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...
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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 3rd day. Control of potassium, phosphorus and magnesium serum levels. Isocaloric EN 25-30Kcal/kg/day after the 5th 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. |
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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-...
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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...
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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...
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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 1st, 2nd, 3rd and 4th 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...
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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. |
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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...
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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: 1st day 250mL/day; 2nd day 500mL/day; from the 3rd 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 4th day. For intubated patients without good tolerance until the 4th 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. 1st day: after electrolyte correction, maximum volume of 625mL (central route). 2nd day: 1250mL. From the 3rd 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 4th 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. |