Inadequate Energy Delivery Is Frequent among COVID-19 Patients Requiring ECMO Support and Associated with Increased ICU Mortality.

BACKGROUND: Patients receiving extracorporeal membrane oxygenation (ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for coronavirus disease 2019 (COVID-19) patients during ECMO therapy. METHODS: We conducted a retrospective analysis of COVID-19 patients requiring venovenous ECMO support at a large tertiary hospital center. Nutrition goals were calculated using 25 kcal/kg body weight (BW)/day. Associations between nutrition support and outcome were evaluated using Kaplan-Meier and multivariable Cox regression analyses. RESULTS: Overall, 102 patients accounted for a total of 2344 nutrition support days during ECMO therapy. On 40.6% of these days, nutrition goals were met. Undernutrition was found in 40.8%. Mean daily calorie delivery was 73.7% of calculated requirements, mean daily protein delivery was 0.7 g/kg BW/d. Mean energy intake of ≥70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity at ECMO start and body mass index (adjusted hazard ratio: 0.372, p = 0.007). CONCLUSIONS: Patients with a mean energy delivery of ≥70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.

Nutrition intake in critically ill patients with coronavirus disease (COVID-19): A nationwide, multicentre, observational study in Argentina.

INTRODUCTION: In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with coronavirus disease (COVID-19) patients. METHODS: A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March and October 2020. INCLUSION CRITERIA: Adult ICU patients>18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48h. Statistical analysis was carried out using IBM-SPSS© 24 programme. RESULTS: One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97g/kg/day (CI 0.95-0.99), P<0.001), and lower caloric intake than those who survived (12.94kcal/kg/day (CI 12.48-13.39) vs 16.47kcal/kg/day (CI 16.09-16.8), P<0.001). A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II>18. CONCLUSIONS: Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.

Malnutrition in older adults.

Malnutrition is a highly prevalent condition in older adults, and poses a substantial burden on health, social, and aged-care systems. Older adults are vulnerable to malnutrition due to age-related physiological decline, reduced access to nutritious food, and comorbidity. Clinical guidelines recommend routine screening for malnutrition in all older adults, together with nutritional assessment and individually tailored nutritional support for older adults with a positive screening test. Nutritional support includes offering individualised nutritional advice and counselling; oral nutritional supplements; fortified foods; and enteral or parenteral nutrition as required. However, in clinical practice, the incorporation of nutritional guidelines is inadequate and low-value care is commonplace. This Review discusses the current evidence on identification and treatment of malnutrition in older adults, identifies gaps between evidence and practice in clinical care, and offers practical strategies to translate evidence-based knowledge into improved nutritional care. We also provide an overview of the prevalence, causes, and risk factors of malnutrition in older adults across health-care settings.

Malnutrition management of hospitalized patients with diabetes/hyperglycemia and COVID-19 infection.

Diabetes mellitus and/or hyperglycemia are highly prevalent medical conditions in patients hospitalized for coronavirus disease 2019 (COVID-19) and are associated with adverse outcomes. In addition, COVID-19 itself can provoke fluctuating and high glucose levels that can be difficult to manage upon hospitalization. Hospitalized patients with COVID-19 are at high risk of malnutrition due to an increase in nutritional requirements and a severe acute inflammatory response. The management of patients with diabetes/hyperglycemia and COVID-19 is challenging and requires a specific nutritional approach, the purpose of which is to fulfill the nutritional requirements while maintaining an optimal glycemic control. In this study, an expert group of nutritional endocrinologists carried out a qualitative literature review and provided recommendations based on evidence and guidelines, when available, or on their own experience. The optimal care based on these recommendations was compared with the routine bedside care as reported by a panel of physicians (mainly, endocrinologists, geriatricians, and internists) treating patients with diabetes/hyperglycemia and COVID-19 in their daily practice. Early screening and diagnosis, a diabetes-specific therapeutic approach, and a close malnutrition monitoring are essential to improve the clinical outcomes of these patients. In conclusion, the proposed recommendations are intended to provide a useful guide on the clinical management of malnutrition in patients with COVID-19 and diabetes/hyperglycemia, in order to improve their outcomes and accelerate their recovery. The comparison of the recommended optimal care with routine clinical practice could aid to identify gaps in knowledge, implementation difficulties, and areas for improvement in the management of malnutrition in this population.

