Protein in the Hospital: Gaining Perspective and Moving Forward

Kuchnia, Adam J.; Teigen, Levi; Nagel, Emily; Ligthart‐Melis, Gerdien C.; Mulasi, Urvashi; Weijs, P.J.M.; Earthman, Carrie P.

doi:10.1002/jpen.1068

Cited by 5 publications

(6 citation statements)

References 85 publications

(150 reference statements)

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“…Despite these limitations, NB is considered a reliable proxy for protein turnover in healthy and acutely ill adults who qualify for both inclusion and exclusion criteria described above . Methods such as radioisotopic phenylalanine and doubly labeled water may provide a better understanding of the metabolic aberrations seen during VV ECMO and other critical illness . Radioisotopic phenylalanine in particular provides a more complete understanding of protein metabolism at the tissue level than NB, which does not elucidate how protein retained by the body is incorporated into cellular structures.…”

Section: Discussionmentioning

confidence: 99%

“…12 Methods such as radioisotopic phenylalanine and doubly labeled water may provide a better understanding of the metabolic aberrations seen during VV ECMO and other critical illness. 25 Radioisotopic phenylalanine in particular provides a more complete understanding of protein metabolism at the tissue level than NB, which does not elucidate how protein retained by the body is incorporated into cellular structures. However, radioisotopic metabolic monitoring is not available at our institution.…”

Section: Discussionmentioning

confidence: 99%

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Are Current Protein Recommendations for the Critically Ill Adequate for Patients on VV ECMO: Experience From a High‐Volume Center

Pelekhaty

Galvagno

Lantry

et al. 2019

J Parenter Enteral Nutr

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Background The nutrition needs of patients requiring extracorporeal membrane oxygenation (ECMO) have not been established in the literature. The purpose of this study is to investigate if current protein recommendations are adequate to achieve nitrogen equilibrium in patients on venovenous ECMO (VV ECMO). Methods Patients aged ≥18 years on VV ECMO admitted November 2016 through January 2018 with a documented nitrogen balance (NB) study were included. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m2) and nonobese (BMI < 30 kg/m2) categories for analysis. Results After exclusions, 55 NB studies in 29 patients were analyzed. Twelve nonobese patients received a median of 2.1 g protein/kg actual body weight (ABW) (interquartile range [IQR]: 1.7–2.5), and median NB was −2.2 g/d (IQR: −7.4 to 2.8). In 17 obese patients, median protein delivery of 2 g protein/kg ideal body weight (IBW) (IQR: 1.7–2.5) achieved a median NB of −7.3 g/d (IQR: −12.6 to −2.8). Obese patients exhibited greater urinary urea nitrogen excretion than nonobese patients did (24.6 vs 17.6 g/d, P < 0.0001). Conclusions Obese and nonobese patients undergoing VV ECMO may require more protein than is currently recommended for critical illness. Monitoring nutrition delivery and serial NB to assess prescription adequacy should be incorporated into routine patient care. Further research is needed to confirm these findings and create specific guidelines for patients on VV ECMO.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Are Current Protein Recommendations for the Critically Ill Adequate for Patients on VV ECMO: Experience From a High‐Volume Center

Pelekhaty

Galvagno

Lantry

et al. 2019

J Parenter Enteral Nutr

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“…We did not address appropriate protein dosing, which is a subject of considerable interest in the medical nutrition community that requires further study to explore the impact of protein delivery on outcomes that matter to patients, health care providers, and the larger healthcare system. As noted by Kuchnia et al, notwithstanding the validity of current protein dosing recommendations, providing adequate protein is problematic for many clinicians …”

Section: Discussionmentioning

confidence: 99%

Achieving Protein Targets in the ICU Using a Specialized High‐Protein Enteral Formula: A Quality Improvement Project

et al. 2019

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Background To meet protein needs in critical illness (CI), guidelines suggest ≥1.2–2.5 g protein/kg/d; however, most intensive care unit (ICU) patients receive ≤0.7 g/kg/d. Higher protein enteral nutrition (EN) formulas may be part of the solution to provide prescribed protein. Our objective was to demonstrate that an EN formula with 37% protein can deliver ≥80% of prescribed protein, without overfeeding calories within the first 5 days of feeding and to describe ICU clinicians' experience. Methods This quality improvement (QI) project included patients requiring exclusive EN for up to 5 days from 6 Canadian ICUs. Rationale for choosing formula, patient's BMI (kg/m2), nutrition targets, daily protein and energy delivered, feeding interruptions, and general tolerance were recorded. Results Forty‐four of 49 patients received the formula ≥2 days. Average protein prescribed was 137.5 g/d (82.5–200) or 1.9 g/kg/d (1.5–2.5). Average protein delivered was 116.9 g/d (33.5–180) or 1.6 g/kg/d (0.4–2.4). Seventy‐five percent to 83% of patients received ≥80% prescribed protein on days 2–5. Average energy prescribed was 1638.6 kcal/d (990–2500) or 17.8 kcal/kg (11–26). Average energy delivered was 1523.9 kcal/d (693.0–2557.5) or 17.3 kcal/kg/d (1.35–64.7). The formula was well tolerated with no gastrointestinal symptoms reported in 38 (86%) patients. The most common reasons to prescribe the formula were obesity and use of fat‐based medications. Conclusions We demonstrated in a QI study that a high‐protein EN formula was tolerated in a small, heterogeneous group of ICU patients and effective in meeting protein targets without overfeeding.

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“…Historically, nitrogen balance, calculated using a simplified formula, has been used to determine protein requirements in healthy and clinical populations [57]. However, 24-h urine collection is cumbersome and the simplified formula underestimates losses from sweat, wounds, burns, drainage tubes, pulmonary and gastrointestinal output, critical illness, and patients with renal insufficiency needing corrections for elevations in blood urea [57,58]; thus, its use in acute care patients is challenging and is generally limited to clinical studies.…”

Section: Currently Available Tools For Assessing Protein Status Are Nmentioning

confidence: 99%

Review of evolution and current status of protein requirements and provision in acute illness and critical care

et al. 2021

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Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guidelinerecommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.

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Protein in the Hospital: Gaining Perspective and Moving Forward

Cited by 5 publications

References 85 publications

Are Current Protein Recommendations for the Critically Ill Adequate for Patients on VV ECMO: Experience From a High‐Volume Center

Are Current Protein Recommendations for the Critically Ill Adequate for Patients on VV ECMO: Experience From a High‐Volume Center

Achieving Protein Targets in the ICU Using a Specialized High‐Protein Enteral Formula: A Quality Improvement Project

Review of evolution and current status of protein requirements and provision in acute illness and critical care

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