title: Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates.
abstract: BACKGROUND
  Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP.
  
  
  METHODS
  This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes.
  
  
  RESULTS
  EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%).
  
  
  CONCLUSIONS
  In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA s.dijkink@lumc.nl.
authors.forename: Suzan
authors.initials: S
authors.lastname: Dijkink
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Eva
authors.initials: E
authors.lastname: Fuentes
authors.affiliation: Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Sadeq A
authors.initials: SA
authors.lastname: Quraishi
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Catrina
authors.initials: C
authors.lastname: Cropano
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Haytham M A
authors.initials: HM
authors.lastname: Kaafarani
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Jarone
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: King
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: DeMoya
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Fagenholz
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Butler
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Daniel Dante
authors.initials: DD
authors.lastname: Yeh
mesh_terms: D000368:Aged; D003422:Critical Care / Q000379:methods / Q000706:statistics & numerical data*; D004044:Dietary Proteins / Q000008:administration & dosage / Q000032:analysis; D002149:Energy Intake; D004750:Enteral Nutrition / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D044342:Malnutrition / Q000453:epidemiology / Q000209:etiology*; D008875:Middle Aged; D009752:Nutritional Status; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D004044:Dietary Proteins
keywords: caloric deficit; clinical protocols; critical illness; enteral nutrition; feeding protocols; intensive care units; nutritional support