Evaluation of Nutritional Status and Anxiety Levels in Patients Applying to the Radiation Oncology Outpatient Clinic during the COVID-19 Pandemic: Turkish Society for Radiation Oncology Group Study (TROD 12:02).

Cancer patients often face malnutrition, which negatively affects their response to cancer treatment. This study aims to analyze the effects of the COVID-19 pandemic on nutritional status and anxiety in cancer patients with different types and stages of cancer. This is a cross-sectional cohort study that includes 1,252 patients with varying cancer types from 17 radiation oncology centers. The nutritional risk scores (NRS-2002) and coronavirus anxiety scale (CAS) scores of all patients were measured. NRS-2002 ≥ 3 and CAS ≥ 5 were accepted as values at risk. Of all patients, 15.3% had NRS-2002 ≥ 3. Breast cancer was the most prevalent cancer type (24.5%) with the lowest risk of nutrition (4.9%, p < 0.001). Nutritional risk was significantly higher in patients with gastrointestinal cancer, head and neck cancer, and lung cancer (p < 0.005) and in patients with stage IV disease (p < 0.001). High anxiety levels (CAS ≥ 5) were significantly related to voluntary avoidance and clinical postponement of hospital visits due to the pandemic (p < 0.001), while clinical postponement was particularly frequent among patients with NRS-2002 < 3 (p = 0.0021). Fear and anxiety in cancer patients with COVID-19 cause hesitations in visiting hospitals, leading to disrupted primary and nutritional treatments. Thus, nutritional monitoring and treatment monitoring of cancer patients are crucial during and after radiotherapy.

Case presentation and panel discussion: Critical illness.

Despite a mounting evidentiary base, controversies surrounding critical care nutrition support persist. Anchored by a case of a 60-year-old male with esophageal cancer who develops acute hypoxemic respiratory failure and septic shock, five panelists from the American Society of Parenteral and Enteral Nutrition (ASPEN) 2021 Pre-Conference discuss key clinical dilemmas in critical care nutrition, including hierarchy of evidence, bedside evaluation of malnutrition, optimal protein dose, use of fiber, and therapies targeting gut function and gut microbiota .

[Place of biomarkers in the renutrition of patients with serious Covid-19 infection: discussion around a clinical case]. / Place des biomarqueurs dans la renutrition des patients ayant une infection grave à Covid-19 : discussion autour d'un cas clinique.

Covid-19 infection is a potentially serious disease. Overweight, obesity, and diabetes are comorbidities frequently found in the severe form of the disease. Appropriate nutritional management of the patient is an integral part of care. We will discuss the renutrition of a 76-year-old, obese (BMI = 35kg/m2), malnourished patient, according to the 2021 Haute Autorité de santé criteria, with Covid-19 infection, admitted to the intensive care unit at the Bordeaux University Hospital for an acute respiratory distress syndrome. Adaptation of nutritional intakes was achieved by clinical and biological monitoring. A refeeding syndrome was treated on the first day of hospitalization in the intensive care unit. After thiamine supplementation and when kalemia and phosphatemia have been normalized, renutrition was started. Parenteral nutrition as a complement to oral nutrition was used. Parenteral nutrition was well tolerated; recommended caloric and protein intakes were achieved by the fourth day of hospitalization. The clinical evolution was favorable. In conclusion, patients with Covid-19 infection should be considered malnourished when admitted to the intensive care unit. Macro and micronutrient intakes adapted to metabolically stressed patients are essential. Biological monitoring including monitoring of ionogram, phosphate, uremia, creatinine, liver function tests and blood glucose is essential in the nutritional management of patients with serious Covid-19 infection.

Long-Term Evolution of Malnutrition and Loss of Muscle Strength after COVID-19: A Major and Neglected Component of Long COVID-19.

