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Feeding the COVID-19 ventilated patient – challenges and solutions.C. O’Hanlon, Clinical Specialist Dietitian, Beaumont Hospital, Dublin, Ireland.IntroductionSupportive care is the keystone of treatment for patients with COVID-19 infection that develop respiratory failure and require admission to the intensive care unit (ICU). Nutrition support is a vital supportive therapy that requires inclusion in treatment bundles for affected patients.Prolonged ICU admissions are expected. Prone position therapy may be required more frequently in ventilated patients with COVID-19. Longer ICU stays are associated with an enhanced risk of developing malnutrition or worsening of existing malnutrition. Obesity appears to be a frequent co-morbidity in critical care patients with COVID-19. Sarcopenia is common in the obese patient in ICU. Malnourished obese patients tend to have poorer outcomes in general1 and are considered high nutritional risk patients in ICU2.Recent guidelines specific for the nutritional management of COVID-19 patients have been produced by the European Society for Clinical Nutrition and Metabolism (ESPEN)3, the American Society for Parenteral and Enteral Nutrition in conjunction with the Society of Critical Care Medicine (ASPEN/SCCM)4, the British Dietetic Association5 (BDA) and by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN)6. The Irish Nutrition and Dietetic Institute (INDI), and the Irish Society for Clinical Nutrition and Metabolism (IrSPEN) have also produced resources to aid clinicians to provide appropriate nutrition support to COVID-19 patients. In addition, nutrition support guidelines for general ICU patients are available from ESPEN7, ASPEN2, the HSE Critical Care Programme8, and elsewhere. Canadian systematic reviews (2018) on nutritional management of patients in ICU are also available on-line at Challenges MalnutritionChallengeThe mean prevalence of malnutrition risk in patients on admission to Irish hospitals is approximately 30%9,10. In the ICU setting prevalence is closer to 50%11. Malnutrition, particularly in the presence of inflammation, adversely impacts every system in the body12,13. Severe muscle depletion will lead to debilitation and reduced quality of life post-ICU7. The catabolic effect of hormones, inadequate nutritional intake and immobility all contribute to this muscle wasting which can occur more rapidly in the ICU setting.SolutionThe dietitian is considered central to the provision of nutrition support and is best placed to provide nutritional advice to the multi-professional team on the optimal way to manage the nutritional needs of critically ill patients14. The presence of a dietitian is associated with better nutritional management and better application of international guideline principles to nutritional care in ICU.15,16 Nutrition bundles and care pathways should be used to guide initial feeding or out-of-hours feeding. The use of remote reviews is recommended where possible to prevent exposure to and spread of COVID-194,5,6.Although screening for nutritional risk remains valid to identify malnutrition risk3, all ventilated COVID-19 patients should commence feeding early using ESPEN’s pragmatic screening approach7, in that all patients in ICU for >48 hours are considered to be at risk of malnutrition. Early enteral feeding is recommended for ventilated ICU patients with COVID-19, that is, within 24-36hr, using a polymeric enteral feeding formula3,4,5. Fluid limitation may influence feed choice. Energy from non-feeding solution sources should be included in nutritional adequacy calculations. A lower energy, higher protein feed may be more appropriate when significant propofol is prescribed to avoid overfeeding and hypertriglyceridemia. Additional protein supplements may be needed to meet requirements4. Early use of prokinetics should be considered where indicated, but caution is needed in the presence of a prolonged QT interval or when medications are prescribed that are associated with prolonged QT intervals. Continuous rather than bolus feeding is recommended3,4 – using the enteral tube that is already in place4. ASPEN recommends avoiding using gastric residual volumes to check tolerance in these patients4. The BDA5 and AuSPEN6 both recommend using a 300ml cut-off for gastric residuals. Nutritional adequacy should be calculated daily4,5,6, that is, comparing nutrition received to prescribed daily targets. Setting feeding targetsChallengeBoth underfeeding and overfeeding are associated with adverse outcomes in ICU patients7. Refeeding syndrome is associated with poorer outcomes17,18. Risk of refeeding syndrome is expected in those COVID-19 patients who present after a period of anorexia for >5days. SolutionESPEN7 recognises different phases of critical illness to help guide the clinician to targeted nutrition support depending on the phase of illness. Lower energy targets are recommended initially (e.g. ≤15-20kcal/kg) - in recognition of the supply of endogenous energy which can vary in the early acute phase and which is not suppressed by exogenous energy supply. In the late acute phase, which can occur from day 3 onwards, targets are increased to progressively reach full energy and protein targets by the end of the first week, or when safe to do so. This strategy has also been adopted by the HSE Critical Care Programme8. Monitoring is essential to enable appropriate adjustment to nutrition support plans19.Consideration is needed for the possible increased risk of refeeding syndrome in COVID-19 patients. Reduced appetite/PO intake pre-ICU admission is common and refeeding prevention and treatment strategies should be considered in nutrition support plans. Follow local policies, procedures, protocols and guidelines (PPPGs) where available. ESPEN7 provides specific guidance for refeeding risk in ICU. General guidance is provided by IrSPEN20, the National Institute for Health and Care Excellence UK21, and ASPEN22 refeeding syndrome guidelines. All guidelines agree that energy provision should be restricted initially and emphasise the importance of monitoring