Effect of high-protein peptide-based formula compared with isocaloric isonitrogenous polymeric formula in critically ill surgical patient

Table 1 The study formula (once peptide) at concentration of 1 kcal:1 mL

	Peptide-based formula	Standard formula
Caloric distribution (Protein: Carbohydrate: Fat)	20:45:35	20:52:28
Source of protein	Whey protein hydrolysate (96%); Leucine (4%)	Sodium caseinate (8%); Soy protein isolate (92%)
Source of carbohydrate	Maltodextrin (79%); Potato starch (21%)	Maltodextrin (64%); Sucrose (32%); Fructo-oligosaccharide (4%)
Source of fat	Fish oil (5%); Canola oil (43%); MCT oil (52%)	Rice bran oil (92%); MCT oil (8%)
Osmolality (mOsm/kg H2O)	290	364
Osmolarity (mOsm/L)	242	307

MCT: Medium chain triglyceride.

Table 2 Baseline characteristics of study participants, n (%)/mean ± SD

	Peptide-based formula (n = 9)	Standard formula (n = 10)	P value
Demographic
Age (yr)	60.1 ± 21.6	49.1 ± 26.0	0.333
Gender (Male)	7 (77.8)	9 (90.0)	0.466
Weight (kg)	66.2 ± 14.3	62.6 ± 10.4	0.533
BMI (kg/m2)	24.2 ± 3.1	22.4 ± 3.8	0.275
GCS score	10.7 ± 3.0	10.0 ± 3.1	0.864
SOFA score	4.0 ± 2.0	4.2 ± 2.0	0.769
1Nutrition status assessment
Risk of malnutrition	4 (44.4)	3 (30.0)	0.752
Mild malnutrition	4 (44.4)	5 (50.0)
Moderate malnutrition	0 (0.0)	1 (10.0)
Severe malnutrition	1 (11.1)	1 (10.0)
Biochemistry
Hemoglobin (g/dL)	9.8 ± 2.4	10.1 ± 1.8	0.793
White blood cells count (× 103/μL)	14.8 ± 4.2	15.0 ± 7.5	0.955
Platelets count (× 103/μL)	218.8 ± 112.7	175.5 ± 85.5	0.253
Neutrophils	84.3 ± 8.5	83.5 ± 5.8	0.826
Monocytes	6.3 ± 3.5	7.2 ± 3.8	0.513
Total lymphocytes count (cell/μL)	1267.1± 1164.8	1006.0 ± 1005.6	0.288
Blood urea nitrogen (mg/dL)	22.3 ± 8.7	21.3 ± 20.6	0.327
Creatinine (mg/dL)	1.1 ± 0.4	1.0 ± 0.9	0.102
Urine urea nitrogen	12.0 ± 6.4	15.4 ± 22.2	0.441
GFR (mL/min/1.73 m²)	74.7± 31.6	103.5 ± 35.8	0.082
Fasting plasma glucose (mg/dL)	128.0 ± 26.7	128.1 ± 49.1	0.374
Alkaline phosphatase (U/L)	92.1 ± 41.2	96.3 ± 64.6	0.859
Aspartate transaminase (U/L)	84.5 ± 52.0	104.3 ± 66.5	0.501
Alanine transaminase (U/L)	32.5 ± 26.0	86.8 ± 99.8	0.154
Nutritional status
Albumin (g/dL)	2.6 ± 0.6	2.5 ± 0.5	0.821
Prealbumin (mg/dL)	10.2 ± 5.3	14.1 ± 8.2	0.236
Retinol binding protein (mg/dL)	2.1 ± 1.7	2.0 ± 1.3	1.000

¹Nutrition status were assessed with Bhumibol Nutrition Triage which is endorsed by Society of Parenteral and Enteral Nutrition of Thailand. NT-1 (score 0-4): Normal or risk of malnutrition; NT-2 (score 5-7): Mild malnutrition; NT-3 (score 8-10): Moderate malnutrition; NT-4 (score >10): Severe malnutrition.

