From: Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients
Citation | Patient population | Study design | Clinical outcome: recovery, survival and length of stay |
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Larsson and colleagues [114] | Severely injured patients (burn or fracture of more than two long bones). Randomized during the first week of trauma (n = 39) to five different amounts of N from 0 to 0.3 g/kg/day | Prospective randomized study | Daily and cumulative N balance increased in the groups with a N intake of up to 0.2 g/kg/day versus the no N group (P <0.001) |
Ishibashi and colleagues [15] | Immediate post-trauma patients (n = 18) or severely septic patients (n = 5) were divided into three groups (A, B, and C) receiving 1.1, 1.5, and 1.9 g/kg FFMc/day protein respectively | Retrospective study | Average loss of total body protein was 1.2 kg. Loss of body protein was greater in group A compared with groups B (P = 0.013) and C (P = 0.023). Protein loss in group B (1.5 g/kg FFMc/day), was half that of group A (1.1 g/kg FFMc/day). Protein loss in groups B and C was not different. An intake of 1.5 g/kg FFMc/day was equivalent to 1.0 g/day/kg body weight measured at the start of the study. Authors recommend the clinician obtains information on pre-illness bodyweight and prescribes 1.2 g/day/kg |
Barr and colleagues [118] | 200 ICU patients (npo >48 hours after their admission): 100 before implementation of a nutritional management protocol, 100 afterwards | Prospective evaluation | Risk of death was 56% lower in patients who received EN (HR: 0.44, 95% CI: 0.24, 0.80, P = 0.007) |
Martin and colleagues [119] | 499 ICU patients with an expected ICU stay of at least 48 hours. Introduction of evidence-based recommendations | Cluster-randomized controlled trial | Implementation of evidence-based recommendations led to more days of EN (P = 0.042), shorter mean hospital stay (P = 0.003) and a trend towards reduced mortality (P =0.058). The mean ICU stay did not differ significantly |
Doig and colleagues [117] | 1,118 patients in the ICU >2 days. Randomization to guideline or control groups. Guideline ICUs used an evidence-based guideline | Cluster-randomized controlled trial | Guideline ICU patients were fed earlier and reached nutritional goals more often compared with control subjects, but did not show significantly different hospital discharge mortality (P = 0.75), hospital LOS (P = 0.97), or ICU LOS (P = 0.42) |
Alberda and colleagues [14] | 2,772 mechanically ventilated patients. Prescribed and received energy was reported | Observational cohort study | Patients received only 56 to 64% of the nutritional prescription for energy and 50 to 65% for protein. Increased provision of energy and protein appear to be associated with improved clinical outcomes, particularly when BMI <25 or ≥35 kg/m2. A 1,000 kcal increase is associated with improved mortality (P = 0.014) and more ventilation-free days (P = 0.003) |
Strack van Schijndel and colleagues [120] | 243 sequential mixed medical-surgical patients. Nutrition according to indirect calorimetry and at least 1.2 g protein/kg/day | Prospective observational cohort study | Reaching nutritional goals improves ICU (P = 0.027) and 28-day mortality (P = 0.005) and hospital survival (P = 0.04) in female patients. When only energy goals but not protein goals are met, ICU mortality is not changed. No differences could be observed for male patients |
Casaer and colleagues [123] | 4,640 ICU patients: 2,312 patients received PN within 48 hours after ICU admission, 2,328 patients received no PN before day 8 | Randomized, multicenter trial | Early provision of PN shows a higher complication rate (26.2% vs 22.8% for ICU infections, P = 0.008), longer mechanical ventilation time (9.7% longer, P = 0.006) and renal replacement therapy (3 days' longer, P = 0.008), and a longer mean hospital duration (6.4% higher likelihood to discharge later, P = 0.04), but no significant impact on mortality |
Weijs and colleagues [121] | 886 mechanically ventilated patients; stratified into three groups: reaching energy and protein target; reaching energy target; and reaching no target | Prospective observational cohort study | Reaching the energy and protein target is associated with a 50% decrease in 28-day mortality. Reaching only the energy target is not associated with an improvement |
Arabi and colleagues [124] | 240 ICU patients randomly assigned to permissive underfeeding or target feeding | Randomized, controlled trial | Permissive underfeeding may be associated with lower mortality rates. Hospital mortality was lower in the permissive feeding group (30.0% vs 42.5%; relative risk: 0.71; 95% CI: 0.50, 0.99; P = 0.04). However, 28-day all-cause mortality was not significantly different between groups (18.3% vs 23.3%; relative risk: 0.79; 95% CI: 0.48, 1.29; P = 0.34) |
Rice and colleagues [125] | 200 mechanically ventilated patients with acute respiratory failure, expected to require mechanical ventilation for at least 72 hours randomized to receive initial trophic (10 ml/hour) or full-energy EN for the initial 6 days | Randomized, open-label study | Mortality to hospital discharge was 22.4% for trophic vs 19.6% for full energy (P = 0.62). The trophic group showed a trend for less diarrhea in the first 6 days (19% vs 24% of feeding days; P =0.08) and significantly fewer episodes of elevated gastric residual volumes (2% vs 8% of feeding days; P <0.001) |
Singer and colleagues [126] | 130 patients expected to stay in ICU >3 days. Randomization to EN with a target determined by indirect calorimetry (study group) or with 25 kcal/kg/day (control group) | Prospective, randomized, controlled trial | Patients in the study group had a higher mean energy (P =0.01) and protein intake (P =0.01) than the control group. They also showed a trend towards reduced mortality (32.3% vs 47.7%, P =0.058), but the number of infectious complications were higher (37 in the study vs 20 in the control group P =0.05) |
Allingstrup and colleagues [122] | 113 ICU patients. Analyzed according to provided amount of protein and AA | Prospective, observational, cohort study | In the low protein and AA provision group, the Kaplan-Meier survival probability was 49% on day 10, compared with 79% and 88% in the medium and high protein and AA groups on day 10, respectively |
Rice and colleagues [127] | 1,000 patients with acute lung injury requiring mechanical ventilation. Randomization to trophic or full enteral feeding for the first 6 days | Randomized, open-label, multicenter trial | Initial trophic feeding did not improve 60-day mortality (23.2% vs 22.2%, P =0.77) or infectious complications (P =0.72, P =0.77, and P =0.24 for ventilator-associated pneumonia, Clostridium difficile colitis and bacteremia, respectively) compared with full enteral feeding |
Heidegger and colleagues [128] | ICU patients who had received less than 60% of their energy target from EN, were expected to stay >5 days, and to survive >7 days. Randomization to SPN (n =153) or EN (n =152). Protein administration was set to 1.2 g/kg ideal bodyweight/day during the study | Randomized controlled trial | Mean energy delivery between days 4 and 8 was higher for the SPN group (103% vs 77% of energy target). Nosocomial infections, between days 9 and 28, were more frequent in the EN group patients (38% vs 27%, P =0.0248). Overall nosocomial infections were not different |