The impact of an individually tailored, stepwise nutrition protocol on energy and protein adequacy in post-ICU patients: The PROSPECT-II observational cohort study
Michelle Carmen Paulus, Imre W. K. Kouw, Nienke van Beek-Westeneng, Ilze de Leeuw, Evita C van Lingen, Mirjam Holverda, Bert Strookappe, Arthur R. H. van Zanten
Abstract
BACKGROUND & AIMS: Adequate nutritional intake is suggested to be essential to support rehabilitation and clinical outcomes in intensive care unit (ICU) survivors. However, nutritional intake during the post-ICU rehabilitation period has often been reported to decrease drastically following ICU discharge, with the most significant deficit observed when transitioning to oral food intake. This study evaluates the effect of an individually tailored, stepwise nutrition protocol, aimed at closely matching daily oral and enteral tube feeding intake from ICU discharge to hospital discharge, on daily energy and protein intake levels in post-ICU patients. METHODS: A prospective, observational, single-centre cohort study was conducted at Gelderse Vallei Hospital, the Netherlands, among 70 adult post-ICU patients with an ICU stay of 72 h or longer who received enteral tube feeding at ICU discharge. An individually tailored, stepwise feeding protocol included the gradual reduction of enteral tube feeding, based on the contribution of actual oral food intake (on the previous day) to total prescribed targets, aiming to achieve ≥95 % of the daily prescribed energy and protein goals. Oral and enteral tube feeding intake was quantified daily using digital photography and food record charts. The primary outcomes, energy and protein intake levels (% adequacy to the prescribed goal), were assessed daily throughout hospitalisation. Secondary outcomes included physical performance (Medical Research Council (MRC) sum score, Chelsea Critical Care Physical Assessment (CPAx), and hand grip strength (HGS)) at ICU and hospital discharge, hospital duration, hospital discharge destination, and mortality rates at hospital discharge and 3 months and 6 months post-ICU discharge. Data are mean ± SD, median (interquartile range [IQR]) or number [percentage]). RESULTS: A total of 70 patients were included (median age: 69 [61-74] years; 36 men (51 %)). The overall mean energy and protein adequacy during the first 14 days after ICU discharge averaged 100.2 ± 28.8 % and 97.1 ± 29.0 %, respectively. The median post-ICU hospital stay was 10 days [7-16], during which 50 patients (71 %) weaned from enteral tube feeding to exclusive oral nutrition on the post-ICU hospital ward. At ICU discharge, median MRC sum score was 42 [36-47], CPAx score 25 [18-30], and handgrip strength 14 [9-21] kg; and at hospital discharge, the MRC sum score increased to 48 [44-51], CPAx score to 40 [34-44], and handgrip strength to 20 [14-28] kg (all p < 0.001). In-hospital mortality was 10 % (n = 7), 3-month mortality was 16 % (n = 11), and 6-month mortality was 19 % (n = 13). CONCLUSION: Daily energy and protein adequacy during the first 14 days after ICU discharge was high, reaching >100 % of prescribed energy and >95 % of protein targets, following a personalised, stepwise nutrition protocol in ICU survivors. The effect on clinical and functional outcomes remains to be further investigated.