Quality of Nutrition in ICU and Subsequent Quality of Life Are Closely Related

The Importance of Nutrition for ICU Patients

Patients in critical condition or after major surgeries can lose up to a kilogram of muscle mass (LBM – lean body mass) per day, with the greatest loss occurring during the first week of ICU hospitalization. Although body weight increases after discharge, much of the gain is fat rather than muscle mass. According to anesthesiologist Prof. Paul E. Wischmeyer, author of the editorial below from the journal Current Opinion in Critical Care, the ABCDE concept, which considers all aspects of ICU patient care, should include the letters F and G: F (feeding) represents the administration of nutrition that, from the very beginning, should have the correct composition and sufficient protein content, and G (gaining function, growing muscle) emphasizes the importance of restoring function and muscle mass.

Proper Timing of Protein Administration

When creating a nutritional plan for ICU patients, it is necessary to consider the metabolic changes that occur in critical conditions. Nutritional needs can vary significantly throughout the illness because, in the initial acute phase, there is massive mobilization of energy reserves. Patients in the early stages of sepsis or severe trauma enter states where the ratio of TEE (total energy expenditure) to REE (resting energy expenditure) is 1.0 in sepsis and 1.1 in trauma, meaning that caloric needs do not significantly increase in the first few days. However, the later phases of the illness and treatment are characterized by a substantial increase in metabolic needs, nearly doubling TEE compared to REE. In the first 24-96 hours, patients should consume fewer calories from non-protein sources, but their nutritional plan should consider that after 24 hours in critical condition, there are significant protein losses.

Recommended Amount of Protein and Focus on Energy Intake Post-Treatment

International surveys show that ICU patients receive an average of 0.6 g of protein/kg/day during the first two weeks, which is only a third to half of the currently recommended values, reaching 1.2-2.0 g/kg/day. Regarding energy intake, a suitable strategy is to consume 15 kcal/kg/day during the acute phase of the illness. Total parenteral nutrition (TPN) or enteral protein supplements are used to achieve these goals. According to several large studies, TPN is a better option to meet the patient's needs without exposing them to the risk of infectious complications due to constantly innovated TPN compositions and various anti-infection measures.

Among patients who receive < 50% of optimal energy and protein intake in the first week of ICU hospitalization, a higher mortality rate is observed compared to those with > 80% of energy needs met. Clinically significant changes in quality of life after ICU hospitalization can be achieved with just a 25% increase in energy needs during the first 8 days in ICU.

Once the acute phase of the illness subsides, total energy and protein intake needs substantially increase. For example, a 70 kg patient who experienced significant weight loss during hospitalization needs an average of 5000 kcal/day for 6 months to 2 years to regain muscle mass and return to their original weight.

Nutrition During Convalescence

Convalescence after an ICU stay can be more complicated for older patients, considering appetite loss, bowel dysfunction related to opioid use, or lack of information about proper diet composition. Post-care should therefore include the administration of oral nutritional supplements (ONS), which contribute to fewer complications, lower mortality, fewer readmissions, and reduced overall treatment costs. Adequate intake of vitamin D, probiotics, and other essential nutrients also play a significant role in convalescence and nutritional care.

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Source: Wischmeyer P. E. Are we creating survivors… or victims in critical care? Delivering targeted nutrition to improve outcomes. Curr Opin Crit Care 2016; 22 (4): 279-284, doi: 10.1097/MCC.0000000000000332.