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Protein Prescription & Delivery Practices in Critically Ill Adults: A Survey of Australian & New Zealand Intensive Care Dietitians

Published in Australian Critical Care, September 2021

View online here

In critically ill patients, adequate provision of protein can attenuate muscle loss, which in turn is associated with an improved recovery. While international guidelines recommend a protein intake of ≥1.2g/kg/day, in practice it is often significantly lower than this due to logistical (e.g. nil by mouth) and clinical (e.g. gastrointestinal intolerance) barriers. This study is a survey of Australian and New Zealand (ANZ) intensive care unit (ICU) dietitians and their reported practices relating to protein prescription, perceived delivery and barriers, and associations between ICU clinical experience and practice. 

The survey was a web-based, descriptive, self-administered questionnaire with 3 sections; demographics; nutrition practices; case study. The survey comprised of 28 multiple choice questions, 7 Likert scales and 7 open-ended questions, and had been tested in this population previously. Dietitians were eligible to answer if they practiced in ANZ, had at least 12 months clinical experience in the care of ICU patients and at least 20% of their current workload was managing ICU patients. 

Of the eligible responses (n66, 100% dietitians), the respondents had a mean clinical experience of 13 years with the majority reporting 20-50% of their position being in the ICU. More than 80% of the respondents said they would prescribe 1.2-1.5g/kg/day for 9/15 clinical conditions provided. Nearly all (97%) would prescribe >1.5g/kg/day for patients with major burns. Protein prescription varied for patients receiving haemodialysis, continuous real replacement therapy or those with an open abdomen. The most commonly cited sources of evidence were the ESPEN guideline (92%), ASPEN guideline (70%) and institutional/site recommendations (41%). When asked about barriers to receiving the protein prescription, respondents ‘agreed’ or ‘strongly agreed’ that fasting periods (76%), avoiding calorie overfeeding (76%) and gastrointestinal intolerance (71%) were barriers. 

This data highlights that dietitians from ANZ most commonly prescribe 1.2-1.5g/kg/day of protein for patients in the ICU, in line with international guidelines. What it also highlights is that patients rarely receive their full prescription, therefore achieving protein adequacy may require a multi-disciplinary approach and more definitive evidence to overcome barriers.