key: cord-1043776-f09s27cw
authors: Green, B.; Phillips, M.; Morgan, L.; Hughes, K.; Terblanche, E.; King, S.; Fiddes, A.; Atwal, K.; Hubbard, G. P.; Stratton, R. J.
title: Critically ill patients with and without SARS-CoV-2 better achieve energy and protein targets with a high-energy, high-protein peptide-based enteral tube feed; insights from a multicentre clinical audit performed during the COVID-19 pandemic
date: 2022-04-30
journal: Clinical Nutrition ESPEN
DOI: 10.1016/j.clnesp.2022.02.073
sha: 5f5cd522304e1bdf57cb0f56f2cabea8600ec866
doc_id: 1043776
cord_uid: f09s27cw

nan

Meeting energy and protein requirements in critically ill patients is important for prognosis, yet difficult to achieve as a consequence of disease, management and/or altered nutritional intake [1] . Improvements in achieving energy and protein requirements with a high-energy, highprotein peptide-based tube feed were observed in community patients with impaired gastrointestinal function [2] . To establish whether this remained true in the critical care setting, where feeding intolerance is observed frequently in patients with [3] and without SARS-CoV-2 [4] , a retrospective multicentre audit was performed. Adults (> 18years) with or without SARS-CoV-2, admitted to critical care across 6 UK hospitals between May 2020 and December 2020, were retrospectively included if they received a peptide-based enteral tube feed (Nutrison Peptisorb Plus HEHP®, Nutricia Ltd), containing 1.5kcal/ml and 7.5g protein/100ml (herein referred to as HEHP). Data were collected from 15 critically ill patients (52±12y; 87% male), with mean length of hospital stay being 26days (range: 7-49days). Of these, 10 were SARS-CoV-2 positive, with the remainder having pancreatitis (n¼3), delayed gastric emptying (n¼1) or unconfirmed diagnosis (n¼1). HEHP was used second line (after whole protein) and indications (multiple were cited for some) for use included tolerance issues (n¼10), elevated energy and protein requirements (n¼5) or due to primary diagnosis (n¼2). Estimated energy and protein intakes (% of requirements achieved) were recorded before and during use of HEHP. In addition, Dietitians were asked whether HEHP allowed patients to better meet their nutrient target Mean intake of HEHP was 2008±461kcal/day and 100±23g protein/day provided over a mean of 12days (range: 3-29days). The percentage of estimated energy and protein targets achieved increased albeit non significantly with the use of HEHP (from 76% before vs 87% during use of HEHP for both) and the direction of effect remained true regardless of SARS-CoV-2 status. Two thirds (67%, n¼10 of 15) of Dietitians reported HEHP helped patients better meet their nutrient targets and 87% (n¼13 of 15) of Dietitians perceived the high protein content of HEHP as beneficial for this patient group. Gastrointestinal tolerance (anecdotal reports) remained largely unchanged in approximately half of SARS-CoV-2 positive patients when using HEHP yet improved for others including non-SARS-CoV-2 patients. Enteral tube feeding in critically ill patients poses numerous difficulties, especially in SARS-CoV-2 positive patients. This audit in critically ill patients demonstrates that a high-energy, high-protein, peptide-based enteral tube feed can help complex patients better achieve energy and protein targets in patients with and without SARS-CoV-2. Delivering enteral feed or medications through a naso-gastric feeding tube (NGT) placed into the lung causes major morbidity. 1 To prevent this from occurring an accurate means of assessing NGT placement is essential. In the UK, the National guidelines for assessment the of NGT position includes the measurement of gastric aspirate pH (<5.5) and assessment of tube placement using x-ray if indeterminate. 1 However there is little evidence to support this as a safe approach in critically ill patients. 2 The aims of this study were to determine the prevalence of acidic tracheal pH in critically ill patients to assess the safety of the current first-line aspirate pH method of NGT confirmation in critical care. Simultaneous pH measurements were taken for aspirates obtained from the NGT, subglottic port and tracheal samples in 106 ventilated patients from June -November 2019 at a university-affiliated, tertiary hospital. The pH from the three sites was obtained and recorded once per nursing shift and electronically entered. Any sample taken as a non-directed bronchial lavage (NBL) also had the pH recorded. Baseline demographic data, relative time of NBL to sampling, and presence of medications used to suppress gastric acid production were recorded. Patient's notes were reviewed by the authors for history or suspicion of aspiration, and documented episodes of emesis. Institutional approval was given for this work Descriptive statistics were used to describe the distribution of pH from each site with specific note made of any instances of pH <5.5. Spearman's correlation were performed between subglottic and tracheal aspirate data. Data were included for 106 patients. Demographics include: mean age of 58.9 years, 78.3% referred from a medical speciality, average APACHE II score 14.6, average SOFA score 7.2, and 28.9% mortality rate overall. Analysis of all aspirates collected demonstrated a significant proportion within both subglottic and sputum aspirates of a pH <5.5, 5.3% and 6.3% respectively, see Table 1 . Fifteen patients accounted for the 27 acidic subglottic aspirates and four patients for the 7 sputum aspirates. Of note, there was a large proportion of NGT aspirates with a pH >5.5, 70.8%. Analysis of simultaneous sputum and subglottic demonstrated a positive correlation, r¼ 0.52 (Confidence Interval 0.31 -0.69), p < 0.0001.

