Nutrition Management of mechanically ventilated patients with COVID-19
Know more about the Nutrition Management of mechanically ventilated patients suffering from COVID-19
The COVID-19 pandemic is a global challenge to people, patients, healthcare professionals, and healthcare systems.
COVID-19 may lead to severe critical illness in patients with comorbidities such as cardiovascular disease, diabetes, cancer, and chronic respiratory disease, specifically in those of advanced age.[i]
Moreover, severe COVID-19 outcomes manifest as uncontrolled inflammation, the so-called cytokine storm.Topics[ii],[iii],[iv]
Acute respiratory distress syndrome (ARDS) is a serious complication of COVID-19 and the main cause of mortality.
Patients with ARDS are highly likely to require ventilation support and, consequently, nutritional therapy.Topics[v]
Both the ESPEN COVID-19 guidelinesTopics[vi] as well as the ASPENTopics[vii] endorsed COVID-19 guidelines aim to give practical guidance to health care professionals regarding nutritional therapy of critically ill COVID-19 patients. Regarding the timing, route, dose, and monitoring of nutrition therapy, the recommendations are very similar to those for other ICU patients admitted with pulmonary compromise and requiring ventilation.7
When to start PN?
Parenteral nutrition should be initiated if the patient is at nutritional risk and enteral nutrition is insufficient and/or contraindicated.6,7 It should be started immediately for malnourished patientsTopics[viii] or those at high-risk7 if oral or enteral nutrition is not feasible.
Fig.1: Timing of parenteral nutrition, macronutrients delivery, and nutrition monitoring in critically ill patients with COVID-19. 6,7,8,9,10 *Propofol: Source of fatty acids: contains 1.1 kcal/ml; CRRT=Continuous Renal Replacement Therapy | ** corresponds to 1.56 g amino acids/kg/d; 100 g parenteral amino acids equivalent to 83 g protein.[xi]
Moreover, COVID-19 patients are at risk of developing gastrointestinal dysfunctions or bowel ischemia. Therefore, the threshold for switching to PN may have to be lower. All these recommendations are fully valid for COVID-19 patients in prone position.7 (Fig. 1)
Take advantage of the anti-inflammatory properties of fish-oil
Omega-3 fatty acids from fish oil are direct precursors of potent mediators which play a key role in the resolution of inflammation.[xii] Experts suggest that fish oil containing formulations may help to clear viral infections.7
Fish oil-containing PN is associated with statistically and clinically significant positive effects on clinical outcomes, such as lower relative risk of infection and sepsis rates, and shorter length of ICU and hospital stay.[xiii] Thus, omega-3 fatty acids are the only specific nutrients that experts recommend as part of the lipid component in PN admixtures in the ESPEN ICU guidelines.8
Be aware of nutritional needs after weaning from mechanical ventilation
After weaning from mechanical ventilation, patients are at risk of swallowing problems at reintroduction of oral intake. This should be assessed in time, with referral to an appropriately trained health care professional if necessary.6
Patients are also at high risk of inadequate energy, protein, and fluid intakes and therefore it is essential to monitor oral intake during the convalescence phase.[xiv]
ESPEN recommends textured modified food for patients with dysphagia after extubation. If swallowing is unsafe enteral nutrition should be administered. If a high aspiration risk exists despite post pyloric feeding route, then parenteral nutrition should be considered with removal of nasoenteral tube while the patient receives swallowing training.6
- 1Cummings MJ, Baldwin MR, Abrams D et al., Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. The Lancet, published online May 19, 2020. https://doi.org/10.1016/S0140-6736(20)31189-2
- 2Li X, Geng M, Peng Y et al., Molecular immune pathogenesis and diagnosis of COVID-19. J Pharm Anal. 2020 Apr;10(2):102-108. doi: 10.1016/j.jpha.2020.03.001. Epub 2020 Mar 5.
- 3Mehta P, McAuley DF, Brown M et al., COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020 Mar 28;395(10229):1033-1034.
- 4Pedersen SF, Ho YC. SARS-CoV-2: a storm is raging. J Clin Invest. 2020 May 1;130(5):2202-2205.
- 5Bear D, Terblanche E. Critical Care Specialist Group Guidance on management of nutrition and dietetic services during the COVID-19 pandemic. 23rd March 2020. Accessed at: https://www.bda.uk.com/resource/critical-care-dietetics-guidance-covid-19.html
- 6Barazzoni R, Bischoff SC, Krznaric Z et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-COV-2 infection. Clinical Nutrition 2020, https://doi.org/10.1016/j.clnu.2020.03.022
- 7Martindale R, Patel JJ, Taylor B et al., Nutrition Therapy in the Patient with COVID-19 Disease Requiring ICU Care. Reviewed and Approved by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, published online April 2020: http://www.nutritioncare.org/COVID19Resources/
- 8Singer P, Reintam Blaser A, Berger MM et al. ESPEN Guideline on Clinical Nutrition in the Intensive Care Unit. Clin Nutr. 2019; 38(1):48-79.
- 9Worthington P, Balint J, Bechtold M et al., When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr. 2017 Mar;41(3):324-377.
- 10McClave SA, Taylor BE, Martindale RG et al., 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 (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.
- 11Hoffer LJ. Human Protein and Amino Acid Requirements. JPEN J Parenter Enteral Nutr. 2016 May;40(4):460-74.
- 12Serhan CN, Levy BD. Resolvins in inflammation: emergence of the pro-resolving superfamily of mediators. J Clin Invest. 2018 Jul 2;128(7):2657-2669.
- 13Pradelli L, Mayer K, Klek S et al. ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis JPEN J Parenter Enteral Nutr. 2020;44:44-57
- 14Van Zanten A, De Waele E, Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. Critical Care. 2019; 23:368.