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Recommendations Summary

CI: Hypocaloric, High Protein Feeding Regimen 2012

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CI: Hypocaloric, High Protein Feeding Regimen

    In obese, critically ill adults, the Registered Dietitian (RD) may consider hypocaloric, high protein feedings. Very limited research in patients primarily receiving enteral nutrition (EN) shows that the effect of hypocaloric, high protein feeding [<20kcal per kg adjusted body weight (ABW) and 2g protein per kg ideal body weight (IBW)] promoted shorter intensive care unit (ICU) stays, although total hospital length of stay (LOS) did not differ. Nitrogen balance was not adversely affected. The effect of this feeding regimen on infectious complications, days on mechanical ventilation, mortality and cost of care is unsubstantiated.

    Rating: Weak
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • Potential risks or harms of hypocaloric, high protein feeding beyond four weeks in obese, critically ill patients are unknown due to very limited evidence in this population
      • Tube feedings often do not reach delivery goal due to interruptions and delays. Underfeeding beyond the level intended may occur and has been associated with negative outcomes. Frequent monitoring and/or adjustment of energy and protein delivery may be required to meet low calorie, high protein EN prescription.  

    • Conditions of Application

      • Only applies to obese, critically ill patients with adequate renal (serum creatinine ≤1.5mg per dL) and hepatic function (serum bilirubin ≤3mg per dL),  as defined by Dickerson et al, 2002 
      • Care must be taken to ensure adequate hydration.

    • Potential Costs Associated with Application

      Costs may be increased with the use of modular protein and/or use of higher protein enteral formula.

    • Recommendation Narrative

      Only one study was included in the evidence analysis for this recommendation:

      • One positive quality retrospective cohort study (Dickerson et al, 2002).

      Impact of Low Calorie, High Protein Feeding in Critically Ill Obese Adults on Mortality

      • One study (Dickerson et al, 2002) provides evidence that the effect of hypocaloric, high protein feeding (<20kcal per kg ABW and 2g protein per kg IBW) on mortality is unclear.

      Impact of Low Calorie, High Protein Feeding in Critically Ill Obese Adults on Infectious Complications

      • One study (Dickerson et al, 2002) provides evidence that the effect of hypocaloric, high protein feeding (<20kcal per kg ABW and 2g protein per kg IBW) on infectious complications is unclear.

      Impact of Low Calorie, High Protein Feeding in Critically Ill Obese Adults on LOS

      • One study (Dickerson et al, 2002) provides limited evidence that hypocaloric, high protein feeding (<20kcal per kg ABW and 2g protein per kg IBW) promoted shorter ICU stays, although total hospital LOS did not differ. Nitrogen balance was not adversely affected.

       Impact of Low Calorie, High Protein Feeding in Critically Ill Obese Adults on Days on Mechanical Ventilation

      • One study (Dickerson et al, 2002) provides evidence that the effect of hypocaloric, high protein feeding (<20kcal per kg ABW and 2g protein per kg IBW) on duration of mechanical ventilation is unclear. 

      Impact of Low Calorie, High Protein Feeding in Critically Ill Obese Adults on Cost of Care

      • There were no studies identified to evaluate impact on cost of care with use of a low calorie, high protein feeding in critically ill obese adults.

    • Recommendation Strength Rationale

      • Grade III evidence is available for the conclusion statements regarding the impact of a low calorie, high protein feeding in critically ill obese adults on:
        • Mortality
        • Infectious complications
        • LOS
        • Mechanical ventilation.  

    • Minority Opinions

      None.