BMI: Body mass index; GCS: Glasgow coma scale; SOFA: Sequential organ failure assessment; GFR: Glomerular filtration rate.

Table 3 Subject characteristics

Subject number	Cause of ICU admission	Type of surgery
1	Traumatic subdural hematoma	Non operative management, close neurological observation
2	Acute calculus cholecystitis, adult respiratory distress syndrome	Open cholecystectomy
3	Closed fracture of shaft of right of humerus, closed fracture of right tibia and fibula severe head injury, maxillofacial injury, traumatic subdural hematoma	Open reduction of fracture with internal fixation humerus. Closed reduction of fracture without internal fixation tibia and fibula. Non operative management, close neurological observation
4	AAST grade II liver injury severe head injury, traumatic subdural hematoma thoracic blunt aortic injury	Craniotomy, tracheostomy, thoracic endovascular repair of the aorta
5	Splenic injury grade 5 left hemothorax	Exploratory laparotomy with splenectomy
6	Large gastric ulcer perforation	Exploratory laparotomy, simple suture with omental patch
7	Omental twist causing omental infarction	Exploratory laparotomy, omentectomy with drainage
8	Sigmoid colon diverticulitis with perforation	Exploratory laparotomy c sigmoidectomy with Hartmann operation
9	Gastric ulcer perforation	Exploratory laparotomy, simple suture with omental patch
10	Traumatic subdural hematoma	Craniotomy
11	AAST grade 4 pancreatic injury	Exploratory laparotomy, distal pancreatectomy, total splenectomy
12	Malignant neoplasm of adrenal gland, gallstone	Unilateral adrenalectomy, total cholecystectomy
13	Acute calculus cholecystitis	Laparoscopic cholecystectomy
14	Closed fracture of acetabulum, fracture of right radius and ulnar bones	Open reduction of fracture with internal fixation of radius and ulnar bones
15	Severe head injury, traumatic subdural hematoma	Craniectomy for clot removal
16	Epidural hematoma, fracture zygoma, fracture orbit, fracture rib with hemothorax right	Craniotomy with clot removal, open reduction with internal fixation facial fractures
17	Distal rectal cancer	Abdominoperineal resection
18	Necrotizing fasciitis with septic shock	Debridement right leg
19	Necrotizing fasciitis right leg	Debridement right leg

AAST: The American Association for the Surgery of Trauma; ICU: Intensive care unit.

Table 4 Percentage change of serum fibronectin level, median (25^th-75^th percentiles)

	Peptide-based formula	Standard formula	P value
Day 3 vs Day 1	17.8 (39.5)	17.5 (100.4)	0.790
Day 5 vs Day 1	21.4 (41.9)	63.4 (150.4)	0.290
Day 11 vs Day 1	65.1 (106.8)	59.1 (211.8)	0.641
Day 14 vs Day 1	11.0 (115.6)	80.5 (357.0)	0.157

Table 5 Comparison of anthropometry between peptide-based formula and standard formula, mean ± SD

	Peptide-based formula			Standard formula			P value (compare between group for day 14)
	Day 1	Day 14	P value	Day 1	Day 14	P value
Body weight (kg)	66.2 ± 14.3	65.2 ± 13.1	0.389	62.6 ± 10.4	58.4 ± 10.5	0.037	0.288
BMI (kg/m2)	24.2 ± 3.1	23.0 ± 2.4	0.471	22.4 ± 3.8	20.9 ± 4.1	0.032	0.273
SMI (kg/m2)	18.4 ± 5.0	15.7 ± 3.7	0.139	16.1 ± 3.2	13.6 ± 3.2	0.003	0.419

BMI: Body mass index; SMI: Skeletal muscle mass index.

Table 6 Comparison of duration to achieve goal of calories between peptide-based formula and standard formula, mean ± SD

Day to reach goal	Peptide-based formula	Standard formula	P value
Step 1 (25 kcal/kg/d up)	2.7 ± 0.6	3.8 ± 2.5	0.462
Step 2 (30 kcal/kg/d up)	7.5 ± 3.5	8.5 ± 0.7	0.733