Critical Care

Innovative nutritional solutions for critically ill patient

This text is meant for healthcare professionals

For patients who are unable to eat or drink adequately themselves, like most critically ill patients, enteral nutrition by means of tube feeding is the preferred way of feeding and is recommended over parenteral nutrition.1,2 Danone Nutricia Research has developed a full range of tube feeding formulas in order to meet each patient’s specific nutritional requirements while also taking into account the upper and lower gastro-intestinal complications.

Protein Content

Energy requirements of patients can differ a lot due to differences in metabolic stress and physical activity. While protein requirements for critically ill, surgical, hospitalised or community patients are considered to be around 1.5 gram/kg bodyweight per day,1,3,4,5,6,7 the protein content per 100 kcal of enteral nutrition products should differ in order to optimally achieve protein requirements with adequate energy provision in all patients requiring tube feeding. Achieving the protein requirements are of utmost importance as inadequate protein intake has been associated with increased mortality rates.8,9

Therefore, over the last few years, a full range of tube feeding formulas has been developed with protein content containing 4, 5 and 6 grams of protein per 100 kcal. Recent insights in energy requirements of critically ill patients indicate that overfeeding should be prevented and energy intake of about 70 – 100% of energy expenditure is recommended.10,11,12 For these patients anenteral nutrition formula with a very high protein content is required with 8g protein / 100 kcal. A randomized double-blind controlled clinical trial has shown that this very high intact-protein formula can successfully provide protein intake according nutritional recommendations without overfeeding.13 

Protein Quality: the development of a unique protein blend

Not only the protein content of a tube feeding formula is important, but also the type and quality of the protein. All current nutritional guidelines indicate that enteral feeding should start with tube feeding formulas with whole or intact proteins.1,2,14 There is no evidence that hydrolysed whey proteins have faster digestion and absorption properties compared to intact whey proteins.15,16,17 Furthermore, studies comparing peptide-based with polymeric formulas do not show a benefit 18,19. Besides the recommendation that tube feeding formulas should contain whole or intact proteins, recommendations from the 2017 Protein Summit20 indicate that high quality proteins like soy, casein or whey should be used. These proteins should contain a complete profile of amino acids, including the essential amino acids.

Danone Nutricia Research has developed a unique protein blend. It is an intact whey-dominant protein blend, consisting of four proteins: whey, casein, soy and pea (P4. By making use of the benefits of each single protein, it was possible to make a protein blend with a better balanced amino acid pattern, following the limiting amino acid principles with a chemical score of 1.3 (which is higher compared to the chemical score of the individual protein sources). Additionally, the non-essential amino acid Arginine found in the blend is much higher compared to the content in whey or casein. Arginine is considered a very important amino acid for critically ill patients because it has been associated with improved wound healing, fewer complications, faster recovery and even reduced mortality21 and might be a limiting amino acid.22

This unique protein blend also has benefits related to upper gastro-intestinal complications.

“Dietary protein delivered through nutrition support therapy is a fundamental prerequisite for muscle protein synthesis and maintenance of function.”

