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Background: Optimal supportive care which includes adequate nutrient delivery remains the cornerstone in managing critically ill patients with COVID-19. Nutrition guiding principles for critically ill patients with COVID-19 strongly recommend providing early enteral nutrition (EEN) within 24-36 hours of admission to the intensive care unit (ICU) or within 12 hours of placement on mechanical ventilation (MV). Moreover, data show critically ill COVID-19 patients have negative alterations in their gut microbiome which is attributed to many factors including insufficient EN and fiber provision. The success and tolerance of EEN with a prebiotic formula in patients with COVID 19 is unknown. Here we aimed to assess, before and after implementation of an enteral feeding protocol, the achievement of EEN, estimated energy goals, and tolerance of a prebiotic formula in MV patients with COVID-19. Method(s): Data were collected and analyzed retrospectively from June 2020-May 2021 and prospectively from June 2021-January 2022. A protocol to promote EEN and improve nutrition delivery with a prebiotic-containing formula to patients within the seven days of ICU admission was created and implemented in June 2021 in the Medical ICU. Time to start EEN following invasive MV was assessed. Feeding adequacy over the first seven days of ICU admission was calculated by dividing the mean total calories of formula infused over the first seven ICU days by the estimated goal calories/day. The average number of bowel movements (BM) over the first seven ICU days was used to evaluate feeding tolerance. To determine the impact of inflammation and co-morbid conditions on feeding adequacy and tolerance, admission C-reactive protein (CRP) and Charlson Comorbidity Index (CCI) were trended with feeding adequacy. The Institutional Review Board approved the study. Result(s): A total of 343 patient records were analyzed with 203 patients in retrospective (R) and 140 patients in prospective groups (P). The post- MV feeding initiation time was shorter after implementing the feeding protocol (Mean 45.2 vs 33.8 hrs, and Interquartile Range (IQR) of Median (hrs) (18, 51) vs (16, 43) for the R and P groups, respectively (p = 0.04). Achievement of feeding goal rates were similar between groups (30.0 % vs 29.5%) (p >0.05). A prebiotic-containing formula was received in 36.2 % of patients in the R group versus 43.4 % in the P group. Providing a prebiotic formula had no impact on achieving goal nutrition in either period. In the R group, patients receiving the non-prebiotic formula had a higher total 7-days BM occurrence compared to the prebiotic formula group (8 vs 5.9 BMs/7 days, p = 0.03). In the P group there were no differences in the number of BMs between non-prebiotic and prebiotic formula groups (5.3 vs 5.0 BMs/7 days, p >0.05). Higher admission CRP and CCI values trended with higher incidence of inadequate feeding. Mean CCI was 4.42 and 4.17 for patients who received less than 25% goal feeding compared to those who received >80% of their goal feeds, respectively. Mean CRP was 12.3 and 11.4 for patients who received < 25% goal feeds compared to those who received >80% of goal feeds, respectively (p > 0.05). There were no differences in overall ICU length of stay between the R (11.7 days) and P (11.1 days) groups. (p = 0.34) Conclusion(s): EEN protocol implementation decreased time to EEN initiation in mechanically ventilated COVID-19 patients but did not affect patients in achieving goal nutrition in the first week of their ICU stay. Furthermore, COVID-19 patients tolerated EEN with prebiotic containing formulas. Further research is warranted to determine the impact of EEN with a prebiotic formula on the gut microbiome in critically ill MV patients with COVID-19.