Post-acute consequences of COVID-19, also termed long COVID, include signs and symptoms persisting for more than 12 weeks with prolonged multisystem involvement; most often, however, malnutrition is ignored. METHOD: The objective was to analyze persistent symptoms, nutritional status, the evolution of muscle strength and performance status (PS) at 6 months post-discharge in a cohort of COVID-19 survivors. RESULTS: Of 549 consecutive patients hospitalized for COVID-19 between 1 March and 29 April 2020, 23.7% died and 288 patients were at home at D30 post-discharge. At this date, 136 of them (47.2%) presented persistent malnutrition, a significant decrease in muscle strength or a PS ≥ 2. These patients received dietary counseling, nutritional supplementation, adapted physical activity guidance or physiotherapy assistance, or were admitted to post-care facilities. At 6 months post-discharge, 91.0% of the 136 patients (n = 119) were evaluated and 36.0% had persistent malnutrition, 14.3% complained of a significant decrease in muscle strength and 14.9% had a performance status > 2. Obesity was more frequent in patients with impairment than in those without (52.8% vs. 31.0%; p = 0.0071), with these patients being admitted more frequently to ICUs (50.9% vs. 31.3%; p = 0.010). Among those with persistent symptoms, 10% had psychiatric co-morbidities (mood disorders, anxiety, or post-traumatic stress syndrome), 7.6% had prolonged pneumological symptoms and 4.2% had neurological symptoms. CONCLUSIONS: Obese subjects as well as patients who have stayed in intensive care have a higher risk of functional loss or undernutrition 6 months after a severe COVID infection. Malnutrition and loss of muscle strength should be considered in the clinical assessment of these patients.

Nutritional management and clinical outcome of critically ill patients with COVID-19: A retrospective study in a tertiary hospital.

BACKGROUND & AIMS: Severe COVID-19 infection is characterized by an inflammatory response and lung injury that can evolve into an acute respiratory distress syndrome that needs support treatment in intensive care unit. Nutritional treatment is an important component of the management of critically ill patients and should be started in the first 48 h of ICU admission to avoid malnutrition. This study describes the characteristics of the patients treated in a tertiary hospital in Madrid during the months of March-May 2020 (first wave), the medical nutrition treatment employed and its influence in the clinical outcome of these patients. METHODS: This is a retrospective study including COVID-19 patients admitted in ICU that needed medical nutrition treatment (MNT). Collected variables included sex, age, BMI, underlying diseases, time from hospitalisation to ICU admission, type of respiratory support (invasive mechanical ventilation (IMV) or high flow nasal cannula (HFNC) or non-invasive ventilation (non-IMV)), caloric and protein requirements (25 kcal/kg adjusted body weight (ABW), 1.3 g/kg ABW/day), MNT type (enteral nutrition (EN), parenteral nutrition (PN), mixed EN + PN), total calories (including propofol) and proteins administered, percentage of caloric and protein goal in ICU day 4th and 7th, metabolic complications, acute kidney failure (AKF), length of stay (LOS) and mortality. Data are expressed as mean ± SD, median (IQR) or frequencies. Statistical analysis was performed with the IBM SPSS Statistics for Windows, Version 25.0. p < 0.05 were considered statistically significant. RESULTS: A total of 176 patients were included (72.7% male), 60.1 ± 13.5 years, BMI 29.9 ± 5.4 kg/m2. Underlying diseases included 47.4% overweight, 39.8% obesity, 49.1% hypertension, 41.4% dyslipidaemia. 88.6% of patients needed IMV, 89.1% prone position, 2.9% ECMO. Time to ICU admission: 2 (4.75) days. Estimated caloric and protein requirements were 1775 ± 202 kcal and 92.4 ± 10.3 g. Calories and proteins administered at days 4th and 7th were 1425 ± 577 kcal and 66 ± 26 g and 1574 ± 555 and 74 ± 37, respectively. Most of the patients received PN (alone or complementary to EN) to cover nutritional requirements (82.4% at day 4th and 77.9% at day 7th). IVM patients received more calories and proteins during the first week of ICU admission. Complications included 77.8% hyperglycaemia, 13.2% hypoglycaemia, 83.8% hypertriglyceridemia, and 35.1% AKF. ICU LOS was 20.5 (26) days. The mortality rate was 36.4%. CONCLUSIONS: In our series, the majority of patients reached energy and protein requirements in the first week of ICU admission due to the use of PN (total or complementary to EN). Patients with HFNC or non-IMV may be at risk of malnutrition if total or complementary PN to oral diet/ONS/tube feeding is not used to cover nutritional requirements. Therefore, if EN is not possible or insufficient, PN can be safely used in critically ill patients with COVID-19 with a close monitoring of metabolic complications.

Nutrition in the Intensive Care Unit-A Narrative Review.

