Nutritional therapy in hospital care of in-patients with Covid-19: evidence, consensus and practice guidelines

WEBER, Thabata Koester; LEANDRO-MERHI, Vânia Aparecida; BERNASCONI, Isabela; OLIVEIRA, Maria Rita Marques de

doi:10.1590/1678-9865202033e200212

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THEMATIC SECTION HUNGER, FOOD AND NUTRITION AND COVID-19 • Rev Nutr 33 • 2020 • https://doi.org/10.1590/1678-9865202033e200212 copy

Nutritional therapy in hospital care of in-patients with Covid-19: evidence, consensus and practice guidelines

Terapia nutricional na atenção hospitalar de pacientes hospitalizados com Covid-19: evidências, consensos e guias de práticas

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

The objective of this work was to review papers that deal with nutritional therapy of inpatients with Covid-19 from the beginning of the pandemic. The survey covered the period until the month of September 2020.

Methods

This is a review of the indexed literature (Scopus, Pubmed and Lilacs), including area consensus.

Results

The review showed that the initial recommendations were based on generic assumptions and, as specific knowledge was being produced, the recommendations became more targeted.

Conclusion

In the health crisis generated by Covid-19, in the context of uncertainties related to nutritional care procedures, knowledge and action strategies were generated, coordinated by researchers and health professionals.

