Macronutrient and micronutrient requirements and therapeutic effects in critically ill patients with SARS-CoV-2: A narrative review.

BACKGROUND: COVID-19 can lead to critical illness and induce hypermetabolism, protein catabolism, and inflammation. These pathological processes may alter energy and protein requirements, and certain micronutrients may attenuate the associated detriments. This narrative review summarizes the macronutrient and micronutrient requirements and therapeutic effects in critically ill patients with SARS-CoV-2. METHODS: We searched four databases for randomized controlled trials (RCTs) and studies that measured macronutrient and micronutrient requirements, published from February 2020 to September 2022. RESULTS: Ten articles reported on energy and protein requirements, and five articles reported the therapeutic effects of ω-3 (n = 1), group B vitamins (n = 1), and vitamin C (n = 3). Patients' resting energy expenditure gradually increased with time, measuring approximately 20 kcal/kg body weight (BW), 25 kcal/kg BW, and 30 kcal/kg BW for the first, second, and third week onwards, respectively. Patients remained in negative nitrogen balances in the first week, and a protein intake of ≥1.5 g/kg BW may be necessary to achieve nitrogen equilibrium. Preliminary evidence suggests that ω-3 fatty acids may protect against renal and respiratory impairments. The therapeutic effects of group B vitamins and vitamin C cannot be ascertained, although intravenous vitamin C appears promising in reducing mortality and inflammation. CONCLUSION: There are no RCTs to guide the optimal dose of energy and protein in critically ill patients with SARS-CoV-2. Additional larger-scale, well-designed RCTs are needed to elucidate the therapeutic effects of ω-3, group B vitamins, and vitamin C.

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.

Energy requirements for critically ill patients with COVID-19.

Early reports suggested that predictive equations significantly underestimate the energy requirements of critically ill patients with coronavirus disease 2019 (COVID-19) based on the results of indirect calorimetry (IC) measurements. IC is the gold standard for measuring energy expenditure in critically ill patients. However, IC is not available in many institutions. If predictive equations significantly underestimate energy requirements in severe COVID-19, this increases the risk of underfeeding and malnutrition, which is associated with poorer clinical outcomes. As such, the purpose of this narrative review is to summarize and synthesize evidence comparing measured resting energy expenditure via IC with predicted resting energy expenditure determined via commonly used predictive equations in adult critically ill patients with COVID-19. Five articles met the inclusion criteria for this review. Their results suggest that many critically ill patients with COVID-19 are in a hypermetabolic state, which is underestimated by commonly used predictive equations in the intensive care unit (ICU) setting. In nonobese patients, energy expenditure appears to progressively increase over the course of ICU admission, peaking at week 3. The metabolic response pattern in patients with obesity is unclear because of conflicting findings. Based on limited evidence published thus far, the most accurate predictive equations appear to be the Penn State equations; however, they still had poor individual accuracy overall, which increases the risk of underfeeding or overfeeding and, as such, renders the equations an unsuitable alternative to IC.

Protein requirements for critically ill ventilator-dependent patients with COVID-19.

BACKGROUND: Recent studies indicate critically ill patients with coronavirus disease 2019 (COVID-19) are hypermetabolic; however, protein requirements in critically ill COVID-19 patients are unknown. Our intent was to evaluate the nitrogen accretion response to varying protein intakes for critically ill ventilator-dependent patients with COVID-19. METHODS: Adult patients (age ≥ 18 years) with COVID-19, admitted to the intensive care unit (ICU) and who required mechanical ventilation were retrospectively evaluated. Patients received continuous enteral nutrition (EN), including supplemental protein boluses, and had a 24-h urine collection for determination of nitrogen balance (NBAL). Data are expressed as mean ± SD with a P-value < .05 as significant. RESULTS: Twenty-two patients provided 29 NBAL determinations. Protein intake from EN and protein supplements was 0.9 ± 0.7 g/kg/day at the time of the NBAL with an NBAL of -12.1 ± 10.9 g/day at 7 ± 4 days in the ICU. Combined caloric intake from EN and propofol at the time of the NBAL was 12 ± 8 kcal/kg/day. Nitrogen equilibrium (NBAL of -4 g/day or better) occurred in five patients. Patients achieving nitrogen equilibrium received more protein than those with a negative NBAL (1.2 ± 0.4 g/kg/day vs 0.8 ± 0.8 g/kg/day, P = .046). The linear regression for NBAL in response to graded increases in protein intake was as follows: NBAL = 8.5 × protein intake (g/kg/day) - 18.8 (r = 0.450, P < .001). CONCLUSION: Critically ill ventilator-dependent patients with COVID-19 exhibit significant variability in nitrogen accretion response to increases in protein intake and often have a markedly negative NBAL.