This study demonstrated a large number of acidic samples outside of the gastrointestinal tract, 5.3% subglottic and 6.3% sputum, with a simultaneously high proportion of aspirates from the gastrointestinal tract not being acidic (70.8%). Given that the pH in tracheal and subglottic examples was moderately correlated, it is possible that the acidic pH in the airway was due to micro-aspiration past the cuff of the endotracheal tube. 3, 4 This raises the possibility that any patient with significant glottic dysfunction and either macro-or micro-aspiration may have an acidic tracheal pH, and raises doubts about the safety validity of pH testing as a means of confirmation of correct placement of an enteral feeding tube in this population. The elevated pH in the gastric samples is likely to be due to the use of protein pump inhibitors as a medication for stress ulcer prophylaxis in the critically ill patient cohort. The data presented suggests that pH testing as a means of confirmation of NGT placement in the critically ill may not be a safe first-line confirmation method. There is an urgent need to develop a safe method to confirm NGT placement in the critically ill Patients transferred out of intensive care recovering from COVID-19 infection are at high risk of malnutrition 1 .Untreated malnutrition has the potential to increase length of stay and increase morbidity and mortality. To inform service planning we aimed to describe nutritional status and dietetic outcomes of patients recovering from COVID-19 infection post ICU admission. Baseline data was collected retrospectively from patient electronic records and included age, gender, comorbidities, weight, height, Body Mass Index (BMI), Vitamin D status, type of nutrition support, length of stay and discharge destination. Of 51 COVID-19 patients transferred out of ICU, 71% remained as inpatients and had further dietetic follow up.

Of those with data sets available, 82% had a decrease in weight during their ICU stay with an average loss of 7.6kg (9% body weight). Thirty percent moved into a lower BMI category over the course of their ICU stay. On discharge from hospital and dietetic service, 50% were weight stable and 29% had gained weight following dietetic input. Seventy two percent of patients required ongoing artificial nutrition support on transfer out of ICU. Prior to discharge home, 82% required advice on a high protein, high calorie diet with 25% of these requiring additional advice for therapeutic diets such as diabetic diets, no added salt diet, dietary advice for stoma management, renal dietary advice and modified consistency dietary advice. In terms of follow up, 11% were referred to community dietetics, 8% returned to dietetic outpatient clinics and 18% were stable on nutrition care plan and discharged from dietetic caseload at ward level. The data obtained highlights the deterioration in nutritional status and risk of malnutrition in this cohort of patients post COVID-19 infection. Ongoing nutrition support and dietetic input should be considered as integral on transfer from ICU to ward level in preventing, treating and diagnosing malnutrition. 

Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition

Nasogastric tube misplacement: continuing risk of death and severe harm

Tracheal pH monitoring and aspiration in acute stroke

The role of the endotracheal tube cuff in microaspiration

CHARACTERISTICS AND NUTRITIONAL OUTCOMES OF PATIENTS RECOVERING FROM COVID-19 INFECTION POST INTENSIVE CARE ADMISSION