Nutritional status of COVID-19 patients one year post-ICU stay

Introduction: Our aim was to describe nutritional status (NS) of critically ill COVID-19 patients 1 year post-ICU stay. Malnutrition and weight loss were observed during hospitalization. Post-ICU discharge patients often continue to suffer from physical complaints and poor nutritional intake, which can negatively affect NS. Methods: Observational study including adult COVID-19 patients 1 year post-ICU stay. NS assessment (nutrient balance, body composition and physical status) was performed. Nutritional intake (energy and protein), nutrition related complaints and losses were examined. Indirect calorimetry (Q-NRG +) was performed to determine nutritional requirements. Body composition (e.g. fat mass, fat free mass) was measured with bio-electrical impedance analysis (InbodyS10). Fat-free mass index (FFMI) and fat mass index (FMI) were calculated. Physical status was determined with handgrip strength (HGS). Overall values ≤ 10th percentile were considered too low and ≥ 90th too high. Descriptive statistics were used for analysis. Results: 48 patients were included (72% male;median age 60 years [IQR 52;65]). Median ICU stay was 19 days [IQR 10;30]. Median weight loss during ICU stay was 13% [IQR - 10;- 16] and 12% of this loss [IQR 7;16] was regained after 1 year. BMI was 26 kg/m2 [IQR 23;30] 1 year post-ICU, of which 24% was obese (BMI > 30 kg/m2). Normometabolism was predominantly observed (62%), followed by hypermetabolism (30%). Mean nutritional intake was 78% of calculated requirements. Nutrition related complaints occurred in < 5% of the patients. Most patients had a high FMI (55%) and minority had low FFMI (35%). Combination of a high FFMI and FMI was present in 17%. Three patients (6%) had low HGS. Conclusions: Weight loss was almost fully regained 1 year post-ICU, often in combination with a high fat mass. A minority had low physical function. Whereas reported calculated requirements were not met, lifestyle coaching remains indicated to optimize NS.

Nutritional intake and gastro-intestinal symptoms in critically ill COVID-19 patients.

BACKGROUND & AIMS: Critically ill COVID-19 patients seem hypermetabolic and difficult to feed enterally, due to gastro-intestinal (GI) symptoms such as high gastric residual volumes (GRV) and diarrhea. Our aim was to describe the association of nutritional intake and GI symptoms during first 14 days of ICU admission. METHODS: Observational study including critically ill adult COVID-19 patients. Data on nutritional intake [enteral nutrition (EN) or parenteral nutrition] and GI symptoms were collected during 14 days after ICU admission. Target energy and protein feeding goals were calculated conform ESPEN guidelines. GI symptoms included GRV (ml/d), vomiting, abdominal distension, and faeces (ml/d). High GRV's were classified as ≥2 times ≥150 ml/d and diarrhea as Bristol stool chart ≥6. GI symptoms were defined as mild if at least one symptom occurred and as moderate when ≥2 symptoms occurred. Acute gastrointestinal injury (AGI) grades of III were classified as GI dysfunction and grades of IV were considered as GI failure with severe impact on distant organs. Linear mixed model analysis was performed to explore the development of nutritional intake and GI symptoms over time at day (D) 0, 4, 10, and 14. RESULTS: One hundred and fifty patients were included [75% male; median age 64 years (IQR 54-70)]. BMI upon admission was 28 kg/m2 (IQR 25-33), of which 43% obese (BMI > 30 kg/m2). Most patients received EN during admission (98% D4; 96% D10-14). Mean energy goals increased from 87% at D4 to 93% D10-14 and protein goals (g/kg) were increasingly achieved during admission (84% D4; 93% D10-14). Presence of moderate GI symptoms decreased (10% D0; 6% D4-10; 5% D14), reversely mild GI symptoms increased. Occurrence of GI dysfunction fluctuated (1% D0; 18% D4; 12% D10; 8% D14) and none of patients developed grade IV GI failure. Development of high GRV fluctuated (5% D0; 23% D4; 14% D10; 8% D14) and occurrence of diarrhea slightly increased during admission (5% D0; 22% D4; 25% D10; 27% D14). Linear mixed models showed only an association between AGI grades III and lower protein intake at day 10 (p = 0.020). CONCLUSION: Occurrence of GI symptoms was limited and seems no major barrier for EN in our group of critically COVID-19 patients. Nutritional intake was just below requirements during the first 14 days of ICU admission. The effect on nutritional status remains to be studied.

Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus.

BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19.

