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Nutritional support is a critical component of care for critically ill patients, impacting their recovery and overall prognosis. Traditional approaches to feeding in the intensive care unit (ICU) have focused on meeting estimated energy requirements, often resulting in unintended consequences such as overfeeding and associated complications. Permissive underfeeding, a concept gaining attention recently, offers a more controlled approach by intentionally providing fewer calories than traditionally recommended. This comprehensive review explores the rationale, evidence, and practical considerations surrounding permissive underfeeding in critically ill patients. We discuss the physiological basis of permissive underfeeding, its potential benefits in mitigating the risks of overfeeding, and the challenges associated with implementation in clinical practice. Through an analysis of critical studies and clinical trials, we evaluate the comparative effectiveness of permissive underfeeding versus traditional feeding methods and examine its impact on patient outcomes. Recommendations for patient selection, monitoring, and future research directions are provided to guide clinicians in optimizing nutritional support strategies for critically ill individuals. By considering the role of permissive underfeeding alongside traditional feeding approaches, healthcare professionals can tailor nutritional interventions to individual patient needs, ultimately improving outcomes in the ICU.

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BACKGROUND: Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU). METHODS: Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed. RESULTS: Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%). CONCLUSIONS: Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.

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BACKGROUND: To determine whether undernutrition affects 60-day mortality in pediatric acute respiratory failure. METHODS: Subjects with acute respiratory failure aged between two months and 13 years were included in the study. The Z-scores were calculated on admission and children were categorized into two groups of undernutrition and normal nutrition. The nutritional intake of the children was measured daily. The outcome was 60-day mortality. RESULTS: A total of 126 patients met the inclusion criteria; 41% were undernourished based on the Z-score of BMI and weight for height, 50% based on the Z-score of height and length for age and 45% based on the Z-score of weight for age. Overall, the 60-day mortality rate was 27.8%. The Cox regression analysis adjusted with PIM2, age and gender, showed that undernutrition has a significant relationship with 60-day mortality based on the weight for age Z-score (HR = 2.33; CI: 1.175-4.638). In addition, undernutrition has a significant relationship with 60-day mortality based on the BMI for age (HR = 3.04; CI:1.070-8.639) and weight for height (HR = 2.62; CI: 1.605-6.658) Z-scores. The mean calorie and protein intake of 72% of the children was less than 80% of their calorie needs. The time to start feeding in 63% of the children was more than 48 h. There was no relationship between the time of starting nutrition and nutritional intake during PICU admission and mortality. CONCLUSION: Undernutrition is prevalent in mechanically ventilated children in the PICU and may be associated with 60-day mortality.

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This research aimed to investigate the effect of refeeding on production, blood biochemical parameters, and reproduction in underfed Kacang goat does. Twelve 2-3-year-old Kacang goats scored (body condition score [BCS]: 1-1.5) with poor body condition but appeared healthy, gave normal births 3-4 months before but no longer nursing their youngs, and anestrus were used in this study. The experiment consisted of 110 days with 14 days of adaptation period and 96 days of feeding treatment and data collection. After the adaptation period, the animals were divided into two groups (A and B), with six animals each. During the first 40 days (underfeeding period), they were fed with kangkong (Ipomoea reptans) straw at a level of 2% of body weight (BW). For the following 56 days (refeeding period), each animal in group A was fed at the level of 4% BW per day while group B was fed at the level of 5% BW per day consisting of 50% kangkong straw and 50% concentrate. Feed intake, average daily gain, body condition, and estrus were assessed in the period of underfeeding and refeeding. Blood samples were collected at the end of the underfeeding and refeeding period for blood biochemical parameter analyses. During the underfeeding period, the animals were anestrous and had poor body condition (BCS: 1.17-1.33) and high serum levels of cortisol, progesterone, and estradiol. Refeeding resulted in a significant increase in BCS (2.75-3.0), restoring estrous cycle, and reduced serum cortisol and progesterone level (p < 0.05). The Kacang goats had good compensatory growth. It could be concluded that refeeding at the level of 4-5% BW would restore undernourished goats' clinical condition, productivity, and reproductive performance after 8 weeks of refeeding.

