DOI: 10.1002/jpen.2620 ISSN: 0148-6071

Association between protocol change to a higher‐protein formula with lower energy targets and nutrient delivery in critically ill patients with COVID‐19: A retrospective cohort study

Kym Wittholz, Chloe Hinckfus, Amalia Karahalios, Haustine Panganiban, Nadine Phillips, Hannah Rotherham, Thomas Rechnitzer, Yasmine Ali Abdelhamid, Adam M. Deane, Kate Fetterplace
  • Nutrition and Dietetics
  • Medicine (miscellaneous)



Guidelines recommend prioritizing protein provision while avoiding excessive energy delivery to critically ill patients with coronavirus disease 2019 (COVID‐19), but there are no prospective studies evaluating such a targeted approach in this group. We aimed to evaluate the effect of a “higher‐protein formula protocol” on protein, energy, and volume delivery when compared with standard nutrition protocol.


This was a retrospective cohort study of adult patients with COVID‐19 who received mechanical ventilation for >72 h and enteral nutrition. Before October 2021, the standard nutrition protocol for patients was 0.7 ml/kg/h ideal body weight (IBW) of a 63 g/L protein and 1250 kcal/L formula. From October 2021, we implemented a higher‐protein formula protocol for patients with COVID‐19. The initial prescription was 0.5 ml/kg/h IBW of a 100 g/L protein and 1260 kcal/L formula with greater emphasis on energy targets being directed by indirect calorimetry when possible. Measured outcomes included protein, energy, and volume delivered.


There were 114 participants (standard protocol, 48; higher‐protein protocol, 66) with 1324 days of nutrition support. The median (95% CI) differences in protein, energy, and volume delivery between targeted and standard protocol periods were 0.08 g/kg/day (−0.02 to 0.18 g/kg/day), −1.71 kcal/kg/day (−3.64 to 0.21 kcal/kg/day) and −1.5 ml/kg/day (−2.9 to −0.1 ml/kg/day). Thirty‐three patients (standard protocol, 7; higher‐protein protocol, 26) had 44 indirect calorimetry assessments. There was no difference in measured energy expenditure over time (increased by 0.49 kcal/kg/day [−0.89 to 1.88 kcal/kg/day]).


Implementation of a higher‐protein formula protocol to patients with COVID‐19 modestly reduced volume administration without impacting protein and energy delivery.

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