Impact of maternal nutrition in viral infections during pregnancy.

Other than being a physiological process, pregnancy is a condition characterized by major adaptations of maternal endocrine and metabolic homeostasis that are necessary to accommodate the fetoplacental unit. Unfortunately, all these systemic, cellular, and molecular changes in maternal physiology also make the mother and the fetus more prone to adverse outcomes, including numerous alterations arising from viral infections. Common infections during pregnancy that have long been recognized as congenitally and perinatally transmissible to newborns include toxoplasmosis, rubella, cytomegalovirus, and herpes simplex viruses (originally coined as ToRCH infections). In addition, enterovirus, parvovirus B19, hepatitis virus, varicella-zoster virus, human immunodeficiency virus, Zika and Dengue virus, and, more recently, coronavirus infections including Middle Eastern respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) infections (especially the novel SARS-CoV-2 responsible for the ongoing COVID-19 pandemic), constitute relevant targets for current research on maternal-fetal interactions in viral infections during pregnancy. Appropriate maternal education from preconception to the early postnatal period is crucial to promote healthy pregnancies in general and to prevent and/or reduce the impact of viral infections in particular. Specifically, an adequate lifestyle based on proper nutrition plans and feeding interventions, whenever possible, might be crucial to reduce the risk of virus-related gestational diseases and accompanying complications in later life. Here we aim to provide an overview of the emerging literature addressing the impact of nutrition in the context of potentially harmful viral infections during pregnancy.

Energy requirements of long-term ventilated COVID-19 patients with resolved SARS-CoV-2 infection.

BACKGROUND & AIMS: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can rapidly progress into acute respiratory distress syndrome accompanied by multi-organ failure requiring invasive mechanical ventilation and critical care treatment. Nutritional therapy is a fundamental pillar in the management of hospitalized patients. It is broadly acknowledged that overfeeding and underfeeding of intensive care unit (ICU) patients are associated with increased morbidity and mortality. This study aimed to assess the energy demands of long-term ventilated COVID-19 patients using indirect calorimetry and to evaluate the applicability of established predictive equations to estimate their energy expenditure. METHODS: We performed a retrospective, single-center study in 26 mechanically ventilated COVID-19 patients with resolved SARS-CoV-2 infection in three independent intensive care units. Resting energy expenditure (REE) was evaluated by repetitive indirect calorimetry (IC) measurements. Simultaneously the performance of 12 predictive equations was examined. Patient's clinical data were retrieved from electronic medical charts. Bland-Altman plots were used to assess agreement between measured and calculated REE. RESULTS: Mean mREE was 1687 kcal/day and 20.0 kcal relative to actual body weight (ABW) per day (kcal/kg/day). Longitudinal mean mREE did not change significantly over time, although mREE values had a high dispersion (SD of mREE ±487). Obese individuals were found to have significantly increased mREE, but lower energy expenditure relative to their body mass. Calculated REE showed poor agreement with mREE ranging from 33 to 54%. CONCLUSION: Resolution of SARS-CoV-2 infection confirmed by negative PCR leads to stabilization of energy demands at an average 20 kcal/kg in ventilated critically ill patients. Due to high variations in mREE and low agreement with calculated energy expenditure IC remains the gold standard for the guidance of nutritional therapy.

Nutrition guidelines for critically ill adults admitted with COVID-19: Is there consensus?

