key: cord-0923360-nd5cjvbh
authors: Chapple, Lee-anne S.; Fetterplace, Kate; Asrani, Varsha; Burrell, Aidan; Cheng, Allen C.; Collins, Peter; Doola, Ra’eesa; Ferrie, Suzie; Marshall, Andrea P.; Ridley, Emma J.
title: Nutrition Management for Critically and Acutely Unwell Hospitalised Patients with COVID-19 in Australia and New Zealand
date: 2020-07-02
journal: Aust Crit Care
DOI: 10.1016/j.aucc.2020.06.002
sha: ca2d4691ecf1829360216e8cfabf1f91899dd64a
doc_id: 923360
cord_uid: nd5cjvbh

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular Acute Respiratory Distress Syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have pre-existing comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and effect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5-7 days in lower nutritional risk patients, and individualised care for high nutritional risk patients where capacity allows. Indirect calorimetry should be avoided due to potential aerosole exposure and therefore infection risk to health care providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly post-ICU, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including up-skilling, ensure adequate nutrition supplies, facilitate remote consultations and optimise foodservice management. These guidelines provide recommendations on how to manage the above aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.

The purpose of this document is to provide evidence-based advice for nutrition management of critically ill and 54 acutely unwell hospitalised patients during the COVID-19 pandemic. It provides key adaptations of usual best 55 practice, taking into consideration staff safety, reduced staffing, resource utilisation, and the clinical condition of the 56 patients. Optimal nutrition for these patients will require strong interdisciplinary collaboration, with flexible 57 approaches to care to accommodate organisational changes resulting from this pandemic situation. As this pandemic 58 is evolving rapidly, this document may be updated. 59 60 We recommend enacting this COVID-19 nutrition guideline when hospitals enter phase 2 management strategies 61 as outlined in the Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guideline (Version 2, 15 th 62

April 2020).

[1] Phase 2 of the tiered ICU pandemic plan refers to a moderate impact on daily operations, with the 63 ICU at or near maximum capacity but still able to meet demand and when up to 25% beds are occupied by patients 64

with pandemic illness.

[1] 65 66

Impact of COVID-19 on nutrition: 67

Patients with COVID-19 pneumonia, who develop respiratory failure, shock or multi-organ failure, require intensive 68 care management with mechanical ventilation (MV) and other organ supports. COVID-19 pneumonia is characterised 69 by high fevers, which induce a catabolic state, resulting in impaired glucose utilisation, increased protein breakdown 70 and energy utilisation. [2] It has been reported that in addition to critical illness, there may be significant effects on 71 appetite, conscious state, and direct gastrointestinal affects resulting in nausea, vomiting, diarrhoea and feeding 72

intolerance. These factors adversely impact nutritional intake and status. Patients with COVID-19 often require 73 prolonged MV and ICU support, resulting in significant immobility, catabolic stress and muscle wastage. [2] These 74 patients are at high risk of malnutrition during the period of critical care, as well as in the recovery phase of this 75

illness, and may stay in hospital for a significant length of time. There is limited available data to guide the optimal 76 nutritional management of patients with COVID-19, and as such, these guidelines are based on the available 77 evidence from other similar conditions such as Acute Respiratory Distress Syndrome (ARDS). [3, 4] For the purpose of the ICU guideline, patients at 'high nutrition risk' who are likely to require or benefit from 105 individualised nutrition assessment on admission are defined as those with: 106

• Anaphylactic food allergy 107

• Pre-existing or suspected malnutrition (e.g. weight <50kg, BMI <18.5 kg/m 2 , recent weight loss of ≥5%) 108

• Weight >120kg or Body Mass Index (BMI) >40 109

• Requiring parenteral nutrition (PN) 110

• Considered at high risk of refeeding 111

• Type 1 diabetes mellitus 112

• Cystic fibrosis 113

• Inborn errors of metabolism 114 115

All other patients are considered to be at 'low nutrition risk' and the use of the standard nutrition algorithm should 116 be considered safe unless otherwise indicated. 117 118

Recommendations: 119

Energy and protein targets: 120 1. We do not recommend the use of indirect calorimetry (IC) in patients with COVID-19.