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Introduction: Advancements in critical care medicine have led to increase in Intensive Care Unit (ICU) survival. ICU survivors often experience cognitive, mental and physical impairments as part of a condition called Post- Intensive Care Syndrome (PICS). While there are several ICU follow-up programs, there is variability in their structure and approach. We describe the creation and implementation of a Post-ICU Recovery Clinic (PIRC). Methods: A retrospective observational study was conducted and included all patients seen in a PIRC of a quaternary health system from December 2019 to September 2020. PIRC visit variables included scores on several validated questionnaires screening for mental health and cognitive disorders, 6-minute walk test, pulmonary function test, change in occupational and driving status, and referrals made during PIRC visit. Statistics reported reflect exclusion of the missing data points. Results: The criteria utilized for patient selection was circulatory shock, acute respiratory distress syndrome (ARDS), mechanical ventilation >7 days, ICU admission >7 days, delirium, cardiac arrest and COVID-19 with ICU stay >2 days. A total of 63 patients were seen in PIRC, 41% of those were ARDS survivors. Given the COVID-19 pandemic, telemedicine was shortly implemented and 62% of the visits were virtual. Median age (IQR) was 59.1 (49.2-71.6), 59% were male, with near equal Caucasian and African American distribution. All patients who had an in-person visit were seen by a critical care physician and advance practice provider, pharmacist, psychiatrist and physical therapist during the visit. 36% screened positive for anxiety or depression as identified by the Patient Health Questionnaire-4 (PHQ- 4), and 11% screened positive for post-traumatic stress disorder (PTSD) identified by the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). Of the patients seen with in-person visit, 45% had either mild or moderate cognitive impairment identified by the Montreal Cognitive Assessment (MOCA). Median 6-minute walk distance was 66% predicted. Median FEV1, FVC, and DLCO was 86, 80, and 60% predicted respectively. From the 61% of patients who were working and 91% who were driving prior to hospitalization, only 22% and 65% had returned to those activities respectively. Thirty four (56%) patients had at least one referral made, with some patients receiving up to 6 referrals. Conclusion: A high prevalence of PICS and social impairments were identified in ICU survivors at a PIRC. Incorporating an inter-disciplinary team approach and standardized surveys were imperative to recognize these impairments in order to support return to the best state of recovery possible.
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RATIONALE: Over 40 million people have recovered from COVID-19. Many of them are intensive care unit (ICU) survivors who are known to frequently face Post Intensive Care Syndrome (PICS), a constellation of new or worsening physical, mental and cognitive impairments that occur after ICU stay. There is scarce data describing PICS in COVID-19 survivors. The Cleveland Clinic established a new Post ICU Recovery Clinic (PIRC) that began seeing COVID-19 survivors in May 2020. The objective of this abstract is to report the incidence of PICS in COVID-19 ICU survivors.METHODS: A retrospective chart review of all COVID-19 patients seen in PIRC from December 2019 to September 2020 was performed. In-hospital variables collected included demographics and clinical course. PIRC visit variables collected included oxygen requirement, scores on several validated questionnaires screening for depression, anxiety, post-traumatic stress disorder (PTSD), cognitive function, instrumental and activities of daily living (iADL and ADL), 6-minute walk test, pulmonary function tests, and change in occupational and driving status. Statistics reported reflect exclusion of the missing data points. RESULTS: A total of 63 patients were seen in PIRC. COVID-19 ICU survivors comprised of 83% (n= 52) and of these, 46.2% (n = 24) had ARDS. Our population was 58% male with near equal Caucasian and African American distribution. The median hospital and ICU length of stay was as 12.5 (IQR 9.0-18.5) and 6 (3.0-12.0) days respectively. PIRC visits took place roughly two months after hospital discharge and 61% (n=31) were virtual visits. Twenty one (45%) patients had a new oxygen requirement, six (38%) had new mild or moderate cognitive impairment as identified by the Montreal Cognitive Assessment (MOCA), 11(52%) screened positive for new anxiety or depression as identified by the Patient Health Questionnaire-4 (PHQ-4), three patients screened positive for new PTSD as identified by the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) or Impact of Event Scale-Revised (IES-R) survey. Majority were independent in all ADL and iADL (91% and 71% respectively). Median distance on 6-minute walk test, % predicted of FEV1, FVC, TLC, and DLCO was 1205 feet, 86.2, 79.7, 74.9, and 62.4 respectively. From the 64% of patients who were working and 94% who were driving prior to hospitalization, only 26% and 78% had returned to those activities respectively. CONCLUSIONS: COVID-19 ICU survivors experience every aspect of PICS two months after hospital discharge. These survivors require comprehensive evaluation to facilitate diagnosis and identify treatments to promote holistic recovery.