Dietetic-led critical care nutrition interventions provided to critically ill patients with COVID-19 in a large London teaching hospital from March 2020 to April 2021

ABSTRACT

Many patients admitted to critical care with COVID-19 were at risk of malnutrition due to pre-existing chronic diseases associated with underlying poor nutritional intake and sarcopenia (1). Combined with increased energy expenditure and catabolism (2), alterations to gastrointestinal function and deficits in nutritional delivery during critical illness all risked declining nutritional status and subsequent poorer functional ability. International nutrition guidelines (3-6) recommend providing early enteral nutrition support using protocols. The UK and Australian versions created during the pandemic (3;4) recommend for individualised nutrition therapy by registered dietitians to anticipate and manage the complications commonly seen in these patients that can impact on the provision and type of nutrition support. The aim of this study is to evaluate the role of the dietitian in the nutrition interventions provided to patients with COVID-19 during critical illness and compare with recommended guidelines (3;4). Data was collected and analysed for adult patients with COVID-19 admitted to the intensive care units (ICU) requiring advanced respiratory support and enteral or parenteral nutrition support for longer than 48 hours during the period March 2020 to April 2021. Patients were followed from ICU admission to ward step down. Data was available for 453 critically ill patients. Demographic data presented as mean (SD);age 60 years old (12), 67% male, weight 84kg (20), BMI 29kg/m2 (6) for 20 ICU days (18), mortality of 55%. 167 patients (37%) were classified as high nutritional risk as determined by experienced critical care dietitians for whom nutritional requirements were individually determined by the dietitian within 24 hours of ICU admission. The remaining patients were seen within a mean of 72hrs. 99% (447/453) were enterally fed and the remaining received parenteral nutrition. Patients received on average 5.2 (4.5) dietetic interventions over the ICU stay, irrespective of nutritional risk. Reasons for dietetic interventions were adjustment of feed to account for calorie provision according to metabolic phase (74%);calories derived from sedation (55%);gastrointestinal dysfunction (32%);weaning from enteral nutrition to oral (32%);and renal, fluid and electrolyte adjustments (26%). A range of enteral feeds were used - the majority of patients (93%) received high protein (6.3-7.5grams protein per 100ml), concentrated (18.5%) (200 kcal per 100ml), peptide (9.5%) and protein supplementation (60%). On average those patients who survived lost 8.2kg (6.4) equating to 8.8% (6.9) of total weight over the ICU stay. A dietetic handover was provided for 100% of patients who transferred to the ward. In this study 100% of patients required dietetic input as their nutritional needs could not be met with protocol alone. A significant number were identified as nutritionally at risk, were prioritised as urgent and seen within the guideline timeframes. The dietitian was needed to tailor dietetic interventions to manage complications common in patients with COVID-19. They were also actively involved in adjusting nutrition interventions to facilitate patients’ nutritional recovery and rehabilitation. Patients lost weight over the ICU stay and all patients were handed over to ward dietitians for further dietetic management. References 1. Zhu N, Zhang D et al. A novel coronavirus from patients with pneumonia in China. NEJM 2020382727-33 2. Whittle, J., Molinger, J., MacLeod, D., et al. Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19. Critical Care 2020 24(1) 1-4. 3. Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic. 2020. (accessed 24.6.21) 4. Chapple, L. A. S., Fetterplace, K., Asrani, V., et al. Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand. Nutrition & Dietetics,2020 77(4), 426-436. 5. Barazzoni, R., Bischoff, S. C., Breda, J et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clinical Nutrition, 2020 39 (6), 1631-1638 6. Martindale, R., Patel, J. J., Taylor, B., et al. Nutrition Therapy in Critically Ill Patients with Coronavirus Disease (COVID-19). Journal of Parenteral and Enteral Nutrition. 2020 44 (7), 1174-1184