and replacing electrolytes, either proactive or reactively, depending on the guideline. Feeding the obese patient in ICU presents its own set of challenges. Hypocaloric, high protein feeding is recommended by ASPEN2. ESPEN7 recommends using indirect calorimetry or using adjusted body weight or weight at BMI >25kg/m2 to determine requirements. Insulin resistance and hyperlipidaemia may be more pronounced in these patients and must be reflected in the feeding and monitoring strategy. Risk of refeeding syndrome in the obese should also be considered and where identified, should be managed in accordance with local PPPG or using the guidelines already mentioned.Gastrointestinal (GI) dysfunctionChallengeA cohort of COVID-19 patients will present with GI symptoms including diarrhoea, nausea, vomiting and abdominal discomfort. This may indicate greater disease severity4. Symptoms may also limit the ability to reach even acute phase targets using enteral feeding. Other patients may fail enteral feeding due to persistent tolerance issues. SolutionParenteral nutrition (PN) may need to be considered for patients with significant GI complications related to COVID-19. ASPEN4 encourages early PN for these patients, while ESPEN3 recommends PN only when all reasonable strategies have been used to maximise enteral feeding delivery. AuSPEN6 and BDA5 agree with ESPEN in recommending early use of prokinetics, followed by nasoenteric feeding if feasible, or PN if not feasible. Prone position therapy ChallengeProlonged prone position therapy is a feature of medical management of COVID-19 ventilated patients. Prone positioning may improve oxygenation, while increasing clearance of bronchial secretions4. Restrictive fluid management, risk of aspiration and regurgitation risks need to be balanced with the ability to achieve and maintain nutritional goals5.SolutionThe European Society of Intensive Care Medicine (ESICM) advocates early enteral feeding for patients in the prone position23. ESPEN reinforces that prone position is not a contra-indication to enteral feeding3. Most patients appear to tolerate intragastric feeding when in the prone position4, but some may need post-pyloric feeding if intragastric feeding is unsuccessful3,5. ASPEN recommends using strategies other than post-pyloric feeding (to limit risk of exposure/spread of COVID-19), such as head of bed elevation to at least 10-25 degrees4. PN may be needed if intolerance persists for 72hr or more5. A lower threshold for using PN is advocated by ASPEN4.Rehabilitation post-ICUChallengeProlonged ICU admission is associated with deconditioning and debilitation, with repercussions on quality of life status post-ICU and post-hospital discharge. Cumulative caloric deficits during ICU stay augment these effects. The presence of dysphagia should also be considered. This may be a consequence of prolonged oral intubation for mechanical ventilation24 and can persist beyond the patient’s critical care stay. It is estimated that over 50% of patients who are post-tracheostomy insertion will also suffer from dysphagia25. SolutionAim for adequate feeding per phase of critical illness – avoiding overfeeding in the early acute phase, but seeking to meet requirements after this. Consider nutrition support as a high priority supportive therapy. Calculate daily nutritional adequacy and adjust plans accordingly. Administer adequate protein. Guideline recommendations vary between a range of 1.2 and 2g protein per kg actual weight per day in non-obese patients. Physical activity when possible in combination with nutrition support may help preserve lean body mass2,7. A planned transition from enteral nutrition to oral nutrition support, when appropriate, should be based on individual monitoring. Speech and Language Therapy (SLT) assessment in liaison with the MDT is essential for optimal management of dysphagic patients. Patients may require periods of nil by mouth and full enteral tube feeding, modified oral intake or a combination of oral and enteral tube feeding. Follow-up of patients will be required post-discharge, for example, in MDT outpatient or outreach clinics to assist in patients’ longer term rehabilitation and recovery. ConclusionNutrition support is a vital component of the overall management of COVID-19 throughout the patient journey, and particularly in ICU. Multi-professional co-operation, good communication and remote review where possible are essential components of the nutritional management of patients with COVID-19. Although current available guidelines differ in their detail, they all agree that: early enteral nutrition should commence in ventilated ICU patients including those in prone position (unless there is a clear contraindication); lower targets are set for the early acute phase; persistent underfeeding and early overfeeding should be avoided, and adequacy of nutrition support is important throughout and will significantly impact recovery and rehabilitation.During this unprecedented pandemic, it is clear that nutrition support is a crucial supportive therapy that must be administered appropriately throughout a patient’s admission and in follow-up post-ICU and hospital discharge.ReferencesAgarwal E, Ferguson M, Banks M, Vivanti A, et al. (2018) Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients. Clinical Nutrition Mar 10 Available from: . [Accessed 31 January 2019].McClave SA, Taylor BE, Martindale RG, et al. (2016) Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN, 40 (2), 159-211.Barazzoni R, Bischoff SC, Krznaric Z, Pirlich M, Singer P, endorsed by the ESPEN Council. (2020). ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-COV-2 infection. Clin Nutr, . Martindale R, Patel JJ, Taylor B, Warren M, McClave SA. (2020). Nutrition therapy in the patient with COVID-19 disease requiring ICU care. Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Available from: [Accessed 2 April 2020].British Dietetic Association (BDA) Critical Care Specialist Group. (2020) Guidance on management of nutrition and dietetic services during the COVID-9 pandemic. Available from: . 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