Innovative strategy to improve enteral nutrition in prone positioning with patients with COVID-19.

BACKGROUND: Enteral nutrition is essential to improve outcomes in patients who are critically ill. Patients in the prone position, including those diagnosed with coronavirus disease 2019 (COVID-19) present additional challenges for enteral nutrition initiation. METHODS: A novel technique for placing feeding tubes while in the prone position was developed using an electromagnetic placement device and specialty trained clinical nurse specialists. Data were assessed retrospectively to determine effectiveness of this new practice. RESULTS: Sixty-eight patients had feeding tubes placed while in the prone position; 75% were able to be placed through the postpyloric route, 22% were placed through the gastric route, and 3% unable to be placed. Use of this technique facilitated earlier initiation of feedings by 2 days from time of admission and almost half a day from intubation to feeding. There was no additional radiation exposure from using this technique. CONCLUSION: Ability to place feeding tubes early while patients were prone reduced delays for starting enteral nutrition. Patients with COVID-19 in the prone position were able to receive effective nutrition support earlier with no additional complications.

Current insights in ICU nutrition: tailored nutrition.

PURPOSE OF REVIEW: To summarize recent research on critical care nutrition focusing on the optimal composition, timing, and monitoring of enteral feeding strategies for (post)-ICU patients. We provide new insights on energy and protein recommendations, feeding intolerance, and describe nutritional practices for coronavirus disease 2019 ICU patients. RECENT FINDINGS: The use of indirect calorimetry to establish individual energy requirements for ICU patients is considered the gold standard. The limited research on optimal feeding targets in the early phase of critical illness suggests avoiding overfeeding. Protein provision based upon the absolute lean body mass is rational. Therefore, body composition measurements should be considered. Body impedance analysis and muscle ultrasound seem reliable, affordable, and accessible methods to assess body composition at the bedside. There is inadequate evidence to change our practice of continuous enteral feeding into intermittent feeding. Finally, severe acute respiratory syndrome coronavirus 2 patients are prone to underfeeding due to hypermetabolism and should be closely monitored. SUMMARY: Nutritional therapy should be adapted to the patient's characteristics, diagnosis, and state of metabolism during ICU stay and convalescence. A personalized nutrition plan may prevent harmful over- or underfeeding and attenuate muscle loss. Despite novel insights, more research is warranted into tailored nutrition strategies during critical illness and convalescence.

Epidemiological characteristics of home enteral nutrition in patients from a Chinese tertiary hospital in 2021: A cross-sectional study.

BACKGROUND AND OBJECTIVES: Home enteral nutrition was reported to be a treatment reducing malnutrition rates and improving the rational allocation of medical resources. We aim to investigate the epidemiological characteristics and improved the management of home enteral nutrition. METHODS AND STUDY DESIGN: 3953 patients with home enteral nutrition were enrolled in West China Hospital, located in Sichuan province, between January 1, 2021, and December 31, 2021. RESULTS: 7238 visit records (3429 females and 3809 males) were included. The median age was 59.0, with the age from 1 to 115. The top two diseases were oncologic disorders (40.3%) and digestive disorders (15.9%). Oral nutritional supplements (86.2%) was the major treatment of home enteral nutrition. The median daily energy intake and daily protein intake were 575.1 kcal and 31.2 g. 25.8%, 39.3%, 34.9% patients choose online clinic (1867), offline clinic (2843) and hospital to home (2528) respectively. Interestingly, 63.6% patients were revisited, and the rate of online clinic, offline clinic and hospital to home was increasingly lower (91.9%, 71.5%, 33.8%) among them, revealing online clinic improving the revisit rate. Most patients lived in Chengdu (60.5%), and 67.4% patients from Chengdu were revisited. The median monthly cost of hospital to home patients (¥ 1863.8) was higher than the total median monthly cost (¥ 1714.5), illustrating the cost may reduce the revisit rate. CONCLUSIONS: Distance, cost and convenience may be the key factors to determine the method of visit and revisit in patients of home enteral nutrition. Online clinic may enhance the patients' follow-up.

The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. METHODS: We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). RESULTS: Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75-1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD -3.44% per week, 95% CI -4.99 to -1.90; p < 0.0001). CONCLUSION: In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530.

Clinical nutrition approach in medical management of COVID-19 hospitalized patients: A narrative review.