IC requires the disconnection of the ventilator circuit which risks exposing staff to the airborne virus. IC also 122 takes considerable time to perform, which will also increase overall exposure to staff. 123 2. We recommend commencing enteral nutrition (EN) support in mechanically ventilated patients using an 124 algorithm with a set rate for up to the first 5 days of ICU admission (see Figure 1 ) 125 3. We recommend providing 25 kcal/kg bodyweight/day after the first 5 days of ICU admission (and up to 30 126 kcal/kg bodyweight/day for severely unwell patients, with malnutrition or those who have a prolonged 127 admission e.g. ECMO, CRRT, or length of MV >7days) and protein prescription of at least 1.2 g/kg 128 bodyweight/day.

• Minimal evidence exists for the optimal nutritional targets in these patients, but in the absence of indirect 130 calorimetry, we recommend calorie prescriptions to be based on 25 kcal/kg bodyweight/day after the first 5 131 days of ICU admission (and up to 30 kcal/kg bodyweight/day for severely unwell patients e.g. ECMO, CRRT, 132 or length of MV >5 days or those with malnutrition) and protein prescription of at least 1.2 g/kg 133 bodyweight/day. [4, 7] Actual body weight (ABW) should be used for patients of normal BMI, and an adjusted 134 body weight for overweight and obese patients as per usual site method (e.g. Ideal Body Weight (IBW) + 25-135 50% [ABW-IBW]). 136

• Current case reports state that fever of between 37.5-39.0 °C is common. The metabolic impact of increased 137 temperature is said to be ~10-13% per every 1°C increase. [8] This should be considered in the overall 138 nutrition prescription. 139

• In obese patients, it is appropriate to commence nutrition as per the algorithm provided, but these patients 140

should be considered high nutrition risk and prioritised for nutrition review. 141

• Contribution of calories from propofol should be considered in the nutrition provision if more than 10% of 142 daily calories are being provided from this source. EN calories should be reduced and adequate protein 143 delivery ensured while considering overall fluid provision. 144

• Recommendations for nutrition provision in patients admitted to ICU and not ventilated within 24 hours are 145 provided in recommendation 18. 146 147

Insertion of a nasogastric tube (NGT) tube for enteral feeding 148 4. We recommend following institutional guidelines regarding appropriate PPE during the insertion of NGT 149 tubes, and avoiding unnecessary NGT changes avoided. 150

• The insertion of a NGT may induce coughing, and nasal and gastric sections may also contain virus. 151

Guidelines for PPE are being constantly reviewed and clinicians should be aware of, and refer to, national 152 and institutional guidelines. 153

• The decision to insert a NGT should include consideration of the risk to staff, the benefit of providing 154 nutrition support, and alternative modes of feeding including PN.

Commencement of nutrition support: 157 5. In MV patients who are low nutrition risk, we recommend commencing EN support within 24 hours of ICU 158 admission via the gastric route using an algorithm with a set rate for up to the first 5 days of ICU admission 159 (see Figure 1 ). 160

This recommendation takes into consideration: the safety of dietitians in ICU (recognising that reducing 161 exposure is a fundamental method of preventing COVID-19 infection);[1] preservation of PPE for clinical staff 162 that have no choice but to be in contact with patients; the workload required for clinicians to calculate an 163

individualised rate considering the high volume of patients anticipated; increased prevalence of 164 hyperglycaemia related to the significant inflammatory response; and the likelihood of gastrointestinal 165 dysmotility with early full feeding in this population. There is no critical care nutrition literature to 166 demonstrate negative consequences of early hypo-caloric feeding strategies for the first 5-7 days of ICU 167 admission. [3, 9] This recommendation is also in keeping with recent international guidelines that 168 recommend the introduction of hypo-caloric nutrition over the first 5-7 days of illness. [ This is to ensure the safe provision of appropriate nutrition support, minimising the risk of refeeding, 174

anaphylactic reactions and to decrease the risk of significant over or underfeeding. with respiratory failure to reduce the risk of extravascular lung water). [9] We recommend selecting an 181 enteral formula that meets caloric needs, without compromising protein delivery. 182

• We recommend avoiding the prescription of a highly concentrated enteral formula (2kcal/ml) unless 183 essential for further fluid restriction. Highly concentrated enteral formula has been shown to delay gastric 184 emptying and therefore they may exacerbate gastrointestinal dysfunction; in addition, these products 185 usually have low protein content. 186 187

Continuing nutrition support: 188 9. We recommend, where possible, keeping enteral tubes in place post-extubation due to the prolonged 189 recovery anticipated for patients who survive COVID-19.