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has overwhelmed hospital systems globally, resulting in less experienced staff caring for critically ill patients within the intensive care unit (ICU). Many guidelines have been developed to guide nutrition care. AIM: To identify key guidelines or practice recommendations for nutrition support practices in critically ill adults admitted with COVID-19, to describe similarities and differences between recommendations, and to discuss implications for clinical practice. METHODS: A literature review was conducted to identify guidelines affiliated with or endorsed by international nutrition societies or dietetic associations which included recommendations for the nutritional management of critically ill adult patients with COVID-19. Data were extracted on pre-defined key aspects of nutritional care including nutrition prescription, delivery, monitoring and workforce recommendations, and key similarities and discrepancies, as well as implications for clinical practice were summarized. RESULTS: Ten clinical practice guidelines were identified. Similar recommendations included: the use of high protein, volume restricted enteral formula delivered gastrically and commenced early in ICU and introduced gradually, while taking into consideration non-nutritional calories to avoid overfeeding. Specific advice for patients in the prone position was common, and non-intubated patients were highlighted as a population at high nutritional risk. Major discrepancies included the use of indirect calorimetry to guide energy targets and advice around using gastric residual volumes (GRVs) to monitor feeding tolerance. CONCLUSION: Overall, common recommendations around formula type and route of feeding exist, with major discrepancies being around the use of indirect calorimetry and GRVs, which reflect international ICU nutrition guidelines.

Maternal nutrients and effects of gestational COVID-19 infection on fetal brain development.

BACKGROUND & AIMS: Maternal gestational infection is a well-characterized risk factor for offsprings' development of mental disorders including schizophrenia, autism, and attention deficit disorder. The inflammatory response elicited by the infection is partly directed against the placenta and fetus and is the putative pathogenic mechanism for fetal brain developmental abnormalities. Fetal brain abnormalities are generally irreversible after birth and increase risk for later mental disorders. Maternal immune activation in animals models this pathophysiology. SARS-CoV-2 produces maternal inflammatory responses during pregnancy similar to previously studied common respiratory viruses. METHOD: Choline, folic acid, Vitamin D, and n-3 polyunsaturated fatty acids are among the nutrients that have been studied as possible mitigating factors for effects of maternal infection and inflammation on fetal development. Clinical and animal studies relevant to their use in pregnant women who have been infected are reviewed. RESULTS: Higher maternal choline levels have positive effects on the development of brain function for infants of mothers who experienced viral infections in early pregnancy. No other nutrient has been studied in the context of viral inflammation. Vitamin D reduces pro-inflammatory cytokines in some, but not all, studies. Active folic acid metabolites decrease anti-inflammatory cytokines. N-3 polyunsaturated fatty acids have no effect. CONCLUSIONS: Vitamin D and folic acid are already supplemented in food additives and in prenatal vitamins. Despite recommendations by several public health agencies and medical societies, choline intake is often inadequate in early gestation when the brain is forming. A public health initiative for choline supplements during the pandemic could be helpful for women planning or already pregnant who also become exposed or infected with SARS-CoV-2.

Indirect calorimetry in critical illness: a new standard of care?

PURPOSE OF REVIEW: Review recent literature on the role of indirect calorimetry in critical care nutrition management. RECENT FINDINGS: Critical illness demands objective, targeted nutritional therapy to prevent adverse effects of underfeeding/over feeding. Thus, all recent societal guidelines recommend indirect calorimetry use to determine energy needs. Very recently, indirect calorimetry technology has finally evolved to allow for accurate, simple, and routine utilization in a wider range of ICU patients. Recent data continues to confirm poor correlation between measured and equation-predicted energy expenditure emphasizing need for indirect calorimetry to be standard of care. This may be particularly true in COVID-19, where significant progressive hypermetabolism and variability in energy expenditure has been shown. Metabolic physiology can change frequently during ICU stay in response to changes in clinical condition or care. Thus, repeated longitudinal indirect calorimetry measures are needed throughout ICU stay to optimize care, with initial data showing improved clinical outcomes when indirect calorimetry targets are utilized. SUMMARY: Personalized ICU care demands objective data to guide therapy. This includes use of indirect calorimetry to determine energy expenditure and guide ICU nutrition therapy. Long-awaited new innovations in indirect calorimetry technology should finally lead to indirect calorimetry to becoming a fundamental component of modern ICU standard of care and clinical research moving forward.

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.

Point-Counterpoint: Indirect Calorimetry Is not Necessary for Optimal Nutrition Therapy in Critical Illness.

