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Background and Aims: Energy and protein provision for critically ill patients who receive oral nutrition often falls below recommended targets. We compared characteristics and nutrition processes during hospital stay (within and post-intensive care unit [ICU] stay) of those who received oral nutrition as the sole nutrition source to those who first commenced enteral (EN) or parenteral nutrition (PN) within an Australian or New Zealand (ANZ) ICU., Methods: Multicentre, observational study of routine nutrition care in 44 hospitals across ANZ, including adult patients within ICU admitted for at least 48 h. Those receiving oral nutrition as the sole source of nutrition (with or without oral nutrition supplements) were included in the 'oral nutrition' group and those who first received EN and/or PN in the ICU as the 'EN/PN group'. The primary outcome was median daily energy delivery in ICU. Data are presented as number (%) or median [interquartile range]., Results: Of the 409 patients enroled, median [IQR] age was 64 [51-74] years and 257 patients (62%) were male. APACHE II score, use of invasive ventilation and hospital length of stay (LOS) were all lower in those receiving oral nutrition (n = 200) compared to those receiving EN/PN (n = 209). In ICU, 63 (31.5%) and 169 (81%) (p < 0.001), patients who were receiving oral nutrition and in the EN/PN group received a nutrition assessment, respectively. Oral nutrition supplements were provided for 40 (20%) patients in the oral nutrition group and 31 of 94 (33%) of those receiving oral nutrition in the EN/PN group (p = 0.019). Energy and protein intake in ICU for the oral nutrition group was 716 [597-1069] kcal/day and 37 [19-46] g/day versus 1158 [664-1583] kcal/day and 57 [31-77] g/day for those receiving EN/PN (p = 0.020 energy, p = 0.016 protein). Quantification of oral nutrition was attempted in 78/294 (27%) patients in ICU and completed on 27/78 (36%) occasions. On the ward, attempts were made for 120/273 (44%) patients, with 60/120 (50%) complete., Conclusion: Patients who received oral nutrition as the sole nutrition source in ICU had lower illness severity, rates of nutrition assessment and provision of oral supplements compared to those who first received EN/PN. Quantification of oral nutrition was often incomplete for all patients in ICU and on the ward., (© 2024 British Dietetic Association.)

Background: Limited literature exists on nutrition practices for long-stay patients in the intensive care unit (ICU). We aimed to compare nutrition practices in the first and second weeks of an ICU admission., Method: A post hoc exploratory analysis of The Augmented vs Routine Approach to Giving Energy Trial (TARGET) randomized controlled trial (RCT) was undertaken. Inclusion criteria were: enrolled in TARGET on day 1 or 2 of ICU admission and ICU length of stay (LOS) >14 days. Clinical characteristics are described, and nutrition delivery and management compared between days 1-7 and 8-14. Data are n (%), mean ± SD, median (interquartile range [IQR]), or mean difference (MD) and 95% confidence interval (95% CI), with P < 0.05 considered significant., Results: Data from 664 patients were analyzed (56.2 ± 16.3 years; 61% male; body mass index 29.2 ± 7.5 kg/m 2 and APACHE II 21.9 ± 8.1). When comparing days 1-7 to 8-14: (1) energy delivery was greater (all sources: 1826 ± 603 vs 1729 ± 689 (MD: 97 [95% CI: 52-140] kcal/day, P < 0.001) and nonnutrition sources: 317 ± 230 vs 192 ± 197 (MD 125 [95% CI: 111-139] kcal/day; P < 0.001); (2) protein delivery was similar (66 ± 20 vs 68 ± 24 (MD: -1.4 [95% CI: -3.2 to 0.4] g/day; P = 0.125]); and (3) fewer patients received parenteral nutrition (PN) (5% vs 9%, P < 0.001) or small intestine feeding (3% vs 8%; P < 0.001)., Conclusion: In this post hoc analysis, patients with an ICU LOS >14 days had greater energy delivery and fewer patients received PN or small intestine feeding during days 1-7 than days 8-14. Uncertainty remains regarding whether these data reflect usual practice and the clinical implications of this., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Background: Children who are critically ill are often reliant on enteral and oral nutrition support. However, there is limited evidence to guide "what" to prescribe, and current practice is unknown. The primary objective of this study was to describe enteral nutrition prescription in children ≤2 years of age in the pediatric intensive care unit (PICU). The secondary objectives were to describe oral nutrition support practices and factors associated with the use of increased energy and protein density nutrition support., Methods: Children ≤2 years of age admitted to participating PICUs over a 2-week period in June 2021 were enrolled. Data were collected on PICU admission days 1 to 7, 14, 21, and 28 on the mode of nutrition, enteral and oral nutrition support prescription, and dietitian intervention., Results: Eighty-four children were included (49 [58%] male; 79 [94%] ≤1 year of age). Enteral nutrition was administered to 79 (94%) children (with expressed breast milk in 45 [57%]). Forty-three children received formula as enteral nutrition. Increased energy and protein density formulas were provided to 14 (33%) children enterally, with concentrated standard infant formula powder being the most common (5 [12%]). Among children offered oral intake (22; 26%), three (14%) received oral nutrition support. Children who received increased energy and protein density enteral nutrition were more likely to receive dietitian intervention (P = 0.002)., Conclusion: In children ≤2 years of age admitted to PICU, expressed breast milk was provided to half of those requiring enteral nutrition and oral nutrition support prescription was infrequent. One third of children receiving formula via enteral nutrition received an increased energy and protein density feed, and this was strongly associated with dietitian intervention., (© 2024 The Author(s). Journal of Parenteral and Enteral Nutrition published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.)