BACKGROUND: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. METHODS: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. RESULTS: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. CONCLUSION: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.

Medical nutrition therapy for patients with malnutrition post-intensive care unit discharge: A case report of recovery from coronavirus disease 2019 (COVID-19).

Patients discharged from an intensive care unit (ICU) are frequently malnourished and experience ongoing inadequate nutrition intake because of a variety of barriers, which may lead to further declines in nutrition status. The coronavirus disease 2019 (COVID-19) pandemic has drawn increased awareness to this vulnerable patient population and the importance of nutrition rehabilitation to promote optimal recovery from acute illness. Despite this, there are no formal guidelines addressing medical nutrition therapy during the post-ICU recovery phase. This review provides an overview of the nutrition management of patients during the post-ICU recovery phase with a specific focus on COVID-19. A case study will demonstrate how medical nutrition therapy improved the nutrition status and quality of life for a patient who became severely malnourished after a prolonged hospitalization for COVID-19.

The snapshot of metabolic health in evaluating micronutrient status, the risk of infection and clinical outcome of COVID-19.

COVID-19 has re-established the significance of analyzing the organism through a metabolic perspective to uncover the dynamic interconnections within the biological systems. The role of micronutrient status and metabolic health emerge as pivotal in COVID-19 pathogenesis and the immune system's response. Metabolic disruption, proceeding from modifiable factors, has been proposed as a significant risk factor accounting for infection susceptibility, disease severity and risk for post-COVID complications. Metabolomics, the comprehensive study and quantification of intermediates and products of metabolism, is a rapidly evolving field and a novel tool in biomarker discovery. In this article, we propose that leveraging insulin resistance biomarkers along with biomarkers of micronutrient deficiencies, will allow for a diagnostic window and provide functional therapeutic targets. Specifically, metabolomics can be applied as: a. At-home test to assess the risk of infection and propose nutritional support, b. A screening tool for high-risk COVID-19 patients to develop serious illness during hospital admission and prioritize medical support, c(i). A tool to match nutritional support with specific nutrient requirements for mildly ill patients to reduce the risk for hospitalization, and c(ii). for critically ill patients to reduce recovery time and risk of post-COVID complications, d. At-home test to monitor metabolic health and reduce post-COVID symptomatology. Metabolic rewiring offers potential virtues towards disease prevention, dissection of high-risk patients, taking actionable therapeutic measures, as well as shielding against post-COVID syndrome.

Nutrition risk prevalence and nutrition care recommendations for hospitalized and critically-ill patients with COVID-19.

BACKGROUND: Nutritional status is an often-overlooked component in infectious disease severity. Hospitalized or critically ill patients are at higher risk of malnutrition, and rapid assessment and treatment of poor nutritional status can impact clinical outcomes. As it relates to the COVID-19 pandemic, an estimated 5% of these patients require admission to an ICU. Per clinical practice guidelines, nutrition therapy should be a core component of treatment regimens. On account of the urgent need for information relating to the nutritional support of these patients, clinical practice guidance was published based on current critical care guidelines. However, a growing body of literature is now available that may provide further direction for the nutritional status and support in COVID-19 patients. This review, intended for the health care community, provides a heretofore lacking in-depth discussion and summary of the current data on nutrition risk and assessment and clinical practice guidelines for medical nutrition therapy for hospitalized and critically ill patients with COVID-19.

Influence of nutritional status on clinical outcomes among hospitalized patients with COVID-19.