Keywords
Coronavirus infection; Nutritional status; Nutrition therapy

Study Title	Study type and design	Objective	Highlights
Nutritional management of the critically ill inpatients with Covid-19. A narrative review [¹⁴14 González-Salazar LE, Guevara-Cruz M, Hernández-Gómez G, Zúñiga AES. Nutritional management of the critically ill inpatient with COVID-19: a narrative review. Nutr Hosp. 2020;34(3):622-30. https://doi.org/10.20960/nh.03180 https://doi.org/10.20960/nh.03180... ].	Narrative review	Indicate nutritional requirements and nutritional support in Covid-19 critical patient.	Patient with non-invasive ventilation: Oral nutritional supplement (hypercaloric and hyperproteic): intake <60% of EE/2 days. Enteral nutrition: insufficient intake for more than 5 days.
			Patient with invasive mechanical ventilation: Hypocaloric EN 15-20Kcal/kg/day (10-20mL/h) with slow progression up to 75% EE on the 3^rd day. Control of potassium, phosphorus and magnesium serum levels. Isocaloric EN 25-30Kcal/kg/day after the 5^th day (>80% EE). Proteins: 1.2-2.0g/kg/day. Obese: 1.3g/kg of adjusted weight/day.
			Post ventilation: Hypercaloric diet (30-35Kcal/kg/day) and hyperproteic diet (≥2.0g/kg/day).
			Patients at risk for refeeding syndrome: Start with 25% of the EG and slow progression after 72 hours. Phosphate, potassium and magnesium monitoring.
Relevant nutrition therapy in Covid-19 and the constraints on its delivery by a unique disease process [¹⁵15 Patel JJ, Martindale RG, McClave SA. Relevant nutrition therapy in COVID-19 and the constraints on its delivery by a unique disease process. Nutr Clin Pract. 2020;35(5):792-9.].	Narrative review	Describe practical and relevant recommendations on how to optimize nutritional therapy in critically ill patients and patients with Covid-19.	Early EN: 24h to 36h of admission to the ICU/up to hours of intubation and setting of mechanical ventilation.
			Use of standard isosmotic polymeric formula. Formula with fibers after tolerance to EN is established.
			Suspension of EN: ↑lactate level or hemodynamic instability with the need to increased vasopressor support.
			Low dose trophic EN slow progression in 1 week: 70-80% of caloric requirement (15-20Kcal/kg of current weight/day). Proteins: 1.2 to 2.0g/kg/day.
			Obese: BMI 30-50Kg/m²: 11 to 14Kcal/kg of current weight/day BMI >50Kg/m²: 22 to 25Kcal/kg of current weight/day Grade I and II obesity: 2.0g of protein/kg of ideal weight/day. Grade III obesity: 25g of protein/kg of ideal weight/day.
			Early PN: indicated when EN is not feasible in high nutritional risk patients, malnourished, prolonged ICU stay and significant gastrointestinal intolerance. Limit the use of soy-based lipid emulsion in the first week. Delay onset of PN by 5 to 7 days in the low-risk patient.
Nutritional support in the setting of persistent inflammation, immunosuppression, and catabolism syndrome [¹⁶16 Rosenthal MD, Brakenridge S, Rosenthal CM, Moore FA. Nutritional support in the setting of persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Curr Surg Rep. 2016;4:32. https://doi.org/10.1007/s40137-016-0152-3 https://doi.org/10.1007/s40137-016-0152-... ].	Review	Identify potential therapies in support of: Chronic critical illness and Persistent Inflammation, Immunosuppression, Catabolism Syndrome	There is a need for prospective studies to assess the benefits of nutritional therapy with w-3, arginine and leucine.
Protocol Nutritional Support in Coronavirus 2019 Disease [¹⁷17 Stachowska E, Folwarski M, Jamioł-Milc D, Maciejewska D, Skonieczna-Zydecka K. Protocol nutritional support in coronavirus 2019 disease. Medicina. 2020;56:289. https://doi.org/10.3390/medicina56060289 https://doi.org/10.3390/medicina56060289... ].	Review	Indicate nutritional recommendations for Covid-19, considering the nutritional therapy indicated for patients with viral and bacterial pneumonia and critical patients.	Critical patients: ESPEN and ASPEN recommendations.
			Patients with mild symptoms of Covid-19: Nutritional support, especially for advanced age or with polymorbidity patients.
			Recovered individuals: maintenance of dysphagia tracking and nutritional status.
			Probiotics: patients using antibiotic therapy with gastrointestinal symptoms could benefit from using probiotics. However, there is a lack of scientific evidence for such prescription in a Covid-19 infection.
Nutrition of the Covid-19 patient in the intensive care unit: a practical guidance [¹⁸18 Thibault R, Seguin P, Tamion F, Pichard C, Singer P. Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance. Crit Care. 2020;24:447. https://doi.org/10.1186/s13054-020-03159-z https://doi.org/10.1186/s13054-020-03159... ].	Review	Review nutritional recommendations for nutritional therapy for critically ill patients, aiming to help health professionals working in the ICU, to manage the patient infected by Covid-19.	Prevent refeeding syndrome: monitor and administer magnesium, phosphate, vitamins and trace elements in the first 3 days of EN or PN.
			Early onset of EN (48h), always in a prone position.
			If EN is impossible, contraindicated or insufficient: Individualized NPT. Gradual progression of the diet of 10, 15, 20 and 25Kcal/kg/day, respectively on the 1^st, 2^nd, 3^rd and 4^th day.
			Nutritional requirements: 25Kcal/Kg/day and 1.3g of protein/Kg/day (consider current weight for patients with BMI <30kg/m² and ideal weight for obese patients BMI≥30kg/m²).
Nutrition management for critically and acutely unwell hospitalized patients with Covid-19 in Australia and New Zealand [⁹9 Chapple LS, Fetterplace K, Asrani V, Burrell A, Cheng AC, Collins P, et al. Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand. Aust Crit Care. 2020;33(5):399-406. https://doi.org/10.1016/j.aucc.2020.06.002 https://doi.org/10.1016/j.aucc.2020.06.0... ].	Guideline	Guidelines for nutritional support of patients infected with Covid-19 during the pandemic.	Possibility for oral diet: high energy density and protein. Consider using an oral supplement and request food registration.
			Impossibility of oral diet or intubation: Assessment of nutritional risk and constant nutritional outcome. EN in the first 24h, via NGT continuous infusion, 1.25Kcal/mL at 50mL/h or 1.5 kcal/mL at 40mL/h.
			Assess residual gastric volume of all patients, especially in the prone position (every 8h) and indicate the use of prokinetics if GRV >300mL. Without altering the intervention, post-pyloric enteral tube or SPL should be considered.
			Nutritional assessment to evolve the infusion of the diet or consider a target of 25Kcal/kg of weight/d, first days, if evaluation is not possible. Increase of the target to 25-30Kcal/kg/day after 5 days.
Easy-to-prescribe nutrition support in the intensive care in the era of Covid-19 [¹⁹19 Watteville A, Genton L, Barcelosc GK, Pugin J, Pichard C, Heidegger CP. Easy-to-prescribe nutrition support in the intensive care in the era of COVID-19. Clin Nutr Espen. 2020;(39):74-8. https://doi.org/10.1016/j.clnesp.2020.07.015 https://doi.org/10.1016/j.clnesp.2020.07... ].	Clinical study	Develop and evaluate pragmatic nutritional protocol in the ICU in the care of patients infected with Covid-19 in University Hospitals in Geneva (Switzerland).	Acute phase (1-4 days): 20Kcal/kg of estimated weight. Post acute phase (after 4 days): 25Kcal/kg/day.
			EN: GIT working and not contraindicated. Gradual progression of the diet: 1^st day 250mL/day; 2^nd day 500mL/day; from the 3^rd day, progression by steps, considering addition of 500mL/d.
			Outcome of PN: For intubated patients with good tolerance reach 80 to 100% TER from the 4^th day. For intubated patients without good tolerance until the 4^th day: supplementary PN.
			For non-intubated patients: Progression of EN (maximum 1000Kcal/day) assess the possibility of oral nutrition, risk of bronchoaspiration and need for supplementary PN.
			NP: GIT not working or EN contraindicated. 1^st day: after electrolyte correction, maximum volume of 625mL (central route). 2^nd day: 1250mL. From the 3^rd day: progression by steps until 80-100% of the estimated energy needs are reached.
			Outcome of PN: If good tolerance reaches 80-100% of needs on the 4^th day. If metabolic or electrolytic disorders occur – assess and correct hyperglycemia, assess liver function and triglycerides and check with the nutrition team.
			The nutritional protocol assessment questionnaire was sent by email to 122 doctors working in the ICU of University Hospitals in Geneva. 76 professionals answered about the use of the protocol: 44 used it routinely, 26 most of the time and only 6 made little use. A positive impact on the patients’ clinical outcome was reported by 71 of the 75 professionals who answered this question.

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[1] Correspondence to: V.A. LEANDRO-MERHI. Email: vapaleme@gmail.com.