BACKGROUND: Malnutrition in COVID-19 hospitalized patients is associated with a high-risk condition to increase disease severity and prolonging the recovery period. Therefore, nutritional therapy, including supplements plays a critical role to reduce disease-related complications and the length of hospital stay. AIM: To review the latest evidence on nutritional management options in COVID-19 hospitalized patients, as well as possibly prescribed supplements. Methods: This review was conducted by considering the latest recommendations, using the guidelines of the American Society of Enteral and Parenteral (ASPEN) and the European Society of Enteral and Parenteral (ESPEN), and searching Web of Science, PubMed/Medline, ISI, and Medline databases. The relevant articles were found using a mix of related mesh terms and keywords. We attempted to cover all elements of COVID-19 hospitalized patients' dietary management. Results: Energy demand in COVID-19 patients is a vital issue. Indirect Calorimetry (IC) is the recommended method to measure resting energy expenditure. However, in the absence of IC, predictive equations may be used. The ratio of administered diet for the macronutrients could be based on the phase and severity of Covid-19 disease. Moreover, there are recommendations for taking micronutrient supplements with known effects on improving the immune system or reducing inflammation. Conclusions: Nutritional treatment of COVID-19 patients in hospitals seems to be an important element of their medical care. Enteral nutrition would be the recommended feeding method for early nutrition support. However, data in the COVID-19 nutritional domain relating to micronutrient supplementation are still fragmentary and disputed, and further study is required.

The Effects of Enteral Nutrition in Critically Ill Patients with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Patients who are critically ill with COVID-19 could have impaired nutrient absorption due to disruption of the normal intestinal mucosa. They are often in a state of high inflammation, increased stress and catabolism as well as a significant increase in energy and protein requirements. Therefore, timely enteral nutrition support and the provision of optimal nutrients are essential in preventing malnutrition in these patients. AIM: This review aims to evaluate the effects of enteral nutrition in critically ill patients with COVID-19. METHOD: This systematic review and meta-analysis was conducted based on the preferred reporting items for systematic review and meta-Analysis framework and PICO. Searches were conducted in databases, including EMBASE, Health Research databases and Google Scholar. Searches were conducted from database inception until 3 February 2022. The reference lists of articles were also searched for relevant articles. RESULTS: Seven articles were included in the systematic review, and four articles were included in the meta-analysis. Two distinct areas were identified from the results of the systematic review and meta-analysis: the impact of enteral nutrition and gastrointestinal intolerance associated with enteral nutrition. The impact of enteral nutrition was further sub-divided into early enteral nutrition versus delayed enteral nutrition and enteral nutrition versus parenteral nutrition. The results of the meta-analysis of the effects of enteral nutrition in critically ill patients with COVID-19 showed that, overall, enteral nutrition was effective in significantly reducing the risk of mortality in these patients compared with the control with a risk ratio of 0.89 (95% CI, 0.79, 0.99, p = 0.04). Following sub-group analysis, the early enteral nutrition group also showed a significant reduction in the risk of mortality with a risk ratio of 0.89 (95% CI, 0.79, 1.00, p = 0.05). The Relative Risk Reduction (RRR) of mortality in patients with COVID-19 by early enteral nutrition was 11%. There was a significant reduction in the Sequential Organ Failure Assessment (SOFA) score in the early enteral nutrition group compared with the delayed enteral nutrition group. There was no significant difference between enteral nutrition and parenteral nutrition in relation to mortality (RR = 0.87; 95% CI, 0.59, 1.28, p = 0.48). Concerning the length of hospital stay, length of ICU stay and days on mechanical ventilation, while there were reductions in the number of days in the enteral nutrition group compared to the control (delayed enteral nutrition or parenteral nutrition), the differences were not significant (p > 0.05). CONCLUSION: The results showed that early enteral nutrition significantly (p < 0.05) reduced the risk of mortality among critically ill patients with COVID-19. However, early enteral nutrition or enteral nutrition did not significantly (p > 0.05) reduce the length of hospital stay, length of ICU stay and days on mechanical ventilation compared to delayed enteral nutrition or parenteral nutrition. More studies are needed to examine the effect of early enteral nutrition in patients with COVID-19.

Does Route of Full Feeding Affect Outcome among Ventilated Critically Ill COVID-19 Patients: A Prospective Observational Study.

