High protein intake during the early phase of critical illness: yes or no?

Abstract

The rationale for the provision of nitrogen from proteins given via the enteral route or from intravenous amino acids is to boost the synthesis of muscle proteins, and thereby to limit the severity of intensive care unit-acquired weakness by the prevention of muscle loss. However, the optimal timing for supplemental nitrogen provision is a matter of debate and controversy. Indeed, consistent data from retrospective studies support an association between high early protein intakes and better outcomes, while recent post-hoc findings from prospective studies raise safety concerns. This pro–con paper details the arguments of both sides and highlights the need for large-scale prospective studies assessing the safety and efficacy of different levels of protein intake in combination with physical activity and summarizes the currently recruiting clinical trials.

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients

“…The main nutrition guidelines for critically ill patients agree that excessive calorie supply in the first days of critical illness should be avoided, proposing a modest calorie goal for the first week (15–20 kcal/kg/d) and prioritizing protein (≈1.5 g/kg/d) and reevaluation after 5 to 7 days to maintain or adjust nutrition goals . Although adequate protein intake has been the cornerstone of nutrition support for severe patients, excess protein (or its early administration) has been the subject of debate and concern among many nutrition support teams. Although the underlying mechanisms are not fully understood, a strong supply of protein has been linked to increased urea generation, increased catabolism mediated by increased glucagon synthesis, reduced myofibrils synthesis, and interference with autophagy processes …”

“…Although adequate protein intake has been the cornerstone of nutrition support for severe patients, excess protein (or its early administration) has been the subject of debate and concern among many nutrition support teams. Although the underlying mechanisms are not fully understood, a strong supply of protein has been linked to increased urea generation, increased catabolism mediated by increased glucagon synthesis, reduced myofibrils synthesis, and interference with autophagy processes …”

“…Although the underlying mechanisms are not fully understood, a strong supply of protein has been linked to increased urea generation, increased catabolism mediated by increased glucagon synthesis, reduced myofibrils synthesis, and interference with autophagy processes. [28][29][30][31] Greed Greed is defined as the sin of excessive attachment to money and a desire to acquire material goods and accumulate wealth. Greed can also connote lack of generosity and pettiness.…”

When and how to manage enteral feeding intolerance?

“…The NUTRIREA-2 trial suggests that attempting to achieve full-dose enteral feeding rapidly in patients at risk for gastrointestinal injury may be associated with adverse events [12]. The optimal dose of protein in the acute phase of critical illness is even less certain, and we await publication of data from randomized controlled trials [13,14].…”

Optimizing nitrogen balance is associated with better outcomes in neurocritically ill patients

“…Insufficient caloric intake has been linked to an increase in morbidity and mortality in patients with severe brain damage [2][3][4][5][6]. Moreover, recent studies suggest that protein balance is more important than the total amount of caloric intake in patients in critical conditions [5,[7][8][9][10][11]. Protein catabolism, triggered by SIR, may result in the depletion of amino acids essential for cellular or tissue repair and therefore may result in long-term metabolic dysfunction [4,[12][13][14].…”