key: cord-1028944-gvlj2bxw authors: Minnelli, Nicole; Gibbs, Lisa; Larrivee, Jennifer; Sahu, Kamal Kant title: Challenges of Maintaining Optimal Nutritional Status in COVID‐19 Patients in Intensive Care Settings date: 2020-08-16 journal: JPEN J Parenter Enteral Nutr DOI: 10.1002/jpen.1996 sha: 6907aabc3864be3922dcbf9a8e1e7246b1eee09f doc_id: 1028944 cord_uid: gvlj2bxw The Coronavirus disease 2019 (COVID‐19) pandemic has threatened patients, healthcare systems, and all countries across the globe with unprecedented challenges and uncertainties. According to the latest literature, most patients with COVID‐19 have mild symptoms that do not require hospital admissions, and only a small percentage of those hospitalized require intensive care. In the intensive care unit (ICU), a Registered Dietitian Nutritionist (RDN) assists the critical care team by formulating, executing, and monitoring the nutritional strategies and interventions to meet the unique requirements of extremely sick patients. However, due to the novelty of COVID‐19 disease, the situation is fluid and guidelines continue to be developed and updated. This article discusses the interim guidelines available for the nutrition support of ICU COVID‐19 patients, and the challenges the critical care team and RDN may face from a nutrition standpoint. This article is protected by copyright. All rights reserved In less than 6 months, Coronavirus disease 2019 (COVID- 19) pandemic has brought the whole world to its knees (1, 2) . As of July 15, 2020, there are a total of 13,560,683 confirmed COVID-19 cases with 583,523deaths across the globe (3) . Most patients (99%) have clinically mild symptoms and are likely to recover. The remaining contributes just 1% of the affected population but constitutes 59,511cases who are critically ill. These patients will need holistic, therapeutic nursing, medical care as well as nutritional care. This article is protected by copyright. All rights reserved. taskforce that is keeping constant track of COVID-19 cases across the country (4) . The COVID-19 pandemic has significantly affected the healthcare system and infrastructure both in the developed and developing countries (1, 5) . As per COVID-NET updates, COVID-19 associated hospitalization rate is 4.6 per 100,000 population; more rates have been noted with increased age, highest amongst more than ≥65 years. Approximately 90% of the hospitalized patients had one or more underlying conditions. The common comorbidities identified are obesity, hypertension, chronic lung disease, diabetes mellitus, cardiovascular disease and malignancies (6, 7) . Almost 4.9-11.5% of the hospitalized patients (amongst all the age groups) require intensive care unit (ICU) admission and/or mechanical ventilation. Unfortunately, these figures increase to as high as 31% for individuals 75 years or above. Patients with COVID-19 might stay in ICU anywhere from few days to a couple of weeks depending upon the severity of disease and recovery. Those who are on mechanical ventilation or are too critically ill to be able to eat need Registered Dietitian Nutritionist's (RDN) advice for enteral nutrition (EN) or parenteral nutrition prescription (PN). EN is an everyday practice of doctors, nurses, and other ICU clinicians and comes second-nature to RDs working with the critical care population. Currently, during the COVID-19 crisis, our experience at a 350-bed community hospital located at urban city (Worcester) in Central Massachusetts has also been extremely challenging. With (8) (9) (10) . During the COVID-19 pandemic peak, each RDN in the facility was required to become a critical care dietitian in a short time, requiring intense training via webinars, researching best practices and competency training in nutrition support. It is the RDN's role to keep abreast of the most recent studies regarding ICU nutrition for the COVID patient and then take that information to practice by educating other members of the critical care team (9) . Additional battles include product shortages, and staffing shortages due to hospital census decreasing, though on the front line the acuity of these patients have skyrocketed (11) . The acuity is higher than any patient population previously seen. As these patients are labile with medical status changing daily, it is imperative that the RDNs provide intensive follow up daily as well (12, 13) The American Society of Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) recently released guidelines specific to nutrition support therapy of COVID-19 patients admitted in critical care units (14) (15) (16) . The recommendation starts with discussing the timing of nutrient delivery, recommending early EN within 24 to 36 hours of admission to the ICU or within 12 hours of intubation ( Figure 1 ). If early EN is not feasible, PN