130 CHAPTER 7 delivery and lower mortality in patients with low skeletal muscle surface area.17,82 However, in this review, four RCTs which reported nutritional assessment that identified patients at high risk for malnutrition at baseline, found no causal effect of enhanced protein delivery on outcomes.50,54,55,58 In addition, due to the lack of reporting baselinemeasurements regarding physical functioning, muscle health or nutritional status, we were unable to identify sufficient information on patients who might benefit more or less from protein and exercise interventions, from both RCTs and NRSI. Earlier research showed that in 2013, only 1.8-3.3% of published RCTs concerning critically ill patients reported QoL outcomes.83 Despite the increased attention of QoL in ICU-survivors,84 the use of QoL outcomes remained limited since only two studies reported these outcomes in ICU-survivors.50,57 The results of this review need to be interpreted with caution since there are certain limitations. The reviewers were frequently unable to identify a significant difference in protein recommendation or delivery which resulted in a moderate agreement in some parts of the selection process. Several studies used “standard care” as the comparator group, but did not clearly define the target amount of protein, delivered protein, or content of EN formula used. In addition, discrepancy was found between the aim of the study and the final target protein requirements set. This made it sometimes unclear whether studies met eligibility criteria in an early stage. To resolve these issues, an attempt was made to contact the authors of the studies to ask for clarification. Next, the results were deliberated by two reviewers until consensus was reached. Furthermore, pooling of the results to perform meta-analysis was not appropriate because of heterogeneous interventions, study methodologies, and a small number of studies that provided similar outcome measures. For future research several aspects must be considered to make an effort to improve nutritional and exercise intervention studies. First, a patients’ health status (nutritional status, physical functioning) must be taken into account to contribute to the direction regarding treatment plans. Second, it is important to recognise and mark the different metabolic phases during critical illness which might influence patients’ ability to respond to nutrition and exercise therapy.85 Third, measurements for physical functioningmust be used, which are appropriate during ICU-admission and after discharge, tailored to the ability of the patient to perform physical tests. Understanding and acting on these points of attention, could be of major advantage in improving outcomes in ICU-survivors.
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