Evaluation of Calorie and Protein Intakes and Clinical Outcomes in Critically Ill Patients: Cross- sectional study

doi:10.21203/rs.3.rs-1990524/v1

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Evaluation of Calorie and Protein Intakes and Clinical Outcomes in Critically Ill Patients: Cross- sectional study

https://doi.org/10.21203/rs.3.rs-1990524/v1

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Background: Critically ill patients admitted to the intensive care unit (ICU) are often hyper-metabolic and hyper-catabolic and at risk of malnutrition. This study aimed to evaluate the amount of energy and protein intake and its correlation with the required amount in critically ill patients.

Method: Seventy patients with critical conditions who were admitted to ICU were eligible (age ≥18 years and over a 3-day stay in ICU). Basic characteristics, medical history, and laboratory test results were extracted from the patients' medical records. Anthropometric indices and APACHE II questionnaire were assessed by an expert nurse. The calorie and protein requirement of patients were considered 25 kcal/kg/day and 1.2 g/kg/day, respectively.

Result: Mean age in the target population was 57.69 ± 20.81 years, and 48.6% were men. The mean actual energy intake was significantly lower than the requirement (531.27 ±365.40 vs. 1583.77 ± 329.36 Kcal/day, P˂0.001). The mean actual protein intake was significantly lower than the requirement (14.94 ±18.33 vs. 74.11 ± 17.89 gr/day respectively, P˂0.001). Patients had a growing trend in providing energy and protein over time. There is a significant reverse correlation between the age of patients and total lymphocyte count (r= -0.38, P=0.003). Also, there is a significant reverse correlation between the Glasgow coma scale and the duration of mechanical ventilation (r=-0.49, P˂0.001). The lowest average calorie and protein intake are in patients with poisoning.

Conclusion: The amount of calorie and protein intake in critically ill patients is significantly less than the recommended amount, therefore, it is necessary to perform routine nutritional assessments.

Malnutrition

Calories

Protein

Nutritional care

ICU

Critically ill patients admitted to the intensive care unit (ICU) are often hyper-metabolic and hyper-catabolic and at risk of malnutrition (1). Malnutrition is independently associated with poorer clinical outcomes and associated with higher mortality risk, longer ICU, and hospital length of stay (LOS).Critically ill patients signs of a systemic inflammatory response appear during the state of catabolic stress (2, 3). In this state, due to physiologic instability, complications such as infection, multiple organ dysfunction, and an increase in the mortality rate is expected (4).

Critically ill patients are often unable to eat, therefore early initiating nutrition support as enteral nutrition (EN) and parenteral nutrition (PN) is important (5). The nutritional intakes of many patients are either too many or too few compared to their metabolic needs (5, 6). The prevalence of malnutrition in ICU patients in developing and developed countries has been estimated to be 78.1% and 50.8%, respectively (1). Inflammatory response associated with increased metabolic rate leads to hyperglycemia, lean body mass wasting, and inability to use nutrients for metabolism (2). The provision of an adequate amount of each nutritional substrate may help these patients. In general, EN is superior to PN, and according to the guideline, it is preferable to start as soon as possible (7, 8). As mentioned, low-calorie and protein intakes, mostly less than 70% of the patients' needs, are related to poor clinical outcomes (2). This study aimed to evaluate the amount of energy and protein intake and its correlation with the amount required for critically ill patients and also survey some clinical outcomes that are specialized for critically ill patients.

This Cross-sectional study was conducted from June 2018 to May 2019. This Cross-sectional study was conducted from June 2018 to May 2019. Patients were recruited from two different ICUs (general and medical ICU), Imam Reza hospital, Mashhad University of Medical Sciences, Mashhad Iran using simple sampling from available ICU patients according to our inclusion criteria (21-and 16-bed units). The study was performed after inspection by the Medical Ethics Committee of the Mashhad University of Medical Sciences (IR.MUMS.MEDICAL.REC.1398.078) about any possible ethical issues.