• This decision should be made in consultation with the dietitian. This takes into consideration the high 191 metabolic demands and the challenges to achieving adequate oral nutrition (e.g. work of breathing, 192 conscious state, potential eating and swallowing difficulties due to weakness, challenges with food selection 193

and feeding with high workloads for bedside staff) and existing data in other populations informing of poor 194 adequacy of nutrition with oral nutrition alone following critical illness. [10-13] 195 • Where wide bore NGT are in situ consider changing to a fine bore NGT prior to extubation if ongoing EN for 196 >5 days is deemed likely. This should take into consideration the associated safety risks to staff, and should 197 be performed using appropriate precautions based on the infectivity status of the patient and coordinated 198 with other clinical care. 199 consistently <50% of prescribed targets. 206 11. We recommend supplemental PN be considered after other measures to improve EN have been 207 attempted or insertion of a post-pyloric enteral feeding tube is deemed unsafe and calorie and protein 208 intake remain significantly less than prescribed targets (i.e. <50% over a 5-7 day period). This should be 209 assessed on a case-by-case basis and the long-term impact of nutrition deficit considered. 210 211

Dietetic assessment and reviews: 212

12. For patients who are not high nutrition risk, we recommend that a nutrition assessment be completed by 213 day 3-5 of ICU admission in most circumstances, depending on staff capacity, or earlier if patients are at 214 high nutritional risk (see Figure 1 ). 215 13. Where dietetic capacity is exhausted, and if a full dietetic review is not possible, we recommend 216

increasing EN targets to meet 25-30 kcal/ kg body weight/ day after day 5 as a minimum.

• Nutritional monitoring should be maintained where possible, including assessment of calorie and protein 218 delivery compared to prescribed targets, feeding intolerance and other complications, to identify patients 219 who may require an escalation in their nutritional care. 220

• It is anticipated there will be a reduction in dietetic workforce with staff illness and increased patient 221 caseload. Therefore, a delay in the conduct of an initial nutrition assessment and less frequent reviews of 222 nutritionally stable patients should be anticipated. Where resources are limited, we recommended 223 dedicating these to the: 224

• first week of illness for high nutrition risk patients only 225

• first week of illness in low nutrition risk patients with feeding complications 226

• second week of illness in patients deemed low nutrition risk on admission 227

• ICU teams should be advised to escalate patients with nutritional concerns quickly to facilitate prioritisation. 228 229

Monitoring of gastric residual volumes (GRV): 230 14. We recommended continuing to measure GRVs in COVID-19 (using the appropriate level of infection 231 control precautions) but using a threshold of less than 300ml and measuring 8 hourly. 232

who are not prone.

• These recommendations are made as the viral load of gastric contents is unknown; however, the risk of not 235 measuring GRVs is increased vomiting which also places staff at risk and hence strategies to avoid vomiting 236 should be taken. 237

• Where applicable, management of feeding intolerance as per ICU protocols should be instated (e.g. use of 238 prokinetics) (See Figure 1) . 239

• Aspirated GRVs should be discarded rather than returned to reduce the risk of splash injury to staff. 240 241

Nutrition for patients in the prone position: 242

16. We recommend that the EN is paused and the NGT be aspirated prior to any position changes. EN should 243

re-commence as soon as possible to avoid unnecessary interruption to feeding. 244

17. We recommend GRV monitoring continue 8 hourly while in the prone position, even if intolerance is not 245 an issue.

• Patients in the prone position should commence EN as per the previous recommendations, with 247 consideration that the prone position is associated with increased GRVs and risk of vomiting. [ 