Objectives: The main aim of this study was to describe nutrition provision in Australian and New Zealand (ANZ) pediatric intensive care units (PICUs), including mode of nutrition and adequacy of enteral nutrition (EN) to PICU day 28. Secondary aims were to determine the proportion of children undergoing dietetics assessment, the average time to this intervention, and the methods for estimation of energy and protein requirements., Methods: This observational study was conducted in all ANZ tertiary-affiliated specialist PICUs. All children ≤18 y of age admitted to the PICU over a 2-wk period and remaining for ≥48 h were included. Data were collected on days 1 to 7, 14, 21, and 28 (unless discharged prior). Data points included oral intake, EN and parenteral nutrition support, estimated energy and protein adequacy, and dietetics assessment details., Results: We enrolled 141 children, of which 79 were boys (56%) and 84 were <2 y of age (60%). Thirty children (73%) received solely EN on day 7 with documented energy and protein targets for 22 (73%). Of these children, 14 (64%) received <75% of their estimated requirements. A dietetics assessment was provided to 80 children (57%), and was significantly higher in those remaining in the PICU beyond the median length of stay (41% in patients staying ≤4.6 d versus 72% in those staying >4.6 d; P < 0.001)., Conclusions: This prospective study of nutrition provision across ANZ PICUs identified important areas for improvement, particularly in EN adequacy and nutrition assessment. Further research to optimize nutrition provision in this setting is urgently needed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: This study aimed to compare recommendations in the American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient with measured energy expenditure in obese, critically ill adults., Methods: After enrollment, measured energy expenditure was attempted at baseline and twice weekly to extubation or day 14. Data are reported as median [interquartile range]., Results: Twenty patients were included. The median baseline and subsequent measured energy expenditures were 2438 [1807-2703] kcal and 2919 [2318-3362] kcal, respectively. Baseline measured energy expenditures were -491 [-788 to -323] kcal lower than subsequent measurements, and week 1 measurements were lower than those of week 2. The median bias between the guideline recommendation of 11-14 kcal/kg of actual body weight and measured expenditure at baseline was -950 [-1254 to -595] kcal/d and -1618 [-1820 to -866] kcal/d at subsequent measurements., Conclusion: Clinically significant variation was observed between measured expenditure and guideline recommendations at all time points., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Aims: To evaluate the effect of energy-dense vs routine enteral nutrition on day-90 mortality by ethnic group in critically ill adults., Methods: Pre-planned subgroup analysis of the 1,257 New Zealanders in a 4,000-participant randomised trial comparing energy-dense enteral nutrition (1.5kcal/mL) with routine enteral nutrition (1kcal/mL) in mechanically ventilated intensive care unit (ICU) patients. The primary purpose of this analysis was to evaluate responses to study treatment by ethnic group (European, Māori, and Pacific Peoples) using ethnicity data recorded in the clinical records. The secondary purpose was to compare the characteristics and outcomes of patients by ethnic group. The primary outcome was day-90 mortality., Results: Among 1,138 patients included in the primary outcome analysis, 165 of 569 (29.0%) assigned to energy-dense nutrition and 156 of 569 patients (27.4%) assigned to routine nutrition died by day 90 (odds ratio; 1.06; 95% CI, 0.92-1.22). There was no statistically significant interaction between treatment allocation and ethnicity with respect to day-90 mortality. Day-90 mortality rates did not vary statistically significantly by ethnic group., Conclusions: Among mechanically ventilated adults in New Zealand ICUs, the effect on day-90 mortality of energy-dense vs routine enteral nutrition did not vary by ethnicity., Competing Interests: Mrs Mackle reports grants from Health Research Council of NZ during the conduct of the study; Dr Ridley reports grants from Baxter Healthcare Corporation, personal fees from Nutricia Australia, personal fees from Baxter Australia, outside the submitted work.

