NOT ENERGY, BUT A BETTER PROVISION OF PROTEIN IN ICU SEEMS TO BE CRITICAL FOR THE SURVIVAL OF PATIENTS WITH COVID-19

ABSTRACT

Background and aims: Although recent data suggests that adequate delivery of nutritional therapy impacts positively on the outcomes, critically ill patients often suffer from underfeeding due to several factors. Causes for low provision of nutrients include fasting, gastrointestinal dysfunction, the conditions imposed by the illness, as observed in COVID-19, poor content of protein in the enteral formulas, and the delivery of non-nutritional calories (i.e., propofol). This study aimed to verify an association between mortality and the energy and protein provided to critically ill patients, including a subgroup affected by the SARS-CoV- 2. Methods: First, general mortality in the ICU was evaluated using logistic regression in patients receiving oral, enteral, and parenteral Nutritional Therapy (NT), according to the rate of NT compliance (calculated by the percentage of days that the nutrition support was offered properly in relation to the total number of days of hospitalization, according to the type of therapy). Also, a subgroup of patients with SARS-CoV-2 infection confirmed by RTPCR, with at least 7 days of hospitalization in the intensive care unit (ICU), requiring MV, and exclusively fed by enteral nutrition were evaluated according to the outcomes discharge or death. Age, gender, Simplified Acute Physiology Score III (SAPS3), ICU length of stay (LOS), days on MV, outcomes (discharge or death), and daily energy and protein provision were collected from electronic medical records. Cox regression analyses and Kaplan Meyer curves were used in statistical analysis of the COVID-19 subgroup. Results: 180 patients (72±15 years, 50% men) were enrolled. The mean LOS was 17±11 days. Nutritional risk was present in 161 patients (89%) and malnutrition in 19 (11%). One hundred and seven patients (59%) were discharged, and 73 (40%) died. The NT compliance rate (%) was negatively associated with the overall mortality in the ICU [OR 0.96 (95% CI 0.94-0.98), p=0.001], even when the model was adjusted by age, nutritional status, LOS, days on MV, and type of NT. Patients with a lower NT compliance rate have significantly higher mortality (p<0.001). Fifty-two patients (66 ± 13 years;54% women) were enrolled in the COVID- 19 subgroup. The mean LOS was 17.8 ± 9.8 days, and SAPS3 was 79 ± 15;all patients needed MV (mean of days was 16 ± 9). Most patients (73%) died. Hazard Ratios (HR) for protein supply, delivered according to patients' ideal body weight (IBW), showed that a protein intake >0.8 g/IBW/day was associated with significantly lower mortality (HR 0.3 (95% CI 0.1-0.7), p=0.04). Energy intake was not related to survival (HR 0.94, (95% CI 0.9-1.0, p=0.09), being the same observed for other variables, such age, days on MV, and SAPS3. Conclusion: protein provision is suggested to be related to reduced mortality in ICU patients with COVID-19.