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Background: Biochemical assessment is considered a useful tool in assessing the patient's nutritional status and intake. However, during critical illness, nutritional biomarkers, such as albumin, and haemoglobin (HB) may reflect the severity of acute illness. The aim of this study is to assess the relationship between energy and protein delivery with the change in albumin, HB, "mean corpuscular volume"(MCV), and "mean corpuscular haemoglobin concentration" (MCHC) levels in critically ill patients. Method: In this prospective observational study we monitored the intake of energy and protein in a group critically ill patients for 6 consecutive days. Biochemical data including albumin, HB, MCV and MCHC was measured on admission and on day 6 of the follow-up. The variation in the biomarkers between admission and day 6 was calculated as the follow-up reading minus the reading obtained upon admission to (Intensive Care Unit) ICU. Results: This study included 43 patients. There was a significant difference in the albumin and HB levels between admission and follow up readings. No statistical association was recorded between the intake and the changes in albumin, MCV and MCHC level during ICU stay. The results showed a significant association between the intake of energy (R = 0.393), and protein (R = 0.385), with the increase in HB level during hospitalisation. Conclusion: Overall, this study showed that most nutritional biomarkers were not influenced by nutritional therapy during the acute phase of illness. These findings may directly undermine the usefulness of the serial measurements of these biomarkers in the early phase of ICU admission.

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OBJECTIVE: The aim of this study was to provide insight into the causes, frequency, and periods of enteral nutrition interruption (ENI) that occur in the intensive care unit (ICU). METHODS: This was a prospective, observational cohort study conducted in the ICU. Demographic data, admission and discharge data, mortality, days of intubation, use of prokinetic drugs, initiation time of enteral nutrition, daily calculated targets of calories and protein, actual daily calories and protein delivered, and duration and causes of ENI were recorded and analyzed. RESULTS: In total, 165 patients were assessed for eligibility during the study inclusion period, 61 of whom were included in our study. Mean age was 60.8 ± 14.3 y, and the majority (41, 67.2%) of participants were men. In the first four study days, approximately 20% of participants had at least one episode of ENI, which gradually decreased until the seventh study day. A total of 115 ENIs occurred in our 7-d follow-up period. The most ENIs occurred in the first 3 d of ICU admission. In the first 4 d, there was a significant difference between mean percentage of goal feeding reached in the ENI group versus the group without periods of ENI (P < 0.001). CONCLUSIONS: The prevalence of unplanned ENIs in ICU patients is highest in the first 3 d of admission. The main cause of ENIs was diagnostic reasons. The ENIs resulted in an average of approximately 25% of patients failing to meet calculated caloric and protein requirements during the first 4 d of admission.

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Calorie restriction regimens are popular for their purported health-promoting effects. However, it is unclear whether chronic reduction in energy intake and subsequent weight loss have beneficial effects in the absence of obesity. To this end, the results of studies that examined the effects of the same diet-induced weight loss in individuals with and without obesity were reviewed. The contribution of lean mass to the total amount of weight lost is greater in participants without obesity than in those with obesity, but the reductions in resting, nonresting, and total energy expenditure are of similar magnitude. Both in the presence as well as in the absence of obesity, weight loss decreases visceral adipose tissue and liver fat, increases insulin sensitivity in skeletal muscle (insulin-mediated whole-body glucose disposal rate) and in adipose tissue (meal-induced or insulin-induced suppression of plasma free fatty acid concentration), and augments insulin clearance rate, without affecting pancreatic insulin secretion. These effects are of similar magnitude in participants with and without obesity and result in reductions in fasting plasma glucose and insulin concentrations. These data suggest that the same degree of calorie restriction and the same amount of weight loss have multiple beneficial effects on health outcomes in individuals without obesity, similar to those observed in individuals with obesity.