Rationale: The long-term effects of delivering approximately 100% of recommended calorie intake via the enteral route during critical illness compared with a lesser amount of calories are unknown. Objectives: Our hypotheses were that achieving approximately 100% of recommended calorie intake during critical illness would increase quality-of-life scores, return to work, and key life activities and reduce death and disability 6 months later. Methods: We conducted a multicenter, blinded, parallel group, randomized clinical trial, with 3,957 mechanically ventilated critically ill adults allocated to energy-dense (1.5 kcal/ml) or routine (1.0 kcal/ml) enteral nutrition. Measurements and Main Results: Participants assigned energy-dense nutrition received more calories (percent recommended energy intake, mean [SD]; energy-dense: 103% [28] vs. usual: 69% [18]). Mortality at Day 180 was similar (560/1,895 [29.6%] vs. 539/1,920 [28.1%]; relative risk 1.05 [95% confidence interval, 0.95-1.16]). At a median (interquartile range) of 185 (182-193) days after randomization, 2,492 survivors were surveyed and reported similar quality of life (EuroQol five dimensions five-level quality-of-life questionnaire visual analog scale, median [interquartile range]: 75 [60-85]; group difference: 0 [95% confidence interval, 0-0]). Similar numbers of participants returned to work with no difference in hours worked or effectiveness at work ( n  = 818). There was no observed difference in disability ( n  = 1,208) or participation in key life activities ( n  = 705). Conclusions: The delivery of approximately 100% compared with 70% of recommended calorie intake during critical illness does not improve quality of life or functional outcomes or increase the number of survivors 6 months later.

Background: Severe burn injuries are associated with hypermetabolism. This study aimed to compare the measured energy expenditure (mEE) with predicted energy requirements (pERs), and to correlate energy expenditure (EE) with clinical parameters in adults with severe burn injury., Methods: Data were retrospectively analysed on 29 burn patients (median (interquartile range) age: 46 (28-61) years, % total body surface area burn: 37% (18-46%)) admitted to an intensive care unit. Indirect calorimetry was performed on 1-4 occasions per patient to measure EE. mEE was compared with pER calculated using four prediction equations. Bland-Altman and correlation analyses were performed., Results: Mean ± SD mEE was 9752 ± 2089 kJ/day (143 ± 32% of predicted basal metabolic rate). Bland-Altman analysis demonstrated clinically important overestimation for three of the four prediction equations and wide 95% limits of agreement for all equations. Overestimation of EE was more marked early post-burn. mEE correlated with day post-burn (r = 0.42, P = 0.004) and number of operations prior to first EE measurement (r = 0.34, P = 0.016), but not with % total body surface area (r = 0.02, P = 0.9)., Conclusions: Patients with severe burn injury exhibit hypermetabolism. The observed poor agreement between pER and mEE at an individual level indicates the value of indirect calorimetry in determining EE in burn injury., (© 2019 Royal Australasian College of Surgeons.)

