Prospective observational cohort study of reached protein and energy targets in general wards during the post-intensive care period: The PROSPECT-I study.

INTRODUCTION: Nutrition plays an essential role in the recovery of critical illness. In the post-Intensive Care Unit (ICU) period, patients typically return to oral nutrition gradually. However, studies quantifying nutritional intake in the post-ICU hospitalization period are scarce and formal guidelines are lacking. This study aims to describe energy and protein intake in detail over the entire post-ICU hospitalization period and explore associations between protein intake and clinical outcomes. METHODS: A prospective observational single-center cohort study was conducted amongst post-ICU patients in general wards after a minimum ICU-stay of 72 h and who received (par)enteral feeding for ≥24 h in the ICU. Oral intake was assessed daily using food order lines and digital photography of meal leftovers. Other data, including amounts of (par)enteral nutrition, were collected from electronic medical records. The primary outcome was to identify energy and protein intake, and reached targets, in the post-ICU period. In addition, length of hospital stay after ICU discharge, readmission and mortality rates were compared between patients meeting protein targets or not. RESULTS: In total, 48 patients were included. Complete nutritional data of 34 patients were analyzed in the current study, adding up to a total number of 484 observational days, 1681 photos and 6634 food order lines. Inter-rater agreement was excellent (ICC 0.878). Overall mean energy and protein adequacy for all nutritional groups was 82.3% (SD 18.3) and 83.1% (SD 19.8). Only 51.2% of the study participants (n = 21) reached overall >90% of prescribed protein targets during their entire post-ICU ward stay. The lowest intake was seen in the patient group with exclusively oral intake (median protein adequacy 75.5%), whereas patients with (supplemental) enteral nutrition (EN) all met >90% of their protein targets. Prescribed targets were below recommendations, and prescribed calories and proteins were neither ordered nor consumed. Discontinuation of EN resulted in immediate marked drops in energy (44.1%) and protein intake (50.7%). Subsequently, patients needed up to six days to reach protein targets again. No differences in clinical outcomes were observed. CONCLUSION: Most patients did not meet energy and protein targets in the post-ICU hospitalization period. Nutrition performance was highly dependent on the route of nutrition and was lowest among patients with oral intake only (despite of food fortification strategies and/or oral nutritional supplements). The best intake was observed in patients receiving (supplemental) EN. However, cessation of EN posed an immediate nutritional risk. No differences in clinical outcomes were found in this study. Our findings stress the need for follow-up studies to close the gap with individualized nutritional support in the post-ICU period to reach protein and energy targets.

Association of bioelectric impedance analysis body composition and disease severity in COVID-19 hospital ward and ICU patients: The BIAC-19 study.

BACKGROUND: The current severe acute respiratory syndrome coronavirus 2 pandemic is unprecedented in its impact. It is essential to shed light on patient characteristics that predispose to a more severe disease course. Obesity, defined as a BMI>30 kg/m2, is suggested to be one of these characteristics. However, BMI does not differentiate between fat mass and lean body mass, or the distribution of fat tissue. The aim of the present study was to assess the body composition of COVID-19 patients admitted to the ward or the ICU and identify any associations with severity of disease. METHODS: We performed an observational cross-sectional cohort study. Bioelectric impedance analysis was conducted amongst all confirmed COVID-19 patients admitted to the ward or ICU of our hospital in the Netherlands, between April 10 and 17, 2020. Body water measurements and derived values were recalculated to dry weight, using a standard ratio of extracellular water to total body water of 0.38. Data were compared between the ward and ICU patients, and regression models were used to assess the associations between baseline characteristics, body composition, and several indicators of disease severity, including a composite score composed of mortality, morbidity, and ICU admission. RESULTS: Fifty-four patients were included, of which 30 in the ward and 24 in the ICU. The mean age was 67 years (95%-CI 64-71), and 34 (63%) were male. Mean BMI was 29.7 (95%-CI 28.2-31.1) kg/m2 and did not differ between groups. Body composition values were not independently associated with disease severity. In multiple logistic regression analyses, a low phase angle was associated with COVID-19 severity in the composite score (OR 0.299, p = 0.046). CONCLUSION: We found no significant associations between body composition, including fat mass, visceral fat area, and fat-free mass, and disease severity in our population of generally overweight COVID-19 patients. A lower phase angle did increase the odds of severe COVID-19. We believe that factors other than body composition play a more critical role in the development of severe COVID-19.