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Dickerson et al
2.

Nicolo et al. Clinical outcomes related to protein
delivery in a critically ill population: a multicenter,
multinational observation study.6

The intent of this retrospective observational study was to
evaluate the impact of prescribed protein delivery on mortality and time to discharge alive using previously collected data
from the International Nutrition Survey 2013. The data sample included patients who were in the ICU for at least 4 days
(n = 2828) and a subsample of patients who were in the ICU
for at least 12 days (n = 1584). About two-thirds of patients
were medical ICU patients. Mean protein intake was 51 and
57 g/d for each group, respectively (61% and 67% of prescribed target intake of 1.2 g/kg/d). Caloric intake was 1100
and 1200 kcal/d (64% and 71% of prescribed target intake of
24 kcal/kg/d) for each group. The investigators stratified
patients based on a protein or energy intake of ≥80% of prescribed protein intake. Achieving a protein intake of ≥80% of
prescribed was associated with reduced mortality for each
duration of ICU stay group (25% vs 33% and 20% vs 27%;
OR of 0.68 and 0.60 for the ≥4 and ≥12 day groups, respectively) and a shorter time to discharge alive with higher protein intake in the 12-day subgroup. However, achievement of
≥80% of goal energy intake was not associated with improved
outcomes. The investigators concluded that achieving a
higher protein intake may be important for survival and
shorter time to discharge alive in ICU patients and that efforts
to achieve prescribed protein intake should be maximized.
These data support other recent studies that have associated improved clinical outcomes with increased protein
intake.28,29 Together, these studies infer the importance of
providing adequate protein intake and may offer an explanation as to why other recent nutritional intervention trials,
which focused on caloric intake while giving "inadequate
amounts" of protein, failed in terms of improving clinical
outcomes. However, the observational nature of this investigation6 and that of others limit the interpretation. In particular, the etiology for why patients only received 60% of what
was prescribed was elusive. Trials to identify the amount of
protein required to improve clinical outcomes for critically
ill patients are warranted. These future randomized controlled trials will need to be conducted in homogeneous ICU
patient populations as not all ICU patients are the same with
some exhibiting more catabolism than others. Currently, clinician experts recommend a protein intake of at least 1.2 g/
kg/d with doses up to 2 to 2.5 g/kg/d depending on the
patient's severity of catabolism.30 These emerging data indicate the importance of achieving adequate protein intake in
critically ill patients.
3.

Petros et al. Hypocaloric vs normocaloric nutrition in
critically ill patients: a prospective randomized pilot
trial.8

normocaloric regimen over the first 7 days in the ICU.
Patients anticipated to require artificial nutrition support for
at least 72 hours were assigned to receive either a normocaloric nutrition regimen (equivalent to daily energy expenditure; n = 54) or a hypocaloric nutrition regimen (50% of daily
energy expenditure; n = 46). Energy requirements were
determined via indirect calorimetry (IC) or by using the
Ireton-Jones equation31 if IC was unavailable. Enteral nutrition was preferentially used, although patients could receive
PN or supplemental PN with EN.
The study groups were similar with respect to age, body
mass index (BMI), and Acute Physiology and Chronic Health
Evaluation II (APACHE II) score, although more patients in
the hypocaloric arm had diabetes mellitus and chronic respiratory disease. Patients who were malnourished (BMI <18.5
kg/m2), >80 years old, or those receiving immunosuppressive therapy were excluded. A higher incidence of nosocomial infections was observed in the hypocaloric group
(26.1% vs 11.1%, P = .046) without any differences in ICU,
hospital, or 28-day mortality. Patients in the hypocaloric
group had lower insulin requirements (P < .05), but experienced more episodes of hypoglycemia (P = .03). Diarrhea
was more frequent in the normocaloric group on days 4 and
5 (P = .036). The authors concluded hypocaloric feeding
over the first 7 days of ICU stay was associated with more
nosocomial infections but improved glycemic control and
less gastrointestinal intolerance.
The findings of this study should be interpreted cautiously.
Patients with higher nutrition risk (eg, preexisting malnourishment, preexisting medical conditions, elderly patients), who
may benefit more from nutrition therapy, were poorly represented or excluded from study enrollment. The intent of this
study was to compare full feeding with hypocaloric feeding,
but the normocaloric group received only 75.5% of the prescribed regimen. Many clinicians would consider both groups
to have been permissively underfed. It is likely that neither
group received recommended amounts of protein (1.2-2 g/
kg/d) according to the Society of Critical Care Medicine
(SCCM)-ASPEN guidelines.16 Recent data suggest that protein provision may be more significant in improving outcomes
than caloric adequacy in critically ill patients6,16,29,32 which
may have confounded the results of this study. Therefore, it is
difficult to extrapolate the results of this study to more diverse
ICU populations. Other studies evaluating permissive and trophic feeding strategies have demonstrated lack of outcome
benefit or harm with full feeding,33,34 but included a narrower
patient population, with few patients more likely to experience
a higher nutrition risk. While it appears hypocaloric, low protein feeding may be better tolerated in this patient subset, it
may be associated with increased risk of nosocomial infections and should be cautiously utilized in broader ICU populations until more evidence is available.
4.

The objective of this single-center pilot trial was to compare the impact of a hypocaloric feeding regimen with a

Al-Dorzi et al. Lower versus higher dose of enteral
caloric intake in adult critically ill patients: a systematic review and meta-analysis.1

Table of Contents for the Digital Edition of Hospital Pharmacy - June 2017