Protein Requirement Changes According to the Treatment Application in Neurocritical Patients

Abstract

Objective: Exploring protein requirements for critically ill patients has become prominent. On the other hand, considering the significant impact of coma therapy and targeted temperature management (TTM) on the brain as well as systemic metabolisms, protein requirements may plausibly be changed by treatment application. However, there is currently no research on protein requirements following the application of these treatments. Therefore, the aim of this study is to elucidate changes in patients' protein requirements during the application of TTM and coma therapy.

Methods: This study is a retrospective analysis of prospectively collected data from March 2019 to May 2022. Among the patients admitted to the intensive care unit, those receiving coma therapy and TTM were included. The patient's treatment period was divided into two phases (phase 1, application and maintenance of coma therapy and TTM; phase 2, tapering and cessation of treatment). In assessing protein requirements, the urine urea nitrogen (UUN) method was employed to estimate the nitrogen balance, offering insight into protein utilization within the body. The patient's protein requirement for each phase was defined as the amount of protein required to achieve a nitrogen balance within ±5, based on the 24-hour collection of UUN. Changes in protein requirements between phases were analyzed.

Results: Out of 195 patients, 107 patients with a total of 214 UUN values were included. The mean protein requirement for the entire treatment period was 1.84±0.62 g/kg/day, which is higher than the generally recommended protein supply of 1.2 g/kg/day. As the treatment was tapered, there was a statistically significant increase in the protein requirement from 1.49±0.42 to 2.18±0.60 in phase 2 (p<0.001).

Conclusion: Our study revealed a total average protein requirement of 1.84±0.62 g during the treatment period, which falls within the upper range of the preexisting guidelines. Nevertheless, a notable deviation emerged when analyzing the treatment application period separately. Hence, it is recommended to incorporate considerations for the type and timing of treatment, extending beyond the current guideline, which solely accounts for the severity by disease.

Keywords: Neurocritical care; Nitrogen balance; Nutrition support; Protein requirement; Urine urea nitrogen.

Fig. 1.

Protein requirements according to neurocritical treatment phases. During the active implementation of targeted temperature management and coma therapy in phase 1, the protein requirement was 1.49±0.42 g/kg/day. However, in phase 2, as the intensive treatment was tapered, it increased to 2.18±0.60 g/kg/day (****p<0.0001). The unit of measurement is g/kg/day.

Fig. 2.

Subgroup analyses of protein requirements based on specific diagnoses. In all subgroup analyses, the trends in phases 1 and 2 were consistent with those observed in the overall patient population. The unit of measurement is g/kg/day (***p<0.001, ****p<0.0001). TBI : traumatic brain injury, SAH : subarachnoid hemorrhage, ICH : intracerebral hemorrhage.