Protein Provision in Critically Ill Adults Requiring Enteral Nutrition: Are Guidelines Being Met?

BACKGROUND: In a previous audit, 81% of enteral protein prescriptions failed to meet protein guidelines. To address this, a very high-protein enteral formula and protein supplements were introduced, and protein prescriptions were adjusted to account for nonnutrition energy sources displacing enteral formula. This follow-up audit compared protein provision in critically ill adults requiring exclusive enteral nutrition (EN), first, with local and international guidelines, and second, after changes to practice, with the previous audit in the same intensive care unit (ICU). METHODS: Data were collected from 106 adults consecutively admitted to the ICU of a U.K. tertiary hospital and requiring exclusive EN ≥3 days. Protein targets based on local guidelines (1.25, 1.5, or 2.0 g/kg/d), nutrition prescription, and delivery were recorded for 24 hours between days 1-3, 5-7, 8-10, and 18-20 post-ICU admission. RESULTS: The proportion of day 1-3 protein prescriptions meeting protein targets increased from 19% in 2015 to 69% in 2017 (P < .0005, φ = 0.50). The median percentage of protein target delivered was lower than prescribed (79% vs 103%; (P < .0005; r = 0.53) and EN delivery only met the target of 22% of patients. The proportion of protein prescriptions meeting protein targets was similar for days 1-3 (69%), 5-7 (71%), and 8-10 (68%), but increased slightly by days 18-20 (74%). The proportion of patients for which EN delivery met protein targets increased with the number of days post-ICU admission (22%, 26%, 37%, and 53% for days 1-3, 5-7, 8-10, and 18-20, respectively). CONCLUSION: The proportion of protein prescriptions meeting guideline targets was higher after changes to practice.

Critical care: Meeting protein requirements without overfeeding energy.

BACKGROUND AND AIMS: Relatively high protein input has been associated with improved clinical outcome in critical illness. However, until recently differences in clinical outcome have been examined in terms of the energy goal-versus under-feeding. Most studies failed to set the energy goal by an accurate measure or estimate of expenditure or independently set protein prescription. This leads to under-prescription of protein, possibly adversely affecting outcome. We determined whether an enteral nutrition prescription could meet local and international protein guidelines. METHODS: Protein prescriptions of consecutive patients admitted to Southmead Hospital ICU and requiring full enteral nutrition were audited against local and international guidelines. Prescriptions were designed to not exceed energy expenditure based on a validated estimation equation, minus non-nutritional energy, and protein requirements were based on local or international guidelines of between 1.2 and 2.5 g protein/kg/d or 2-2.5/kg ideal body weight (Hamwi ideal body weight)/d. RESULTS: From 15/1/15 to 12/4/15 139 ICU patients were prescribed full enteral nutrition. Protein prescriptions failed to meet local guidelines in 75% (p < 0.001) and international guidelines in 45-100%. Prescriptions meeting at least 90% of protein guidelines and 130 g of carbohydrate could be increased from between 0 and 55%, depending on the guideline, to between 53 and 94% using a protein supplement and 82 and 100% using a protein plus glucose supplement. Non-nutritional energy (NNE) proportionately reduces feed protein prescription and contributed 19% of energy expenditure in 10% of patients. CONCLUSIONS: We need feeds with a lower non-protein energy: nitrogen (NPE:gN) ratio and/or protein supplementation if prescriptions are to meet protein guidelines for critical illness. NNE must be adjusted for in prescriptions to ensure protein needs are met.