key: cord-1030283-6birz5w7
authors: Barbosa, C. L.; Ferreira, C. H.; Gimeniz, N.L.F.D.A.; Souza, T.M.S.; de Oliveira, C.M.V.; Siqueira, B.S.D.S.; de Souza, R.C.D.; Coutinho, D.M.D.C.; Júnior, E. G.
title: Nutrition therapy in critically ill patients with covid-19 in prone position: a feasible protocol
date: 2021-12-31
journal: Clinical Nutrition ESPEN
DOI: 10.1016/j.clnesp.2021.09.307
sha: f150633063dd38ea44e3a2ba55dc42201a685ff9
doc_id: 1030283
cord_uid: 6birz5w7

nan

Rationale: The use of Parenteral Nutrition (PN) has evolved over the years due to technical improvements that make PN as safe as EN. Indeed, their use and when to administered PN in critical care has been controversial [1] . The aim of our study was to describe the use of PN in the ICU, as well as its different patterns of administration. We also evaluated nutritional variables associated with mortality when total PN was administered. Methods: National multicenter prospective observational study (37 hospitals). Demographic data and comorbidities, reason for admission, nutritional assessment, caloric-protein dose administered (up to 14 days), laboratory variables, and complications, were collected. Statistical analysis was performed independently using univariant and multivariate analysis (SPSS 20.0). Results: 229 patients who received PN during their admission to the ICU were included. The mean age was 63.55±13.9 years; 67.7% were men; BMI: 26.9±5.1 Kg$m -2 ;APACHE II: 20.3±7.6. 48% and 46.7% were medical and surgical patients respectively. Only 23.6%(54) received early PN (<48h). They received a mean caloric and protein dose of 19.1±6.7 Kcal/Kg/d and 0.99±0.4 g/Kg/d respectively. 112 (49%) received total PN and 117 (51%) received also enteral nutrition (mixed PN). Mortality in these subgroups was highly variable, with lower mortality for patients who received total PN (24.11% vs 37.21% (NE-PN) vs 25.68% (PN-NE), as well as the patterns of administration in mixed PN (see Figure 1 ). When analyzing factors associated with mortality, it was observed that a high NUTRIC Score (Hazard Ratio (HR): 1.334; 95% CI: 1.013-1.758; P¼0.041) was associated with higher mortality, while higher Prealbumin levels on day 7 they wereassociated with lower mortality (HR: 0.982; 95% CI: 0.971-0.994; P¼0.002). Conclusion: There is great variability when PN is administered in the ICU, which may probably require a greater consensus and higher standardization among different hospitals. Nutritional risk, as well as laboratory variables, may be associated with mortality in these patients. Rationale: Appropriate nutritional therapy (NT) determines favorable outcomes in COVID-19 (CV19) critically ill patients (CIP) 1 which presents great challenges due to complications that hinder progression of diet to the protein energetic target. As it is a new disease, most Guidelines showed inadequate recommendations regarding NT. Especially the infusion of enteral nutrition (EN) in the prone position (PP), which, differently from what recommended, was not safe, except in a trophic flow 2 . There are 3 challenges to NTof CIP with CV19 that have raised disagreements between teams: 1-high energy expenditure of CV19 3,4 ; 2-EN during the PP 5 ; 3-need to use opioids, sedatives and neuromuscular blockers in usually higher doses 6 . Methods: Literature review. Results: Recommendations Protocol: 1)Early EN: start EN, 24-48 h after hemodynamic resuscitation/metabolic stability. 2)EN Indication: oral diet's acceptability <60% of required, and if Non-invasive Ventilation/Non-Rebreather masks are applied for a long time (patient cannot eat and breathe at the same time). High-flow nasal catheter facilitates swallowing. 3)PP: position a orogastric (OGT) and a nasoenteric tube (NET) immediately after orotracheal intubation to avoid repetitive exposure to virus 7 . Confirm the radiological positioning of the NET 6h after. 4)EN formula Type: polymeric EN with high caloric density/hyperprotein (1,5 or 2 kcal/mL): CV19 patients are often anasarcated, hypervolemic and poorly distributed. 5)EN in PP: open the OGT 3 h before pronating the patient and draine gastric content. Raise the head of the bed by 30º (reverse Trendelenburg position-RTP), infuse prokinetics drugs and only then, start EN, but no more than in trophic flow (around 20-30 mL/h) during prone perid. Do not infuse water filtered by the nasoenteric tube during PP. 6)EN in Supine Position: start EN 1 h supine the patient. Increase diet flow to the total caloric value, but don't try to compensate for the low volume infused in the PP, as this will bring risk of gastroparesis and vomiting. 7)EN x vasoative drugs (VAD): NE is permissive if VAD are between 0.14-0.3 mcg/kg/min 7 . 8)Indication of Parenteral Nutrition (PN): start PN, by a multi-chamber bag, if PP greater than 3 days or if RTP impracticable. 9)PN bag type: prefer smaller volume PN bag with 625 mL (infusion in central venous access) avoiding water overload. Peripheral infusion bag contains 1206 mL. 10)Total Parenteral Nutrition: if gastric intolerance greater than 5-7 d and PP more than 7 d and/or patients with severe Nutritional Risk 2 . Conclusion: Enormous difficulties in adequately nourishing CIP with CV19 during PP led to the development of this protocol. This is easy to apply, based on the real world of the lack of human and financial resources from the pandemic caused by SARS-CoV-2.

Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with CV19 in N York city area

Hanidziar D, Bittner E. Sedation of Mechanically Ventilated CV19 Patients: Challenges and Special Considerations

AN ANALYSIS OF NUTRITION SUPPORT IN THE INTENSIVE CARE UNIT DURING THE COVID19 PANDEMIC

Connor 2 . 1 Department of Clinical Nutrition, Ireland; 2 Department of Anaesthetics