Evaluation of Energy and Protein Intakes and Clinical Outcomes in Critically Ill Patients: Cross-sectional Study

Document Type : Research Paper


1 Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.

2 Department of Nutrition, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran.

3 Research Center for Gastroenterology and Liver Disease, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

4 Faculty of Critical Care Medicine, Lung Disease Research Center, Mashhad University of Medical Science, Mashhad, Iran.

5 Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

6 Assistant Professor of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

7 Social Development and Health Promotion Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.

8 Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.

9 Medical Doctor, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

10 Department of Anesthesiology and Critical Care, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.


Introduction: Critically ill patients admitted to the intensive care unit are often hyper-metabolic, hyper-catabolic, and at malnutrition risk. This study aimed to evaluate the amount of energy and protein intake and its correlation with the required amount in critically ill patients. Methods: A total of 70 patients with critical conditions admitted to the ICU were eligible (age≥18 years and over a 3-day stay in ICU). Basic characteristics, medical history, and laboratory test results were extracted from the patient’s medical records. Anthropometric indicators and the APACHE II questionnaire were assessed. Patients’ energy and protein requirements were 25kcal/kg/day and 1.2g/kg/day, respectively. Results: The mean age in the target population was 57.69±20.81 years, and 48.6% were men. The mean actual energy intake was significantly lower than the requirement (531.27±365.40 vs. 1583.77±329.36 Kcal/day, P˂0.001). The mean actual protein intake was significantly lower than the requirement (14.94±18.33 vs. 74.11±17.89 gr/day, respectively, P˂0.001). Energy and protein provision to the patients had a growing trend over time. There was a significant reverse correlation between the age of patients and total lymphocyte count (r= -0.38, P=0.003). In addition, there was a significant reverse correlation between the Glasgow coma scale and mechanical ventilation duration (r=-0.49, P˂0.001). The lowest average energy and protein intake were in patients with poisoning. Conclusion: The energy and protein intake in critically ill patients is significantly less than recommended, requiring routine nutritional assessments.


