Improvement in Protein Delivery for Critically Ill Patients Requiring High‐Dose Propofol Therapy and Enteral Nutrition

Abstract

Background Patients with traumatic brain (TBI) injury often require a high dosage of propofol, which can provide an excessive caloric intake. We evaluated our strategy of using liquid protein supplement boluses concurrently with high protein–containing enteral nutrition (EN) formulas and formula rate reduction to avoid caloric overfeeding and inadequate protein intake. Methods Adult patients (aged >17 years) with TBI admitted to the trauma intensive care unit (TICU) who received concurrent propofol and EN were retrospectively reviewed. Caloric intakes from propofol and EN were obtained. Actual protein intake was compared with projected protein intakes from high protein content and standard protein content enteral formulas when given at an isocaloric intake. Results Fifty‐one patients were enrolled. Average caloric intake from propofol was 356 ± 243 kcal/d or 5 ± 3 kcal/kg/d (range, <1–15 kcal/kg/d). Daily EN caloric intake ranged from 7 ± 4 kcal/kg/d (day 2) to 16 ± 9 kcal/kg/d (day 5; P < .001). Average protein intake ranged from 0.6 ± 0.4 g/kg/d (day 2) to 1.5 ± 0.7 g/kg/d (day 5; P < .001). The modified EN strategy resulted in daily delivery of 24%–38% more protein than an isocaloric regimen with a high protein–content formula and twice as much protein than the standard protein–content formula (P < .001). Conclusion The strategy of providing an EN regimen comprised liquid protein boluses, and high and very high protein–containing EN formulas at a reduced rate improved protein delivery without caloric overfeeding.

Augmented Renal Clearance Following Traumatic Injury in Critically Ill Patients Requiring Nutrition Therapy

“…Accuracy was evaluated by comparison of nursing intake and output records with recorded laboratory volume, determination if the patient had left the unit for a procedure or surgery, and interview of the nurse caring for the patient for violations in collection procedures. A 24 h collection also ensures validity of the measurement as it avoids the potential for erroneous measurements with shorter collection times as the longer collection duration dampens the influence of normal diurnal variation in creatinine excretion [ 45 ] and reduces errors from short-lived activations in renal functional reserve due to intermittent enteral protein boluses commonly employed in clinical practice [ 22 , 29 , 30 ]. Our stricter definition of ARC (mCrCl > 149 mL/min/1.73 m 2 ) along with an ample number of patients in each group provided greater clarity in identifying patients with substantial ARC where unintentional therapeutic underdosing of renally-eliminated medications, electrolytes, and nutrients may occur.…”

Impact of Propofol Sedation upon Caloric Overfeeding and Protein Inadequacy in Critically Ill Patients Receiving Nutrition Support

“…A total of fourteen research publications and abstracts published from 1995 to 2021 were obtained from the literature ( Table 1 ) [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Five publications [ 4 , 7 , 9 , 12 , 14 ] were only available in abstract form with limited information.…”

“…Thus, reducing the rate of the continuous EN formula will also reduce the protein intake. Patients with traumatic injuries and TBI are among the most likely populations to receive prolonged, high dose propofol therapy (Table 1) [5,6,9] and require a greater protein intake than many other critically ill patients [22,33]. Therefore, a simple reduction in EN rate to decrease calories will result in decreased protein intake which could potentially be detrimental to clinical outcomes.…”

“…Despite this improvement, we were still unable to meet protein goals for some patients because of interruptions in EN delivery due to feeding intolerance, multiple surgical procedures, inability to provide intravenous erythromycin (due to drug shortage, prolonged QTc interval, or significant drug-interaction) despite tachyphylaxis to metoclopramide therapy, and hemodynamic instability [38,39]. Actual protein intake from the modified EN regimen compared to projected protein intakes with "standard" formulas when given at an isocaloric intake as the modified EN regimen (p < 0.001) for patients who received concurrent enteral nutrition and propofol [6]. Daily protein intakes for each regimen that contain a different letter (e.g., a, b, or c) are significantly different from one another (p < 0.05).…”

“…25 mL/h × 24 h = 600 mL 600 mL × 1.1 kcal/mL = 660 kcals 660 kcals/90 kg = 7.3 kcal/kg or about 7 kcal/kg Actual protein intake from the modified EN regimen compared to projected protein intakes with "standard" formulas when given at an isocaloric intake as the modified EN regimen (p < 0.001) for patients who received concurrent enteral nutrition and propofol [6]. Daily protein intakes for each regimen that contain a different letter (e.g., a, b, or c) are significantly different from one another (p < 0.05).…”