BACKGROUND AND AIMS: Several factors that worsen the prognosis of the new coronavirus SARS-CoV-2 have been identified, such as obesity or diabetes. However, despite that nutrition may change in a lockdown situation, little is known about the influence of malnutrition among subjects hospitalized due to COVID-19. Our study aimed to assess whether the presence of malnutrition among patients admitted due to COVID-19 had any impact on clinical outcomes compared with patients with the same condition but well nourished. METHODS: 75 patients admitted to hospital due to COVID-19 were analyzed cross-sectionally. Subjective Global Assessment (SGA) was completed by phone interview. Clinical parameters included were extracted from the electronic medical record. RESULTS: According to the SGA, 27 admitted due to a COVID-19 infection had malnutrition. Patients not well nourished were older than patients with a SGA grade A (65 ± 14.1 vs 49 ± 15.1 years; p < 0.0001). Length of hospital stay among poorly nourished patients was significantly higher (18.4 ± 15.6 vs 8.5 ± 7.7 days; p = 0.001). Mortality rates and admission to ICU were greater among subjects with any degree of malnutrition compared with well-nourished patients (7.4% vs 0%; p = 0.05 and 44.4% vs 6.3%; p < 0.0001). CRP (120.9 ± 106.2 vs 60.8 ± 62.9 mg/l; p = 0.03), D-dimer (1516.9 ± 1466.9 vs 461.1 ± 353.7 ng/mL; p < 0.0001) and ferritin (847.8 ± 741.1 vs 617.8 ± 598.7mcg/l; p = 0.03) were higher in the group with malnutrition. Haemoglobin (11.6 ± 2.1 vs 13.6 ± 1.5 g/dl; p < 0.0001) and albumin 3.2 ± 0.7 vs 4.1 ± 0.5 g/dl; p < 0.0001) were lower in patients with any degree of malnutrition. CONCLUSIONS: The presence of a poor nutritional status is related to a longer stay in hospital, a greater admission in the ICU and a higher mortality.

Nutritional management of individuals with obesity and COVID-19: ESPEN expert statements and practical guidance.

The COVID-19 pandemics has created unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Among other important risk factors for severe COVID-19 outcomes, obesity has emerged along with undernutrition-malnutrition as a strong predictor of disease risk and severity. Obesity-related excessive body fat may lead to respiratory, metabolic and immune derangements potentially favoring the onset of COVID-19 complications. In addition, patients with obesity may be at risk for loss of skeletal muscle mass, reflecting a state of hidden malnutrition with a strong negative health impact in all clinical settings. Also importantly, obesity is commonly associated with micronutrient deficiencies that directly influence immune function and infection risk. Finally, the pandemic-related lockdown, deleterious lifestyle changes and other numerous psychosocial consequences may worsen eating behaviors, sedentarity, body weight regulation, ultimately leading to further increments of obesity-associated metabolic complications with loss of skeletal muscle mass and higher non-communicable disease risk. Therefore, prevention, diagnosis and treatment of malnutrition and micronutrient deficiencies should be routinely included in the management of COVID-19 patients in the presence of obesity; lockdown-induced health risks should also be specifically monitored and prevented in this population. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing clinical practice guidance for nutritional management of COVID-19 patients with obesity in various clinical settings.

Managing malnutrition in the community during the COVID-19 pandemic.

The prevalence of risk factors for malnutrition has increased during the coronavirus disease 2019 (COVID-19) pandemic. These risk factors include various symptoms and effects of COVID-19, such as breathlessness, coughing, inflammation, sarcopenia, anorexia and loss of taste or smell, as well as the side effects of treatment. In addition, public health infection prevention and control measures can inadvertently reduce access to food and increase social isolation, thus adversely affecting people's nutritional status. This article outlines practical interventions for preventing and managing malnutrition in the community, particularly where it is exacerbated by the social restrictions in place to contain the COVID-19 pandemic.

COVID-19 and nutritional deficiency: a review of existing knowledge.

COVID-19 has resulted in an ongoing global pandemic, which spread largely among people who have had close contact with the infected person. The immunopathology of the SARS-CoV-2 virus includes the production of an excess amount of pro-inflammatory cytokines "a cytokine-storm". The respiratory system (main), cardiovascular system and the gastrointestinal tract are the most affected body systems during viral infection. It has been found that most of the patients who require admission to hospital are elderly or have chronic underlying diseases. Higher cases of malnutrition and co-morbidities like diabetes mellitus and cardiovascular diseases are reported in elderly patients due to which, the immune system weakens and hence, the response to the virus is diminished in magnitude. A deficiency of micronutrients results in impaired immune responses leading to improper secretion of cytokines, alterations in secretory antibody response and antibody affinity which increases susceptibility to viral infection. The deficiency of various micronutrients in COVID-19 patient can be treated by appropriate nutritional supplements, prescribed after evaluating the patients' nutritional status. Here we aim to highlight the role of a few particular nutrients namely Vitamin D, Vitamin C, Omega-3 fatty acids, Zinc and Magnesium along with the synergistic roles they play in enhancing immunity and thus, maintaining homeostasis.