There are reports of children COVID-19 or COVID-19 like symptoms with hyperinflammatory multisystem syndrome, ARDS, gastrointestinal and atypical Kawasaki disease presenting to PICU worldwide temporally associated with COVID-19, for which there are important nutrition support considerations. As a result, the European Society of Pediatric and Neonatal Intensive Care - Metabolism, Endocrine and Nutrition group (ESPNIC-MEN) and paediatric nutritionists working in PICUs are being consulted regarding nutrition management of critically ill children with COVID-19 or COVID-19 like symptoms. Therefore, the aim of this short report is to provide a summary of nutrition support recommendations for critically ill children with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 and surviving sepsis recommendations from February 2020.

Energy expenditure and feeding practices and tolerance during the acute and late phase of critically ill COVID-19 patients.

BACKGROUND & AIMS: Different metabolic phases can be distinguished in critical illness, which influences nutritional treatment. Achieving optimal nutritional treatment during these phases in critically ill patients is challenging. COVID-19 patients seem particularly difficult to feed due to gastrointestinal problems. Our aim was to describe measured resting energy expenditure (mREE) and feeding practices and tolerance during the acute and late phases of critical illness in COVID-19 patients. METHODS: Observational study including critically ill mechanically ventilated adult COVID-19 patients. Indirect calorimetry (Q-NRG+, Cosmed) was used to determine mREE during the acute (day 0-7) and late phase (>day 7) of critical illness. Data on nutritional intake, feeding tolerance and urinary nitrogen loss were collected simultaneously. A paired sample t-test was performed for mREE in both phases. RESULTS: We enrolled 21 patients with a median age of 59 years [44-66], 67% male and median BMI of 31.5 kg/m2 [25.7-37.8]. Patients were predominantly fed with EN in both phases. No significant difference in mREE was observed between phases (p = 0.529). Sixty-five percent of the patients were hypermetabolic in both phases. Median delivery of energy as percentage of mREE was higher in the late phase (94%) compared to the acute phase (70%) (p = 0.001). Urinary nitrogen losses were significant higher in the late phase (p = 0.003). CONCLUSION: In both the acute and late phase, the majority of the patients were hypermetabolic and fed enterally. In the acute phase patients were fed hypocaloric whereas in the late phase this was almost normocaloric, conform ESPEN guidelines. No significant difference in mREE was observed between phases. Hypermetabolism in both phases in conjunction with an increasing loss of urinary nitrogen may indicate that COVID-19 patients remain in a prolonged acute, catabolic phase.

Feeding practises and REE in critically ill COVID-19 patients

Rationale: The optimal feeding strategy in critically ill COVID-19 patients is challenging. They seem particularly difficult to feed enterally, presenting with high gastric residual volumes (GRV) and diarrhoea. Our aim was to describe feeding practises and measured resting energy expenditure (mREE) during the acute and late phases of critical illness. Methods: Observational study including critically ill mechanically ventilated adult COVID-19 patients. Indirect calorimetry (IC;Q-NRG+) was used to determine mREE during the acute (day 1-7) and late phase (> day 7) of critical illness. Data on enteral nutrition (EN) and parenteral nutrition (PN) were collected on the same day. Comparison of mREE and predicted REE (pREE) (mREE/pREE *100%) was performed to explore hypometabolism (<90%) and hypermetabolism (>110%). In both phases parameters for intolerance to EN were collected on consequent days such as GRV (mL/d), vomiting, abdominal distention and diarrhoea. Results: We enrolled 35 patients in whom 42 IC measurements were performed (20 acute phase;22 late phase). Median age 63 year [IQR 47-69], 80% male. BMI upon admission was 27.8 kg/m2 [IQR 24.2-34.0], 43% obese (BMI>30 kg/m2). During the acute phase mREE was 1956 kcal [IQR 1846-2441] and respiratory quotient (RQ) 0,72 [IQR 0,67-0,81];10% was hypometabolic, 60% hypermetabolic. The median delivery of energy was 64% of mREE. All patients received EN;70% via nasogastric tube (NGT) and 30% via nasoduodenal tube (NDT). Median GRV was 195 mL/d [IQR 41-450], 5% vomited, 5% abdominal distention and 20% diarrhoea. In the late phase mREE was 2374 kcal [IQR 1828-2711] and RQ 0,81 [IQR 0,74-0,86];9% was hypometabolic and 68% hypermetabolic. The median delivery of energy was 92% of mREE. All patients except one received EN;50% NGT and 50% NDT, with a median GRV of 48 mL/d [IQR 15-180]. A total of 5% vomited, 9% abdominal distention and 15% diarrhoea. Conclusion: In both the acute and late phase the majority of the patients were hypermetabolic. Almost all patients were fed enterally, with a slightly higher presence of EN intolerance parameters during the acute phase. In the acute phase patients were fed hypocaloric whereas in the late phase this was almost normocaloric (64% vs 92% of mREE) conform our ESPEN based nutrition protocol. Elaborate data analysis are planned and will be presented at the conference. Disclosure of Interest: None declared