ABSTRACT
Background: Optimal supportive care which includes adequate nutrient delivery remains the cornerstone in managing critically ill patients with COVID-19. Nutrition guiding principles for critically ill patients with COVID-19 strongly recommend providing early enteral nutrition (EEN) within 24-36 hours of admission to the intensive care unit (ICU) or within 12 hours of placement on mechanical ventilation (MV). Moreover, data show critically ill COVID-19 patients have negative alterations in their gut microbiome which is attributed to many factors including insufficient EN and fiber provision. The success and tolerance of EEN with a prebiotic formula in patients with COVID 19 is unknown. Here we aimed to assess, before and after implementation of an enteral feeding protocol, the achievement of EEN, estimated energy goals, and tolerance of a prebiotic formula in MV patients with COVID-19. Method(s): Data were collected and analyzed retrospectively from June 2020-May 2021 and prospectively from June 2021-January 2022. A protocol to promote EEN and improve nutrition delivery with a prebiotic-containing formula to patients within the seven days of ICU admission was created and implemented in June 2021 in the Medical ICU. Time to start EEN following invasive MV was assessed. Feeding adequacy over the first seven days of ICU admission was calculated by dividing the mean total calories of formula infused over the first seven ICU days by the estimated goal calories/day. The average number of bowel movements (BM) over the first seven ICU days was used to evaluate feeding tolerance. To determine the impact of inflammation and co-morbid conditions on feeding adequacy and tolerance, admission C-reactive protein (CRP) and Charlson Comorbidity Index (CCI) were trended with feeding adequacy. The Institutional Review Board approved the study. Result(s): A total of 343 patient records were analyzed with 203 patients in retrospective (R) and 140 patients in prospective groups (P). The post- MV feeding initiation time was shorter after implementing the feeding protocol (Mean 45.2 vs 33.8 hrs, and Interquartile Range (IQR) of Median (hrs) (18, 51) vs (16, 43) for the R and P groups, respectively (p = 0.04). Achievement of feeding goal rates were similar between groups (30.0 % vs 29.5%) (p >0.05). A prebiotic-containing formula was received in 36.2 % of patients in the R group versus 43.4 % in the P group. Providing a prebiotic formula had no impact on achieving goal nutrition in either period. In the R group, patients receiving the non-prebiotic formula had a higher total 7-days BM occurrence compared to the prebiotic formula group (8 vs 5.9 BMs/7 days, p = 0.03). In the P group there were no differences in the number of BMs between non-prebiotic and prebiotic formula groups (5.3 vs 5.0 BMs/7 days, p >0.05). Higher admission CRP and CCI values trended with higher incidence of inadequate feeding. Mean CCI was 4.42 and 4.17 for patients who received less than 25% goal feeding compared to those who received >80% of their goal feeds, respectively. Mean CRP was 12.3 and 11.4 for patients who received < 25% goal feeds compared to those who received >80% of goal feeds, respectively (p > 0.05). There were no differences in overall ICU length of stay between the R (11.7 days) and P (11.1 days) groups. (p = 0.34) Conclusion(s): EEN protocol implementation decreased time to EEN initiation in mechanically ventilated COVID-19 patients but did not affect patients in achieving goal nutrition in the first week of their ICU stay. Furthermore, COVID-19 patients tolerated EEN with prebiotic containing formulas. Further research is warranted to determine the impact of EEN with a prebiotic formula on the gut microbiome in critically ill MV patients with COVID-19.