Meeting nutritional requirements in critically-ill patients with COVID-19: Does the patient's position really matter?

ABSTRACT

Introduction: Prone positioning and veno-venous extracorporeal membrane oxygenation (VV-ECMO) can improve oxygenation in patients with COVID 19-induced acute respiratory distress syndrome (ARDS).1 Enteral feeding in the prone position has challenges, including possible aspiration risk of gastric contents and potential for disruption to enteral feeding.2 National guidelines2 were implemented locally;including a reduction in the maximum acceptable gastric residual volume (GRV) and the avoidance of bolus feeding while patients were in prone position. Objectives: • To explore the nutritional adequacy of patients in the prone position with COVID-19 on our critical care unit during the second surge (November 2020-April 2021) • To compare nutritional adequacy of days when patients were in prone versus supine position • To identify any factors that impacted on nutritional adequacy • To provide recommendations for improvement Methods: Patients with COVID-19 who required intubation, were placed in prone position at any time during their admission and had been assessed by the dietitian, were included. Total daily energy and protein intakes, from enteral (EN) and parenteral nutrition (PN), propofol and intravenous glucose were obtained from our computerised information system (Metavision) for each full day. If nutritional aims were not met then reasons for this were investigated. Nutritional adequacy was defined as ≥ 80% of energy and protein received per day.3 Results: Data for 34 patients was collected (see Table 1). A total of 1142 ICU days were included 106 (9.3%) prone position days and 1036 (90.7%) supine position days. Patients received EN on 1098 days (96.1%) and PN on 44 days (3.9%). Only 4 of the 44 PN days occurred whilst a patient was in the prone position (0.4%). On prone position days, patients received an average 80% of their prescribed energy and 56% of their prescribed protein requirements, compared with 95% prescribed energy and 84% prescribed protein on supine position days. The average received across both prone and supine position days was 94% energy and 82% of protein. The 4 most frequent barriers to meeting protein requirements when in prone position were • Reduction of NG feed rate when GRV's were higher than maximum acceptable volume • Use of a standard 4g protein/100ml 'Out of Hours' enteral feed • Fasting for procedures • Failure to give protein supplement boluses when patient returned to supine position Conclusion: Patient position affected nutritional intake, with energy and protein intake being lower on prone position days compared with supine position days. As only 9.3% of total ICU days were prone position days, average energy and protein received across all days still achieved nutritional adequacy. An increase in a patient's prone position days during ICU admission is likely to result in greater nutritional deficit, particularly for protein. Recommendations to improve nutritional adequacy on prone position days • Consider use of post-pyloric feeding to increase feed tolerance • Use of a higher protein 'out of hours' enteral feed • Raised awareness of standard fasting times to ensure minimum disruption to feeding • Consider administration of protein supplement boluses in prone position when GRV's are within the accepted range .