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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 6  |  Issue : 4  |  Page : 283-286

What's new in Academic International Medicine? The importance of nutrition in hospitalized COVID-19 patients


1 Department of Pharmacy, The Ohio State University Wexner Medical Center; Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, USA
2 Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
3 Department of Nursing, The Ohio State University Wexner Medical Center, Columbus, OH, USA

Date of Submission12-Nov-2020
Date of Acceptance24-Nov-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Anthony T Gerlach
Department of Pharmacy, The Ohio State University Wexner Medical Center; Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-5568.304608

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How to cite this article:
Gerlach AT, Thomas S, Byrd CA. What's new in Academic International Medicine? The importance of nutrition in hospitalized COVID-19 patients. Int J Acad Med 2020;6:283-6

How to cite this URL:
Gerlach AT, Thomas S, Byrd CA. What's new in Academic International Medicine? The importance of nutrition in hospitalized COVID-19 patients. Int J Acad Med [serial online] 2020 [cited 2021 Apr 17];6:283-6. Available from: https://www.ijam-web.org/text.asp?2020/6/4/283/304608



The year 2020 will be known as the year of coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2. At this time of writing, there have been over 40 million cases worldwide, with 1.15 million deaths.[1] While many patients are asymptomatic, the pandemic has taxed health systems worldwide. It has been reported that intensive care unit (ICU) admission among hospitalized patients varied between 3% and 100% but estimated to be between 20% and 40% in large multinational registry and meta-analysis.[2],[3] Healthcare practitioners, researchers, and healthcare societies have come together worldwide to study and share treatment strategies. Currently, there is no cure for COVID-19 and supportive care remains the cornerstone of treatment, especially for critically ill patients.[4]

Ten months into the global pandemic, some therapies such as dexamethasone, remdesivir, and prone positioning, have positive outcomes, but supportive care, including nutrition support, is integral to care.[4] Nutritional support, especially in critically ill patients is often overlooked but helps to improve outcomes.[5] Malnutrition is common and is associated with increased morbidity and mortality.[5],[6] For those patients with COVID-19 worse outcomes and higher mortality are reported in the elderly, obese polymorbid individuals, and the malnourished.[6] Unique to the COVID-19 pandemic, delivery of nutrition therapy must balance patient outcomes and strategies to reduce spread and exposure to health-care providers.[4] Therefore, nutritional support may be more complex in those hospitalized patients with COVID-19, especially critically ill.

It has been reported that patients that are admitted to ICU may have had symptoms for up to 10 days.[7] Loss of taste, smell, appetite, increased fatigue, presence of fever, diarrhea, nausea, and vomiting are common and it is possible that patients may have been eating poorly and have sustained weight loss before admission. Up to 58% of these patients may have anorexia on admission.[4] Refeeding risk must be assessed, included in nutrition advancement care plan, and monitored closely. If identified to be at risk, initiate at 25% of calorie goal and advance slowly while maintaining normal levels of potassium, phosphorous, and magnesium.[4],[8] These patients also should be supplemented with thiamine.

Due to the high transmittable nature of the virus and to preserve personal protective equipment (PPE), bedside assessment are not done by dietitians and mostly assisted in care remotely. Attempts are made by clinicians to reach out to family members to assess pre-existing malnutrition. Other factors in the initial assessment must also consider, the severity of respiratory failure, treatments being used such as proning, extracorporeal membrane oxygenation (ECMO), use of neuromuscular blocking agents, steroid treatment, and use of propofol. As a result, estimate nutritional needs may vary between patients, but assessing gastrointestinal function and tolerance to enteral nutrition (EN) should be considered in all. Other considerations include multisystem organ failure, use of therapies such as continuous renal replacement therapy, which increases protein demands, hemodynamic status, and use of vasopressors. It is safe to start EN with stable vasopressor requirements.[8] All of these factors will affect the delivery, tolerance, and adequacy of nutrition support.

To minimize patient contact, nasogastric tubes should be used for initiation of EN. Trial of prokinetics and or semi-elemental formula are recommended before attempting post-pyloric feeding access to minimize exposure when patient develop intolerance, especially in those requiring proning and those with ileus. Feeding interruptions and fluid status should also be monitored and the nutrition support regimen should be tailored to meet the nutritional needs of the patient. As in the case of any ICU patients, early initiation of EN is critical to minimize malnutrition associated complications. If EN is delayed or not tolerated parenteral nutrition (PN) must be considered.

The Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition (ASPEN) published 12 recommendations to assist clinicians to initiate and monitor appropriate nutrition therapy to these patients.[4] Some of the key recommendations are summarized below.

