Page 27 - Delaware Medical Journal - July/August 2020
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P UC
C
C
C
C
C
CBA
A
ATLS
S
S
S
SRIE
E
E
E
E
E
E ECE AR R R
R
R
RHTE
E
E
EMP
P
P
P
PAO
O
O
OELR
R
R
RTNHT
T
T
T
T
T
T
Figure 1
consensus was achieved. Figure 1 is the algorithm created for use at ChristianaCare.
The feeding algorithm does highlight two caveats to starting feeds or an oral diet directly on patient admission. These include patients with multiple food allergies who may not be able to tolerate the semi-elemental formula recommended and patients who develop severe electrolyte abnormalities
due to renal failure. These situations likely will require the assistance of the registered dietitian (RD) to recommend an appropriate enteral feeding formula or to make individualized nutritional plan.
DISCUSSION
The COVID-19 feeding algorithm adapted from ASPEN and SCCM recommendations
provides an easy-to-follow approach that eliminates the need for clinicians to calculate personalized nutrition support interventions. Many of the principles of nutrition support during critical illness are appropriate for the COVID-19 population. These include (1) the initiation of early enteral feeding within 24- 36 hours of admission to the ICU or within 12 hours of intubation, (2) prioritization of gastric feeding access with consideration
for jejunal feeding-tube placement in the event of gastric intolerance, (3) conservative days of critical illness with advancement to repletion goals based on patients’ progress and blood chemistries, (4) consideration of lipid calories from propofol when calculating nutrition requirements, and (5) consideration of total parenteral nutrition in those patients with preexisting GI conditions or acute
GI symptoms leading to enteral feeding intolerance to avoid high cumulative caloric
3 Most of these principles were incorporated into the algorithm with the exception for the consideration of propofol, which would be addressed once the patient moved beyond trophic levels of feeding.
Patients with COVID-19 can rapidly progress to Acute Respiratory Distress Syndrome (ARDS) and other complications from sepsis, including acute renal
failure and volume overload. Guidelines recommend prone positioning and the use of paralytic agents in patients with severe hypoxemia.7 It is anticipated that a subset
of critically ill patients with COVID-19
will also require multiple vasopressors.
The prone position and use of vasopressors, especially escalating dosage of vasopressors, can challenge the provision of adequate feeding. Trophic enteral feedings have been shown to be well tolerated and be
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