is recommended to be initiated as soon as possible. Trophic feedings of 10-20ml/hr should be initiated first, advancing slowly over the first week. Total calorie intake in the first week does not seem to be the main concern, as 15-20 calories/kg of actual body This article is protected by copyright. All rights reserved. weight should be the nutrition prescription. The standing recommendations for protein, 1.2-2 grams/kg of bodyweight continue (16) . EN is preferred to PN, though EN should be withheld in the patient who is hemodynamically unstable requiring either escalating/ high doses of vasopressors, multiple vasopressors, and/or with rising lactate levels. PN should then be considered with the addition of abdominal distention or pain, dilated loops of the small bowel, pneumatosis intestinalis or increasing NG outputs within 6-12 hours of trophic feeding initiation. The recommendations do address and condone EN in the patient undergoing prone positioning. A high protein (>20%) polymeric formula is recommended as the first line of therapy. Monitoring of medications such as propofol which is suspended in a fat emulsion should be taken into consideration when prescribing EN or PN as this influence triglyceride levels and provides 1.1 calories/kg as fat. Additionally, serum phosphate, magnesium, and potassium levels should be monitored closely for the incidence of refeeding syndrome (17) . Since COVID-19 is a novel disease, one must take into consideration the physiological changes of what is documented in the literature about patients with ARDS, pneumonia, septic shock and those who are critically ill requiring mechanical ventilation (18) . For example, in addition to ASPEN, the European Society of Clinical Nutrition and Metabolism (ESPEN) base their COVID guidelines on their past guidelines along with expert advice (19) . The majority of patients who are admitted to the ICU have already been "sick" for a few days and likely have underlying conditions. Poor PO intake, GI symptoms, and even underlying malnutrition prior to admission set the patient back from a nutrition standpoint. Those who are critically ill experience a phase of catabolism, and acute phase protein synthesis leads to a loss of lean body mass, electrolyte abnormalities and alterations in nitrogen balance (20) . This article is protected by copyright. All rights reserved. Furthermore, for patients requiring a long duration of ICU stay, supportive care from the use of medical nutrition therapy can greatly benefit the patient in the acute phase by providing energy to assist in fighting this battle. EN in the ICU patient provides more than just macro and micronutrients. Even at a trophic rate, EN maintains gut integrity in the intestinal villi by maintaining tight junctions and stimulating blood flow through the intraepithelial cells (20) . Nutrient interaction with mucosal cells and gut-associated lymphoid tissue is thought to play a role in immune functions such as deactivation of viruses (21) . Companies that supply EN formulas have reported a 200% increase in formula sales and demand since the COVID pandemic began. As mentioned above, it is recommended that RDNs use a high-protein formula to feed these patients on mechanical ventilation (15) . However, without the ability to obtain these formulas, meeting patient protein needs specifically is not just difficult, but near to impossible for some patients. This is especially true for those who are overweight or obese, in which a case series of patients from hospitals in New York City suggests that 41% of COVID patients have as an underlying condition (22) . Studies have shown that critically ill patients with COVID-19 are not only presenting with pneumonia and acute respiratory distress syndrome (ARDS), but many of them are also progressing to sepsis and septic shock as well (23) . A retrospective case series shows that up to 95% of patients receiving mechanical ventilation needed vasopressor support (24) . It is widely known that early EN has been shown to decrease ICU length of stay, decrease mortality, and infection rate as opposed to when it is started later in the hospital stay in non-This article is protected by copyright. All rights reserved. COVID critically ill patients (18, 25, 26) . While feeding the critically ill patient and taking into consideration vasoactive medications and propofol infusion is common practice for the critical care RDN, challenges arise since EN may be delayed due to the high requirement and lengthy time frame of use of vasoactive medications in this patient population (27) . Executing an early nutrition should always be aimed for and COVID-19 with circulatory shock should not be considered as a contraindication to EN unless there is accompanying enteral feed intolerance (35 After initiation of EN, reaching