• Assessing the position of the NGT at the site of entry into the nasal cavity after placing the patient in the 249 prone position is important to assess the potential risk of pressure injury. 250 251

Nutrition for non-ventilated patients and those receiving high flow nasal oxygen (HFNO): 252 18. We recommend routine provision of an appropriate oral diet (e.g. high energy, high protein), and oral 253 nutrition supplements (e.g. 1.5 or 2 kcal/ml oral supplement) as soon as oral intake is commenced. 254 19. We recommend advocating for escalation to EN, with consideration given to the safety risk of NGT 255 placement, for patients not receiving MV and meeting <50% of energy and protein targets orally for ≥5-7 256 days, despite provision of oral nutritional supplements, or if intubation is expected. 257

• The provision of nutrition in patients receiving HFNO is difficult due to fasting for potential intubation and 258 oral intake is often poor due to nausea, delirium, fatigue, poor appetite, and difficulty breathing. [15] These 259 symptoms are commonly reported in critically ill patients. [16] . Specifically for patients with COVID-19, loss 260 of taste and smell have been reported as a consequence, which may influence oral intake across the 261 spectrum of illness (including recovery). [17] Dietetic assessment and reviews: 290 21. For patients transferring to the ward from ICU, we recommend that the ICU dietitian provides an 291 appropriate handover to the ward dietitian within 24 hours of ICU discharge.

• This is to ensure the safe and appropriate transition of care from ICU to the ward, this handover should 293

include the nutritional status of the patients (if malnutrition is present, was it pre-existing or hospital-294 acquired) and the assessed nutritional adequacy over the ICU admission. 295 296 22. For patients admitted directly to the ward, we recommend the implementation of local pathways to 297 optimise nutrition provision for patients as soon as possible, prior to full nutritional assessment, where 298 appropriate (See Figure 2) . 299

• This takes into consideration the level of risk and also the availability of staffing and allows dietitians to focus 300 on patients who require complex nutrition support and those at high nutritional risk. 301 302 23. We recommend a Dietetic consultation for high nutrition risk patients be conducted within 24 hours. 303

• High risk patients include those requiring EN or PN, or who have anaphylactic food allergy, cystic fibrosis, or 304 inborn errors of metabolism. 305

• Other patients at high nutritional risk should be seen within 24-72 hours (e.g. patients at high risk of re-306 feeding, severe malnutrition, or patients with medical conditions in which specific nutrition therapy is 307 required) based on dietetic capacity. 308

24. We recommend that nutritional monitoring is maintained, including the monitoring of intake and weight 309 (where possible), and high nutritional risk patients are reviewed at least twice weekly and lower risk 310 patients at least weekly.

Continuing nutrition support: non-face-to-face management activities. 329

• Potential Nutrition Assistant/AHA tasks could include: assistance with monitoring of oral intake; 330 quantification of oral nutrition supplement compliance; liaison with bedside staff regarding menu 331 preferences; assisting with food service tasks; assistance with facilitating ICU transfer; and obtaining weight 332 history etc). 333 334

Food service considerations: 335 30. We recommend developing food service systems to enable electronic or phone meal ordering to minimise 336 contact with the patient at the bedside while enable patient menu selection and ensuring optimal 337 nutrition provision.

Other contingency planning: 340

In combination with these protocols, we recommend sites consider the following: 341

• Ensuring adequate equipment for EN is available, given the expected increase in bed numbers and patients, 342

including feeding pumps, giving sets and EN formula (including consideration of strategies for management, 343

where some of the ICU may be isolated from the rest and planning for potential EN or delivery system 344 shortages with an appropriate contingency plan, such as equipment to facilitate gravity or bolus feeding). 345

• Local instructions should be developed to communicate to staff where all nutritional products (e.g. pumps, 346

giving sets, formulae) are stored, and how to access additional stock. 347

• Providing appropriate up-skilling to non-ICU dietetic staff in ICU or non-acute staff in other ward areas, 348

including the necessary IT access. 349

• Ensuring dietitians are able to facilitate nutrition by being competent at pump operation and changing of EN 350 formula and giving sets to reduce the workload expectation on nursing staff. This should include non-COVID-351