Clinicians have widely recognized that indirect calorimetry (IC) is the "gold standard" for measuring energy expenditure (EE) and thus would intuitively anticipate that its use would be needed to provide optimal nutrition support in critical illness. Recent studies in the literature as well as dramatic changes in clinical practice over the past decade, though, would suggest that such a precise measure by IC to set energy goals is not required to maximize clinical benefit from early feeding in the intensive care unit (ICU). Results from randomized controlled trials evaluating permissive underfeeding, use of supplemental parenteral nutrition to achieve tight calorie control, and caloric density of formulas to increase energy delivery have provided an important perspective on 3 pertinent issues. First, a simple weight-based predictive equation (25 kcal/kg/day) provides a clinically useful approximation of EE. Second, a precise measure of EE by IC does not appear to improve outcomes compared with use of this less accurate estimation of energy requirements. And third, providing some percentage of requirements (50%-80%), achieves similar clinical benefit to full feeding (100%) in the early phases of critical illness. The value from IC use lies in the determination of caloric requirements in conditions for which weight-based equations are rendered inaccurate (anasarca, amputation, severe obesity) or the clinical state is markedly altered (such as the prolonged hyperinflammatory state of coronavirus disease 2019 [COVID-19]). In most other circumstances, routine use of IC would not be expected to change clinical outcomes from early nutrition therapy in the ICU.

Point-Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit.

Iatrogenic malnutrition and underfeeding are ubiquitous in intensive care units (ICUs) worldwide for prolonged periods after ICU admission. A major driver leading to the lack of emphasis on timely ICU nutrition delivery is lack of objective data to guide nutrition care. If we are to ultimately overcome current fundamental challenges to effective ICU nutrition delivery, we must all adopt routine objective, longitudinal measurement of energy targets via indirect calorimetry (IC). Key evidence supporting the routine use of IC in the ICU includes (1) universal societal ICU nutrition guidelines recommending IC to determine energy requirements; (2) data showing predictive equations or body weight calculations that are consistently inaccurate and correlate poorly with measured energy expenditure, ultimately leading to routine overfeeding and underfeeding, which are both associated with poor ICU outcomes; (3) recent development and worldwide availability of a new validated, accurate, easy-to-use IC device; and (4) recent data in ICU patients with coronavirus disease 2019 (COVID-19) showing progressive hypermetabolism throughout ICU stay, emphasizing the inaccuracy of predictive equations and marked day-to-day variability in nutrition needs. Thus, given the availability of a new validated IC device, these findings emphasize that routine longitudinal IC measures should be considered the new standard of care for ICU and post-ICU nutrition delivery. As we would not deliver vasopressors without accurate blood pressure measurements, the ICU community is only likely to embrace an increased focus on the importance of early nutrition delivery when we can consistently provide objective IC measures to ensure personalized nutrition care delivers the right nutrition dose, in the right patient, at the right time to optimize clinical outcomes.

[Comparison of expert recommendations on clinical nutrition for hospitalized patients with COVID-19]. / Comparación de las recomendaciones de expertos sobre nutrición clínica en pacientes hospitalizados con COVID-19.

INTRODUCTION: Introduction: in SARS-CoV-2-infected patients nutritional requirements are increased. These patients present symptoms that make food intake and nutrient absorption difficult, therefore involving nutritional risk. On the other hand, acute respiratory complications require prolonged ICU stays, and this predisposes to increased malnutrition and loss of skeletal muscle mass and function, which can lead to poor quality of life, disability and morbidity long after discharge. For this reason, the world's leading nutrition societies and associations believe that nutritional therapy should be considered a part of the basic treatment of patients with COVID-19. Methods: we have reviewed and compared 9 expert recommendations (ER) published by nutrition societies and associations from China, Spain, Brazil, Europe, Colombia, Australia, America, and the United Kingdom, in relation to critical and non-critical hospitalized patients due to the COVID-19 pandemic. Conclusions: the 9 ERs reviewed agree on the importance of nutritional management in critical and non-critical hospitalized patients with COVID-19, as well as on the early detection of nutritional risk, the intervention, and subsequent follow-up. Even so, each published document has its own particularities and puts a special stress on some specific aspect.