goal calories and protein, and keeping them there, is a difficult task. As propofol provides calories from fat, the dietetics professional must adjust the rate of EN to compensate for the calories that propofol provides, thus the patients may not receive their target caloric and protein needs while on this infusion. This requires consistent communication with nursing staff so the EN can be titrated to goal as medically appropriate. Prone positioning is one of the interventive care strategies in critically ill patients suffering with (ARDS) in order to prevent lung injury, recruit more alveoli for gas exchange, and improve oxygenation (28) . In COVID-19 related ARDS , prone positioning is being used both in ventilated and non-ventilated patients (29, 30) . Feeding a patient who is mechanically This article is protected by copyright. All rights reserved. ventilated and in prone position is a daunting task and a new normal to see in the ICU. While COVID-19 is a novel disease, practicing a prone positioning is a regular exercise by intensivists in patients with ARDS. Similarly, feeding in the prone position has been studied in the past and found to be a safe, practicable exercise without any increased complications (31) . A prokinetic agent may also be used in this situation to improve gut motility and tolerance to EN. Experience from the previously conducted studies have served as a good foundation to execute tube feeding in critically ill COVID-19 patients in prone position as we await further studies specific to our COVID patients (32) (33) (34) . ASPEN recommends following the general guidelines of nutrition for ICU patients in COVID-19 as well. EN may become interrupted or halted during the paralysis and proning process. Small studies referenced in the ASPEN guidelines have shown no significant difference in GI symptoms in feeding the prone patient as opposed to supine as long as the patient's head of the bed is raised (4). ESPEN guidelines recommend supplying a small amount, 30% of calories while prone (13) .There is a lack of studies addressing EN for the patient on neuromuscular blockers, however, ESPEN guidelines for the critically ill patient suggest EN can be provided in the patient on neuromuscular blockers. Pronation is one of the most challenging aspects of managing ARDS patients during the COVID-19 pandemic especially when it comes to feeding the critically ill COVID-19 patients. There is a common belief amongst the health care professionals and nursing staff that feeding in a prone position could be detrimental due to the aspiration risk. One of the job responsibilities of the RDN is to educate the physicians with the current ASPEN recommendations for feeding in the prone position. Typically, tube feeds are held about 1 hour before proning and started thereafter. The max rate we have fed a patient in the prone position was 50ml/hr, though the majority of our patients received trophic feeds 10-20ml/hr This article is protected by copyright. All rights reserved. while in the prone position. The RDN would follow up multiple times a day to assess if a patient was going to prone or supine. It was difficult to meet our patient's energy and protein needs when proned due to the novelty of feeding in the prone position in our facility. Inability to begin EN due to hemodynamic instability combined with paralytics and the prone positioning could leave patients without nutrition for days if not weeks, which likely warrants a conversation to consider parenteral nutrition (PN). In combination with the severe fluid overload, electrolyte abnormalities, and the above-mentioned benefit of EN, PN becomes even more of a less than the attractive option for clinicians, RDNs, and patient outcomes alike. . Only one patient, from our experience, needed supplemental PN as this patient was proned and unproned for hours and days at a time. After the prescription of EN or nutrition support, the RDNmust be vigilant in addressing gastrointestinal (GI) issues, interpreting laboratory results, and interaction with medications. A recent review showed that patients with COVID-19 may develop different degrees (14-78%) of liver dysfunction (37) . Similarly, Pan et al. reported that of the 204 patients with COVID-19, 50% of patients reported digestive symptoms including lack of appetite, diarrhea, vomiting, and abdominal pain (38) . Balancing the opioids, and paralytics with EN is a daunting task for the RDN, as gut motility is a moving target and varies with the type and dose of narcotics used such as fentanyl can slow GI motility. Prokinetic agents which are typically used as a motility agents, are suggested to be used in COVID patients if needed, and strongly considered when feeding in the prone position as discussed above. (19, 33) . This article is protected by