A Comparison of High and Usual Protein Dosing in Critically Ill Patients With Obesity: A Post Hoc Analysis of an International, Pragmatic, Single-Blinded, Randomized Clinical Trial

Tweel LE 1 , Compher C 2 , Bear DE 3 , Gutierrez-Castrellon P 4 , Leaver SK 5 , MacEachern K 6 Show all authors , Ortiz-Reyes L 7 , Pooja L 8 , León A 9 , Wedemire C 10 , Lee ZY 11 , Day AG 12 , Heyland DK 13

Affiliations 

  • 1 Clinical and Preventive Nutrition Sciences, Rutgers University, School of Health Professions, New Brunswick, NJ
  • 2 Department of Biobehavioral Health Science, University of Pennsylvania, School of Nursing, Philadelphia, PA
  • 3 Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
  • 4 Department of Biomedical Research, Center for Translational Research, Hospital GEA, Mexico City, Mexico
  • 5 Department of Critical Care Medicine, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
  • 6 Departments of Critical Care and Clinical Nutrition, Mount Sinai Hospital, Toronto, ON, Canada
  • 7 Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
  • 8 Department of Dietetics, Apollo Hospitals Enterprises Ltd, Navi Mumbai, Mumbai, India
  • 9 Department of Clinical Nutrition, Hospital General Dr. Manuel Gea González, Mexico City, Mexico
  • 10 Department of Dietitian Services, Abbotsford Regional Hospital, Abbotsford, BC, Canada
  • 11 Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
  • 12 Kingston Health Science Centre Research Institute, Kingston, ON, Canada
  • 13 Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
Crit Care Med, 2024 Apr 01;52(4):586-595.
PMID: 37930244 DOI: 10.1097/CCM.0000000000006117

Abstract

OBJECTIVES: Across guidelines, protein dosing for critically ill patients with obesity varies considerably. The objective of this analysis was to evaluate whether this population would benefit from higher doses of protein.

DESIGN: A post hoc subgroup analysis of the effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicenter, pragmatic, registry-based randomized trial.

SETTING: Eighty-five adult ICUs across 16 countries.

PATIENTS: Patients with obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m 2 ( n = 425).

INTERVENTIONS: In the primary study, patients were randomized into a high-dose (≥ 2.2 g/kg/d) or usual-dose protein group (≤ 1.2 g/kg/d).

MEASUREMENTS AND MAIN RESULTS: Protein intake was monitored for up to 28 days, and outcomes (time to discharge alive [TTDA], 60-d mortality, days of mechanical ventilation [MV], hospital, and ICU length of stay [LOS]) were recorded until 60 days post-randomization. Of the 1301 patients in the primary study, 425 had a BMI greater than or equal to 30 kg/m 2 . After adjusting for sites and covariates, we observed a nonsignificant slower rate of TTDA with higher protein that ruled out a clinically important benefit (hazard ratio, 0.78; 95% CI, 0.58-1.05; p = 0.10). We found no evidence of difference in TTDA between protein groups when subgroups with different classes of obesity or patients with and without various nutritional and frailty risk variables were examined, even after the removal of patients with baseline acute kidney injury. Overall, 60-day mortality rates were 31.5% and 28.2% in the high protein and usual protein groups, respectively (risk difference, 3.3%; 95% CI, -5.4 to 12.1; p = 0.46). Duration of MV and LOS in hospital and ICU were not significantly different between groups.

CONCLUSIONS: In critically ill patients with obesity, higher protein doses did not improve clinical outcomes, including those with higher nutritional and frailty risk.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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