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BACKGROUND: Little is known about metabolic and nutrition characteristics of patients with coronavirus disease 2019 (COVID-19) and persistent critical illness. We aimed to compare those characteristics in patients with PCI and COVID-19 and patients without COVID-19 infection (non-CO)-primarily, their energy balance. METHODS: This is a prospective observational study including two consecutive cohorts, defined as needing intubation for >10 days. We collected demographic data, severity scores, nutrition variables, length of stay, and mortality. RESULTS: Altogether, 104 patients (52 per group) were included (59 ± 14 years old [mean ± SD], 75% men) between July 2019 and May 2020. SAPSII, Nutrition Risk Screening (NRS) score, proportion of obese patients, duration of intubation (18.2 ± 11.7 days), and mortality rates were similar. Patients with COVID-19 (vs non-CO) had lower SOFA scores (P = 0.013) and more frequently needed prone position (P < 0.0001) and neuromuscular blockade (P < 0.0001): lengths of ICU (P = 0.03) and hospital stays were shorter (P < 0.0001). Prescribed energy targets were below those of the ICU protocol. The energy balance of patients with COVID-19 was significantly more negative after day 10. Enteral nutrition (EN) started earlier (P < 0.0001). During the first 10 days, COVID-19 patients received more lipid (propofol sedation) and less protein. Higher admission C-reactive protein (P = 0.002) decreased faster (P < 0.001). Whereas intestinal function was characterized by constipation in both groups during the first 10 days, diarrhea was less common in patients with COVID-19 thereafter. CONCLUSION: Compared with non-CO patients, COVID-19 patients were not more obese, had lower SOFA scores, and were fed more rapidly with EN, because of a more normal gastrointestinal function possibly due to fewer non-respiratory organ failures: their energy balances were more negative after the first 10 days. Propofol sedation reduced protein delivery.

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Critical illness leads to significant metabolic alterations that should be considered when providing nutritional support. Findings from key randomized controlled trials (RCTs) indicate that underfeeding (<70% of energy expenditure [EE]) during the acute phase of critical illness (first 7 days of intensive care unit [ICU] admission) may not be harmful and could instead promote autophagy and prevent overfeeding in light of endogenous energy production. However, the optimal energy target during this period is unclear and full starvation is unlikely to be beneficial. There are limited data regarding the effects of prolonged underfeeding on clinical outcomes in critically ill patients, but recent studies show that oral food intake is suboptimal both in the ICU and following discharge to the acute care setting. It is hypothesized that provision of full nutrition (70-100% of EE) may be important in the recovery phase of critical illness (>7 days of ICU admission) for promoting recovery and rehabilitation; however, studies on nutritional intervention delivered from ICU admission through hospital discharge are needed. The aim of this review is to provide a narrative synthesis of the existing literature on metabolic alterations experienced during critical illness and the impact of underfeeding on clinical outcomes in the critically ill adult patient.

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INTRODUCTION: Regulation of endogenous glucose production (EGP) is essential for glucose homeostasis. It includes gluconeogenesis (GNG) from non-carbohydrate substrates and hepatic glycogenolysis. Both these pathways are dysregulated in acute stress, but the magnitude of this deregulation cannot be assessed in clinical practice. The study aims at identifying clinically available variables predictive of EGP and GNG magnitude by modeling routinely available data. METHODS: This exploratory study is based on the data from the Supplemental Parenteral Nutrition study 2 (SPN2), which measured EGP and GNG at days 4 and 10 in 23 critically ill patients. The correlation between EGP and GNG and 83 potential clinical indicators were explored, using single-stage and multivariate analysis. RESULTS: On single-stage analysis, the strongest correlations were noradrenaline dose at day 4 with GNG (R = 0.71; P = 0.0004) and Nutrition risk screening score (NRS) with EGP (R = 0.42; P = 0.05). At day 10, VO2 (R = 0.59, P = 0.04) was correlated with GNG and VCO2 with EGP (R = 0.85, P = 0.00003). Cumulated insulin dose between days 5 and 9 was correlated to EGP at day 10 (R = 0.55, P = 0.03). Our multivariate model could predict EGP at day 4 (VCO2, glucose and energy intake) with an error coefficient (e.c.) between 7.8% and 23.4% (minimal and maximal error), and GNG at day 10 (age, mean and basal blood glucose), with an e.c. of 18.5% and 29.9%. GNG at day 4 and EGP at day 10 could not be predicted with an e.c. < 40%. CONCLUSION: This preliminary exploratory study shows that GNG and EGP have different predictors on days 4 and 10; EGP is more correlated with the metabolic level, while GNG is dependent on external factors. Nevertheless, a bundle of variables could be identified to empirically assess the magnitude of both values. Our results suggest that a robust model might be built, but requires a prospective study including a larger number of patients.

