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Background: International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice. Methods: We conducted a prospective, randomized, blinded, parallel‐group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range). Results: The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high‐protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day; difference, 0.53 [95% CI, 0.38–0.69] g/kg/d protein), with no difference in energy delivery (difference, −26 [95% CI, −190 to 137] kcal/kg/d). There were no between‐group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90‐day mortality (14/55 [26%] vs 15/56 [27%]; risk difference, −1.3% [95% CI, −17.7% to 15.0%]). Conclusion: Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline–recommended levels with doses similar to usual care during critical illness. [ABSTRACT FROM AUTHOR]

Lack of reporting consistency is common in randomized controlled trials (RCTs) in critical care nutrition. This impacts synthesis and interpretation and may misinform clinical practice. The objective was to evaluate reporting of parallel‐group RCTs of enteral or parenteral nutrition interventions in critically ill adults against the recommendations in the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines and a priori–defined nutrition criteria. A systematic search of CENTRAL, MEDLINE, EMBASE, and CINAHL was conducted to identify RCTs published from January 2011 to February 14, 2020. The primary outcome was the percentage of CONSORT criteria "completely met" (a score of 1) from all included studies (out of a total possible score of 37). Secondary outcomes included the percentage of CONSORT criteria that were "partially" or "not met" and the percentage of a priori–defined nutrition criteria that were "completely," "partially," or "not met" (adjusted to reflect criteria applicable to the paper). Data are presented as mean (standard deviation). Comparisons of normally distributed continuous data were made using a t‐test (P <.05). Of 18,969 articles identified, 56 studies met inclusion criteria. Of these, 60% (19%) of the eligible CONSORT criteria were "completely met," 20% (9%) "partially met," and 20% (15%) "not met." For the nutrition criteria, 41% (20%) of the eligible criteria were "completely met," 25% (14%) "partially met," and 34% (17%) "not met." Reporting against CONSORT guidelines was variable and often incomplete in relation to important a priori–defined nutrition variables. [ABSTRACT FROM AUTHOR]

Critical illness causes substantial muscle loss that adversely impacts recovery and health‐related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient‐centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients. [ABSTRACT FROM AUTHOR]

Introduction: The development of bedside methods to assess muscularity is an essential critical care nutrition research priority. We aimed to compare ultrasound-derived muscle thickness at 5 landmarks with computed tomography (CT) muscle area at intensive care unit (ICU) admission. Secondary aims were to (1) combine muscle thicknesses and baseline covariates to evaluate correlation with CT muscle area and (2) assess the ability of the best-performing ultrasound model to identify patients with low CT muscle area.Methods: Adult patients who underwent CT scanning at the third lumbar area <72 hours after ICU admission were prospectively recruited. Muscle thickness was measured at mid-upper arm, forearm, abdomen, and thighs. Low CT muscle area was determined using published cutoffs. Pearson correlation compared ultrasound-derived muscle thickness and CT muscle area. Linear regression was used to develop ultrasound prediction models. Bland-Altman analyses compared ultrasound-predicted and CT-measured muscle area.Results: Fifty ICU patients were enrolled, aged 52 ± 20 years. Ultrasound-derived muscle thickness at each landmark correlated with CT muscle area (P < .001). The sum of muscle thickness at mid-upper arm and bilateral thighs, including age, sex, and the Charlson Comorbidity Index, improved the correlation with CT muscle area (r = 0.85; P < .001). Mean difference between ultrasound-predicted and CT-measured muscle area was -2 cm2 (95% limits of agreement, -40 cm2 to +36 cm2 ). The best-performing ultrasound model demonstrated good ability to identify 14 patients with low CT muscle area (area under curve = 0.79).Conclusion: Ultrasound shows potential for assessing muscularity at ICU admission (Clinicaltrials.gov NCT03019913). [ABSTRACT FROM AUTHOR]

Enteral energy delivery above requirements (overfeeding) is believed to cause adverse effects during critical illness, but the literature supporting this is limited. We aimed to quantify the reported frequency and clinical sequelae of energy overfeeding with enterally delivered nutrition in critically ill adult patients. A systematic search of MEDLINE, EMBASE, and CINAHL from conception to November 28, 2018, identified clinical studies of nutrition interventions in enterally fed critically ill adults that reported overfeeding in 1 or more study arms. Overfeeding was defined as energy delivery > 2000 kcal/d, > 25 kcal/kg/d, or ≥ 110% of energy prescription. Data were extracted on methodology, demographics, prescribed and delivered nutrition, clinical variables, and predefined outcomes. Cochrane "Risk of Bias" tool was used to assess the quality of randomized controlled trials (RCTs). Eighteen studies were included, of which 10 were randomized (n = 4386 patients) and 8 were nonrandomized (n = 223). Only 4 studies reported a separation in energy delivery between treatment groups whereby 1 arm met the definition of overfeeding, which reported no between-group differences in mortality, infectious complications, or ventilatory support. Overfeeding was associated with increased insulin administration (median 3 [interquartile range: 0-41.8] vs 0 [0-30.6] units/d) and upper-gastrointestinal intolerance in 1 large RCT and with duration of antimicrobial therapy in a small RCT. There are limited high-quality data to determine the impact of energy overfeeding of critically ill patients by the enteral route; however, based on available evidence, overfeeding does not appear to affect mortality or other important clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults.Methods: This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]).Results: Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m2 , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement.Conclusions: Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy. [ABSTRACT FROM AUTHOR]