Consensus recommendations from the international protein summit23

1.
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 Journal of parenteral and enteral nutrition 2016, 40(2):159-211.
2.
ESPEN Guidelines on Enteral Nutrition: Intensive care. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J; DGEM (German Society for Nutritional Medicine), Ebner C, Hartl W, Heymann C, Spies C; ESPEN (European Society for Parenteral and Enteral Nutrition). Clin Nutr. 2006 Apr;25(2):210-23. Epub 2006 May 11.
3.
Hurt RT, McClave SA, Martindale RG, Ochoa Gautier JB, Coss-Bu JA, Dickerson RN, Heyland DK, Hoffer LJ, Moore FA, Morris CR et al: Summary Points and Consensus Recommendations Fro mkkl;;mk ;mklm the International Protein Summit. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition 2017, 32(1_suppl):142S-151S.
4.
Singer P, Hiesmayr M, Biolo G, Felbinger TW, Berger MM, Goeters C, Kondrup J, Wunder C, Pichard C: Pragmatic approach to nutrition in the ICU: expert opinion regarding which calorie protein target. Clinical nutrition 2014, 33(2):246-251.
5.
Van Zanten AR: Should We Increase Protein Delivery During Critical Illness? JPEN Journal of parenteral and enteral nutrition 2016, 40(6):756-762.
6.
Deutz, N.E. et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group Clinical Nutrition 33 (2014) 929e936.
7.
Weimann et al. ESPEN guideline, Clinical nutrition in surgery. Clinical Nutrition 2017.
8.
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 Journal of parenteral and enteral nutrition 2016, 40(1):45-51.
9.
Zusman O, Theilla M, Cohen J, Kagan I, Bendavid I, Singer P: Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study. Critical care 2016, 20(1):367.
10.
Weijs PJ, Looijaard WG, Beishuizen A, Girbes AR, Oudemans-van Straaten HM: Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients. Critical care 2014, 18(6):701.
11.
Zusman O, Theilla M, Cohen J, Kagan I, Bendavid I, Singer P: Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study. Critical care 2016, 20(1):367.
12.
13 Pierre Singer, Annika Reintam Blaser, Mette M. Berger, Waleed Alhazzani, Philip C. Calder, Michael Casaer, Michael Hiesmayr, Konstantin Mayer, Juan Carlos Montejo, Claude Pichard, Jean-Charles Preiser, Arthur R.H. van Zanten, Simon Oczkowski, Wojciech Szczeklik, Stephan C. Bischoff ESPEN guideline on clinical nutrition in the intensive care unit PII: S0261-5614(18)32432-4, DOI: 10.1016/j.clnu.2018.08.037, Reference: YCLNU 3608 To appear in: Clinical Nutrition 2018.
13.
Arthur R. H. van Zanten1*, Laurent Petit2, Jan De Waele3, Hans Kieft4, Janneke de Wilde5, Peter van Horssen5, Marianne Klebach5 and Zandrie Hofmans Very high intact-protein formula successfully provides protein intake according to nutritional recommendations in overweight critically ill patients: a double-blind randomized trial. Critical Care (2018) 22:156. 10.1186/s13054-018-2070-5″ target=”_blank” rel=”noopener noreferrer”>https://doi.org/10.1186/s13054-018-2070-5.
14.
M.S. Sioson, et al. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A consensus statement. Clin Nutr ESPEN. 2018 Apr;24:156-164.
15.
Farup J. et al, Effect of degree of hydrolysis of whey protein on in vivo plasma amino acid appearance in humans. Springerplus. 2016 Mar 31;5:382.
16.
Farnfield, M.M. et al, Plasma amino acid response after ingestion of different whey protein fractions. Int J Food Sci Nutr. 2009 Sep;60(6):476-86.  .
17.
Fouillet, H. et al, Approaches to quantifying protein metabolism in response to nutrient ingestion. J Nutr. 2002 Oct;132(10):3208S-18S.  .
18.
Heyland et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003 Sep-Oct;27(5):355-73.
19.
Van Zanten and Elke. Hydrolysed protein enteral nutrition is not superior to polymeric whole protein feeding with regard to gastrointestinal feeding tolerance and feeding adequacy. Crit Care. 2017 Sep 5;21(1):232. doi: 10.1186/s13054-017-1817-8.
20.
Hurt RT, McClave SA, Martindale RG, Ochoa Gautier JB, Coss-Bu JA, Dickerson RN, Heyland DK, Hoffer LJ, Moore FA, Morris CR et al: Summary Points and Consensus Recommendations From the International Protein Summit. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition 2017, 32(1_suppl):142S-151S.
21.
Parenteral or Enteral Arginine Supplementation Safety and Efficacy1–3 Martin D Rosenthal,4,5 Phillip W Carrott,6 Jayshil Patel,7 Laszlo Kiraly,8 and Robert G. J Nutr 2016;146(Suppl):2594S–600S.
22.
Juan B. Ochoa Gautier, MD, FACS, FCCM1; Robert G. Martindale How Much and What Type of Protein Should a Critically Ill Patient Receive? (Nutr Clin Pract. 2017;32(suppl 1):6S-14S).
23.
Hurt et al, Summary points and consensus recommendation from the international protein summit, Nutrition in Clinical Practice 2017.