Intensive Care

Advancing early assessment of energy expenditure and optimal nutritional provision for improved recovery in critically ill patients in the intensive care unit (ICU).

Critically ill patients in the ICU for more than 48 hours should be considered at risk of malnutrition.¹ Those with critical illness, undergoing surgery and elderly patients are particularly at high risk.^3,4 Protein is an essential nutrient for maintaining muscle synthesis and avoiding muscle degradation¹ and is considered the most important macronutrient for healing wounds and maintaining lean body mass.⁵ Hospitalized patients including elderly, burn victims, or those with multiple trauma need markedly higher protein intake than healthy people to maintain body mass and function.²

Malnutrition is very frequent in the ICU and has severe detrimental effects

Due to the potentially severe consequences of malnutrition, it is recommended that all critically ill patients admitted to hospital are screened for nutritional risk.¹ However, it is estimated that only half of malnourished patients are recognized in routine clinical practice,^₇ and sarcopenia often goes unnoticed.⁸ Sarcopenia increases the risk of complications and infections and may lead to prolonged hospitalization, permanent injury or even death.^9,10

~60%

of critically ill patients already have generalized muscle loss when admitted to the ICU⁹

~50%

of the required protein intake is not delivered to most patients during their first week in the ICU^11,12

~1 kg

of muscle mass is lost a day in critically ill adult patients during their first 5 days of ICU stay¹³

To deliver effective nutrition support, physicians must understand a patient’s calorie and protein needs

ESPEN guidelines recommend that every critically ill patient who stays in the ICU for more than 48 hours should be considered at risk for malnutrition.¹ Also, a clinical assessment should be made to assess malnutrition.¹ ESPEN guidelines recommend indirect calorimetry be used to determine resting energy expenditure for critically ill and mechanically ventilated patients.¹ To support clinicians in the assessment of their patients’ energy requirements, Baxter offers tools and software for accurate measurement of energy expenditure for both ventilated and spontaneously breathing patients.

In critically ill patients, high protein intake matters

Timely nutrition that meets protein targets while providing calories 10-20% below the energy target has been associated with lower mortality.¹⁴

Adapted from Weijs PJ, et al. Crit Care 2014. Graph showing both that the early high-protein intake was associated with lower mortality and that early feeding at 10-20% below energy target during the first 4 days was associated with lower mortality. — Adapted from Weijs PJ, et al. Crit Care 2014.
Graph showing both that the early high-protein intake was associated with lower mortality and that early feeding at 10-20% below energy target during the first 4 days was associated with lower mortality.¹⁴

ESPEN and ASPEN guidelines recommend higher protein content for critically ill patients.^1,5 The most frequently recommended protein target for critically ill patients is 1.3-1.5 g/kg/day^4,15,16 or even up to 2.0–2.5 g/kg/day.^6,15Baxter offers a range of solutions with high protein content that meets the international guideline recommendations for nutritional support in critically ill patients.

Supplemental Parenteral Nutrition (SPN)

In ICU patients, studies indicate that with the use of enteral nutrition alone, complications may arise from underfeeding because of insufficient nutritional intake.^17,18 Individually optimized energy provision with SPN administered between day 4 and day 8 could improve clinical outcomes in severely ill patients in the ICU for whom enteral nutrition (EN) alone is insufficient.¹⁷ A systematic review and meta-analysis found that combining EN with SPN improved the protein and energy intakes in critically ill adult patients while decreasing the risk of ICU mortality and nosocomial infections with no adverse effects on other clinical outcomes when initiated before day 8.¹⁹ Baxter offers the broadest selection of ready-to-use three-chamber parenteral nutrition (PN) bags to meet the unique nutrition needs of each patient.

Learn more about the importance of protein in critically ill patients

Watch Dr. Paul Wischmeyer explain the power of protein in clinical nutrition

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Licensed ready-to-use three-chamber-bag solutions and indirect calorimetry for malnutrition treatment in the ICU

3CB PN solutions designed for adult patients

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Indirect calorimetry device to accurately measure energy needs

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See References

Singer P et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019 Feb;38(1):48-79.
Correia MI et al. (2014) Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group. Journal of the American Medical Directors Association 15: 544-50. 2.
Kubrak C and Jensen L (2007) Malnutrition in acute care patients: a narrative review.International journal of nursing studies 44: 1036-54. 3.
Norman K et al. (2008) Prognostic impact of disease-related malnutrition. Clin Nutr 27: 5-15.
McClave SA 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 Feb;40(2):159-211.
Ziegler TR (2009) Parenteral nutrition in the critically ill patient. New England Journal of Medicine 361: 1088-97.
Kruizenga HM et al. (2006) Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the Short Nutritional Assessment Questionnaire (SNAQ). Eur J Intern Med 17: 189-94.
Sheean PM et al. (2014) The prevalence of sarcopenia in patients with respiratory failure classified as normally nourished using computed tomography and subjective global assessment. JPEN Journal of parenteral and enteral nutrition 38: 873-9.
Weijs PJ et al. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. Crit Care. 2014 Jan 13;18(2):R12.
Heyland DK et al. (2016) Combining nutrition and exercise to optimize survival and recovery from critical illness: conceptual and methodological issues. Clinical Nutrition 35: 1196-206.
Heyland DK et al. (2011) Optimal amount of calories for critically ill patients: depends on how you slice the cake! Critical care medicine39: 2619-26.
Heyland DK et al. (2017) Protein delivery in the intensive care unit: optimal or suboptimal? Nutrition in Clinical Practice 32:58S-71S.
Monk DN et al. Sequential changes in the metabolic response in critically injured patients during the first 25 days after blunt trauma. Ann Surg. 1996 Apr;223(4):395-405.
Weijs PJ et al. Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients. Crit Care. 2014 Dec 14;18(6):701.
Rousseau A-F et al. (2013) ESPEN endorsed recommendations: nutritional therapy in major burns. Clinical nutrition 32: 497-502.
Hoffer LJ and Bistrian BR (2013) Why critically ill patients are protein deprived. JPEN Journal of parenteral and enteral nutrition 37: 300-9. 17
Heidegger CP, et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet. 2013;381(9864):385-393.
Delsoglio M, et al. How to choose the best route of feeding during critical illness. Clin Nutr ESPEN. 2020;37:247-254.
Alsharif DJ, et al. Effect of Supplemental Parenteral Nutrition Versus Enteral Nutrition Alone on Clinical Outcomes in Critically Ill Adult Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients. 2020;12(10):2968.

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