copyright. All rights reserved. metoclopramide, loperamide, and erythromycin and has the potential to cause cardiac arrhythmias like torsades de pointes or prolonged QTc interval More recently, Remdesivir is being used as an experimental drug for COVID-19. Singh et. al compiled a critical review of many trials using Remdesivir for COVID-19 (41) . The clinical benefit appears inconsistent at this time, however some side effects are bound to occur as with any drug. Like their review found, a marked increase in LFT's has been observed at our facility (unpublished data) . As active gastrointestinal side effects from medications like Remdesiver occur, such as vomiting, deranged hepatic and even renal lab values, it may be a practical approach to temporarily withhold the EN or PN nutrition support and continue to follow up daily. (36) . Additionally, acute kidney injury in ICU patients with COVID-19 can fluctuate electrolytes in the body, more so in patients requiring renal replacement therapy (22) . Nutrition therapy as well can directly alter electrolyte values and the RDNs must take this into careful consideration when providing medical nutrition therapy. Signs and symptoms of aspiration must be monitored as well. As this disease is already a detriment to the lung, an aspiration event would only halt the healing process (42) . According to ASPEN, checking for gastric residual volume (GRV) in this patient population is not preferred due to exposure concerns and interruption of EN delivery, but monitoring for signs and symptoms such as abdominal distention, vomiting, bowel movements and flatus are bedside techniques to be done by nurses and physicians during their physical assessment (14) . There is ample evidence that suggests that people with diabetes are particularly exposed to a worse prognosis if infected (43) . Blood glucose control can pose another challenge in the ICU COVID-19 for a patient with or without diabetes. . While blood glucose levels already This article is protected by copyright. All rights reserved. rise due to metabolic stress, some patients may be administered steroids or medications dispensed in a 5% dextrose and water. On the opposite end, hydroxychloroquine may lower blood glucose levels. Again, the RDN must monitor the amount of carbohydrate being provided from EN or PN and discuss this with the critical care team in a timely fashion. Worldwide, we have witnessed that even the best of health care facilities has suffered from shortages in almost all the health sectors in providing adequate patient care during COVID-19 pandemic (45) . Inadequacy of PPEs, lack of ICU beds, scarce ventilators, medication shortages are only few to name (46) . Nutrition care also suffered the brunt of COVID-19 crisis (47) . Small community health care centers who are not used to manage critically ill patients are also providing medical treatment and nutrition care to these patients. Barrocas et al recently discussed the strategies that could be implemented for allocation of the nutrition resources during COVID-19 crisis keeping ethical factors into consideration (11) . In current scenarios, where many times it might not be possible to provide the ideal nutritional care to all the patients in need, the nutrition support professionals could help the treating team and respective RDN's in a collective, informed decision making by using the standardized prognostic and survival parameters (11) . Nutrition support professionals can provide essential inputs with regards to the type of feed, route of delivery, volume etc. When scarcity of resources is a major concern, they can triage and evaluate which patients could benefit the most. With regards to the enteral formula shortages, it is difficult to provide or generalize any suggestion due to the varying resource availabilities and local practices. A unique issue during the COVID pandemic for some hospitals and RDNs may be the availability of feeding pumps. With the increase in ICU admissions and the need for This article is protected by copyright. All rights reserved. mechanical ventilation, more patients need enteral nutrition as a feeding option. In cases when enteral feeding pump machines are scarce, alternative option of gravity bag feeding may be utilized to ensure patients receive timely and adequate EN. Bolus feeding, however, is not recommended nor feasible in the COVID population according to the ASPEN guidelines (27, 44) . Protein is one of the most important macronutrients to meet the nutritional need of critically ill patients (both COVID and non-COVID). At our center, we frequently used modular for our patients (with a composition of 15 grams per 30 ml protein modular). Based on chart review and laboratory results, typically, the RDN would order the protein modular a day ahead. This allows the RN's to