Main Subjects

  1. Lew CCH, Yandell R, Fraser RJ, Chua AP, Chong MFF, Miller M. Association between malnutrition and clinical outcomes in the intensive care unit: a systematic review. Journal of Parenteral and Enteral Nutrition. 2017;41(5):744-58.
  2. Patkova A, Joskova V, Havel E, Kovarik M, Kucharova M, Zadak Z, et al. Energy, protein, carbohydrate, and lipid intakes and their effects on morbidity and mortality in critically ill adult patients: a systematic review. Advances in Nutrition. 2017;8(4):624-34.
  3. Martins C, Pecoits-Filho R, Riella M, editors. Nutrition for the post–renal transplant recipients. Transplantation Proceedings; 2004: Elsevier.
  4. Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, et al. Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit. American Journal of Respiratory and Critical Care Medicine. 2017;195(7):906-11.
  5. Yahyapoor F, Keshani M, Sedaghat A, Feizi A, Clark CC, Bagherniya M, et al. The effects of adjunctive treatment with l-carnitine on monitoring laboratory variables in ICU patients: a double-blinded randomized controlled clinical trial. Trials. 2023;24(1):3.
  6. Koekkoek KW, van Zanten AR. Nutrition in the ICU: new trends versus old-fashioned standard enteral feeding? Current Opinion in Anesthesiology. 2018;31(2):136-43.
  7. Wandrag L, Gordon F, O’Flynn J, Siddiqui B, Hickson M. Identifying the factors that influence energy deficit in the adult intensive care unit: a mixed linear model analysis. Journal of Human Nutrition and Dietetics. 2011;24(3):215-22.
  8. Mo YH, Rhee J, Lee E-K. Effects of nutrition support team services on outcomes in ICU patients. Yakugaku Zasshi. 2011;131(12):1827-33.
  9. Gostyńska A, Stawny M, Dettlaff K, Jelińska A. Clinical nutrition of critically ill patients in the context of the latest ESPEN guidelines. Medicina. 2019;55(12):770.
  10. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019;38(1):48-79.
  11. Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, et al. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Medicine. 2017;43:380-98.
  12. Nachvak M, Hedayati S, Hejazi N, Motamedi Motlagh A, Shafizade A, Shojaee M. Nutritional assessment in ICU patients with enteral feeding in Amol hospitals. Razi Journal of Medical Sciences. 2018;24(163):92-104.
  13. Ndahimana D, Kim E-K. Energy requirements in critically ill patients. Clinical Nutrition Research. 2018;7(2):81.
  14. Campbell CG, Zander E, Thorland W. Predicted vs measured energy expenditure in critically ill, underweight patients. Nutrition in Clinical Practice. 2005;20(2):276-80.
  15. Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Critical Care Medicine. 2016;44(2):390-438.
  16. Singer P, Anbar R, Cohen J, Shapiro H, Shalita-Chesner M, Lev S, et al. The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Medicine. 2011;37:601-9.
  17. Gubari MI, Norouzy A, Hosseini M, Mohialdeen FA, Hosseinzadeh-Attar MJ. The relationship between serum concentrations of pro-and anti-inflammatory cytokines and nutritional status in patients with traumatic head injury in the Intensive Care Unit. Medicina. 2019;55(8):486.
  18. van Zanten ARH, De Waele E, Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. Critical Care. 2019;23(1):1-10.
  19. Ahmadinegad M, Karamouzian S, Lashkarizadeh MR. Use of glasgow coma scale as an indicator for early tracheostomy in patients with severe head injury. Tanaffos. 2011;10(1):26.
  20. Jeejeebhoy KN. Permissive underfeeding of the critically ill patient. Nutrition in Clinical Practice. 2004;19(5):477-80.
  21. Looijaard WG, Dekker IM, Beishuizen A, Girbes AR, Oudemans-van Straaten HM, Weijs PJ. Early high protein intake and mortality in critically ill ICU patients with low skeletal muscle area and-density. Clinical Nutrition. 2020;39(7):2192-201.
  22. Patel JJ, Martindale RG, McClave SA. Controversies surrounding critical care nutrition: an appraisal of permissive underfeeding, protein, and outcomes. Journal of Parenteral and Enteral Nutrition. 2018;42(3):508-15.
  23. Weijs PJ, Looijaard WG, Beishuizen A, Girbes AR, Oudemans-van Straaten HM. Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients. Critical Care. 2014;18:1-10.
  24. Zusman O, Theilla M, Cohen J, Kagan I, Bendavid I, Singer P. Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study. Critical Care. 2016;20(1):1-8.
  25. Nicolo M, Heyland DK, Chittams J, Sammarco T, Compher C. Clinical outcomes related to protein delivery in a critically ill population: a multicenter, multinational observation study. Journal of Parenteral and Enteral Nutrition. 2016;40(1):45-51.
  26. Ferrie S, Allman‐Farinelli M, Daley M, Smith K. Protein requirements in the critically ill: a randomized controlled trial using parenteral nutrition. Journal of Parenteral and Enteral Nutrition. 2016;40(6):795-805.
  27. Allingstrup MJ, Kondrup J, Wiis J, Claudius C, Pedersen UG, Hein-Rasmussen R, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Medicine. 2017;43:1637-47.
  28. Casaer MP, Wilmer A, Hermans G, Wouters PJ, Mesotten D, Van den Berghe G. Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. American Journal Of Respiratory And Critical Care Medicine. 2013;187(3):247-55.
  29. Koekkoek WK, van Setten CC, Olthof LE, Kars JH, van Zanten AR. Timing of PROTein INtake and clinical outcomes of adult critically ill patients on prolonged mechanical VENTilation: the PROTINVENT retrospective study. Clinical Nutrition. 2019;38(2):883-90.
  30. Wikjord K, Dahl V, Søvik S. Effects on nutritional care practice after implementation of a flow chart‐based nutrition support protocol in an intensive care unit. Nursing Open. 2017;4(4):282-91.
  31. Elke G, van Zanten AR, Lemieux M, McCall M, Jeejeebhoy KN, Kott M, et al. Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Critical Care. 2016;20:1-14.
  32. Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: an observational study. Clinical Nutrition. 2006;25(1):37-44.