Master Class 2025: Critical Care: Cutting Edge and Beyond the Evidence (MC)-Rice - Critical Care Master Class 2025

Rice - Critical Care Master Class 2025 - Nutrition and Mobilization

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This presentation from the CHEST International Conference (October 2025) explores current evidence and emerging insights on nutrition and mobilization in critically ill patients, focusing on energy and protein delivery, timing, and feeding methods.<br /><br />A 55-year-old male with COPD, diabetes, hypertension, pneumonia, and septic shock illustrates the challenges of critical care nutrition. Key questions include the choice between enteral vs. parenteral feeding, timing initiation (immediate vs. delayed), caloric goals (trophic vs. full feeding), protein dosing, formula composition, and safety monitoring (gastric residuals, GI tolerance).<br /><br />Meta-analyses and large RCTs (e.g., Compher et al. 2022; Reignier et al. 2023) show no significant mortality or ICU length-of-stay benefit from higher versus lower calorie feeding in critically ill adults. Recommendations suggest moderate calorie provision (12-25 kcal/kg/day) during the first 6-10 ICU days, reflecting moderate-quality evidence and a weak recommendation.<br /><br />Regarding protein, guidelines recommend 1.2-2.0 g/kg/day, higher for trauma/burn patients, though evidence is very low quality. A major RCT (Heyland et al. 2023) comparing high (2.2 g/kg/day) versus lower protein doses found no difference in 60-day hospital discharge or mortality, with signals of harm in patients with acute kidney injury (AKI) and high severity scores. Anabolic resistance—impaired muscle protein synthesis despite adequate digestion—may explain limited benefits of increased protein.<br /><br />Further RCTs, including Bels et al. (2024), confirm no clear functional benefit from high protein dosing. Adverse outcomes in subgroups like AKI patients raise caution. Early feeding in shock remains controversial; a 2018 French trial (Reignier et al.) found no mortality difference between early enteral and parenteral nutrition in mechanically ventilated patients on vasopressors.<br /><br />Early mobilization and exercise in ICU appear promising for reducing length-of-stay but interplay with nutrition requires further study.<br /><br />In summary, contemporary evidence supports moderate energy provision and cautious, individualized protein dosing in critically ill patients. Early full feeding is not universally beneficial and may be harmful in subgroups, particularly those with renal dysfunction or shock. Close attention to metabolic phase, organ function, and nutritional tolerance is critical for optimizing outcomes.

Keywords

critical care nutrition

energy delivery

protein dosing

enteral feeding

parenteral feeding

ICU nutrition guidelines

COPD in critical illness

acute kidney injury and nutrition

early mobilization ICU

nutrition timing in sepsis