NEW PERSPECTIVES ON PROTEIN INTAKES

Interview with Paul Wischmeyer M.D. by Anne Ruizendaal, Nestlé Health Science.

From the Metabolic and Nutritional Issues in the ICU Workshop – 29-30 May 2018, Brussels, Belgium.

AR: Professor Paul Wischmeyer, today we heard about different insights in protein intake. high, low, something in between in the first phase of ICU admission. What are your thoughts about it, and what are your take home messages for your colleagues?

PW: Sure, so I think the data on protein delivery in the first week, the acute phase, of ICU stay are evolving. And I think one of the things we’re learning is perhaps the very early aggressive protein delivery greater than let’s say a 1g/kg in the first 72 hours of ICU stay may not be needed and may have risks associated with it. And then subsequent to that though I think our data continues to grow, that there are stronger signals that getting to protein goals of 1.2 to 2g/kg after day three seems to be associated, at least in large observational trials, with improved outcomes, improved survival, and other improved, meaningful outcomes in patients. But I think the key take home message is…and many, many years of doing survey data people’s practices and others and seeing that data, most of us never reach these goals. The average protein delivery in the first 12 days of ICU stay has remained at 0.6g/kg/day, which is far below any guideline or any recommendation, it’s a third of the guideline, and so I think the message that people should take away is not to reduce the protein they’re delivering, but to do as they often have done and ramp up your feeding whether it be calories or protein over the first three days, especially as the patient gets more stable, and then get to goal protein of above 1.2g/kg/day as you reach day three, and that’s a very reasonable goal to achieve.

AR: Okay. Yeah, and we saw already the ESPEN guidelines, the preliminary ones that are going up to 1.2 or 1.3.

PW: Yep, yep.

AR: Okay, regarding the very nice presentation on the micro-biome, for me it’s a thing, do you recommend probiotics for routine use in the ICU?

PW: I don’t know that I would say when it comes to probiotics in the ICU that we should say they should be routine, but I think what they are showing is there are signals both in well done individual trials and in our meta-analyses for probiotics reducing the risk of infection, particularly it appears ventilator associated pneumonia may be a good target of an infection that can be intervened on with probiotics. I think the lead paper in The Blue Journal from a number of years ago, the American Journal of Respiratory and Critical Care Medicine, showed us in a well designed NIH funded trial that lactobacillus GG, one capsule smeared in the mouth, one given down a feeding can reduce ventilator associated pneumonia by about half. I think that should be done with some caution, you don’t want to give it to patients who have indwelling new vascular grafts, indwelling new hard wear, although it may prove to be safe we don’t have enough information to say it is, but I think in other patients who don’t have some of these other limitations and that paper has excellent listings of who should and who shouldn’t receive probiotics. I think we should be very encouraged that we can do great benefit. I think we can also benefit antibiotic associated diarrhoea and we have analysis data in may thousands of patients we can reduce the C diff colitis or the colostrum ulcerative colitis rates and I think the most telling paper of all that shows us the future is this large paper in Nature that studied over 4000 full term newborns in India and showed significant reductions in  respiratory infection, sepsis, from a lack of probiotic and prebiotic combination formula.

AR: Okay. Of course, that was another question. How do you feel about the prebiotics and the combination of pre and probiotics?

PW: So I think the fact that that large trial of over 4000 infants, again published in Nature, showed us a benefit of a probiotic-prebiotic combination, an FOS combination, says that there’s likely to be a role for prebiotics and I think we need to continue to increase our data in the ICU for prebiotics. Actually we at Duke are doing a trial right now on the role of prebiotics versus standard formula, non prebiotic containing formulas in microbiome outcomes and does it affect the makeup of the microbiome over time.

AR: Okay. Thank you so much.