102 CHAPTER 6 6.4 DISCUSSION To the best of our knowledge, this is the first study reporting protein and energy intake in the first year of ICU-recovery. In this prospective cohort study, we show that the majority of ICU-patients does not meet the lower limit of protein intake (1.2 g/kg/d) or the advised average daily energy intake (25 kcal/kg/d) as indicated by local protocol during the initial seven days of ICU-admission and also not throughout the first year of recovery. Daily protein intake during ICU-stay was evenworse in patients receiving no enteral or parenteral nutrition. Additionally, only a small proportion visited a registered dietician or SLT in the recovery period, or used dietary supplements. Nevertheless, dietary supplementation in the post-ICU period had a higher protein intake throughout the year and a higher energy intake at 3-months after admission. During ICU-admission, generally, protein intake is to be gradually increased over the first few days to reach a target of 1.2 to 2.0 g/kg/d.19,20 However, our study found that on day seven of ICU-admission, only a small proportion of patients still admitted to the ICU reached this target. In addition, median daily protein intake during the first week of ICU-admission remained below 1.2 g/ kg/d, independent of feeding strategy. Although there are no clear guidelines on post-ICU protein intake, nutritional experts speculate intakes up to 2.5 g/ kg/d may be necessary to support muscle regeneration and general recovery.17 Furthermore, the traditional recommendation for protein intake for healthy elderly people is 1.0 g/kg/d, which increases depending on the level of physical activity.27 A recent Dutch study of 423 ICU-patients found protein intake during the first three days of admission to be 0.7 g/kg/d [0.4-1.0] g/kg/d, which increased to 1.2 (SD 0.3) g/kg/d at day four to seven,28 which is higher compared to our findings. Two of the known barriers for adequate dietary support during hospital stay are the transitional care and consistency in using the feeding tube.29 Our data showed that the use of EN or PN resulted in an increased protein and energy intake during the first week of ICU-admission. However, it is commonly known that feeding tubes are often removed after transfer to a general ward or care facility. A small study described that this often happened without assessment of oral nutritional intake at that moment, leaving the patient vulnerable for insufficient intake.30 The results of barriers for nutritional intake and a lack of continued nutritional care in the hospital may be exacerbated throughout the recovery phase of ICU-survivors.
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