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OBJECTIVES: High-flow nasal-cannula (HFNC) oxygen therapy is increasingly used in the management of respiratory distress. Since this treatment may be required for many days and may impair nutritional intake, this study planned to observe the energy and protein intake of individuals receiving this therapy. METHODS: Forty consecutive patients requiring HFNC oxygenation after extubation or to prevent intubation from November 2017 to June 2018 were included in the study. Demographics, route of nutrition (oral, enteral, or parenteral), calories and protein prescribed and administered, and complications were noted until discharge. Statistical analysis used χ2 or Kruskal-Wallis H test. RESULTS: HFNC oxygen therapy was applied for 42 d in the 40 participants. Overall, individuals with HFNC oxygenation therapy received 449.5 (interquartile range [IQR], 312-850) kcal/d and 19.25 (IQR, 13.9-33.3) g/d protein. Twenty-one participants treated with enteral nutrition received 387 (IQR, 273-931) kcal/d and 18.5 (IQR, 13.9-33.3) g/d protein, whereas those with oral feeding (n = 13) received higher totals of calories, 600 (IQR, 459-850) kcal/d (P = 0.056), and protein, 22 (IQR, 20-45) g/d (P = 0.005). Four participants received parenteral nutrition alone, providing 543 (IQR, 375-886.5) kcal/d and 8.7 (IQR, 0-20) g/d protein. When parenteral nutrition was administered with enteral nutrition, it provided only 324 (IQR, 290-358) kcal/d. Two participants did not receive any nutritional support. The overall length of stay in the intensive care unit was 8 (IQR, 5-17.5) d. Participants receiving enteral nutrition had a longer stay (14 d; IQR, 8-20) than the oral-diet group (4 d; IQR, 2-10; P < 0.03). The rate of intubation after HFNC therapy was not significantly different between the groups (P = 0.586). CONCLUSIONS: Administration of HFNC oxygen therapy was associated with significant underfeeding. In order to reach optimal caloric and protein intake, parenteral nutrition may be considered.

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BACKGROUND: Enteral nutrition (EN) is an essential therapeutic intervention. Many studies internationally have reviewed feeding practices in intensive care units (ICUs) and recorded the incidence of underfeeding in these settings, yet none were performed in the Middle East, including Saudi Arabia. The purpose of the study is to assess the adequacy of EN delivery and investigate the enteral feeding practices in the ICU at a specialized tertiary care hospital in Saudi Arabia. METHODS: In this observational study, we prospectively monitored energy and protein delivery for 6 consecutive days in critically ill patients. Malnutrition was assessed by Nutrition Risk Screening (NRS-2002) scores. Underfeeding was identified by comparing the intake against the calculated requirements. Patients were categorized into early and late EN starters to investigate whether the time of EN initiation impacts the cumulative nutrition intake. RESULTS: This study included 43 patients. About 44% (19 of 43) of the patients were malnourished on admission to ICU, and the prevalence of underfeeding was >90%. The median cumulative intake of energy and protein was 39% and 31% of the estimated requirements, respectively. Patients who started early EN had statistically higher cumulative energy and protein intake (P-value = .00). Patients treated with inotropes received less energy and protein compared with those who did not receive inotropes (P-value = .00). Higher NRS-2002 score was associated with fewer ventilation-free hours (r = -0.369, P-value = .045). CONCLUSION: Protein underfeeding remains a significant problem in ICU settings. The time of EN initiation plays a major role in determining when the nutrition requirements will be met. Therefore, it is crucial to implement effective feeding protocols to ensure early initiation of EN when permissible.