Seventy patients with critical conditions admitted to ICU were screened for eligibility. Inclusion criteria: age range > 18–80 years; ICU admission; all patients were evaluated from the first 24 h of admission for 3-days; Exclusion criteria include death within the first three days of admission; pregnancy and lactation; Chronic and Acute renal failure and Hepatic encephalopathy; and inability to obtain informed consent cases.

The specialized nutritionist recorded data on the daily calorie and protein intakes from EN and PN during ICU admission. Basic characteristics, medical history, and laboratory test results were extracted from the patients' medical records. Anthropometric and dietary data were measured by the specialized nutritionist or extracted from medical records. Ulna length using a tape measure and measuring accuracy of 0.1 cm was applied to determine patients' heights and based on height, ideal body weight was calculated. Mid-arm muscle circumference (MAC) was assessed by measuring accuracy of 0.1 cm for each patient.

For initial EN via a nasogastric tube in both groups, the hospital gavage formula with a specific amount of calories and protein (measured by Quality TESTA Laboratory Control) was Used, and nutrition-related confounders were modified. EN started continuously at the flow rate of 25 ml/h; this rate was increased every 6 hours according to patient tolerance to achieve the desirable calorie if the patients displayed no gastrointestinal symptoms (diarrhea, vomiting, abdominal distention, and gastric residual volume > 300 mL).

Patients' calorie and protein requirements were calculated according to ESPEN (European Society for Parenteral and Enteral Nutrition) guideline recommendations (7). The calorie and protein requirement based on the condition and underlying disease of patients were considered 25 kcal/kg/day and 1.2 g/kg/day, respectively (7). The energy and protein content of hand-made formulas (measured by Quality TESTA Laboratory Control) were assessed, and they were compared with the required amount for each patient.

Statistical analysis

Statistical analyses were conducted with SPSS version 19 (SPSS Institute, Chicago, IL, USA). Descriptive statistics were used to examine the characteristics of patients. Independent samples t-tests were used to determine the difference between patients' intake and requirements in each evaluation session. Pearson correlation coefficient was used to show the association of some clinical outcomes with age and GCS (Glasgow coma scale). A value of p < 0.05 was used as a criterion for statistical significance.

There were 70 eligible patients included in the study. The mean age in the target population was 57.69 ± 20.81 years; 48.6% (34)were men, and 51.4% were women. Among these participants, 25.7% (18) were poisoned patients, 21.4% (15) had respiratory problems, 15.7% (11) had sepsis, 11.4% (8) had gastrointestinal disorders, and 5.7% (4) had hematological disorders, 2.9% (2) renal disorders, 1.4% (1) cardiovascular disorders and 15.7% (11) suffered from other disorders. Among the patients studied, 15.7% received EN, 22.8% received PPN, 61.4% received SPN (Supplemental Parenteral Nutrition). Mean height was 157.97 ± 9.26 cm, weight was 65.26 ± 7.40 kg, and MAC was 26.10 ± 3.47 cm. The mean length of ICU and hospital stay was 24.18 ± 25.20 days (range: 3-120 days) and 28.83 ± 26.81 days (range: 5-134 days), mean duration of mechanical ventilation was 2.43 ± 2.17 days. And 61.7% (47) were dependent on mechanical ventilation. The mortality rate during the study was 60% (42 from 70 subjects) (Table 1).

Table 1

Demographic and baseline characteristics of patients (n = 70).
Variable	Value
Age (mean ± SD)	57.69 ± 20.81
Sex (n, percent)	48.6% men (34) 51.4% women (36)
Weight (means ± SD)	65.257 ± 7.399
Height (means ± SD	167.97 ± 9.261
MAC (mean ± SD)	26.10 ± 3.475
Diagnosis (n, percent)
Respiratory disorders	21.4% (15)
Poisoning	25.7% (18)
Gastrointestinal disorders	11.4% (8)
Sepsis	15.7% (11)
Renal disorders	2.9% (2)
Hematologic disorders	5.7% (4)
Cardiovascular disorders	1.4% (1)
Other	15.7% (11)
Type of feeding rout (n, percent)
EN	15.7% (11)
PPN	22.8% (16)
SPN	61.4% (15)
Ventilator Dependence (n, percent)
Yes	67.1% (47)
No	32.9% (23)
Length of hospital stay (days)	28.833 ± 26.817(66)
Duration of ICU stay (days)	24.181 ± 25.00(66)
Duration of mechanical ventilation (days)	2.428 ± 2.170
APACHE	15.63 ± 4.428
Mortality rate (n, percent)	60% (42)
MAC, Mid Arm Circumference; EN, Enteral Nutrition; PPN, Parenteral Nutrition, SPN, Supplemental Parenteral Nutrition