INTRODUCCIÓN: Introducción: la infección por SARS-CoV-2 implica riesgo nutricional debido a la dificultad de cubrir los requerimientos nutricionales aumentados en presencia de una sintomatología que dificulta la ingesta y la absorción de nutrientes. Por otro lado, las complicaciones respiratorias agudas requieren estancias prolongadas en unidades de cuidados intensivos (UCI) y esto predispone a una mayor desnutrición y a pérdida de masa y función del músculo esquelético, que a su vez puede conducir a una mala calidad de vida, discapacidad y morbilidad mucho después del alta. Por este motivo, las principales sociedades y asociaciones de nutrición clínica del mundo consideran que la terapia nutricional debe considerarse parte del tratamiento básico de los pacientes con COVID-19. Métodos: se han revisado y comparado 9 recomendaciones de expertos (RE) publicadas por sociedades y asociaciones de nutrición clínica de China, España, Brasil, Europa, Colombia, Australia, América y Reino Unido, a raíz de la pandemia por COVID-19, en relación a los pacientes hospitalizados críticos y no críticos. Conclusiones: las 9 RE revisadas coinciden en la importancia del tratamiento nutricional en los pacientes hospitalizados críticos y no críticos con COVID-19, así como en la detección precoz del riesgo nutricional, la intervención y el seguimiento. Aun así, cada documento publicado tiene sus propias particularidades e incide especialmente en algún aspecto.

Safety and tolerance of enteral nutrition in COVID-19 critically ill patients, a retrospective study.

BACKGROUND: There is a lack of evidence about the tolerance of enteral nutrition (EN) in COVID-19 critically ill patients. However, several gastrointestinal manifestations related to COVID-19 have been described. The aims of this study were to analyze the incidence of gastrointestinal intolerance (GI) associated to EN (diarrhea, vomiting, gastroparesis and constipation) and to describe energy/protein provision along with biochemical alterations during the first week of EN. METHODS: A retrospective cohort of COVID-19 critically ill patients under mechanical ventilation. We reported daily enteral nutrition infusion and gastrointestinal manifestations within the first week of intubation and enteral nutrition initiation. RESULTS: Fifty-two patients were included; 40.3% were overweight and 46.2% were obese. During the first 7 days of EN, manifestations of GI intolerance such as vomiting, diarrhea and gastroparesis were present in 18 patients (32.4%). Hypernatremia (39%) was the most frequent electrolyte abnormality. Only Acute Kidney Injury (AKI) diagnosis was associated with a higher energy deficit on day 7. No associations between drug prescription and GI intolerance were observed. On day 4, 94.5% of patients were receiving more than 80% of energy requirements and 94.2% of protein requirements. Accumulated energy and protein deficits at day 3 were 2171.2 ± 945 kcal and 114.9 ± 49.2 g, respectively; and 2586.4 ± 1151 kcal, 133.3 ± 60.4 g at day 7. CONCLUSION: Enteral nutrition is feasible and well-tolerated in COVID-19 patients with mechanical ventilation within the first week of enteral nutrition initiation. More studies are needed to elucidate the impact of nutritional therapy on infection course and outcomes.

The Food Bank of Madrid: A Linear Model for Optimal Nutrition.

This work proposes a mathematical linear programming model that addresses the food provisioning problem of the food bank of Madrid. It aims to determine the most appropriate weekly decisions to meet the macro-nutritional requirements of the beneficiaries of this social service, by minimizing the total cost considering third-party donations. The model has been applied to a realistic case study considering a sociological structure of beneficiaries categorized by age and gender and representing the first decile of incomes of the Spanish population. The demand of macronutrients is satisfied by means of nine different groups of food, used to provide some level of variability in the consumption patterns of the beneficiaries. The results provide insight on cost-cutting opportunities related to centralizing the decision-making process, indicating a 10% reduction both in provisioning costs and food quantities. This suggests that the proposed model might serve as a tool for designing new strategies for the provisioning or evaluation of economic and social support policies for the food bank of Madrid.

Second Wave of COVID-19 Global Pandemic and Athletes' Confinement: Recommendations to Better Manage and Optimize the Modified Lifestyle.

Coronavirus 2019 (COVID-19) is an infectious viral disease that has spread globally, resulting in the ongoing pandemic. Currently, there is no vaccine or specific treatment for COVID-19. Preventive measures to reduce the chances of contagion consist mainly of confinement, avoiding crowded places, social distancing, masks, and applying strict personal hygiene as recommended by the World Health Organization (WHO). After the first wave of infection in many countries, the potential effects of relaxing containment and physical distancing control measures suggest that as a result of these measures, a second wave of COVID-19 appears probable in these countries. In sport, the period of self-isolation, and quarantine, for COVID-19 affects the physical preparation of athletes as well as their mental health and quality of life to an even greater extent (i.e., nutrition, sleep, healthy lifestyle), and thus, relevant and practical recommendations are needed to help alleviate these physical and mental health concerns. Our review aims to summarize the physiological and psychological effects of detraining associated with athletes' confinement during the proposed second wave of COVID-19. This article also proposes answers to questions that concern the advantages and disadvantages of different types of social media platforms, the importance of nutrition, and the effects of sleep disturbance on the health and modified lifestyle of athletes during this worldwide pandemic. Thus, this review provides some general guidelines to better manage their modified lifestyle and optimally maintain their physical and mental fitness with respect to measures taken during this restrictive proposed second wave of the COVID-19 confinement period.

