key: cord-0949818-x73bffvj
authors: Zanardi, M.; De Carli, L.; Ponta, M.L.; Pezzana, A.
title: Nutritional approach to coronavirus patients: our experience in 914 COVID bed hospital
date: 2020-08-10
journal: Nutrition
DOI: 10.1016/j.nut.2020.110965
sha: 8f3a3b1530e139cc31e297ef4d7ad3c142990b0d
doc_id: 949818
cord_uid: x73bffvj

• SARS-CoV-2 infection imposes nutritional choices based on pragmatism and simplicity. • ICU and sub-intensive care units patients are largely overweight or obese. • Enteral nutrition is the first choice even in patients in non-invasive ventilation. • The difficult nursing care of SARS Cov2 patients makes CVC management more complex.

Our Clinical Nutrition Service operates in a Hospital Company composed of five hospital facilities that has guaranteed, during the period of maximum inflow, a total of 914 COVID-19 beds, equal to 23% of 4006 hospitalized patients in the Piedmont Region, of which 56 were hospitalized in ICU and 54 in the subintensive area unit. Since the first days of the pandemic, we have been involved in the nutritional management of SARS-CoV-2 patients and, like our colleagues with a nutritional expertise, we have been committed to building a nutritional protocol, with indications delineated differently depending on the severity of the clinical conditions and the intervention setting. The document, born from the little evidence available in mid-February 1 , has been subject to continuous updating and revision on the basis of the increase in literature data [2] [3] [4] [5] [6] and thanks to the comparison with colleagues directly involved in patient care 7, 8 . We think it is useful to share our experience gained in our hospitals and our choices, strongly believing that creating dialogue and confrontation between health care professionals s necessary to lead to conscious and shared therapeutic choices for the management of patients affected by a new and still largely unknown disease.

A framework of difficult clinical care management such as COVID-19 infection imposes choices based on pragmatism and simplicity. It was necessary to revise our traditional model of patient care with a consultative or telemedicine approach in relation to objective difficulties (scarcity of personale protective equipment, especially in the initial phase of the pandemic and consequent limitations in access to COVID-19 areas). This has made it necessary, in many cases, to delegate to other healthcare professionals the collection of anthropometric data and some suggestive clinical aspects on which to rely on in order to estimate the calorieprotein requirements and set up an ad personam therapeutic plan. In drawing up the protocol, we have hypothesized the management of a standard patient by using literature data and clinical observations. In particular, in analogy with Caccialanza 7 data from a Hospital in Pavia, also in our reality patients admitted to ICU and subintensive care unit are largely overweight with cases of severe obesity. In many patients, the glycemic compensation is difficult and the pulmonary picture often requires a nutritional therapy with low fluid content.

Like our colleagues in Pavia, our protocol includes in multivitamins and trace elements to be infused intravenously. Considering the long time needed to obtain the blood dosage of vitamin D, we opted for early supplementation in all hospitalized patients with 30,000 IU of 25-OH cholecalciferol. In our reality, patients remained in ICU for as long as invasive ventilation was necessary; in sub-intensive care units, patients were admitted with the need for noninvasive (NIV) CPAP ventilation until weaning from it. Unlike Pavia's experience, in the presence of invasive ventilation we chose enteral nutrition via naso-gastric tube (NGT) in the first instance.

In agreement with anaesthesiologists and resuscitation specialists 9,10 , the enteral route was preferred not only because it is the most physiological route, but also because of the criticality in CVC positioning in SARS-CoV-2 patients, the difficulty of nursing management of the central venous access and the high risk of sepsis.

For enteral nutrition, a high-calorie polymeric formula with reduced content of simple sugars and high content of lipids, rich in antioxidants and omega 3 fatty acids has been indicated as first choice; the total volumes of formula and hydration have been contained within 1500 ml per day. Despite initial hesitations related to the need for pronation, rare episodes of poor tolerance were reported so it was necessary to start parenterale nutrition (PN) with formulas of small volume, very concentrated and hyperproteic. In cases of diarrhoea linked to the viral pathology, enteral nutrition was not suspended, but the speed of administration was slowed down.

In patients ventilated with CPAP and unable to be fed orally, despite the possibility of air leakage, it was nevertheless chosen to continue enteral nutrition with NGT even if NIV masks with a port for NGT were not available. We have not had any cases in which it was necessary to suspend enteral nutrition due to poor tolerance, nor any worsening of respiratory gas exchanges due to air leakage.

Patients weaned from CPAP have been systematically supplemented with highcalorie and high-protein Oral Nutritional Supplements (ONS) in the amount of two to four/five per day whenever there was a possibility of stopping ventilation, often for a short period of time, thus requiring an easily accessible and usable energy source.

We are aware that our protocol has some operational limitations, but it was developed as a rapid and pragmatic response to a rapidly evolving emergency situation. In our case history, enteral nutrition has been a valuable tool for nutritional therapy in COVID-19 patients in intensive and sub intensive care units.

In these days, when the course of the pandemic seems to have stabilized in our country, our Hospital maintains 621 COVID-19 beds, equal to 29% of 2153 COVID-19 beds in Piedmont. A dedicated facility (COVID-19 OGR) has also been opened for the dedicated and multi-specialist management of infected patients; the experience that will be gained in the near future will be paramount to implement the nutritional management of those affected by SARS-CoV-2.

Zhejiang da xue xue bao Yi xue ban =

Providing nutritional support for the patient with COVID-19

Optimal nutritional status for a wellfunctioning immune system is an important factor to protect against viral infections

Nutritional management and support in COVID-19: Emerging nutrivigilance

Short Report -Medical nutrition therapy for critically ill patients with COVID-19

Nutritional support in coronavirus 2019 disease

Early nutritional supplementation in noncritically ill patients hospitalized for the

Rationale and feasibility of a shared pragmatic protocol

Nutrition support in the time of SARS-CoV-2 (COVID-19)

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Nutrition Therapy in Critically Ill Patients with Coronavirus Disease (COVID-19)

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.