The mean actual energy intake for the study population was 531.2726 ± 365.40 Kcal/day, while the mean energy requirement was 1583.77 ± 329.36 Kcal/day, based on patients' stress and bedridden period time. A comparison of the means showed a significant difference between actual energy intakes and requirements (P˂0.001). Mean actual protein intake and requirement were 14.94 ± 18.33 gr/day and 74.11 ± 17.89 gr/day, respectively, and the analysis for comparing these means for protein showed a significant difference (P˂0.001) (Table 2).

Table 2

Mean Actual energy and protein intakes and requirements
Variable	Mean ± SD
Actual Energy intake (Kcal/day)	531.272 ± 365.40
Energy requirement (Kcal/day)	1583.77 ± 329.36
P value	P˂0.001
Actual protein intake (Kcal/day)	14.94 ± 18.33
Protein requirement (Kcal/day)	74.11 ± 17.89
P-value	P˂0.001
Note: Quantitative data are reported as mean (SD).

Data showed that the percentage of calories and protein supply based on requirements in the total population were 34.70 ± 22.03 and 20.33 ± 14.85, respectively. Over time, patients had a growing trend in providing the energy and protein they needed (Table 3).

Table 3

Percentage of calories and protein supply in first 3 days of ICU admission
Time (days)	Energy (mean ± SD)	protein (mean ± SD)
1	28.608 ± 18.977	12.389 ± 21.036
2	37.836 ± 25.464	21.552 ± 29.952
3	41.565 ± 27.483	27.056 ± 33.618
Total	34.708 ± 22.033	20.332 ± 14.854
Note: Quantitative data are reported as mean (SD).

There was a significant correlation between disease severity (according to the APACHE II score) and insufficient protein intake (r = 0.374, P = 0.042) (Fig. 1). Despite the correlation between disease severity and inadequate energy intake, there was no significant relationship (r = 0.336, P = 0.070).

The lowest average calorie and protein intake are in patients with poisoning. The association between underlying diseases and insufficient calorie intake was significant (P = 0.03), while for protein intake, this relationship was not statistically significant (P = 0.417) (Table 4, 5).

Table 4

The association between underlying diseases and calorie intake
Underlying diseases	Mean Calorie intake (MD ± SD)	Mean Ratio Calorie intake* (MD ± SD)
Respiratory disorders	652.37 ± 445.41	43.51 ± 26.98
Poisoning	378.85 ± 186.29	24.57 ± 10.19
Gastrointestinal disorders	421.66 ± 402.14	32.61 ± 31.28
Sepsis	766.69 ± 301.52	44.03 ± 18.60
Other	487.61 ± 377.75	32.57 ± 19.88
P value	0.03	0.08
*Percentage ratio of calories intake to required calories. Note: Quantitative data are reported as mean (SD). Association between underlying diseases and calorie intake were compared using one-way ANOVA.

Table 5

The association between underlying diseases and protein intake
Underlying diseases	Mean Protein intake (MD ± SD)	Mean Ratio Protein intake* (MD ± SD)
Respiratory disorders	20.57 ± 22.23 ()	30.64 ± 36.05
Poisoning	7.60 ± 12.30	9.24 ± 13.34
Gastrointestinal disorders	13.50 ± 20.11	21.89 ± 33.08
Sepsis	22.93 ± 14.50	27.99 ± 19.99
Other	13.33 ± 19.64	17.72 ± 24.04
P value	0.15	0.15
*Percentage ratio of protein intake to protein required Note: Quantitative data are reported as mean (SD). Association between underlying diseases and protein intake were compared using one-way ANOVA.