Background: Propofol sedation is common in critically ill patients, providing energy of 1.1 kcal/mL when administered as a 1% solution. We aimed to determine the proportion of energy administered as propofol on days 1-5 in the intensive care unit (ICU) and any association with outcomes.Methods: Retrospective observational study in a quaternary ICU from January-December 2012. Inclusion criteria were length of stay (LOS) ≥5 days, age ≥18 years, and provision of mechanical ventilation (MV) for ≥5 days. Outcome measures included proportion of total daily energy provided as propofol, overall energy balance, hospital mortality, duration of MV, and ICU LOS.Results: Data from 370 patients were analyzed, 87.8% (n = 325) of whom received propofol during days 1-5 in ICU. A median [interquartile range (IQR)] of 119 [50-730] kcal was provided as propofol per patient-day. Proportion of energy provided by propofol as a percentage of total energy delivered was 55.4%, 15.4%, 9.3%, 7.9%, and 9.9% days 1-5, respectively. Patients administered propofol received a greater proportion of their total daily energy prescription compared with those who were not (P < .01). Proportion of energy provided as propofol was not significantly different based on hospital mortality (P = .62), duration of MV (P = .50), or ICU LOS (P = .15).Conclusion: Propofol contributes to overall energy intake on days 1-5 of ICU admission. Energy balance was higher in those receiving propofol. No association was found between the proportion of energy delivered as propofol and outcomes. [ABSTRACT FROM AUTHOR]

Background: In the critically ill, energy delivery from enteral nutrition (EN) is often less than the estimated energy requirement. Parenteral nutrition (PN) as a supplement to EN may increase energy delivery. We aimed to determine if an individually titrated supplemental PN strategy commenced 48-72 hours following ICU admission and continued for up to 7 days would increase energy delivery to critically ill adults compared to usual care EN delivery.Methods: This study was a prospective, parallel group, phase II pilot trial conducted in six intensive care units in Australia and New Zealand. Mechanically ventilated adults with at least one organ failure and EN delivery below 80% of estimated energy requirement in the previous 24 hours received either a supplemental PN strategy (intervention group) or usual care EN delivery. EN in the usual care group could be supplemented with PN if EN remained insufficient after usual methods to optimise delivery were attempted.Results: There were 100 patients included in the study and 99 analysed. Overall, 71% of the study population were male, with a mean (SD) age of 59 (17) years, Acute Physiology and Chronic Health Evaluation II score of 18.2 (6.7) and body mass index of 29.6 (5.8) kg/m2. Significantly greater energy (mean (SD) 1712 (511) calories vs. 1130 (601) calories, p < 0.0001) and proportion of estimated energy requirement (mean (SD) 83 (25) % vs. 53 (29) %, p < 0.0001) from EN and/or PN was delivered to the intervention group compared to usual care. Delivery of protein and proportion of estimated protein requirements were also greater in the intervention group (mean (SD) 86 (25) g, 86 (23) %) compared to usual care (mean (SD) 53 (29) g, 51 (25) %, p < 0.0001). Antibiotic use, ICU and hospital length of stay, mortality and functional outcomes were similar between the two groups.Conclusions: This individually titrated supplemental PN strategy applied over 7 days significantly increased energy delivery when compared to usual care delivery. Clinical and functional outcomes were similar between the two patient groups.Trial Registration: Clinical Trial registry details: NCT01847534 (First registered 22 April 2013, last updated 31 July 2016). [ABSTRACT FROM AUTHOR]

Background: Nutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed "supplemental parenteral nutrition"), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill.Methods/design: This prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first).Discussion: This trial aims to determine if provision of a supplemental parenteral nutrition strategy to critically ill adults will increase energy intake compared to usual care in Australia and New Zealand. Trial outcomes will guide development of a subsequent larger randomised controlled trial.Trial Registration: NCT01847534 (First registered 5 February 2013, last updated 14 October 2015). [ABSTRACT FROM AUTHOR]