Increasing Enteral Protein Intake in Critically Ill Trauma and Surgical Patients

Abstract

Background Published guidelines recommend providing at least 2 g/kg/d of protein for critically ill surgical patients. It may be difficult to achieve this level of intake using standard enteral formulas, thus necessitating protein or amino acid supplementation. Herein, we report our approach to enteral protein supplementation and its relationship with urinary nitrogen excretion and serum transthyretin concentrations. Methods This was a retrospective cohort study in which we reviewed critically ill trauma and surgical patients treated with supplemental enteral protein according to a protocol aiming to deliver a total of 2 g/kg/d of protein. We collected detailed nutrition data over a 2‐week period after admission and obtained additional data through discharge to determine caloric and protein intake as well as complications. We also compared urine nitrogen excretion and transthyretin concentrations between these patients and a control group who did not receive supplemental protein. Results Fifty‐three subjects received early protein supplementation. Formula and protein supplement each provided ≈1.2 g/kg/d of protein by intensive care unit day 4. This resulted in a median total protein intake of 2.2 g/kg/d through day 14. One patient developed acute kidney injury, and 1 patient had 3 episodes of vomiting. By the third week, serum transthyretin concentrations increased to a median of 21 mg/dL compared with 13 mg/dL in subjects not receiving early supplementation. Conclusion It is safe to deliver supplemental protein enterally to critically ill surgical and trauma patients and reach 2 g/kg/d of protein intake during the first week of illness.

A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life

“…It is necessary for nutritional support to maintain adequate metabolic pathways without causing redistributions that compromise the functionality and structure of the organs. The importance of protein intake has been observed in EL patients, resulting in reduction in infectious complications, hospital stay, morbidity associated with energy excess, and in turn reduced mortality in cases of sepsis [ 25 ].…”

Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines

“…7 Many studies have shown improved outcomes with early highprotein diet (up to 2 g/kg per day). [63][64][65][66][67][68] Obese patients should be given special nutritional considerations. Obesity is a risk factor for severe ARDS in the setting of bacterial or viral infections, ischemic heart disease, and complicated post-cardiotomy shock.…”

“…Current ESPEN guidelines recommend a 1.3 g/kg/day protein intake combined with an exercise program 7 . Many studies have shown improved outcomes with early high‐protein diet (up to 2 g/kg per day) 63–68 …”

How to achieve nutrition goals by actual nutrition guidelines

“…Yet, although a significant increase of protein intake was achieved by using this protocol, not all their patients received optimal protein intake (> 80%) of the aimed target, which pose the question why the investigators did not consider the use of protein supplements. In a recent study, O’Keefe et al demonstrated that the combined use of empiric EN protein supplement is safe, when used in combination with EN in critically ill patients, and reaches 2 g/kg/day of protein intake per day [9]. In fact, enteral protein supplementation is one of a number of possible ways which has previously been demonstrated to increase protein intake in critically ill patients [8].…”