Reviewer: Manpreet Mundi, MD, Medical Director, Home Enteral Nutrition Program; Chair of Food Services; Chair of Outpatient Nutrition, Mayo Clinic, Rochester, MN
References: Martindale 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.
Barazzoni, Rocco, Stephan C. Bischoff, Zeljko Krznaric, Matthias Pirlich, and Pierre Singer. ESPEN Expert Statements and Practical Guidance for Nutritional Management of Individuals with Sars-Cov-2 Infection. Clinical Nutrition, March 2020. https://doi.org/10.1016/j.clnu.2020.03.022.
Commentary: As of May 11, there have been over 4 million confirmed cases of COVID-19 and over 280,000 deaths worldwide. The United States alone is fast approaching 80,000 deaths. Despite social distancing, which has flattened the case rate and mortality curves, the end of the pandemic is not yet in sight. Like other frontline healthcare workers, the nutrition community must be prepared and remain dynamic to manage patients in the new landscape that has been created by the COVID-19 pandemic.
Approximately 5% of those who contract the SARS-CoV-2 virus require critical care services, often related to respiratory failure requiring prolonged endotracheal intubation. In the absence of definitive therapy for COVID-19, good supportive care remains the cornerstone of caring for critically ill COVID-19 patients. Nutrition support is an essential component of good supportive care. In a recent article published jointly by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, Martindale and colleagues provide recommendations relating to nutritional support for critically ill patients with COVID-19. Their recommendations are rooted in key guiding principles that are relevant to COVID-19, including limiting patient exposure and protecting healthcare workers by ‘clustering’ care, following CDC and WHO guidelines for utilizing personal protective equipment (PPE), and preserving PPE. They outline 12 key recommendations and highlight that the timing of nutrition support is one of the most important issues. They recommend enteral nutrition be initiated within 24-36 hours of intensive care unit (ICU) admission in a patient unable to maintain volitional oral intake. The authors point out some unique circumstances related to COVID-19, including gastrointestinal symptoms (related to COVID-19), circulatory shock, and characteristics of the affected, such as older age, anorexia, and pre-existing co-morbidities. These patient and disease characteristics lead to a greater risk for enteral feeding intolerance. Consequently, the authors underscore the recommendation for early transition to parenteral nutrition (PN) when gastric feeding is not tolerated. This recommendation is anchored on the key guiding principle of limiting patient-healthcare provider interactions since insertion of a naso-jejunal tube places healthcare staff at higher risk of direct exposure to the SARS-CoV-2 virus. Next, authors recommend that enteral feeds be started slowly and advanced to an energy goal of 15-20 kcal/kg (70-80% of caloric requirements) and protein goal of 1.2-2.0 g/kg/day. For PN, conservative dextrose and volume should be used early in the disease and slowly advanced as tolerated. Other key COVID-19 relevant recommendations include not checking gastric residual volumes and, based on safety data, starting early EN in patients undergoing extracorporeal membrane oxygenation and prone positioning, both of which are modalities used in COVID-19 related refractory hypoxemic respiratory failure.
Similar to hospitalized patients, the “clustering” approach should also be followed with outpatient nutrition support. Nutrition support providers should make every effort to conduct as much care as possible through telehealth in order to prevent unnecessary exposure. Routine laboratory studies, if they cannot be deferred, should be conducted at the patient’s home or local facility. Additionally, providers should be aware that patients with SARS-CoV-2 infection may present with nonspecific symptoms such as respiratory changes, fever, and GI deterioration. Thus, given the high prevalence of COVID-19, nutrition patients reporting these symptoms should be assessed for both SARS-CoV-2 infection and other nutrition related complications such as central line associated bloodstream infections.
The COVID-19 pandemic has limited family and medical access to patients and has created resource shortages. The nutrition community, as an essential front-line service, has been called upon to create new guidelines in order to optimize patient outcomes and protect health care staff. In addition to implementing key recommendations outlined in recent publications, we must also appreciate the emotional toll of the pandemic and use compassion and a non-judgmental approach with our patients and colleagues in order to support each other through the challenges with which we are now faced.
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