Delivering a higher-protein diet for Trauma Patients (Ignite)

Currently, protein prescriptions for critically ill patients range from 0.5-3.8 g/kg/d. There is an insufficient evidentiary basis to establish which level of protein administration is right for which patient population. We will take usual practices (following the current ICU Nutrition guideline of Gold Coast Health) and create two groups randomising eligible patients to a lower prescription (equal to 1.2 g/kg/d) or to a higher prescribed protein intake (equal to 2.2 g/kg/d) for the duration of their ICU admission. Following randomisation, prescription according to group assignment will be undertaken by the ICU dietitian or ICU medical team with the intervention administered by ICU nurses as part of patient care practices. In both groups, targets will be set using pre-ICU dry actual weight. For patients with BMI greater than 30, ideal body weight based on a BMI of 25 will be used. For the higher protein group, we will use Nutrison Protein Intense (Nutricia; 10g protein/100ml) which provides a higher protein to energy ratio in line with current guidelines. The control group will receive Nutrison Protein Plus Multifibre (Nutricia; 6.3g/100ml). Enteral feeding solutions for both groups will be delivered as a continuous infusion. Once on the ward, protein supplementation will continue by providing high protein oral nutrition supplement (Resource 2.0; Nestlé Health Science) which will provide an additional 19.7g of protein in one 237ml supplement (an additional 40g of protein per day). In the event that flavour fatigue occurs, alternative protein supplementation will be prescribed using higher protein food supplements such as Up n Go Protein Energize (Sanitarium; 16.8g per serve), Quest Protein bars (Quest Nutrition; 21g protein), Chobani Fit high protein yoghurt (Chobani; 15 g). Intervention adherence in ICU is monitored as part of the clinical trial by reporting nutritional adequacy (proportion of prescribed nutrition received). When the patient is discharged to the ward, we will monitor (though chart audit and direct observation) the prescription, delivery and consumption of oral nutrition supplements in the intervention group to assess compliance with the study intervention. We will also collect consumption of ONS in the control group (both product and protein consumed) for the control group to assess the degree of treatment differentiation. Although this trial is not about caloric dose, we want to encourage participating clinicians to be conservative in meeting energy targets and avoid overfeeding. Caloric goals should be the same in both groups. We will endorse the guidelines for energy targets set forth by American Society of Parenteral and Enteral Nutrition/ Society of Critical Care Medicine, especially as it pertains to the obese patient. For non-obese patients, we suggest that their caloric prescription be around 20-25 kcal/kg/day using a simple weight based formula. If the site chooses to use more sophisticated equations or indirect calorimetry, that is permissible. For obese patients, if indirect calorimetry is used, the goal of the nutritional prescription should be to provide energy not to exceed 65%–70% of measured requirements. If indirect calorimetry is unavailable or not used, consistent with the published guidelines, we suggest using the weight-based equation 11–14 kcal/kg actual body weight per day for patients with BMI in the range of 30–50 and 22–25 kcal/kg ideal body weight per day for patients with BMI >50. In both groups, targets will be achieved through any combination of enteral nutrition (high protein content in high group if available), protein supplements, and parenteral nutrition or amino acids only (as clinically available). The only difference between the two groups is the protein targets that are set. Similar efforts should be used in both groups to achieve at least 80% of these targets. The remainder of care provided to eligible patients will be at the discretion of ICU providers.