Should We Prescribe More Protein to Critically Ill Patients?

There is no clear evidence for future RCT assessment of different protein intake levels in high-risk patients. Fortunately, the next trial will help resolve this dispute. NEXIS trial (ICU severity nutrition and exercise: combined cycle power and amino acid randomization trial) funded by the National Institute of Health, provides early cardiovascular circulation, innovative physical activity intervention, and intravenous Evaluate long-term hospitalization for effects Amino acid recovery in ICU patients (up to 5 g / kg / day). In this patient population, early cardiovascular circulation has been shown to be feasible and safe and may affect short term functional outcomes [32, 36]. The main result of the NEXIS trial is a 6-minute walk test, a series of comprehensive results characterizing the effect of treatment on muscle mass, muscular strength and functional ability, and quality of life based on recent consensus statements [ 37]. The exam will start in the summer of 2017 and will be held at any time in 2021 [38].

At the same time, researchers are planning large-scale multicenter, practical, volunteer-led randomized clinical trials based on registration, randomly assigning high-dose proteins to 4,000 high-risk patients (≧ 2.2 g). ) / Kg / day) or routine care (≦ 1.2 g / kg / day) [39] EFFORT (called high protein dose effect in critically ill patients) test. All other aspects of clinical care are determined by local standards, but it is recommended that participating sites avoid excessive caloric intake and follow ASPEN / SCCM guidelines on caloric content to be prescribed. Perhaps the unique feature of this large RCT is that it only adopts "nutritious high-risk patients". Moderate to severe malnutrition (defined in the field assessment), (3) Vulnerable (clinical vulnerability level 5 of drugs) (4), low (25 or less) or high BMI (35 or more) Or more; (4) muscle loss - (agent's SARC - F score is 4 or more); or (5) from a screening point of view, the estimated duration of mechanical ventilation is> 4 days. Consider including or excluding subgroups of patients with high protein demand (eg kidney failure, burns, trauma, or obesity) or low demand (eg liver disease or elderly patients). Since the provider's idea of ​​what is deterministic and what is best is variable, we do not exclude them, and some a priori subgroup analysis can be applied to these important sub- We have concluded that it was planned to evaluate the effect of protein administration in the group. The main results of the study were secondary outcomes including 60 day mortality and discharge hours, nutritional appropriateness, in-hospital mortality, ICU and re-hospitalization rate, mechanical ventilation time, ICU stay, and hospital stay . The EFFORT exam started registration in January 2018 (For details, please visit www.criticalcarenutrition.com). To participate in these trials, clinicians need to "balance" and believe that all drug delivery strategies are safe and effective.

In critically ill patients and patients with infectious diseases and chronic diseases with inflammation, the protein requirement is more than routine and a significant loss of protein occurs. Serum proteins commonly used to assess protein status are often affected by disease. These include albumin, prealbumin, transthyretin and retinol binding protein. In other healthy individuals, reducing protein and caloric intake does not cause hypoproteinemia. However, in the presence of infections, liver and kidney diseases, surgery and other metabolic rate increases, other conditions including immune activation and inflammation, the cytokines direct protein synthesis to acute phase proteins, followed by reduction of serum proteins . Alternatively, cytokines will direct amino acids to energy production rather than protein synthesis.

In patients with metabolic stress, both protein deficiency and overdose can cause problems. Even transient protein calorie deficiency may shift the assimilation balance of severe patients from catabolism to catabolism. The American Intestinal and Parenteral Nutrition Society recommends a protein requirement of 1.25 to 2.0 g / kg for critically ill patients and an intake of 1.2 to 1.5 g / kg to promote healing of the liver It is required. Decubitus However, other people have stated that at levels above 1.2 g / kg protein, body protein losses will not decrease further. Therefore, clinical decisions on protein requirements may be necessary for individualized treatment of patients.