  1. 15–20 kcal/kg/d and 1.2–2 g protein/kg using actual body weight (ABW). The use of indirect calorimetry was discouraged to minimize the risk of exposure and due to the aerosolization. About 2–2.5 g/kg/d of protein is recommended for patients undergoing continuous renal replacement therapy
  2. Start early EN at low dose using isotonic (1.5 kcal/ml.) high-protein formula within 24–36 h of ICU admission or within 12 h of intubation. Advance to ~80% of goal during the acute phase of illness that lasts 7–10 days
  3. Early gastric feeding is recommended over PN, including in patients undergoing ECMO and proning with a low threshold to start PN if needed. It is advised to keep the head of the bed elevated to a minimum of 10°–25° (reverse Trendelenburg) with gastric feeding while proning
  4. Do not check gastric residual volume
  5. Limit pure soybean lipid emulsions in the 1st week, but this is often not followed with wide range use of propofol in most of these critically ill patients.


In patients with severe COVID-19 infection, it appears that there is a prolonged systemic inflammatory response resulting in hypermetabolic status beyond the 7–10 days. Just as overfeeding can cause increased ICU morbidity and mortality, underfeeding may also contribute to the same. COVID-19 patients continue to be hypermetabolic based on a study of 22 COVID-19 ICU patients.[9] Measured resting energy expenditure (mREE) was compared to predicted resting energy expenditure (pREE) by doing indirect calorimetry every 72 h. The pREE was based on Harris–Benedict equation calculated using actual body weight for non-obese patients with body mass index (BMI) <30 and adjusted body weight for those with BMI >30. Average ventilator days were 14.4. mREE ranged between 15 and 20 kcal/kg for the 1st week of ICU stay. It was noted that metabolic rate continued to increase with longer stay reaching 150%–200% pREE by week three. Severity of organ failure, pharmacological paralysis, or prone positioning did not affect mREE significantly. The mREE was also significantly higher than the ASPEN recommendation of 11–14 kcal/kg of ABW generally used for obese patients. Close attention should be paid in the transition of EN and/or PN to oral diet post-extubation, since these patients continue to be hypermetabolic with poor appetite and possible dysphagia.

The severity of respiratory illness seen in particular with the COVID-19 patient population often leads to difficult scenarios when it comes to the use of EN. Often due to the severe hypoxia demonstrated in this population prone ventilation is often required. EN is still the preferred route for nutrition even during proning. There are certain pragmatic things that clinicians can due to mitigate the potential for aspiration, which is the main provider concern. Elevating the head of the bed 15°–20° through the use of reverse Trendelenburg, placing a post-pyloric dobhoff tube although not necessary, increasing tube feeds slowly on patients that have high vasopressor requirements, and the addition of prokinetic agents are some ways to assist.[6] However, the main obstacle with this is organizational culture and ensuring that all team members are adhering to the same standards is imperative to supplying adequate nutrition. Organizational practice guidelines can assist health-care providers to align with standards of care.

Similarly to proning, ECMO is a supportive therapy used to assist with the severe refractory hypoxemia and/or hypercarbia seen in COVID-19 patients. EN is still considered the preferred route of nutrition. Special consideration should be considered in this population due to their increased risk for bowel ischemia and gastroparesis.[6] Nutrition should be given slowly at trophic levels with gradual increases based on patient tolerance, especially if the patient is receiving concurrent vasopressors.[6]

Hospitalized patients with COVID-19 may develop hyperglycemia for a variety of reasons including stress response, drug-induced, or because of underlying comorbidities such as diabetes mellitus. These patients are often treated with steroids, specifically dexamethasone based on large randomized studies that demonstrated better morbidity and mortality.[10],[11] The minimal dosing of steroids to show effectiveness is currently unknown, but higher and prolonged therapy may cause worse hyperglycemia. The use of continuous enteral or PN may exacerbate hyperglycemia. The latest Surviving Sepsis Guidelines recommend maintaining glucose <180 mg/dL (10 mmol/L), based on the results of many multinational studies. The use of insulin therapy may increase the risk of hypoglycaemia, but the use of nutrition support maybe associated with less hypoglycemia.[12] Glycemic control in patients but this may hard in hospitalized patients with COVID-19 when there is a shortage of PPE. As a result, the effective insulin therapy may not be started until glucose is severely high. In a study of 259,040 critically ill patients mortality increased as mean glucose increased independent of illness severity.[13] Some are using pumps outside rooms and continuous glucose monitors. Regardless severe hyperglycemia should be treated.