There was a significant reverse correlation between the age of patients and total lymphocyte count (coefficient= -0.38, P = 0.003). Also, The results indicated that as the GCS increases, the duration of mechanical ventilation decreases (coefficient=-0.49, P˂0.001). Other correlations between age and serum albumin and duration of ICU stay and association between GCS and duration of ICU and hospital stay were not statistically significant.

The results of the present study showed that the actual intake of protein and calories in patients admitted to the ICU is significantly less than the values recommended by the guidelines. According to previous studies, achieving the desired level of calorie and protein intake is one of the important and key points to achieving positive clinical outcomes (9). Low protein and calorie intake in our study were probably due to NPO of several patients in the first 3 days of hospitalization, unstable hemodynamic conditions, gavage intolerance, and also a low percentage of protein and calories in hospitalized gavage which we used to feed patients, our results are consistent with the findings of Campbell et al. study (10). Another similar study showed that patients admitted to the ICU received only 65% of their calorie needs and 61% of their protein requirements (11).

Nutritional evaluation in patients in critical conditions is different from other patients, it is necessary to prepare an efficient nutritional treatment protocol along with medical treatment (8, 12). One of the components of nutritional assessment is intermittent and continuous nutrition monitoring during ICU stay (12, 13). Nutritional protocols in ICU patients recommend starting feeding within the first 24 hours of admission and gradually increasing over time (13, 14).

Since in the acute phase of the critically ill patients, the inflammatory cascade lead to reduces nutritional intake, loss of muscle protein, and consequently poor clinical outcomes (15, 16), similar results were obtained in our study and calorie, and protein intake was significantly lower than recommended by guidelines, therefore, it is necessary to start nutritional interventions as soon as the patient's condition stabilizes to improve calorie and protein intake and prevent malnutrition.

Given that increasing, the level of consciousness reduces the rate of mechanical ventilation and consequently reduces the need for intubation (17). One study showed that increasing calorie and protein intake in patients admitted to the intensive care unit, especially patients with a body mass index (BMI) greater than 35 or less than 25, was associated with better clinical outcomes including decreasing of mortality rate and increased ventilator-free days (VFDs) that this result is in line with the findings of our study that increasing the GCS level reduced the duration of mechanical ventilation (16). The optimal amount of protein and calories in patients admitted to the ICU has not yet been fully determined, but some studies have shown that a hypocaloric diet for obese patients admitted to the ICU has better clinical outcomes (10, 11, 18). One study conducted by Looijaard et al. showed that increasing protein intake in the acute phase of patients with low skeletal muscle area admitted to the ICU is associated with a reduction in mortality rate (19). In general, the results of studies on the administration of high-protein diets in patients admitted to the ICU are very controversial (20). Some observational studies have shown beneficial effects of high protein intake with clinical outcomes, while these benefits have not been fully confirmed in clinical trial studies, however, few studies have found that very early protein intake is even harmful (21-26). A retrospective study showed that low protein intake (<0.8 g/kg/day) in the first 3 days of ICU admission along with high protein intake ((>0.8 g/kg/day)) after the third day of admission was associated with a reduction in 6-month mortality, in addition, low protein intake throughout the all ICU stay was associated with worst clinical outcomes (27). Weijs et al. reported that high protein intake (>1.2 g/kg/day protein on day 4 of ICU admission) is associated with improved clinical outcomes (21).

Based on the systematic review conducted by Lew et al., malnutrition in patients admitted to the ICU lead to poor clinical outcomes and increased length of hospital stay in the critically ill patients (1), therefore, performing nutritional assessments and then starting nutritional support can prevent malnutrition or treat existing malnutrition. According to the previous studies, nutritional support by a specialist nutrition team can improve calorie intake, reduce clinical complications and mortality in patients admitted to the intensive care unit (28, 29). Therefore, it can be concluded that nutritional support by a nutrition support team (NST) can be effective in improving clinical complications, reducing the length of ICU stay, and ultimately reducing mortality. It can also be said that the medical and nutritional treatment of patients admitted to the ICU is a multidisciplinary task and should involve clinical nutrition specialists, surgeons, nurses, intensivists, and pharmacists that this teamwork leads to achieving the desired protein and calorie goals.

