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.1McClave 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 … Continue reading,2ESPEN 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 … Continue reading 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,3McClave 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 … Continue reading,4Hurt 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 … Continue reading,5Singer 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. … Continue reading,6Van Zanten AR, Should We Increase Protein Delivery During Critical Illness? JPEN Journal of parenteral and enteral nutrition. Published on 2016, 40(6):756-762 ,7Deutz, N.E, et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group Clinical Nutrition 33. Published on (2014) 929e936. ,8Weimann, et al. ESPEN guideline, Clinical nutrition in surgery. Clinical Nutrition. Published on 2017 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.9Nicolo 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 … Continue reading,10Zusman 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. … Continue reading

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.11Weijs 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 … Continue reading,12Zusman 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. … Continue reading,13Pierre 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 … Continue reading 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.14Arthur R. H. van Zanten, Laurent Petit, Jan De Waele, Hans Kieft, Janneke de Wilde, Peter van Horssen, Marianne Klebach and Zandrie Hofmans deel. Very high intact-protein formula successfully … Continue reading

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.15McClave 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 … Continue reading,16ESPEN 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 … Continue reading,17M.S. Sioson, et al. Nutrition therapy for critically ill patients across the Asia Pacific and Middle East regions: A consensus statement. Clin Nutr ESPEN. Published on 2018 Apr;24:156-164. There is no evidence that hydrolysed whey proteins have faster digestion and absorption properties compared to intact whey proteins.18Farup J, et al. Effect of degree of hydrolysis of whey protein on in vivo plasma amino acid appearance in humans. Springerplus. Published on 2016 Mar 31;5:382 ,19Farnfield, M.M, et al. Plasma amino acid response after ingestion of different whey protein fractions. Int J Food Sci Nutr. Published on 2009 Sep;60(6):476-86 ,20Fouillet H et al. Approaches to quantifying protein metabolism in response to nutrient ingestion. J Nutr. Published on 2002 Oct;132(10):3208S-18S Furthermore, studies comparing peptide-based with polymeric formulas do not show a benefit .21Heyland, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. Published on 2003 … Continue reading,22Van Zanten and Elke del. Hydrolysed protein enteral nutrition is not superior to polymeric whole protein feeding with regard to gastrointestinal feeding tolerance and feeding adequacy. Crit Care. … Continue reading Besides the recommendation that tube feeding formulas should contain whole or intact proteins, recommendations from the 2017 Protein Summit23Hurt 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 … Continue reading 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 mortality24Parenteral 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. Published on … Continue reading and might be a limiting amino acid.25Juan 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. Published on 2017;32(suppl 1):6S-14S)

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 summit26Hurt, et al. Summary points and consensus recommendation from the international protein summit, Nutrition in Clinical Practice. Published on 2017

View References

View References
1, 3, 15 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. Published on 2016, 40(2):159-211
2, 16 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. Published on 2006 Apr;25(2):210-23. Epub 2006 May 11
4 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 . Published on 2017, 32(1_suppl):142S-151S
5 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. Published on 2014, 33(2):246-251
6 Van Zanten AR, Should We Increase Protein Delivery During Critical Illness? JPEN Journal of parenteral and enteral nutrition. Published on 2016, 40(6):756-762
7 Deutz, N.E, et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group Clinical Nutrition 33. Published on (2014) 929e936.
8 Weimann, et al. ESPEN guideline, Clinical nutrition in surgery. Clinical Nutrition. Published on 2017
9 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. Published on 2016, 40(1):45-51
10, 12 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. Published on 2016, 20(1):367
11 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. Published on 2014, 18(6):701
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: Published on del 10.1016/j.clnu.2018.08.037
14 Arthur R. H. van Zanten, Laurent Petit, Jan De Waele, Hans Kieft, Janneke de Wilde, Peter van Horssen, Marianne Klebach and Zandrie Hofmans deel. 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. Published on (2018) 22:156 10.1186/s13054-018-2070-5″
17 M.S. Sioson, et al. Nutrition therapy for critically ill patients across the Asia Pacific and Middle East regions: A consensus statement. Clin Nutr ESPEN. Published on 2018 Apr;24:156-164.
18 Farup J, et al. Effect of degree of hydrolysis of whey protein on in vivo plasma amino acid appearance in humans. Springerplus. Published on 2016 Mar 31;5:382
19 Farnfield, M.M, et al. Plasma amino acid response after ingestion of different whey protein fractions. Int J Food Sci Nutr. Published on 2009 Sep;60(6):476-86
20 Fouillet H et al. Approaches to quantifying protein metabolism in response to nutrient ingestion. J Nutr. Published on 2002 Oct;132(10):3208S-18S
21 Heyland, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. Published on 2003 Sep-Oct;27(5):355-73
22 Van Zanten and Elke del. Hydrolysed protein enteral nutrition is not superior to polymeric whole protein feeding with regard to gastrointestinal feeding tolerance and feeding adequacy. Crit Care. Published on 2017 Sep 5;21(1):232. doi: 10.1186/s13054-017-1817-8
23 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. Published on 2017, 32(1_suppl):142S-151S
24 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. Published on 2016;146(Suppl):2594S–600S
25 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. Published on 2017;32(suppl 1):6S-14S)
26 Hurt, et al. Summary points and consensus recommendation from the international protein summit, Nutrition in Clinical Practice. Published on 2017