adjust the timings to give the modular along with the other scheduled medications to avoid unnecessary exposure. Usually, we would give two 30ml modular at a time. Our facility prepared for the potential shortage of feeding pump and ordered the gravity feeding sets as a backup. So far, we are able to feed all our patients via the pump and never required gravity feeding as of now. However, instructions have been provided to the RDN's in the facility for gravity feedings, in case this is needed in the future. The first line of therapy recommended from the ASPEN guidelines is a high protein, isotonic formula. Until, we have literature available regarding which enteral formula should be used in shortage situations, it would be the RDN's clinical judgement and call to choose which formula next in line, that the hospital has available, best suits the patient's need. It is unknown if PN would be preferred over EN in times of enteral formula shortages as this topic is not yet studied and needs further research. This article is protected by copyright. All rights reserved. Vitamins and micronutrients play indispensable role in various body functions, enzymatic reactions, and immune functions (48, 49) (Figure 2 ). Many clinical trials are underway to study the benefit of vitamin and mineral supplementation in the COVID-19 patients. Vitamin D has been widely studied in ICU patients prior to COVID-19 era and now during COVID-19 pandemic. Use of Vitamin D, especially higher doses in ICU settings have been studied in past and there are conflicting results. Amrein et al (VITdAL-ICU randomized clinical trial) did not find high-dose vitamin D3 mortality benefit except in the severe vitamin D deficiency subgroup (50, 51) . Hematological parameters have been studied in great depth owing to their prognostic role during previous and current pandemic (8, 52, 53) . Based on these observations, studies have focused in anemia and vitamin D deficiency are interlinked in critical care settings. Smith et al did a double-blind, randomized, placebo-controlled trial using high-dose vitamin D3 (54) . Participants were divided into 3 arms [a] placebo group, [b] 250,000 IU D3 group, and [c] 500,000 IU D3 group, respectively. They found that 500,000 IU D3 group participants were found to have significantly increased hemoglobin Grant et al's recent review received criticism for their recommendations to use vitamin D3 (10,000 IU/day for few weeks followed by 5000 IU/day) by people at risk of COVID-19 to reduce the risk of infection (55) . Hence, without concrete evidence, the risks and benefits must be weighed carefully before giving mega vitamin doses to COVID 19 patients(58) . Early data suggests that Vitamin C, D, A, and zinc as an adjunct to pharmacological management to manage COVID-19 patients. These vitamins have been studied in the past for This article is protected by copyright. All rights reserved. their antioxidant properties and role in preventing various medical conditions like coronary artery diseases (59) . The RDN would not be the provider recommending additional vitamins and minerals for the specific treatment of COVID-19 in our facility. In some instances, extra supplementation may be warranted based on the COVID-19 patient past medical history or other factors. Examples include a multivitamin with minerals if the patient was unable to meet the recommended daily allowance via enteral feeding, and Vitamin C 1000 mg and zinc 250mg for 10 days if the patient had pressure injuries as if their renal function allowed. Thiamine and folic acid would be recommended in the patient who may be at risk for refeeding syndrome with underlying malnutrition. From a dietetics perspective, as addressed above, the RDNs must follow up with COVID-19 patients in ICU daily at least as their status can change quickly. The RDN must find a balancing act in addressing nutrition issues in COVID-19 patients. RDNs must not overfeed or underfeed as this could lead to the inability to wean off mechanical ventilation (20) . However, RDNs must provide adequate calories and protein to assist in the hypermetabolic state of these patients. Wound healing and sarcopenia become an issue as patients spend days on mechanical ventilation or bedbound. In conclusion, it is apparent that there is no one-size-fits-all medical nutrition therapy for critically ill patients with COVID-19. This review is to provide an outline of what we do currently know, and to explore the potential areas of study (Table 1) . Consistent monitoring, evaluation of trends, and constant communication with the multidisciplinary team seem to be This article is protected by copyright. All rights reserved. one of the most effective ways to assure timely and adequate nutrition is being provided to our COVID-19 patients. COVID-19 pandemic is a