Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance

Abstract

Five to 10% of the coronavirus SARS-CoV-2-infected patients, i.e., with new coronavirus disease 2019 (COVID-19), are presenting with an acute respiratory distress syndrome (ARDS) requiring urgent respiratory and hemodynamic support in the intensive care unit (ICU). However, nutrition is an important element of care. The nutritional assessment and the early nutritional care management of COVID-19 patients must be integrated into the overall therapeutic strategy. The international recommendations on nutrition in the ICU should be followed. Some specific issues about the nutrition of the COVID-19 patients in the ICU should be emphasized. We propose a flow chart and ten key issues for optimizing the nutrition management of COVID-19 patients in the ICU.

How the Covid-19 epidemic is challenging our practice in clinical nutrition—feedback from the field

“…Recent studies or guidelines state that the Covid-19 patient at high risk for malnutrition [3][4][5][6][7]. The most severe cases are encountered in particular, but not exclusively, in patients with a chronic disease (such as organ failure, obesity with body mass index (BMI) ≥35 [8,9], type 2 diabetes 2 or cancers), elderly and/or polymorbid conditions [10].…”

“…These diseases often mask underlying protein malnutrition and sarcopenia [11,12]. Covid-19 patients should be considered at high risk of malnutrition [3][4][5][6][7], like in other severe respiratory infections characterized by: inflammatory syndrome and hypercatabolism, increased energy expenditure linked to ventilation work [5,6]. In the absence of early and adequate nutritional support, this combination will lead to a rapid deterioration of respiratory muscle function, aggravating the consequences of viral pulmonary damage [4,5].…”

“…In the absence of early and adequate nutritional support, this combination will lead to a rapid deterioration of respiratory muscle function, aggravating the consequences of viral pulmonary damage [4,5]. Hypermetabolism and physical immobilization expose to rapid muscle wasting because of concomitant drastic reduction in food intake [4][5][6][7], which is secondary to several factors: anorexia, dyspnea, dysosmia, and dysgueusia [13]. Finally, digestive symptoms (diarrhea, vomiting, or abdominal pain) [14][15][16][17], stress, confinement, organizational problems, and staff shortage will contribute to limit meal offering and ingestion.…”

“…A recent prospective, randomized, unblinded, multicenter trial demonstrated that providing early nutritional support, mostly orally, in hospitalized patients at risk of malnutrition significantly decreased 30-day complications and mortality in comparison to patients on standard hospital diet [23]. The high probability of malnutrition [3][4][5][6][7] and its association with a worse clinical outcome [24] are justifying an active strategy of nutrition screening and support in the Covid-19 patient (https://www.nutritioncare.org/uploadedFiles/Documents/ Guidelines_and_Clinical_Resources/Nutrition%20Therapy %20COVID-19_SCCM-ASPEN.pdf) [4,5,25]. This would help the patients reinforcing their immune defenses and potentially limiting the evolution toward a severe form of the disease.…”

“…Indirect calorimetry is the reference method to assess the energy requirements [10]. In the context of the Covid-19 epidemic, indirect calorimetry using a canopy is generally contraindicated because the usual decontamination procedures cannot be guaranteed in most wards in an epidemic context [6]. Only in some specialized ICUs, already trained for indirect calorimetry and adequately staffed, could the use of indirect calorimetry be considered for some metabolically unstable patients, e.g., staying more than 10 days in the ICU or those on full PN [6].…”