19 patients within the ICU. 352

• Minimising workload and risk of food borne infection by avoiding the use of decanting of formula unless 353 absolutely necessary. 354

• Reviewing contingency processes with Food Service, to ensure optimal food choices are available and the 355 maintenance of compliance with hospital food service guidelines, to ensure nutritional adequacy, with 356

considerations for staff shortages. 357

• Adapting workspace and team structure where possible to facilitate COVID-19 vs non-COVID-19 areas and 358 staff. 359

• Planning for an occurrence of exposure within the nutrition team and how this will be managed at an 360 operational level. 361

• Consideration of a 7-day service in ICU and on-call service for out of hours support may be of benefit in some 362 centres 363

• Formalising communication pathways with bedside clinicians and food service to enable remote nutrition 364 assessment and reviews where possible to limit clinician contact at the bedside such as alternatives for 365 attendance at ward rounds. 366

• Considering areas for advanced scope of practice to support medical and nursing staff where appropriate 367 e.g. post-pyloric tube insertion. 368 369

Conclusions and application to practice:

The global pandemic caused by SARS-CoV-2 has resulted in a large number of patents requiring admission to 372

intensive care for management of symptoms relating to COVID-19 infection. Within 24-72 hrs • Please use in conjunction with local nutrition policy and procedures.

• The dietitian or treating consultant may elect to commence the standard algorithm in high nutrition risk patients • Medical and nursing teams to please contact the Dietitian if a nutritional assessment is necessary earlier than stated in the algorithm. • For first GRV >300ml commence prokinetics as per usual site practices (e.g. metoclopramide IV 10mg 6hourly together with erythromycin IV 200mg bd) for 24 -72hrs where possible and no contraindications exist. • If GRV remains >300ml, despite prokinetics, consider post-pyloric feeding or supplemental PN.

• Nutrition support should be escalated if energy and protein delivery are <50% of prescribed targets for ≥5-7 days.

In prone position Conduct 8hrly GRVs. If GRV>300ml follow protocol below

In addition to 8hr aspirates, turn feeds off, and aspirate tube prior to turning 

Australian and New Zealand Intensive Care Society: ANZICS COVID-19 Guidelines. Version 2

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study

Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial

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

Virological assessment of hospitalized patients with COVID-2019

Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19

ESPEN guideline on clinical nutrition in the intensive care unit

Clinical methods: The history, physical, and laboratory examinations

Energy-Dense versus Routine Enteral Nutrition in the Critically Ill

Energy and protein deficits throughout hospitalization in patients admitted with a traumatic brain injury

What Happens to Nutrition Intake in the Post-Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults

Nutritional rehabilitation after ICU -does it happen: a qualitative interview and observational study

Measuring nutrition-related outcomes in a cohort of multi-trauma patients following intensive care unit discharge

Early enteral nutrition in mechanically ventilated patients in the prone position

Nutrition-related outcomes and dietary intake in non-invasively mechanically ventilated critically ill adult patients: A pilot observational descriptive study

Nutrition intake in the post-ICU hospitalization period

Association of chemosensory dysfunction and Covid-19 in patients presenting with influenza-like symptoms

 Figure 2 : Acute Ward Nutrition Algorithm for Management of Patients with COVID-19 in Australia and New Zealand Algorithm to be enacted on instruction of senior medical and nutrition staff

Refer to the Dietitian if: • Loss of weight ≥ 5% • Consuming < 50 % of meals Standard Nutrition Care (Completed by nursing staff or a suitably trained staff memberconsideration of resources and staff safety is paramount) • Determine and enter an appropriate diet code for the patients' condition • Screen for malnutrition using a validated screening tool, where possible (within 24 hours) • Weigh patients where possible, ensuring appropriate cleaning of equipment (with in 24 hours) • Determine if the patient needs assistance with feeding (identify how this will be done in isolation)• Implement strategies where possible to enable food choices • Optimise the management of nausea, pain and altered bowel function • Minimise unnecessary fasting • Encourage family and patient education on the importance of nutrition as a therapeutic intervention for recovery