Nutrition guidelines for critically ill adults admitted with COVID-19: Is there consensus?

Abstract

Introduction The Coronavirus Disease 2019 (COVID-19) pandemic has overwhelmed hospital systems globally, resulting in less experienced staff caring for critically ill patients within the intensive care unit (ICU). Many guidelines have been developed to guide nutrition care. Aim To identify key guidelines or practice recommendations for nutrition support practices in critically ill adults admitted with COVID-19, to describe similarities and differences between recommendations, and to discuss implications for clinical practice. Methods A literature review was conducted to identify guidelines affiliated with or endorsed by international nutrition societies or dietetic associations which included recommendations for the nutritional management of critically ill adult patients with COVID-19. Data were extracted on pre-defined key aspects of nutritional care including nutrition prescription, delivery, monitoring and workforce recommendations, and key similarities and discrepancies, as well as implications for clinical practice were summarized. Results Ten clinical practice guidelines were identified. Similar recommendations included: the use of high protein, volume restricted enteral formula delivered gastrically and commenced early in ICU and introduced gradually, while taking into consideration non-nutritional calories to avoid overfeeding. Specific advice for patients in the prone position was common, and non-intubated patients were highlighted as a population at high nutritional risk. Major discrepancies included the use of indirect calorimetry to guide energy targets and advice around using gastric residual volumes (GRVs) to monitor feeding tolerance. Conclusion Overall, common recommendations around formula type and route of feeding exist, with major discrepancies being around the use of indirect calorimetry and GRVs, which reflect international ICU nutrition guidelines.

Role of Early Enteral Nutrition in Mechanically Ventilated COVID-19 Patients

“…Long-standing research has shown early EN within 12 hours, or even 48 hours, after start of MV can be quite challenging to achieve ( 11 ). A review article reported that when intensivists were surveyed regarding their reasoning behind delayed EN in COVID-19 patients, the most common reason was fear of aspiration in patients with limited respiratory reserve coupled with concern for an often-unpredictable clinical course ( 3 ). Additional challenges to early EN include the common use of prone positioning as clinicians are often hesitant to feed patients in prone position for fear of aspiration.…”

“…Further, recent literature indicates nutritional status in COVID-19 patients is an independent risk factor for in-hospital mortality and is associated with poor clinical outcomes ( 2 ). The complex clinical course of severe COVID-19, including gastrointestinal involvement and severe acute respiratory syndrome, often makes it challenging to achieve practice recommendations for early EN ( 3 ). Despite published recommendations highlighting importance of early EN, there is a notable lack of evidence describing its association with outcome and hypothesized benefit in COVID-19 patients undergoing mechanical ventilation (MV).…”

Effect of Whey Proteins on Malnutrition and Extubating Time of Critically Ill COVID-19 Patients

“…However, monitoring the need for nutritional support and relative response to it, is challenging. Society nutrition guidelines and recent metanalyses [27,28] have highlighted how the changes in body weight and its composition are not reliable biomarkers of nutritional state for these patients because of their extensive hydration and catabolism. Moreover, metabolic status indexes such as nitrogen balance and protein turnover are difficult to assess in clinical practice because of the risks and complexity of measurements [28].…”

Does Route of Full Feeding Affect Outcome among Ventilated Critically Ill COVID-19 Patients: A Prospective Observational Study

“…In all cases, nutrition support was administered continuously (mL per h). Malnourished patients (BMI < 17 or clinical diagnosis) were assigned to a parenteral nutrition protocol designed to reduce the risk of refeeding syndrome [ 11 , 16 ]. In the parenteral group (presence of uncontrolled shock, uncontrolled life-threatening hypoxemia, hypercapnia or acidosis, hemodynamic instability, or when energy intake was consistently <50% of targets over 5–7 days), all patients received only parenteral nutrition via a central venous catheter depending on the results of daily haemodynamic assessments and nonfunctional digestive tract.…”

“…One important question is route of nutritional support administration (enteral vs. parenteral), the effects of which on outcome remain unclear [ 13 , 14 ]. Up to the present moment, administration of energy needs via the enteral route is the preferred method of choice according to published guidelines [ 15 , 16 ] although it is affiliated with higher rates of gastrointestinal intolerance [ 17 ]. Parenteral feeding is more invasive, provides higher amounts of calories, and is associated with a higher risk of complications [ 18 ].…”