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on low-dose vasopressors3,8 as well as those who are in the prone position.9 Therefore, the feeding algorithm encourages the initiation of EN despite the prone position or use of low-dose vasopressors while monitoring for GI intolerances.
At the height of critical illness, patients
are at risk of gastrointestinal dysmotility, sepsis, and hypotension, which puts them at increased risk for ischemia and/or reperfusion injuries. Early initiation of EN is associated with lower ICU mortality and hospital mortality than those receiving late EN in patients receiving low-dose vasopressors.3,8 Gastrointestinal complications, such as nausea, vomiting, and diarrhea can also occur in a subset of COVID-19 patients.10 In light
of these possible GI complications, a semi- elemental, high-protein enteral feeding may be helpful in establishing feeding tolerance for the mechanically ventilated patient and
is the initial recommended formula in the algorithm.
Many hospitalized COVID-19 patients do not require mechanical ventilation and are able to consume oral diets. However, the loss of smell and taste has been reported, which is likely to negatively impact appetite at a time of increased metabolic demand.11 The use
of non-invasive positive pressure ventilation
dyspneic patients can also present challenges to meeting patients’ nutritional needs.12-14 Liberalizing diets (i.e. no therapeutic diet restrictions) along with the use of oral nutritional supplements (ONS) may be helpful to increase calorie and protein intake. The consideration of earlier supplemental tube feeding is another option to meet the patients’ estimated needs after failed trials with ONS. Because patients can become quickly deconditioned from COVID-19, the continuation of ONS at time of discharge to home or rehab may be valuable.15
Supplementation of certain multivitamins and minerals along with the possible use
of probiotics is being considered to reduce the symptoms or side effects of COVID-19.
Probiotics are recommended to regulate
the gut microbiota and to reduce the risk
for gut bacterial translocation.16 Vitamin C may support immune function, may act as a weak antihistamine, and may help decrease the incidence of pneumonia.17 Vitamin D aids in stimulating the maturation of many types of cells, including immune cells. Additionally, since the virus was detected during the winter of 2019, those affected by 18-20 of cell-mediated immunity and increases susceptibility to infectious diseases.21 It
is also important for the maintenance
and development of immune cells. Supplementation could also help manage COVID-19 symptoms, such as diarrhea and lower-respiratory-tract infections.22
The incidence of malnutrition in hospitalization has been reported to be around 4% and appropriate nutrition support is associated with improved outcomes.23,24 Unfortunately, the incidence of malnutrition in this population is not
of the limitations of RD assessments
malnutrition is dependent on the RDs being able to collect information on oral intake adequacy, weight history, and being able to perform a Nutrition Focused Physical Exam (NFPE). The conservation of PPE is essential during the COVID-19 pandemic as many facilities are facing shortages of supplies. Therefore, RDs
at ChristianaCare have been forced to modify the manner in which assessments impossible to classify malnutrition in these patients.
For most ICU patients who are mechanically ventilated, the RDs could communicate with the nursing staff or
call patient family members to obtain relevant information. For non-mechanically ventilated patients, the RDs were able to call into patient rooms to conduct nutrition
assessments. In normal circumstances,
the RD assessment involves collecting information on diet and nutritional adequacy, weight history, and performing an NFPE as able. However, to conserve PPE, we are currently deferring NFPE, making it nearly impossible to assess patients for muscle and fat wasting. during the COVID-19 pandemic may
to formally identify for the reasons discussed above, we anticipate times when patients will present with periods
of reduced nutritional intake that will
be obvious to the admitting clinician. Recognizing that these patients are at increased risk of refeeding syndrome,
we included recommendations that clinicians monitor electrolytes, including phosphorus.25 Our recommendations for the initiation of total parenteral nutrition (TPN) after approximately one week of inadequate nutrition are based on general recommendations for care of critically ill patients.3 We do, however, recognize that a subset of the COVID-19 population may symptoms, intolerance of tube feeds, or clinical evidence of prior malnutrition. In such cases, the clinician should consider earlier TPN on a case-by-case basis.
Finally, while there are no approved pharmacologic therapies for COVID-19, many clinicians have started to use hydroxychloroquine and azithromycin based on limited evidence that it might be effective.26 Both of these medications carry the side of effects of prolongation of the QT interval, which is also a side effect of metoclopramide (Reglan). Reglan is commonly used to improve feeding tolerance due to impaired gastric emptying. As a result of this shared side- this to our algorithm. It is worth noting that azithromycin also has promotility effects in the gastrointestinal tract.
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