Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

Peter J M Weijs, Wilhelmus G P M Looijaard, Albertus Beishuizen, Armand R J Girbes, Heleen M Oudemans-van Straaten, Peter J M Weijs, Wilhelmus G P M Looijaard, Albertus Beishuizen, Armand R J Girbes, Heleen M Oudemans-van Straaten

Abstract

Introduction: Early protein and energy feeding in critically ill patients is heavily debated and early protein feeding hardly studied.

Methods: A prospective database with mixed medical-surgical critically ill patients with prolonged mechanical ventilation (>72 hours) and measured energy expenditure was used in this study. Logistic regression analysis was used to analyse the relation between admission day-4 protein intake group (with cutoffs 0.8, 1.0, and 1.2 g/kg), energy overfeeding (ratio energy intake/measured energy expenditure > 1.1), and admission diagnosis of sepsis with hospital mortality after adjustment for APACHE II (Acute Physiology and Chronic Health Evaluation II) score.

Results: A total of 843 patients were included. Of these, 117 had sepsis. Of the 736 non-septic patients 307 were overfed. Mean day-4 protein intake was 1.0 g/kg pre-admission weight per day and hospital mortality was 36%. In the total cohort, day-4 protein intake group (odds ratio (OR) 0.85; 95% confidence interval (CI) 0.73 to 0.99; P = 0.047), energy overfeeding (OR 1.62; 95%CI 1.07 to 2.44; P = 0.022), and sepsis (OR 1.77; 95%CI 1.18 to 2.65; P = 0.005) were independent risk factors for mortality besides APACHE II score. In patients with sepsis or energy overfeeding, day-4 protein intake was not associated with mortality. For non-septic, non-overfed patients (n = 419), mortality decreased with higher protein intake group: 37% for < 0.8 g/kg, 35% for 0.8 to 1.0 g/kg, 27% for 1.0 to 1.2 g/kg, and 19% for ≥ 1.2 g/kg (P = 0.033). For these, a protein intake level of ≥ 1.2 g/kg was significantly associated with lower mortality (OR 0.42, 95%CI 0.21 to 0.83, P = 0.013).

Conclusions: In non-septic critically ill patients, early high protein intake was associated with lower mortality and early energy overfeeding with higher mortality. In septic patients early high protein intake had no beneficial effect on mortality.

Figures

Figure 1
Figure 1
Flow chart.
Figure 2
Figure 2
Hospital mortality for septic and non-septic patients with protein intake higher and lower than 1.2 g/kg. *P = 0.003.
Figure 3
Figure 3
Hospital mortality for cumulative energy deficit over the first 4 days of ICU stay for non-septic patients (n = 726;P = 0.053). Reference is the measured resting energy expenditure of the patient. *P = 0.012.
Figure 4
Figure 4
Hospital mortality for all patients per protein intake group and for all non-septic and non-overfed patients per protein intake group. *P = 0.008; **P = 0.047.