Background: Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults., Methods: This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR])., Results: Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m 2 , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement., Conclusions: Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Underfeeding and overfeeding has been associated with adverse patient outcomes. Resting energy expenditure can be measured using indirect calorimetry. In its absence, predictive equations are used. A systematic literature review was conducted to determine the prevalence of underprescription and overprescription of energy needs in adult mechanically ventilated critically ill patients by comparing predictive equations to indirect calorimetry measurements., Methods: Ovid MEDLINE, CINAHL Plus, Scopus, and EMBASE databases were searched in May 2013 to identify studies that used both predictive equations and indirect calorimetry to determine energy expenditure. Reference lists of included publications were also searched. The number of predictive equations that underestimated or overestimated energy expenditure by ±10% when compared to indirect calorimetry measurements were noted at both an individual and group level., Results: In total, 2349 publications were retrieved, with 18 studies included. Of the 160 variations of 13 predictive equations reviewed at a group level, 38% underestimated and 12% overestimated energy expenditure by more than 10%. The remaining 50% of equations estimated energy expenditure to within ±10 of indirect calorimetry measurements. On an individual patient level, predictive equations underestimated and overestimated energy expenditure in 13-90% and 0-88% of patients, respectively. Differences of up to 43% below and 66% above indirect calorimetry values were observed., Conclusions: Large discrepancies exist between predictive equation estimates and indirect calorimetry measurements in individuals and groups. Further research is needed to determine the influence of indirect calorimetry and predictive equation limitations in contributing to these observed differences., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Background: Whilst nutrition is vital to survival in health, the precise role of nutrition during critical illness is controversial. More specifically, the exact amount of energy that is required during critical illness to optimally influence clinical outcomes remains unknown. The aim of this systematic literature review and meta-analysis is to evaluate the clinical effects of optimising nutrition to critically ill adult patients, such that the entire predicted amount of energy that the patient requires is delivered, on mortality and other important outcomes., Methods: A systematic literature review and meta-analysis will be conducted by searching for studies indexed in Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Library. Searches will be restricted to English. Studies will be considered for inclusion if they are a parallel randomised controlled trial investigating a nutrition intervention in an adult critical care population, where one arm delivers 'full predicted energy from nutrition' (defined as provision of ≥80% of the predicted energy required) and the other arm delivers energy less than 80% of the predicted requirement. Two authors will independently perform title screening, full-text screening, data extraction and quality assessment for this review. The quality of individual studies will be assessed using the 'Risk of Bias' tool, and to assess the overall body of evidence, a 'Summary of Findings' table and the Grades of Recommendation, Assessment, Development and Evaluation system will be used, all recommended by the Cochrane Library. Pending the study heterogeneity that is determined, a fixed-effect meta-analysis with pre-defined subgroup analyses will be performed., Discussion: Currently, it is controversial whether optimal energy delivery is beneficial for outcomes in critically ill patients. This systematic review and meta-analysis will evaluate whether delivering optimal energy to critically ill adult patients improves outcomes when compared to delivery of lesser amounts., Systematic Review Registration: PROSPERO CRD42015027512.

Background: Critically ill patients typically receive ∼60% of estimated calorie requirements., Objectives: We aimed to determine whether the substitution of a 1.5-kcal/mL enteral nutrition solution for a 1.0-kcal/mL solution resulted in greater calorie delivery to critically ill patients and establish the feasibility of conducting a multicenter, double-blind, randomized trial to evaluate the effect of an increased calorie delivery on clinical outcomes., Design: A prospective, randomized, double-blind, parallel-group, multicenter study was conducted in 5 Australian intensive care units. One hundred twelve mechanically ventilated patients expected to receive enteral nutrition for ≥2 d were randomly assigned to receive 1.5 (n = 57) or 1.0 (n = 55) kcal/mL enteral nutrition solution at a rate of 1 mL/kg ideal body weight per hour for 10 d. Protein and fiber contents in the 2 solutions were equivalent., Results: The 2 groups had similar baseline characteristics (1.5 compared with 1.0 kcal/mL). The mean (±SD) age was 56.4 ± 16.8 compared with 56.5 ± 16.1 y, 74% compared with 75% were men, and the Acute Physiology and Chronic Health Evaluation II score was 23 ± 9.1 compared with 22 ± 8.9. The groups received similar volumes of enteral nutrition solution [1221 mL/d (95% CI: 1120, 1322 mL/d) compared with 1259 mL/d (95% CI: 1143, 1374 mL/d); P = 0.628], which led to a 46% increase in daily calories in the group given the 1.5-kcal/mL solution [1832 kcal/d (95% CI: 1681, 1984 kcal/d) compared with 1259 kcal/d (95% CI: 1143, 1374 kcal/d); P < 0.001]. The 1.5-kcal/mL solution was not associated with larger gastric residual volumes or diarrhea. In this feasibility study, there was a trend to a reduced 90-d mortality in patients given 1.5 kcal/mL [11 patients (20%) compared with 20 patients (37%); P = 0.057]., Conclusions: The substitution of a 1.0- with a 1.5-kcal/mL enteral nutrition solution administered at the same rate resulted in a 46% greater calorie delivery without adverse effects. The results support the conduct of a large-scale trial to evaluate the effect of increased calorie delivery on clinically important outcomes in the critically ill., (© 2014 American Society for Nutrition.)