Protein requirement in critical illness

Hoffer, L. John

doi:10.1139/apnm-2015-0551

Cited by 23 publications

(28 citation statements)

References 29 publications

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“… There is a lack of randomized controlled trials (RCTs) that evaluate critically ill patients randomized to different doses of protein provision, adjusted for ideal energy intake, and then followed for long‐term clinical outcomes 35 , 36 Protein and calorie doses are typically recommended based on actual body weight 24 , 37 .…”

Section: Protein Requirements In the Icumentioning

confidence: 99%

Summary Points and Consensus Recommendations From the International Protein Summit

et al. 2017

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The International Protein Summit in 2016 brought experts in clinical nutrition and protein metabolism together from around the globe to determine the impact of high-dose protein administration on clinical outcomes and address barriers to its delivery in the critically ill patient. It has been suggested that high doses of protein in the range of 1.2-2.5 g/kg/d may be required in the setting of the intensive care unit (ICU) to optimize nutrition therapy and reduce mortality. While incapable of blunting the catabolic response, protein doses in this range may be needed to best stimulate new protein synthesis and preserve muscle mass. Quality of protein (determined by source, content and ratio of amino acids, and digestibility) affects nutrient sensing pathways such as the mammalian target of rapamycin. Achieving protein goals the first week following admission to the ICU should take precedence over meeting energy goals. High-protein hypocaloric (providing 80%-90% of caloric requirements) feeding may evolve as the best strategy during the initial phase of critical illness to avoid overfeeding, improve insulin sensitivity, and maintain body protein homeostasis, especially in the patient at high nutrition risk. This article provides a set of recommendations based on assessment of the current literature to guide healthcare professionals in clinical practice at this time, as well as a list of potential topics to guide investigators for purposes of research in the future.

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Section: Protein Requirements In the Icumentioning

confidence: 99%

Summary Points and Consensus Recommendations From the International Protein Summit

et al. 2017

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“…Recognizing that widely used EN regimens systematically fall short of their nutrition target, clinical investigators in several centers carried out large randomized clinical trials (RCTs) that compared standard (inadequate) EN with the same EN supplemented with PN that infused large amounts of dextrose but very little protein substrate. When these trials indicated no overall difference in clinical outcomes, a high‐profile clinical practice review endorsed “permissive underfeeding” (protein‐deficient low‐energy EN) for at least the first week of a patient's stay in an intensive care unit (ICU), on the grounds that there is no good evidence that doing otherwise improves clinical outcomes . In agreement with this conclusion, ASPEN suggests tolerating a week or longer of permissive underfeeding before initiating PN in critically ill patients in whom EN has failed to achieve its goal (weak recommendation, very‐low‐quality evidence)…”

Section: Evolution Of Critical Care Nutritionmentioning

confidence: 99%

“…Differing magnitudes of these 3 effects, ie, sicker patients are more difficult to feed enterally, protein dose, and energy substrate resistance, coupled with the failure or inability of authors to identify or adjust for them in their analyses, may well explain why permissive underfeeding is associated with better outcomes in some observational studies but worse outcomes in others. The clinching evidence for this conclusion is provided by the many RCTs that compared high‐energy, protein‐deficient SNS with low‐energy, protein‐deficient SNS (permissive underfeeding) and found it of little or no benefit . In conclusion, the benefits of permissive underfeeding, when they occur, are not due to protein deprivation, but rather because it avoids energy overfeeding.…”

Section: Permissive Underfeeding and Clinical Outcomesmentioning

confidence: 99%

High‐Protein Hypocaloric Nutrition for Non‐Obese Critically Ill Patients

Hoffer

2018

Nut in Clin Prac

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High-protein hypocaloric nutrition, tailored to each patient's muscle mass, protein-catabolic severity, and exogenous energy tolerance, is the most plausible nutrition therapy in protein-catabolic critical illness. Sufficient protein provision could mitigate the rapid muscle atrophy characteristic of this disease while providing urgently needed amino acids to the central protein compartment and sites of tissue injury. The protein dose may range from 1.5 to 2.5 g protein (1.8-3.0 g free amino acids)/kg dry body weight per day. Nutrition should be low in energy (≈70% of energy expenditure or ≈15 kcal/kg dry body weight per day) because efforts to match energy provision to energy expenditure are physiologically irrational, risk toxic energy overfeeding, and have repeatedly failed in large clinical trials to demonstrate clinical benefit. The American Society for Parenteral and Enteral Nutrition currently suggests high-protein hypocaloric nutrition for obese critically ill patients. Short-term high-protein hypocaloric nutrition is physiologically and clinically sensible for most protein-catabolic critically ill patients, whether obese or not.

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“…The results have been very disappointing. The flawed logic of this calorie-focused approach has been analyzed elsewhere [22,25,26]. The hypothesis that continues to await rigorous testing is that prompt, high-protein (2–2.5 g/kg per day) hypocaloric nutrition may improve clinical outcomes in catabolic critical illness.…”

Section: Effects Of Starvation and Disease On Protein Metabolism Amentioning

confidence: 99%

Parenteral Nutrition: Amino Acids

Hoffer

2017

Nutrients

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There is growing interest in nutrition therapies that deliver a generous amount of protein, but not a toxic amount of energy, to protein-catabolic critically ill patients. Parenteral amino acids can achieve this goal. This article summarizes the biochemical and nutritional principles that guide parenteral amino acid therapy, explains how parenteral amino acid solutions are formulated, and compares the advantages and disadvantages of different parenteral amino acid products with enterally-delivered whole protein products in the context of protein-catabolic critical illness.

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Protein requirement in critical illness

Cited by 23 publications

References 29 publications

Summary Points and Consensus Recommendations From the International Protein Summit

Summary Points and Consensus Recommendations From the International Protein Summit

High‐Protein Hypocaloric Nutrition for Non‐Obese Critically Ill Patients

Parenteral Nutrition: Amino Acids

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