References

    1. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–517. doi: 10.1056/NEJMoa1102662.
    1. Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, Davies AR, O’Leary M, Solano T, Peake S. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013;309:2130–2138. doi: 10.1001/jama.2013.5124.
    1. Arabi YM, Tamim HM, Dhar GS, Al-Dawood A, Al-Sultan M, Sakkijha MH, Kahoul SH, Brits R. Permissive underfeeding and intensive insulin therapy in critically ill patients: a randomized controlled trial. Am J Clin Nutr. 2011;93:569–577. doi: 10.3945/ajcn.110.005074.
    1. Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307:795–803. doi: 10.1001/jama.2011.1985.
    1. Fraipont V, Preiser JC. Energy estimation and measurement in critically ill patients. JPEN J Parenter Enteral Nutr. 2013;37:705–713. doi: 10.1177/0148607113505868.
    1. van Schijndel RJMS, Weijs PJM, Koopmans RH, Sauerwein HP, Beishuizen A, Girbes ARJ. Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care. 2009;13:R132. doi: 10.1186/cc7993.
    1. Weijs PJM, Stapel SN, de Groot SDW, Driessen RH, de Jong E, Girbes ARJ, van Schijndel RJMS, Beishuizen A. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr. 2012;36:60–68. doi: 10.1177/0148607111415109.
    1. Allingstrup MJ, Esmailzadeh N, Wilkens Knudsen A, Espersen K, Hartvig Jensen T, Wiis J, Perner A, Kondrup J. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr. 2012;31:462–468. doi: 10.1016/j.clnu.2011.12.006.
    1. Elke G, Wang M, Weiler N, Day AG, Heyland DK. Close to recommended caloric and protein intake by enteral nutrition is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Crit Care. 2014;18:R29. doi: 10.1186/cc13720.
    1. Singer P, Hiesmayr M, Biolo G, Felbinger TW, Berger MM, Goeters C, Kondrup J, Wunder C, Pichard C. Pragmatic approach to nutrition in the ICU: expert opinion regarding which calorie protein target. Clin Nutr. 2014;33:246–251. doi: 10.1016/j.clnu.2013.12.004.
    1. Vanhorebeek I, Gunst J, Derde S, Derese I, Boussemaere M, Guiza F, Martinet W, Timmermans JP, D’Hoore A, Wouters PJ, Van den Berghe G. Insufficient activation of autophagy allows cellular damage to accumulate in critically ill patients. J Clin Endocrinol Metab. 2011;96:E633–E645. doi: 10.1210/jc.2010-2563.
    1. Casaer MP, Wilmer A, Hermans G, Wouters PJ, Mesotten D, Van den Berghe G. Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. Am J Respir Crit Care Med. 2013;187:247–255. doi: 10.1164/rccm.201206-0999OC.
    1. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS, Velloso C, Seymour J, Agley CC, Selby A, Limb M, Edwards LM, Smith K, Rowlerson A, Rennie MJ, Moxham J, Harridge SDR, Hart N, Montgomery HE. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310:1591–1600. doi: 10.1001/jama.2013.278481.
    1. Derde S, Vanhorebeek I, Guiza F, Derese I, Gunst J, Fahrenkrog B, Martinet W, Vervenne H, Ververs EJ, Larsson L, Van den Berghe G. Early parenteral nutrition evokes a phenotype of autophagy deficiency in liver and skeletal muscle of critically ill rabbits. Endocrinology. 2012;153:2267–2276. doi: 10.1210/en.2011-2068.
    1. Choi AJ, Ryter SW. Autophagy in inflammatory diseases. Int J cell biol. 2011;2011:732798. doi: 10.1155/2011/732798.
    1. van Schijndel RJM S, Weijs PJM, Sauerwein HP, de Groot SDW, Beishuizen A, Girbes ARJ: An algorithm for balanced protein/energy provision in critically ill mechanically ventilated patients.e-SPEN, Eur e-J Clin Nut Metab 2007, 2:69–74.
    1. Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr. 2009;28:387–400. doi: 10.1016/j.clnu.2009.04.024.
    1. Compher C, Frankenfield D, Keim N, Roth-Yousey L. Best practice methods to apply to measurement of resting metabolic rate in adults: a systematic review. J Am Diet Assoc. 2006;106:881–903. doi: 10.1016/j.jada.2006.02.009.
    1. Weijs PJM, Sauerwein HP, Kondrup J. Protein recommendations in the ICU: g protein/kg body weight - which body weight for underweight and obese patients? Clin Nutr. 2012;31:774–775. doi: 10.1016/j.clnu.2012.04.007.
    1. van Schijndel RJMS, de Groot SDW, Driessen RH, Ligthart-Melis G, Girbes ARJ, Beishuizen A, Weijs PJM. Computer-aided support improves early and adequate delivery of nutrients in the ICU. Neth J Med. 2009;67:388–393.
    1. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Critical care medicine. 2004;32:858–873. doi: 10.1097/01.CCM.0000117317.18092.E4.
    1. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive care medicine. 2008;34:17–60. doi: 10.1007/s00134-007-0934-2.
    1. Masiero E, Agatea L, Mammucari C, Blaauw B, Loro E, Komatsu M, Metzger D, Reggiani C, Schiaffino S, Sandri M. Autophagy is required to maintain muscle mass. Cell Metab. 2009;10:507–515. doi: 10.1016/j.cmet.2009.10.008.
    1. Hermans G, Casaer MP, Clerckx B, Guiza F, Vanhullebusch T, Derde S, Meersseman P, Derese I, Mesotten D, Wouters PJ, Van Cromphaut S, Debaveye Y, Gosselink R, Gunst J, Wilmer A, Van den Berghe G, Vanhorebeek I. Effect of tolerating macronutrient deficit on the development of intensive-care unit acquired weakness: a subanalysis of the EPaNIC trial. The lancet Respiratory medicine. 2013;1:621–629. doi: 10.1016/S2213-2600(13)70183-8.
    1. Virgin HW, Levine B. Autophagy genes in immunity. Nat Immunol. 2009;10:461–470. doi: 10.1038/ni.1726.
    1. Klaude M, Mori M, Tjader I, Gustafsson T, Wernerman J, Rooyackers O: Protein metabolism and gene expression in skeletal muscle of critically ill patients with sepsis.Clin Sci(Lond) 2012, 122:133–142.
    1. Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, Costanza MC, Thibault R, Pichard C. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet. 2013;381:385–393. doi: 10.1016/S0140-6736(12)61351-8.
    1. Savard JF, Faisy C, Lerolle N, Guerot E, Diehl JL, Fagon JY. Validation of a predictive method for an accurate assessment of resting energy expenditure in medical mechanically ventilated patients. Crit Care Med. 2008;36:1175–1183. doi: 10.1097/CCM.0b013e3181691502.
    1. Faisy C, Guerot E, Diehl JL, Labrousse J, Fagon JY. Assessment of resting energy expenditure in mechanically ventilated patients. Am J Clin Nutr. 2003;78:241–249.
    1. Frankenfield D, Smith JS, Cooney RN. Validation of 2 approaches to predicting resting metabolic rate in critically ill patients. JPEN J Parenter Enteral Nutr. 2004;28:259–264. doi: 10.1177/0148607104028004259.
    1. Singer P, Anbar R, Cohen J, Shapiro H, Shalita-Chesner M, Lev S, Grozovski E, Theilla M, Frishman S, Madar Z. The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med. 2011;37:601–609. doi: 10.1007/s00134-011-2146-z.
    1. Weijs PJM, Wischmeyer PE. Optimizing energy and protein balance in the ICU. Curr Opin Clin Nutr Metab Care. 2013;16:194–201. doi: 10.1097/MCO.0b013e32835bdf7e.

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