The outbreak of the new coronavirus strain SARS-CoV-2 (COVID-19) highlighted the need for appropriate feeding practices among critically ill patients admitted to the intensive care unit (ICU). This study aimed to describe feeding practices of intubated COVID-19 patients during their second week of hospitalization in the First Department of Critical Care Medicine, Evaggelismos General Hospital, and evaluate potential associations with all cause 30-day mortality, length of hospital stay, and duration of mechanical ventilation. We enrolled adult intubated COVID-19 patients admitted to the ICU between September 2020 and July 2021 and prospectively monitored until their hospital discharge. Of the 162 patients analyzed (52.8% men, 51.6% overweight/obese, mean age 63.2 ± 11.9 years), 27.2% of patients used parenteral nutrition, while the rest were fed enterally. By 30 days, 34.2% of the patients in the parenteral group had died compared to 32.7% of the patients in the enteral group (relative risk (RR) for the group receiving enteral nutrition = 0.97, 95% confidence interval = 0.88-1.06, p = 0.120). Those in the enteral group demonstrated a lower duration of hospital stay (RR = 0.91, 95% CI = 0.85-0.97, p = 0.036) as well as mechanical ventilation support (RR = 0.94, 95% CI = 0.89-0.99, p = 0.043). Enteral feeding during second week of ICU hospitalization may be associated with a shorter duration of hospitalization and stay in mechanical ventilation support among critically ill intubated patients with COVID-19.

Barriers to nutrition therapy in the critically ill patient with COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has created challenges for intensivists, as high ventilatory demands and prolonged hypermetabolism make it difficult to sustain nutrition status. The purpose of this survey was to determine current practices in nutrition therapy and identify barriers to its delivery. METHODS: A survey about delivering nutrition therapy to critically ill patients with COVID-19 was sent to clinicians at academic and community hospitals from September to December 2020. RESULTS: Of 440 who viewed the survey, 199 (45%) completed the questionnaire. Respondents were composed of 30%, physicians and 70% registered dietitians, with 51% representing community programs, 43% academic institutions, and 6% Veterans Affairs centers. Half (49%) had protocols for managing critically ill patients with COVID-19, and 21% had a protocol for nutrition therapy. Although most respondents (83%) attempted to feed by the intragastric route, only 9% indicated that energy/protein needs were met. The biggest barriers to delivery of enteral nutrition (EN) involved the patients unpredictable clinical course and fear of aspiration given the lack of respiratory reserve. Intensivists were reluctant to add supplemental parenteral nutrition (PN) because of perceived lack of benefit. CONCLUSION: The survey results would suggest that strategies for nutrition therapy based on the intragastric infusion of EN are unsuccessful in meeting the energy/protein needs of critically ill patients with COVID-19. It is likely these barriers exist in providing nutrition to non-Covid-19 critically ill patients. Intensivists need protocols that optimally deliver intragastric EN, consider early postpyloric infusion, and address adding supplemental PN in a deteriorating nutrition status.

CE: Monitoring Adult Patients for Intolerance to Gastric Tube Feedings.

ABSTRACT: Gastric tube feeding is a common and valuable intervention for patients in a variety of care settings. While tube feeding can save the lives of patients for whom oral feeding isn't possible, intolerance to tube feeding is a potential complication. This article discusses risk factors for feeding intolerance; the assessment of signs and symptoms of feeding intolerance; the various means of assessing gastric emptying, including the practice of monitoring gastric residual volume (GRV); the controversy surrounding GRV monitoring in assessing feeding tolerance; and the special considerations for monitoring feeding tolerance in acutely and critically ill adults with coronavirus disease 2019. The author, a nurse researcher with extensive experience in the area of enteral feeding, briefly summarizes recommendations and guidelines for enteral feeding published by national and international health care organizations between 2015 and 2020, and offers her perspective on best nursing practices for monitoring food tolerance in adults.

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.

Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research.

The purpose of this scoping review by the American Society for Parenteral and Enteral Nutrition (ASPEN) Coronavirus Disease 2019 (COVID-19) Nutrition Task Force was to examine nutrition research applicable to the COVID-19 pandemic. The rapid pace of emerging scientific information has prompted this activity to discover research/knowledge gaps. This methodology adhered with recommendations from the Joanna Briggs Institute. There were 2301 citations imported. Of these, there were 439 articles fully abstracted, with 23 main topic areas identified across 24 article types and sourced across 61 countries and 51 specialties in 8 settings and among 14 populations. Epidemiological/mechanistic relationships between nutrition and COVID-19 were reviewed and results mapped to the Population, Intervention, Comparator, Outcome, and Time (PICO-T) questions. The aggregated data were analyzed by clinical stage: pre-COVID-19, acute COVID-19, and chronic/post-COVID-19. Research gaps were discovered for all PICO-T questions. Nutrition topics meriting urgent research included food insecurity/societal infrastructure and transcultural factors (pre-COVID-19); cardiometabolic-based chronic disease, pediatrics, nutrition support, and hospital infrastructure (acute COVID-19); registered dietitian nutritionist counseling (chronic/post-COVID-19); and malnutrition and management (all stages). The paucity of randomized controlled trials (RCTs) was particularly glaring. Knowledge gaps were discovered for PICO-T questions on pediatrics, micronutrients, bariatric surgery, and transcultural factors (pre-COVID-19); enteral nutrition, protein-energy requirements, and glycemic control with nutrition (acute COVID-19); and home enteral and parenteral nutrition support (chronic/post-COVID-19). In conclusion, multiple critical areas for urgent nutrition research were identified, particularly using RCT design, to improve nutrition care for patients before, during, and after COVID-19.

