobilization to a sitting position by day 10 was achieved earlier (p = 0.03), and mean calorie delivery (20.1 vs. 16.8 kcal/kg/day, p = 0.01) and mean protein delivery (1.4 vs. 0.8 g/kg/day, p < 0.01) were higher in the intervention group.

Conclusion

The protocolized intervention, combining early mobilization and high-protein nutrition, contributed to the achievement of treatment goals and prevention of femoral muscle volume loss.

Trial registration number

The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03827-8.