According to the previous studies, enteral nutrition is the preferred method of feeding in ICU patients to reduce the rate of infections and decrease the length of ICU stay (30), and considering that in our study, only 15.7% of patients received antral nutrition, so it shows that there is no nutrition support team in the intensive care unit, therefore, nutritional guidelines in the intensive care units of our hospitals should be re-evaluated and nutritional assessments, nutritional care, and nutritional interventions performed by the nutrition support team should be considered.

Similar to other studies, the present work had some limitations. The first limitation was patients' weight was not measured but was asked of the patient or his/her companion. The patients were highly heterogeneous in terms of the type of disease, and this could affect the outcomes. Even the amount of calories and protein they needed may have been different, but in this study, it was considered the same for all patients. It is suggested that homogeneous patients be selected in future studies.

The difference between the energy received and the amount required leads to many problems. The major use of hospital gavage that does not provide enough energy and protein, administration of gavage to all patients with the same volume according to a routine schedule, failure to administration nutritional advice to adjust the appropriate diet for each patient can be among the causes we knew this difference (31).

The reason for the low protein and calorie intake of patients in this study can be the NPO state of several patients in the first 3 days of hospitalization, unstable hemodynamic conditions and feeding intolerance, exclusion of TPN patients from this study, low protein and calorie percentage in hospital gavage solutions (in one study our hospital gavage contained 0.65 kcal per cc and 4.2 g of protein per 100 cc), the variability of the contents of the gavage solution and frequent interruption of the gavage due to the non-implementation of standard protocols in the intensive care units of the hospital. For further studies, it is recommended that patients be evaluated after the first week to assess their intake status.

It can be concluded that the amount of calorie and protein intake in patients admitted to the ICU is significantly less than the recommended amount, therefore, it is necessary to perform nutritional assessments and determine the feeding route and amounts of calorie and protein by the nutrition support team, for feeding patients to prevent or treat existing malnutrition.

Acknowledgements

The support provided by Mashhad University of Medical Sciences (MUMS) to conduct this study is highly acknowledged.

Author Contribution:

Ahmad Bagheri Moghaddam: Supervision, Conceptualization, Methodology, Writing - Review & Editing, Project administration. Mohaddeseh Badpeyma: Project administration, Writing - Review & Editing, Data Curation, Visualization, Investigation. Mahsa Malekahmadi: Writing - Original Draft, Visualization. Alireza Sedaghat: Methodology, Project administration, Writing - Review & Editing. Andisheh Norouzian Ostad: Investigation. Majid Khadem-Rezaiyan: Formal analysis, Writing - Review & Editing. Naseh Pahlavani: Writing - Original Draft. Fatemeh Ebrahimbay Salami: Investigation

Funding

The trial is funded by the Mashhad University of Medical Sciences. These centers support all stages of the study (the study's design and collection, analysis, interpretation of data, and writing the manuscript).

Availability of data and materials

All the required data have been included in the manuscript and its supplementary information files. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from ethical committee of MUMS. The ethical approval code is IR.MUMS.MEDICAL.REC.1398.078. The informed consent will be obtained from all study participants or their legal guardian. All study procedures were in accordance with the ethical standards of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that there are no conficts of interest.

Author details

^aStudent Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran. ^bDepartment of Nutrition, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran. ^cResearch Center for Gastroenterology and Liver Disease, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ^dFaculty of Critical care Medicine, Lung Disease research center, Mashhad University of Medical Science, Mashhad, Iran. ^e Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. ^fAssistant Professor of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences. Mashhad, Iran. ^g Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran. ^h Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. ⁱMedical Doctor, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran. ^j Department of Anesthesiology and Critical Care, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

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No competing interests reported.

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