liquid situation and more literature and recommendations regarding the nutritional support in COVID-19 patients are expected to publish in the coming few weeks (6) . It is imperative that the ICU team including the dietitian keep abreast of these studies daily to provide optimal care for patients. Current perspective on pandemic of COVID-19 in the United States Cardiovascular factors predicting poor outcome in COVID-19 patients Live): 8,228,019 Cases and 444,442 Deaths from COVID-19 Virus Pandemic -Worldometer Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 -COVID-NET, 14 States COVID-2019: update on epidemiology, disease spread and management. Monaldi Arch Chest Dis Arch Monaldi Mal Torace Trajectory of the COVID-19 pandemic: chasing a moving target Managing patients with hematological malignancies during COVID-19 pandemic Cancer treatment during COVID-19 pandemic Oncology Dietitians Sound Alarm in Key Nutrition Needs of Cancer Patients During COVID-19 Pandemic Re: From the frontlines of COVID-19-how prepared are we as obstetricians? A commentary Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19 Hypermetabolism and COVID-19 COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition Nutrition Therapy in the Patient with COVID-19 Disease Requiring ICU Care ASPEN | Resources for Clinicians Caring for Patients with Coronavirus The importance of the refeeding syndrome1 1Disclaimer: It is recommended that readers check drug and electrolyte dosages and concentrations with their pharmacies before patient administration. The authors accept no responsibility for errors in the article CT chest findings in coronavirus disease-19 (COVID-19) ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection Krause's Food & the Nutrition Care Process Enteral feeding and its impact on the gut immune system and intestinal mucosal barrier Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area Management of Critically Ill Adults With COVID-19 Clinical Characteristics of Covid-19 in New York City Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation Early enteral nutrition in acutely ill patients: a systematic review Nutritional Support in Coronavirus Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan's Experience Should I prone non-ventilated awake patients with COVID-19? This article is protected by copyright. All rights reserved Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position Nursing issues in enteral nutrition during prone position in critically ill patients: A systematic review of the literature. Intensive Crit Care Nurs Safety and Outcomes of Early Enteral Nutrition in Circulatory Shock Emerging pharmacotherapy for COVID-19 Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): What do we know till now? Clinical Characteristics of COVID-19 Patients With Digestive Symptoms in Hubei, China: A Descriptive, Cross-Sectional, Multicenter Study A tale of twists: loperamide-induced torsades de pointes and ventricular tachycardia storm Cardiac drugs and outcome in COVID -19 Remdesivir in COVID-19: A critical review of pharmacology, pre-clinical and clinical studies Plasma membrane wounding and repair in pulmonary diseases COVID-19 and diabetes management: What should be considered? ASPEN Report on Nutrition Support Practice Processes with COVID-19: The First Response India Fights Back: COVID-19 Pandemic Concerns for lowresource countries, with under-prepared intensive care units, facing the COVID-19 pandemic This article is protected by copyright. All rights reserved A call to action to address COVID-19-induced global food insecurity to prevent hunger, malnutrition, and eating pathology Optimal Nutritional Status for a Well-Functioning Immune System Is an Important Factor to Protect against Viral Infections Dietary micronutrients in the wake of COVID-19: an appraisal of evidence with a focus on high-risk groups and preventative healthcare Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: the VITdAL-ICU randomized clinical trial Vitamin D and critical illness outcomes Hematological findings in coronavirus disease 2019: indications of progression of disease From Hematologist's desk: The effect of COVID-19 on the blood system High-Dose Vitamin D3 Administration Is Associated With Increases in Hemoglobin Concentrations in Mechanically Ventilated Critically Ill Adults: A Pilot Double-Blind, Randomized, Placebo-Controlled Trial Vitamin D Supplementation in Influenza and COVID-19 Infections. Comment on: Evidence That Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths Nutrients Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths 25-Hydroxyvitamin D Concentrations Are Lower in Patients with Positive PCR for SARS-CoV-2 Association of Vitamin D Deficiency with Coronary Artery Disease This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.