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BACKGROUND & AIMS: Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care. METHODS: This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available. RESULTS: In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001). CONCLUSIONS: The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.

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PURPOSE: We describe a case of severe, prolonged neutropenia in an adolescent girl hospitalized for anorexia nervosa (AN) which occurred during a refeeding procedure in the absence of refeeding syndrome. METHODS: This case report includes retrospective anamnestic, clinical and biological data from the patient's medical record. A literature review was conducted on the haematological changes described in the undernutrition and refeeding periods, and also on recent data for underfeeding syndrome in patients with anorexia nervosa. CONCLUSION: Leuconeutropenia is an adaptive condition observed in undernutrition in AN, usually rapidly and completely reversible in the course of refeeding and weight gain. We describe a rare case of severe, prolonged neutropenia despite appropriate care in the absence of refeeding syndrome and without gelatinous bone marrow transformation. We suggest that neutropenia in adolescent anorexia nervosa could be a stigma of underfeeding syndrome resulting from an overly cautious refeeding strategy. LEVEL OF EVIDENCE: Level V, descriptive study.

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BACKGROUND: Nutritional support in the critically ill aims to avoid under and overfeeding, adjusting to changes in energy expenditure during critical illness. The sedation propofol provides significant fat and energy load. We investigated whether changing from 1% to a 2% propofol, would decrease non-nutritional energy, avoid energy overfeeding and increase the amount of protein delivered. METHODS: A retrospective observational study was performed. The primary outcome was protein delivery. Secondary outcomes were energy from propofol fat and the total energy delivered from nutrition and propofol. RESULTS: In total, 100 patients were investigated, with 50 patients in each group. The propofol dose was comparable for each group. The nutrition energy prescribed was significantly less for the 1% compared to 2% group, taking the energy from propofol into consideration. Both groups had similar protein targets, although the amount delivered was significantly higher in the 2% group. Thirty-six percent of individuals receiving 1% exceeded 45% of total energy from fat. The poor delivery of nutrition resulted in inadequate energy and protein, irrespective of propofol dose. CONCLUSIONS: We investigated the impact of propofol on energy overfeeding and under delivery of protein, and highlighted suboptimal nutritional provision. Work is needed to investigate the harm that high-fat delivery may pose in light of poor nutrition delivery.

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BACKGROUND & AIMS: Identifying the prevalence of underfed patients and risk factors for underfeeding in patients with total parenteral nutrition (TPN) is essential to improve the management of patients receiving TPN. The aim of this study was to examine the prevalence and risk factors for underfeeding using a medical claims database. METHODS: In this retrospective cohort study using a medical claims database, we analyzed patient characteristics, timing and duration of nutrition prescription, daily dose of nutrients, and types of parenteral nutrition products administered after central venous catheter (CVC) insertion in hospitalized Japanese patients between 2009 and 2018. The mean prescriptions of energy <20 kcal/kg/day, amino acids <1.0 g/kg/day, and fat <2.5 g/day received by patients between the 4th and 10th day after CVC insertion were regarded as underfeeding. To study the association between nutritional adequacy and body mass index (BMI) with TPN, the proportions of patients with a prescription of energy ≥20 kcal/kg/day or amino acids ≥1.0 g/kg/day were calculated and categorized according to BMI, and the Cochran-Armitage trend test was performed. RESULTS: Of 54,687 patients included in the study, 70.3% were aged ≥70 years, and 31.3% had a BMI <18.5. The mean prescription of energy was insufficient in 49.9% of patients, and 82.9% were insufficiently prescribed with amino acids. In addition, 44.4% of the patients were never prescribed a single dose of fat emulsion during their hospital stay. On the 10th day after CVC insertion, the majority of patients used commercial 2-in-1 compounds containing carbohydrates and amino acids. A higher BMI was associated with underfeeding of energy and amino acids (both p < 0.001). CONCLUSIONS: It is important to adjust the nutrition dose according to the patient's body size and weight, and it is necessary to supplement inadequate nutrients by single-nutrition solutions in addition to compounded solutions.