Clinicians are trying to better understand the pathophysiology of COVID-19, and this includes why some patients develop hypertriglyceridemia.[4] Especially early during the pandemic, there was a domino effect of changes in critical hierarchy and team compensation and significant personal protection shortage resulting in increased depth of sedation.[14] Propofol is a sedative hypnotic that is emulsion in a soy-based lipid emulsion and known to cause hypertriglyceridemia. Several anecdotal reports around the world stated many COVID-19 patients rapidly developed hypertriglyceridemia.[4] A recently published metabolomics profiling in critically ill patients with COVID-19 and healthy controls reported a 0.3 fold decreased in lysophsophatidylcholines.[15] These compounds are produced by phospholipase A2 metabolism of fatty acids and are decreased in sepsis which may contribute to the inflammatory effect.[15],[16],[17] Decreased phospholipase A2 activity is associated with hypertriglyceridemia, and may at least partially explain the andoctal report of rapid hypertriglyceridemia. The use of enteral medications and intravenous lipid formulations should always be assessed, as they can be a significant of calories. Soy-based intravenous lipids formation, including propofol and clevidipine, are more likely to cause hypertriglyceridemia. Further metabolomics studies are needed in patients with COVID-19, especially on fatty acid and triglyceride metabolism.

The provision of nutrition support in hospital patients with COVID-19 is a balancing act of improving patient outcomes while minimizing exposure to health care professionals. Nutrition support should be assessed on all patients with COVID-19 while hospitalized and after discharge. While data are lacking to COVID-19 disease, nutrition support, especially in critically ill patients is a proactive therapy that may reduce the length of stay, complications, and disease severity. As COVID-19 is a new disease more data are needed in this population, especially targeting complications such as hypertriglyceridemia. The provision of nutritional support also must balance safety to health-care providers, especially when PPE supplies are low. Plans to assess and treat hyperglycemia, provision of nutrition during prone positioning, and potentially early use of PN should be developed. Finally, more research is needed concerning nutrition support including research of metabolomics of COVID-19 patients.



 
  References Top

1.
WHO Coronavirus Disease (COVID-19) Dashboard. Available from: https://covid. 19.who.int. [Last accessed on 2020 Oct 27].  Back to cited text no. 1
    
2.
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VIRUS COVID-19 Registery. Available from: https://sccmcovid19.org. [Last accessed on 2020 Oct 27].  Back to cited text no. 3
    
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Martindale R, Patel JJ, Taylor B, Arabi YM, Warren M, McClave SA. Nutrition therapy in critically Ill patients with coronavirus disease 2019. JPEN J Parenter Enteral Nutr 2020;44:1174-84.  Back to cited text no. 4
    
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Gerlach AT, Murphy C. An update on nutrition support in the critically Ill. J Pharm Pract 2011;24:70-7.  Back to cited text no. 5
    
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Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clin Nutr 2020;39:1631-8.  Back to cited text no. 6
    
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Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 7
    
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Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med 2020;48:122-5.  Back to cited text no. 8
    
9.
Whittle J, Molinger J, MacLeod D, Haines K, Wischmeyer PE; LEEP-COVID Study Group. Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19. Crit Care 2020;24:581.  Back to cited text no. 9
    
10.
Tomazini BM, Maia IS, Cavalcanti AB, Berwanger O, Rosa RG, Veiga VC, et al. Effect of dexamethasone on days alive and ventilator-free in patients with moderate or severe acute respiratory distress syndrome and COVID-19. JAMA 2020;324:1307-16.  Back to cited text no. 10
    
11.
RECOVERY Collaborative Group; Peter Horby, Lim WS, Emberson JR, Mafham M, Bell JL, et al. Dexamethasone in hospitalized patients with Covid-19 Preliminary report. N Engl J Med 2020;Jul 17:NEJMoa2021436.  Back to cited text no. 11
    
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Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017;45:486-552.  Back to cited text no. 12
    
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Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med 2009;37:3001-9.  Back to cited text no. 13
    
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Devlin JW, O'Neal HR, Thomas C, Daly MA, Stollings JL, Janz DR, et al. Strategies to optimize ICU liberation (A to F) bundle performance in critically Ill adults with coronavirus disease 2019. Crit Care Explor 2020;2:e0139.  Back to cited text no. 14
    
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Fraser DD, Slessarev M, Martin CM, Daley M, Patel MA, Miller MR, et al. Metabolomics profiling of critically Ill coronavirus disease 2019 patients: Identification of diagnostic and prognostic biomarkers. Crit Care Explor 2020;2:e0272.  Back to cited text no. 15
    
16.
Jiang R, Chen S, Shen Y, Wu J, Chen S, Wang A, et al. Higher levels of lipoprotein associated phospholipase A2 is associated with increased prevalence of cognitive impairment: The APAC study. Sci Rep 2016;6:33073.  Back to cited text no. 16
    
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Mecatti GC, Fernandes Messias MC, Sant'Anna Paiola RM, Figueiredo Angolini CF, da Silva Cunha IB, Eberlin MN, et al. Lipidomic profiling of plasma and erythrocytes from septic patients reveals potential biomarker candidates. Biomark Insights 2018;13:1-13  Back to cited text no. 17
    




 

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