Relevant Nutrition Therapy in COVID-19 and the Constraints on Its Delivery by a Unique Disease Process.

Worldwide, as of July 2020, >13.2 million people have been infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. The spectrum of coronavirus disease 2019 (COVID-19) ranges from mild illness to critical illness in 5% of cases. The population infected with SARS-CoV-2 requiring an intensive care unit admission often requires nutrition therapy as part of supportive care. Although the various societal guidelines for critical care nutrition meet most needs for the patient with COVID-19, numerous factors, which impact the application of those guideline recommendations, need to be considered. Since the SARS-CoV-2 virus is highly contagious, several key principles should be considered when caring for all patients with COVID-19 to ensure the safety of all healthcare personnel involved. Management strategies should cluster care, making all attempts to bundle patient care to limit exposure. Healthcare providers should be protected, and the spread of SARS-CoV-2 should be limited by minimizing procedures and other interventions that lead to aerosolization, avoiding droplet exposure through hand hygiene and use of personal protective equipment (PPE). PPE should be preserved by decreasing the number of individuals providing direct patient care and by limiting the number of patient interactions. Enteral nutrition (EN) is tolerated by the majority of patients with COVID-19, but a relatively low threshold for conversion to parenteral nutrition should be maintained if increased exposure to the virus is required to continue EN. This article offers relevant and practical recommendations on how to optimize nutrition therapy in critically ill patients with COVID-19.

Impact of COVID-19 on diagnosis and management of paediatric inflammatory bowel disease during lockdown: a UK nationwide study.

BACKGROUND: COVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic. METHODS: For the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD. RESULTS: All centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres. CONCLUSIONS: Diagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.

[Nutritional management of the critically ill inpatient with COVID-19. A narrative review]. / Manejo nutricional del paciente hospitalizado críticamente enfermo con COVID-19. Una revisión narrativa.

INTRODUCTION: The current COVID-19 pandemic mainly affects older people, those with obesity or other coexisting chronic diseases such as type-2 diabetes and high blood pressure. It has been observed that about 20 % of patients will require hospitalization, and some of them will need the support of invasive mechanical ventilation in intensive care units. Nutritional status appears to be a relevant factor influencing the clinical outcome of critically ill patients with COVID-19. Several international guidelines have provided recommendations to ensure energy and protein intake in people with COVID-19, with safety measures to reduce the risk of infection in healthcare personnel. The purpose of this review is to analyze the main recommendations related to adequate nutritional management for critically ill patients with COVID-19 in order to improve their prognosis and clinical outcomes.

INTRODUCCIÓN: La pandemia actual por COVID-19 afecta principalmente a personas mayores, con obesidad o con otras enfermedades crónicas coexistentes como diabetes de tipo 2 e hipertensión arterial. Se ha observado que alrededor del 20 % de los pacientes requerirán hospitalización y algunos de ellos necesitarán soporte de ventilación mecánica invasiva en unidades de cuidados intensivos. El estado nutricional parece ser un factor relevante que influye en el resultado clínico de los pacientes con COVID-19 críticamente enfermos. Diversas guías internacionales han publicado recomendaciones para asegurar la ingesta energética y proteica de las personas con COVID-19, junto con medidas de seguridad para disminuir el riesgo de infección por parte del personal de salud. El propósito de esta revisión es analizar las principales recomendaciones relacionadas con el adecuado manejo nutricional del paciente hospitalizado críticamente enfermo con COVID-19 con la finalidad de mejorar el pronóstico y los resultados clínicos.

ASPEN Report on Nutrition Support Practice Processes With COVID-19: The First Response.

Coronavirus disease 2019 (COVID-19) has changed nutrition care processes in hospitals and in the home setting. This paper summarizes clinician reports on these changed processes, including overall nutrition care, nutrition assessment, enteral nutrition and parenteral nutrition care steps, and food and oral supplement delivery. Also included are teaching, logistics, and personnel issues around changes in the work environment. Use of safe, standardized, evidence-based processes in the face of altered care patterns is critical.

Home medical nutrition during SARS-CoV-2 pandemic - A position paper.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed. METHODS: The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS: the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information. CONCLUSIONS: the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.