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Despite sound basis to suspect that aggressive and early administration of nutritional support may hold therapeutic benefits during sepsis, recommendations for nutritional support have been somewhat underwhelming. Current guidelines (ESPEN and ASPEN) recognise a lack of clear evidence demonstrating the beneficial effect of nutritional support during sepsis, raising the question: why, given the perceived low efficacy of nutritionals support, are there no high-quality clinical trials on the efficacy of permissive underfeeding in sepsis? Here, we review clinically relevant beneficial effects of permissive underfeeding, motivating the urgent need to investigate the clinical benefits of delaying nutritional support during sepsis.

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BACKGROUND: Underfeeding in intensive care patients on enteral nutrition is commonplace and multifactorial. This can be exacerbated by interruptions caused by routine fasting for procedures and investigations. Our study aims to demonstrate that a volume based feeding protocol can overcome the barriers of underfeeding and safely increase energy and protein delivery in UK intensive care patients, potentially improving clinical outcomes. METHODS: In this single centre cohort study, data were collected from adult mechanically ventilated patients. We compared the standard care of rate based feeding, from an International Nutrition Survey (2014/15) to the new intervention of volume based feeding, in a mixed medical and surgical intensive care unit. The primary outcomes were the proportion of energy and protein daily targets delivered. Secondary outcomes compared the effects on gastrointestinal tolerance, glycaemic control, mortality, mechanical ventilation days, length of stay in intensive care unit and hospital. RESULTS: From a total of 82 patients (rate based feeding = 27, volume based feeding = 55), volume based feeding patients received significantly more prescribed energy (52% versus 81%; p < 0.001) and protein (40% versus 74%; p < 0.001). There was no significant difference in gastrointestinal symptoms such as gastric residual volumes (p = 0.62), glycaemic control (p = 0.94) or insulin usage (p = 0.75). Although there was an improvement in energy and protein delivery, there were no differences in mechanical ventilation days (p = 0.12), mortality (p = 0.06), length of stay in intensive care unit (p = 0.93) and hospital (p = 0.72) between the groups. CONCLUSION: Compared to rate based feeding, volume based feeding significantly improved energy and protein provision with no adverse effects on glycaemic control or gastrointestinal tolerance, clinical outcomes were not affected.

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BACKGROUND: Although mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge. METHODS: This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey. RESULTS: Based on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis. CONCLUSIONS: During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a "victim" of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.

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Metabolic alterations in the critically ill have been studied for more than a century, but the heterogeneity of the critically ill patient population, the varying duration and severity of the acute phase of illness, and the many confounding factors have hindered progress in the field. These factors may explain why management of metabolic alterations and related conditions in critically ill patients has for many years been guided by recommendations based essentially on expert opinion. Over the last decade, a number of randomized controlled trials have been conducted, providing us with important population-level evidence that refutes several longstanding paradigms. However, between-patient variation means there is still substantial uncertainty when translating population-level evidence to individuals. A cornerstone of metabolic care is nutrition, for which there is a multifold of published guidelines that agree on many issues but disagree on others. Using a series of nine questions, we provide a review of the latest data in this field and a background to promote efforts to address the need for international consistency in recommendations related to the metabolic care of the critically ill patient. Our purpose is not to replace existing guidelines, but to comment on differences and add perspective.

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