Hypermetabolism and Coronavirus Disease 2019.

BACKGROUND: Hypermetabolism has been described in stress states such as trauma, sepsis, acute respiratory distress syndrome, and severe burn injuries. We hypothesize that patients with Coronavirus disease 2019 (COVID-19) may develop a hypermetabolic state, which may be a major contributing factor to the extraordinary ventilatory and oxygenation demands in patients with COVID-19. METHOD: Resting energy expenditure (REE), carbon dioxide production (VCO2 ), and oxygen consumption (VO2 ) were measured by indirect calorimetry on 7 critically ill patients with COVID-19. RESULTS: The median measured REE was 4044 kcal/d, which was 235.7% ± 51.7% of predicted. The median VCO2 was 452 mL/min (range, 295-582 mL/min), and the median VO2 was 585 mL/min (range, 416-798 mL/min). CONCLUSION: Critically ill patients with COVID-19 are in an extreme hypermetabolic state. This may explain the high failure rates for mechanical ventilation for these patients and highlights the potential need for increased nutrition requirements for such patients.

Challenges of Maintaining Optimal Nutrition Status in COVID-19 Patients in Intensive Care Settings.

The coronavirus disease 2019 (COVID-19) pandemic has threatened patients, healthcare systems, and all countries across the globe with unprecedented challenges and uncertainties. According to the latest literature, most patients with COVID-19 have mild symptoms that do not require hospital admissions, and only a small percentage of those hospitalized require intensive care. In the intensive care unit (ICU), a registered dietitian nutritionist (RDN) assists the critical care team by formulating, executing, and monitoring the nutrition strategies and interventions to meet the unique requirements of extremely sick patients. However, because of the novelty of COVID-19, the situation is fluid and guidelines continue to be developed and updated. This article discusses the interim guidelines available for the nutrition support of ICU COVID-19 patients and the challenges the critical care team and RDN may face from a nutrition standpoint.

Nutritional challenges in older adults during the COVID-19 pandemic / Desafios nutricionais na saúde de idosos em tempos de pandemia da COVID-19

ABSTRACT It has been documented that the older adults of the population are at the greatest risk of mortality due to the coronavirus disease; consequently, they could be the population most affected by the measures of social isolation and reduction of virus contagion implemented worldwide. Social isolation can expose older adults to an increased nutritional risk due to factors such as socioeconomic insecurity, which could affect food acquisition and the need for support in daily tasks and meals. The institutionalized older adults often depend on food donations, which may have reduced due the economic crisis caused by the pandemic, and the aging process itself causes changes in nutritional necessitie and eating habits. In the coronavirus pandemic, nutritionists and dietitians can offer remote nutritional follow-up. Moreover, the government actions, such as the implementation of educational and social service programs, should be applied to support healthy aging and minimize exposure to nutritional risks and coronavirus disease.

RESUMO Tem sido documentado que os idosos são a população de maior risco para mortalidade por COVID-19. Consequentemente, pode ser a mais afetada pelas medidas de isolamento social e de redução de contágio pelo vírus implementadas em todo o mundo. O isolamento social pode expor os idosos ao risco nutricional aumentado devido a alguns fatores, como: a insegurança socioeconômica, a qual pode afetar a aquisição de alimentos; a necessidade de apoio nas tarefas e nas refeições diárias; a possível redução de doações de alimentos para idosos institucionalizados, em virtude da crise econômica ocasionada pela pandemia; e o próprio processo do envelhecimento, que causa alterações das necessidades nutricionais e do hábito de se alimentar. Contudo, no contexto da pandemia do novo coronavírus, nutricionistas podem oferecer acompanhamento nutricional remoto. Além disso, ações governamentais, como a implementação de programas educacionais e de serviço social, devem ser aplicadas para o envelhecimento saudável e para a minimização da exposição ao risco nutricional e à COVID-19.