C.-P. Heidegger

We Support Elevated Protein Requirements in the Intensive Care Unit but Need New Solutions

We read with great interest the excellent review on elevated protein requirements in critically ill patients, including recommendations for future research in this field published in the April issue. Indeed, protein requirements remain a debated issue, although the data are accumulating in favor of requirements ranging between 1.5 and 2 g/kg/d, and we entirely agree with the positions expressed by the authors. We thank John Hoffer for stating that “the Heidegger article is terrific” but react to the affirmation that “the article text barely mentions protein” and “they didn’t give enough protein or even devote much attention to it.” This is inaccurate! Due to the limited space in the Lancet journal, we were requested to cut the text extensively, which ended with too little space for this important information, as we had to focus on the main end point (infectious complications). We never published the protein data and would like to fill this gap. Briefly, the randomized Swiss supplemental parenteral nutrition study recruited on day 3 patients who were still critically ill enough to require further several days of ICU treatment and who were receiving insufficient enteral feeding (despite a normal gut function), defined as <60% of calculated target (25 kcal/kg/body weight [BW]). Intervention was guided by indirect calorimetry after day 3. The protein target was 1.2 g/kg/BW (90 g/d as a mean; see Figure 1). But we did not achieve this target because we were using industrial triplechamber bags with a fixed amount of protein, without added glutamine. Nevertheless, the intervention group received 81%–93% of this target (ie, 0.95–1.1 g/kg), while control patients received significantly less with 56%–63% (0.55–0.7 g/kg; P < .001). This dose is among the highest tested until 2013 and certainly contributed to the better outcome. Why not more? Because another aim was to avoid exceeding the measured energy expenditure, which was about 100 kcal/d lower than the equation prediction. Achieving protein target while not overfeeding is a conundrum with the until now available commercial nutrition solutions. This lack of nitrogen might actually be an argument for completing the bags with the missing glutamine at nutrition doses and for designing trials according to the recommendation by Hoffer et al. We hope these data will support the evolution toward patient-adapted solutions. Mette M. Berger, MD, PhD Service of Intensive Care and Burns, Lausanne University Hospital, Lausanne, Switzerland Claudia P. Heidegger, MD Service of Intensive Care, Geneva University Hospital, Geneva, Switzerland Claude Pichard, MD, PhD Nutrition Unit, Geneva University Hospital, Geneva, Switzerland

Epidural analgesia in critically ill patients with acute pancreatitis: the multicentre randomised controlled EPIPAN study protocol

Background Acute pancreatitis (AP) is associated with high morbidity and mortality in its most severe forms. Most patients with severe AP require intubation and invasive mechanical ventilation, frequently for more than 7 days, which is associated with the worst outcome. Recent increasing evidence from preclinical and clinical studies support the beneficial effects of epidural analgesia (EA) in AP, such as increased gut barrier function and splanchnic, pancreatic and renal perfusion, decreased liver damage and inflammatory response, and reduced mortality. Because recent studies suggest that EA might be a safe procedure in the critically ill, we sought to determine whether EA reduced AP-associated respiratory failure and other major clinical outcomes in patients with AP. Methods and analysis The Epidural Analgesia for Pancreatitis (EPIPAN) trial is an investigator-initiated, prospective, multicentre, randomised controlled two-arm trial with assessor-blinded outcome assessment. The EPIPAN trial will randomise 148 patients with AP requiring admission to an intensive care unit (ICU) to receive EA (with patient-controlled epidural administration of ropivacaine and sufentanil) combined with standard care based on current recommendations on the treatment of AP (interventional group), or standard care alone (reference group). The primary outcome is the number of ventilator-free days at day 30. Secondary outcomes include main complications of AP (eg, organ failure and mortality, among others), levels of biological markers of systemic inflammation, epithelial lung injury, renal failure, and healthcare-associated costs. Ethics and dissemination The study was approved by the appropriate ethics committee (CPP Sud-Est VI). Informed consent is required. If the combined application of EA and standard care proves superior to standard care alone in patients with AP in the ICU, the use of EA may become standard practice in experienced centres, thereby decreasing potential complications related to AP and its burden in critically ill patients. The results will be disseminated in a peer-reviewed journal. Trial registration number NCT02126332.

SUN-PP069: Energy Expenditure (EE) in Mechanically Ventilated Patients: Espen Equation Using Different Body Weights (BW) Vs. Indirect Calorimetry (IC)

Methods All mechanically ventilated patients staying >72h in ICU, with Fi02 < 60%, PEEP < 9cmH2O, no pulmonary fistula or lung multi-resistant bacteria were included and had IC measurement. We calculated EE with the ESPEN equation (20-25 kcal/kg acute phase and 25-30 kcal/kg post-acute phase), using several BW: anamnestic (BWAN), measured (BWMES), adjusted for water balance (BWADJ) and ideal BW calculated for a body mass index of 22.5 and 25 kg/m. Results are presented as mean ± SD. Calculated EE was compared to EE measured by IC, with ANOVA repeated measure and Bonferroni posthoc test, as well as Bland-Altman analysis.

PP013-SUN DIARRHEA IN THE INTENSIVE CARE UNIT (ICU): RESPECTIVE CONTRIBUTION OF FEEDING AND ANTIBIOTICS

PP012-SUN Outstanding abstract ASSOCIATION BETWEEN PLASMA AND ERYTHROCYTE COPPER LEVELS, AND ANTIOXIDANT STATUS IN CRITICALLY ILL PATIENTS WITH SYSTEMIC INFLAMMATORY RESPONSE SYNDROME E.M. Planells1, L. Saez2, J. Molina-Lopez2, D. Florea2, M. Navarro2, B. Quintero3, C. Cabeza3, A. Perez de la Cruz4, M. Rodriguez Elvira5. 1Physiology, University of Granada, Otura, Granada, 2Physiology, 3Phisico-Chemical, University of Granada, 4Unidad Nutricion y Dietetica, 5Unidad Cuidados Intensivos, Hospital Virgen de las Nieves, Granada, Spain

Reply to the comments by Drs. Marik and Emery and Dr. Singer

Sir: We would to like to thank Dr. Singer for his correspondence. The point is extremely well taken, and we share the view that accurately measuring metabolic expenditures is an important goal. We want to emphasize the lack of randomized controlled trials demonstrating the effectiveness of this approach in the critical care setting. Although it is true that the caloric targets may be inaccurate based on prediction formulas instead of measurement with calorimetry, it is very common in critically ill patients to lag behind for several days before achieving an adequate caloric intake, and in most cases a caloric deficit develops. Therefore even if the caloric goal is not established precisely, the risk of underfeeding is particularly high at least in the first few days after admission to the ICU. With the use of supplemental nutrition particular attention should be paid to prevent excessive caloric intake. We also thank Drs. Marik and Emery for their commentary. It seems that in fact their views and ours are very close. As the authors mention, the Canadian guidelines recommend to maximize the EN before administrating PN, and this is exactly what we propose in our clinical commentary (see Fig. 1). Indeed, we recommend that supplemental PN be considered only if protein and calorie targets are not reached by the enteral route at day 4. This proposal is also in line with the recently published ESPEN guidelines (Clinical Nutrition, 2006). The various studies cited in favor of “permissive underfeeding” are definitively not in line with the recommendations mentioned above. Many studies have demonstrated that the ICU patient population is at greater risk of underfeeding than “eufeeding”, and in our opinion targeting prolonged underfeeding must not be a recommendation in this population. Finally, and this is probably the most important point, we have also mentioned that a well conducted prospective clinical trial is needed to confirm this approach of combined nutrition.