Without doubt, in medicine as in life, one size does not fit all. We do not administer the same drug or dose to every patient at all times, so why then would we live under the illusion that we should give the same nutrition at all times in the continuum of critical illness? We have long lived under the assumption that critical illness and trauma lead to a consistent early increase in metabolic/caloric need, the so-called “hypermetabolism” of critical illness. What if this is incorrect? Recent data indicate that early underfeeding of calories (trophic feeding) may have benefits and may require consideration in well-nourished patients. However, we must confront the reality that currently ICU nutrition delivery worldwide is actually leading to “starvation” of our patients and is likely a major contributor to poor long-term quality of life outcomes. To begin to ascertain the actual calorie and protein delivery required for optimal ICU recovery, an understanding of “starvation” and recovery from starvation and lean body mass (LBM) loss is needed. To begin to answer this question, we must look to the landmark Minnesota Starvation Study from 1945. This trial defines much of the world’s knowledge about starvation, and most importantly what is required for recovery from starvation and massive LBM loss as occurs in the ICU. Recent and historic data indicate that critical illness is characterized by early massive catabolism, LBM loss, and escalating hypermetabolism that can persist for months or years. Early enteral nutrition during the acute phase should attempt to correct micronutrient/vitamin deficiencies, deliver adequate protein, and moderate nonprotein calories in well-nourished patients, as in the acute phase they are capable of generating significant endogenous energy. Post resuscitation, increasing protein (1.5–2.0 g/kg/day) and calories are needed to attenuate LBM loss and promote recovery. Malnutrition screening is essential and parenteral nutrition can be safely added following resuscitation when enteral nutrition is failing based on pre-illness malnutrition and LBM status. Following the ICU stay, significant protein/calorie delivery for months or years is required to facilitate functional and LBM recovery, with high-protein oral supplements being essential to achieve adequate nutrition.
National Heart, Lung, ans Blood Institute Acute Respiratory Distress Syndrome Clinical Trials Network, Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, 8, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307:795–803. CrossRef
Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Vols I–II. Minneapolis: University of Minnesota Press; 1950.
Kalm LM, Semba RD. They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment. J Nutr. 2005;135(6):1347–52. PubMed
Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. Experimental Starvation in Man: A Report from the Laboratory of Physiological Hygiene, University of Minnesota. Minneapolis: University of Minnesota; 1945.
Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. Rehabilitation Following Experimental Starvation in Man: A Report from the Laboratory of Physiological Hygiene, University of Minnesota. Minneapolis: University of Minnesota; 1946.
Fürst P. Protein and amino acid metabolism: Composition of stressed and nonstressed states. In: Cresci G, editor. Nutrition support for the critically ill patient. Boca Raton: Taylor & Francis (CRC); 2005. p. 29.
McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. CrossRefPubMed
Wischmeyer PE, San-Millan I. Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology. Crit Care. 2015;19 Suppl 3:S6. PubMed
Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, Davies AR, O'Leary M, Solano T, Peake S, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013;309(20):2130–8. CrossRefPubMed
Nicolo M, Heyland DK, Chittams J, Sammarco T, Compher C. Clinical outcomes related to protein delivery in a critically ill population: a multicenter, multinational observation study. JPEN. 2016;40(1):45–51. CrossRef
Wei X, Day AG, Ouellette-Kuntz H, Heyland DK. The association between nutritional adequacy and long-term outcomes in critically ill patients requiring prolonged mechanical ventilation: a multicenter cohort study. Crit Care Med. 2015;43(8):1569–79.
Wischmeyer PE, Hasselmann M, Kummerlen C, Kozar R, Kutsogiannis DJ, Karvellas CJ, Besecker B, Evans DK, Preiser JC, Gramlich L, et al. A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Crit Care. 2017;21(1):142. CrossRefPubMedPubMedCentral
Stratton R, Green C, Elia M. Disease-Related Malnutrition: An Evidence-Based Approach to Treatment. Wallingford: CABI Publishing; 2003. CrossRef
Philipson TJ, Snider JT, Lakdawalla DN, Stryckman B, Goldman DP. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013;19(2):121–8. PubMed
Deutz NE, Matheson EM, Matarese LE, Luo M, Baggs GE, Nelson JL, Hegazi RA, Tappenden KA, Ziegler TR, Group NS. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial. Clin Nutr. 2016;35(1):18–26. CrossRefPubMed
Amrein K, Schnedl C, Holl A, Riedl R, Christopher KB, Pachler C, Urbanic Purkart T, Waltensdorfer A, Munch A, Warnkross H, et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: the VITdAL-ICU randomized clinical trial. JAMA. 2014;312(15):1520–30. CrossRefPubMed
Whigham LD, Butz DE, Johnson LK, Schoeller DA, Abbott DH, Porter WP, Cook ME. Breath carbon stable isotope ratios identify changes in energy balance and substrate utilization in humans. Int J Obes (Lond). 2014;38(9):1248–50. CrossRef
- Tailoring nutrition therapy to illness and recovery
Paul E. Wischmeyer
- BioMed Central
Neu im Fachgebiet AINS
Meistgelesene Bücher aus dem Fachgebiet AINS
Mail Icon II