Targeted Full Energy and Protein Delivery in Critically Ill Patients: A Pilot Randomised Control Trial

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Intensive care admissions, particularly for prolonged periods are often associated with muscle weakness, deconditioning, malnutrition and impaired long-term functional status. Nutrition is a potential modifiable factor to attenuate this deterioration. However defining what optimal nutrition is for critically ill patients in order to improve their outcomes remains controversial and needs further investigation. Despite feeding protocols, internationally and at the Royal Melbourne Hospital (RMH), patients continue to receive inadequate energy and protein compared to recommended targets. Results from our recently completed observational study in Intensive Care at RMH showed that accumulating an energy debt over an Intensive Care Unit (ICU) admission is associated with decreased muscle strength, physical function and the diagnosis of ICU Acquired Weakness (ICUAW). Patients with poorer strength and suboptimal physical function had a longer ICU length of stay and a higher requirement for inpatient rehabilitation, which is associated with increased health costs. This pilot randomised controlled trial aims to determine if a feeding protocol based on energy and protein targets, using a volume approach decreases muscle wastage and improves muscle strength and functional outcomes at discharge from the ICU compared to standard care. Patients will be randomised to standard care or the targeted feeding protocol which aims to provide 25kcal per kilogram and 1.5g protein per kilogram, which is in line with international best practice guidelines. The study period is from day of enrolment until ICU day 15 or discharge from ICU. Data collection will be the same for both groups and will include demographic data, the amount of energy and protein delivered, nutritional markers; such as weight and nutritional status and outcome such as length of stay and length of mechanical ventilation. Muscle strength and physical function will be assessed by the physiotherapist using standardised methods, which have been validated in the ICU. Muscle mass will be measured using ultrasound, which is a non-invasive technique, which has been safely used in the ICU. Data from this study will assist in informing future research studies to answer important clinical questions, including; should higher protein recommendations be targeted and what are the effects of improved calorie and protein delivery on functional outcomes for patients. This study will provide feasibility data to inform large multicentre randomised control trials.

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