Enteral Nutrition in the Mechanically Ventilated Patient

Multidisciplinary nutritional support team and survival outcomes in patients with sepsis: a nationwide population-based cohort study in South Korea

BACKGROUND

The South Korean government implemented a multidisciplinary nutritional support team (NST) system to focus on the proper evaluation and supply of nutritional status in hospitalized patients who are at a higher risk of malnutrition.

METHODS

This nationwide population-based cohort study included patients diagnosed with sepsis who were admitted to hospitals from 2016 to 2020. The NST should consist of four professional personnel (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). The NST group included patients with sepsis admitted to a hospital with an NST system, whereas the non-NST group included patients with sepsis admitted to a hospital without an NST system.

RESULTS

A total of 323,841 patients with sepsis were included in the final analysis, and 120,274 (37.1%) admitted to a hospital with an NST system were included in the NST group. In the multivariable Cox regression analysis, the NST group showed a 15% lower 90-day mortality than the non-NST group (hazard ratio [HR]:0.85, 95% confidence interval [CI]:0.83, 0.86; P < 0.001). The NST group shows 11% lower 1-year all-cause mortality than the non-NST group (HR:0.89, 95% CI:0.87, 0.90; P < 0.001). In subgroup analyses, a more evident association of the NST group with lower 90-day mortality was shown in the intensive care unit admission group and age ≥65 years old group.

CONCLUSIONS

Multidisciplinary NST intervention is associated with improved survival outcomes in patients with sepsis. Moreover, this association was more evident in patients with sepsis aged ≥65 years old who were admitted to the ICU.

Early Enteral Nutrition Could Be Associated with Improved Survival Outcome in Cardiac Arrest

Background

Although the latest European and US guidelines recommend that early enteral nutrition (EN) be attempted in critically ill patients, there is still a lack of research on feeding strategies for patients after cardiac arrest (CA). Due to the unique pathophysiology following CA, it remains unknown whether evidence from other diseases can be applied in this condition.

Objective

We aimed to explore the relationship between the timing of EN (within 48 hours or after 48 hours) and clinical outcomes and safety in CA.

Method

From the MIMIC-IV (version 2.2) database, we conducted this retrospective cohort study. A 1 : 1 propensity score matching (PSM) analysis was also conducted to prevent potential interference from confounders. Moreover, adjusted proportional hazards model regression models were used to adjust for prehospital and hospitalization characteristics to verify the independence of the association between early EN initiation and patient outcomes.

Results

Of the initial 1286 patients, 670 were equally assigned to the early EN or delayed EN group after PSM. Patients in the early EN group had improved survival outcomes than those in the delayed EN group within 30 days (HR = 0.779, 95% confidence interval [CI] [0.611-0.994], p = 0.041). Similar results were shown at 90 and 180 days. However, there was no significant difference in neurological outcome between the two groups at 30 days (51% vs. 57%, odds ratio [OR] = 0.786, 95% CI [0.580-1.066], p = 0.070). Patients who underwent early EN had a lower risk of ileus than patients who underwent delayed EN (4% vs. 8%, OR = 0.461, 95% CI [0.233-0.909], p = 0.016). Moreover, patients who underwent early EN had shorter hospital stays.

Conclusion

Early EN could be associated with improved survival outcomes for patients after CA. Further studies are needed to verify it. However, at present, we might consider early EN to be a more suitable feeding strategy for CA.

Increasing the Volume of Delivered Enteral Feeds Using a Volume-Based Feeding Protocol in a Neuroscience Intensive Care Unit

BACKGROUND

Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings.

LOCAL PROBLEM

This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed.

METHODS

This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project.

RESULTS

During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients.

CONCLUSIONS

Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

Association of energy delivery with short-term survival in mechanically ventilated critically ill adult patients: a secondary analysis of the NEED trial

BACKGROUND AND AIMS

The optimal energy delivery for mechanically ventilated patients is controversial, particularly during the first week of ICU admission. This study aimed to investigate the association between different caloric adequacy and 28-day mortality in a cohort of critically ill adults on mechanical ventilation.

METHODS

This is a secondary analysis of a multicenter, cluster-randomized controlled trial. Eligible patients were divided into four quartiles (Q1-Q4) according to caloric adequacy calculated by the actual average daily energy delivery during the first seven days of ICU stay divided by energy requirement as a percentage. Cox proportional hazards models were used to examine the impact of different quartiles of caloric adequacy on 28-day mortality in the whole cohort and subgroups with different nutritional risk status at enrollment.

RESULTS

A total of 1587 patients were included in this study, with an overall 28-day mortality of 15.8%. The average caloric adequacy was 26.3 ± 11.9% (Q1), 52.5 ± 5.5% (Q2), 71.7 ± 6.4% (Q3), 107.0 ± 22.2% (Q4), respectively (p < 0.001 among quartiles). Compared with Q1, Q3 was associated with lower mortality in the unadjusted model (hazard ratio [HR] = 0.536; 95% confidence interval [CI], 0.375-0.767; P = 0.001) and adjusted model (adjusted HR = 0.508; 95% CI, 0.339-0.761; P = 0.001). This association remained valid in the subgroup of high nutritional risk patients (unadjusted HR = 0.387; 95% CI, 0.238-0.627; P < 0.001 and adjusted HR = 0.369; 95% CI, 0.216-0.630; P < 0.001, respectively), but not in those with low risk.

