Development of a Medium Care Unit Using an Inexperienced Respiratory Staff: Lessons Learned during the COVID-19 Pandemic.

The different waves of the COVID-19 pandemic caused dramatic issues regarding the organization of care. In this context innovative solutions have to be developed in a timely manner to adapt to the organization of the care. The establishment of middle care (MC) units is a bright example of such an adaptation. A multidisciplinary MC team, including expert and non-expert respiratory health care personnel, was developed and trained to work in a COVID-19 MC unit. Important educational resources were set up to ensure rapid and effective training of the MC team, limiting the admission or delaying transfers to ICU and ensuring optimal management of palliative care. We conducted a retrospective analysis of patient data in the MC unit during the second COVID-19 wave in Belgium. The aim of this study was to demonstrate the feasibility of quickly developing an effective respiratory MC unit mixing respiratory expert and non-expert members from outside ICUs. The establishment of an MC unit during a pandemic is feasible and needed. MC units possibly relieve the pressure exerted on ICUs. A highly trained multidisciplinary team is key to ensuring the success of an MC unit during such kind of a pandemic.

Nutrition evaluation and management of critically ill patients with COVID-19 during post-intensive care rehabilitation.

BACKGROUND: Among hospitalized patients with coronavirus disease 2019 (COVID-19), up to 12% may require intensive care unit (ICU) management. The aim of this prospective cohort study is to assess nutrition status and outcome in patients with COVID-19 following ICU discharge. METHODS: Patients requiring a minimum of 14 days' stay in the ICU with mechanical ventilation were included. Nutrition status was assessed at inclusion (ICU discharge) and follow-up (after 15, 30, and 60 days). All patients had standardized medical nutrition therapy with defined targets regarding energy (30 kcal/kg/d) and protein intake (1.5 g/kg/d). RESULTS: Fifteen patients were included (67% males); the median age was 60 (33-75) years old. Body mass index at ICU admission was 25.7 (IQR, 24-31) kg/m². After a median ICU stay of 33 (IQR, 26-39) days, malnutrition was present in all patients (11.3% median weight loss and/or low muscle mass based on handgrip strength measurement). Because of postintubation dysphagia in 60% of patients, enteral nutrition was administered (57% nasogastric tube; 43% percutaneous endoscopic gastrostomy). After 2 months, a significant improvement in muscle strength was observed (median handgrip strength, 64.7% [IQR, 51%-73%] of the predicted values for age vs 19% [IQR, 4.8%-28.4%] at ICU discharge [P < 0.0005]), as well as weight gain of 4.3 kg (IQR, 2.7-6.7 kg) (P < 0.0002). CONCLUSIONS: Critically ill patients with COVID-19 requiring ICU admission and mechanical ventilation have malnutrition and low muscle mass at ICU discharge. Nutrition parameters improve during rehabilitation with standardized medical nutrition therapy.

Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

The use of enteral access for continuous delivery of levodopa-carbidopa in patients with advanced Parkinson's disease.

BACKGROUND: Continuous delivery to the jejunum of levodopa-carbidopa is a promising therapy in patients with advanced Parkinson's disease, as it reduces motor fluctuation. Percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) placement is a suitable option for this. However, studies focused in PEG-J management are lacking. OBJECTIVES: We report our experience regarding this technique, including technical success, adverse events and outcomes, in patients with advanced Parkinson's disease. METHODS: Twenty-seven advanced Parkinson's disease patients (17 men, median age: 64 years, median disease duration: 11 years) were included in a retrospective study from June 2007 to April 2015. The median follow-up period was 48 months (1-96). RESULTS: No adverse events were noted during and after nasojejunal tube insertion (to assess treatment efficacy). After a good therapeutic response, a PEG-J was placed successfully in all patients. The PEG tube was inserted according to Ponsky's method. The jejunal extension was inserted during the same procedure in all patients. Twelve patients (44%) experienced severe adverse events related to the PEG-J insertion, which occurred after a median follow-up of 15.5 months. Endoscopy was the main treatment modality. Patients who experienced severe adverse events had a higher comorbidity score (p = 0.011) but were not older (p = 0.941) than patients who did not. CONCLUSIONS: While all patients responded well to levodopa-carbidopa regarding neurological outcomes, gastro-intestinal severe adverse events were frequent and related to comorbidities. Endoscopic treatment is the cornerstone for management of PEG-J related events. In conclusion, clinicians and endoscopists, as well as patients, should be fully informed of procedure-related adverse events and patients should be followed in centres experienced in their management.

Enteral access in adults.

Enteral feeding is widely used for hospitalized patients but is also used for ambulatory persons living at home or in home care settings. Aside from decisions that must be made about appropriate nutrient delivery, choices related to which type of enteral access will be used and the procedures for enteral access surveillance are extremely important. In this paper we review the various techniques for establishment of enteral access in adult patients. Prevention and treatment of potential complications are detailed. The use of protocols that are written by a multidisciplinary nutrition team is mandatory. It is also of vital importance to discuss treatment plans with the patient and care givers, to assure appropriate follow-up, and to consider ethical issues related to enteral feeding.