Home | CommonSpirit Health



Nutrition Therapy (Enteral Nutrition) Guidance During COVID-19CommonSpirit Health is committed to improving patient experience, safety and quality. The purpose of this document is to provide guidance in Nutrition Therapy to patients with COVID-19 Disease Requiring ICU Care, as well as pump prioritization. This document is based on recent (April 1, 2020) publication from the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN). Tube Feeding Pump PrioritizationIf there are feeding pump shortages, ICU patients on vent will be prioritized to be fed using a pump.If necessary, feeding pump can be split between 2 patients changed to cyclic feeding, with proper sanitation between each patient (i.e. Pt 1 on 10hrs during the day, Pt 2 on 10hrs at night).Gravity feeding can be used as a last resort, if no feeding pumps are available.Time of Nutrition DeliveryInitiating early enteral nutrition (EN) within 24-36 hour of admission to ICU or within 12 hours of intubation should be the goal.The majority of patients with sepsis or circulatory shock have been shown to tolerate early EN at a trophic rate. (trophic rate = 10-20ml/hr or 500kcal/day).Unless escalating vasopressors (to maintain MAPS > or = 65) combined with EN intolerance with symptoms of ileus are present, COVID-19 disease with shock should not be seen as a contraindication to trophic EN.Route, Tube Placement, and Method of Nutrition DeliveryInfusion of formula into the stomach via 10-12 Fr feeding nasogastric tube. If gastric feeding is unsuccessful due to enteral feeding intolerance, use of a prokinetic agent to enhance motility is recommended as the second step.Post pyloric EN is not recommended.Early PN should be initiated as soon as possible in the high-risk patient for whom early gastric EN is not feasible. If unable to meet 80% of kcal and protein needs after 1 week, then PN should be initiated.Continuous rather than bolus EN is strongly recommended. Cyclic tube feeding can be used, if pumps are limited. Pumps are the preferred method for COVID-19 patients on a ventilator. ?If there are shortages of closed system enteral formulas, open system may be substituted but shorter hang time. Gravity infusion can be done by direct spike sets to the Ready to Hang (RTH) liters or utilize the 8 oz cartons to pour into the gravity bags for infusion. If the patient room allows for pumps to be placed “outside” the room, this should also include the feeding pump and bag set if possible. Consult pharmacy for concerns regarding medication administration. If there are shortages of closed system enteral formulas, open system may be substituted but shorter hang time.Nutrition DoseEnergy goal is 15-20 kcal per kg of actual body weight (ABW), which should be 70-80% of caloric requirements initially. Hypocaloric or trophic feeds and advancing to full dose slowly over the first week of critical illness to meet energy goal. Follow ASPEN guidelines for critical care vent patients.Protein goal is 1.2-2.0 g/kg of ABW per day if BMI <30 or 2g/kg of IBW if BMI >30 (this is a guideline and not a substitute for clinical judgement). Formula SelectionA standard high protein polymeric isosmotic enteral formula should be used in the early acute phase. Considerations of specialty formulas should be evaluated with patients on vasopressor support, GI dysfunction, or other clinical comorbidities. Consider fish oil containing formulations may be of benefit in immune modulation and helping to clear viral infections (Abbott– Pivot 1.5, Vital AF 1.2; Nestle – Impact Peptide 1.5, Peptamen AF 1.2).If receiving high propofol infusion, suggest hypocaloric, higher protein nutrition prescription (Abbott – Vital High Protein, Vital AF 1.2; Nestle – Peptamen Intense VHP, Peptamen AF 1.2).If utilizing PN, suggest limiting soybean oil based lipids or utilizing alternative mixed lipid emulsions, such as SMOF lipids. Monitoring Nutrition ToleranceGastric residual volume (GRV) monitoring is not reliable for detection of delayed gastric emptying and risk of aspiration, has been shown to be a deterrent to the delivery of EN, and should not be utilized as a monitor of feeding tolerance. Prone Positioning Recommend patient requiring prone positioning receive early EN.Recommend keeping HOB elevated (Reverse Trendelenburg) to at least 10-25 degrees.ECMORecommend initiation of early trophic EN with patients on VA or VV ECMO, with slow advancement to goal over the first week of critical illness. For additional information on Nutrition Therapy to patients with COVID-19 Disease Requiring ICU Care, pump prioritization, or questions regarding this communication, please contact Connie Clemmons-Brown, Brenda Downs or Deisell Martinez. Connie Clemmons-Brown MBA, RN, CENPBrenda Downs, MSN, APRN, ACNS-BCSystem SVP Patient Care ServicesSystem Director Acute Care Clinical InstituteNursing, National Office Brenda.Downs@ Connie.ClemmonsBrown@ Deisell Martinez, Ph.D.Food and Nutrition Services Leader for Dignity Facilities?dmartinez@ ReferenceMartindale RG, Patel JJ, Taylor BE, Warren MM, McClave SA; Society of Critical Care Medicine (SCCM); American Society for Parenteral and Enteral Nutrition (ASPEN). Nutrition Therapy in the Patient with COVID-19 Disease Requiring ICU Care. Updated April 1, 2020. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download