CONCLUSIONS

Energy delivery near the 70% energy requirements in the first week of ICU stay was associated with reduced 28-day mortality among mechanically ventilated critically ill patients, especially in patients with high nutrition risk at admission.

Early enteral nutrition is associated with improved outcomes in critically ill mechanically ventilated medical and surgical patients

BACKGROUND AND AIMS

Data suggest that guidelines for enteral nutrition (EN) initiation are not closely followed in clinical practice. In addition, critically ill mechanically ventilated (MV) patients have varying metabolic needs, which often increase and persist over time, requiring personalized nutrition intervention. While both over- and under-nutrition can impact patient outcomes, recent data suggest that targeted early EN delivery may reduce mortality and improve clinical outcomes. This study examined if early EN improves clinical outcomes and decreases costs in critically ill patients on MV.

METHODS

Data from a nationwide administrative-financial database between 2018 and 2020 was utilized to identify eligible adult critical care patients. Patients who received EN within 3 days after intubation (early EN) were compared to patients who started EN after 3 days of intubation (late EN). Outcomes of interest included hospital mortality, discharge disposition, hospital and intensive care unit (ICU) length of stay (LOS), MV days, and total cost. After inverse-probability-of-treatment weighting, outcomes were modeled using a nominal logistic regression model for hospital mortality and discharge disposition, a linear regression model for cost, and Cox proportional-hazards model for MV days, hospital and ICU LOS.

RESULTS

A total of 27,887 adult patients with early MV were identified, of which 16,772 (60.1%) received early EN. Regression analyses showed that the early EN group had lower hospital mortality (OR = 0.88, 95% CI, 0.82 to 0.94), were more likely to be discharged home (OR = 1.47, 95% CI 1.38 to 1.56), had fewer MV days (HR = 1.23, 95% CI, 1.11 to 1.37), shorter hospital LOS (HR = 1.43, 95% CI, 1.33 to 1.54) and ICU LOS (HR = 1.36, 95% CI, 1.27 to 1.46), and lower cost (-$21,226; 95% CI, -$23,605 to -$18,848) compared to the late EN group.

CONCLUSIONS

Early EN within 3 days of MV initiation in real-world practice demonstrated improved clinical and economic outcomes. These data suggest that early EN is associated with decreased hospital mortality, increased discharge to home, and decreased hospital and ICU LOS, time on MV, and cost compared to delayed initiation of EN; highlighting the importance of early EN to optimize utcomes ando support the recovery of critically ill patients on MV.

The clinical impact of implementation of a nutritional treatment protocol in critically ill adults with SARS-CoV-2 infection

INTRODUCTION

The critical patient affected by SARS-CoV-2 is at risk of malnutrition. The need to avoid volume overload and manoeuvres that delay reaching nutritional requirements such as pronation make the nutritional approach to these patients complex. To ensure adequate treatment, a nutritional support protocol was developed as a clinical practice guideline adapted to the COVID-19 patient.

OBJECTIVE

To describe and analyse the results of introducing a nutritional support protocol aimed at SARS-CoV-2 patients admitted to the intensive care unit (ICU) of the Consorcio Hospital General Universitario de Valencia (CHGUV) from March to May 2020.

MATERIAL AND METHODS

Observational, descriptive, retrospective and longitudinal design to evaluate compliance with a nutritional support protocol.

RESULTS

Thirty-one consecutive patients were included but nutritional follow-up could not be performed in eight. Of the remaining 23 patients, only eight reached 80% of caloric requirements before the tenth day after starting treatment (good compliance group) and 15 after the eleventh day (poor compliance group). In the group with «good compliance» 75% (n=6) were discharged and 25% died (n=2), compared to the group with «bad compliance» where 53% (n=8) were discharged and 47% (n=7) died (Chi square test, p-value=0.019). Those patients who reached 80% of caloric needs during ICU stay had a shorter length of stay compared to those who did not (median days of admission=14, IQR=10-16 and median days of admission=22, IQR=13-39, p-value=0.025).

CONCLUSIONS

Introducing a nutritional protocol during the first weeks of the SARS-CoV-2 pandemic could improve clinical outcomes by promoting healing and reducing associated complications.

Nursing strategies for the mechanically ventilated patient

The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.

Knowledge, attitudes, and practices of registered dietitians and nutritionists regarding enteral and parenteral nutrition support in Ghana: a needs assessment study

Background

There is a paucity of data on enteral and parenteral (EN and PN) nutrition support (NS) provided by nutrition and dietetic practitioners in adult acute care settings in Ghana. Furthermore, gray literature suggests that Ghanaian clinical nutrition professionals (CNPs) are seldom involved in advanced nutrition care teams.

Objectives

To assess the knowledge, attitudes, and practices of Ghanaian CNPs regarding EN and PN.

Methods

An online cross-sectional survey was administered to Ghanaian CNPs ahead of a professional development workshop on EN and PN Support. Participants were asked questions about initiation and timing of NS, and knowledge on availability of commercial formula. A 5-point Likert scale was used to assess self-efficacy in using EN and PN. To assess practical knowledge on EN and PN, participants were asked to identify whether EN or PN was indicated for seven short case scenarios. Open-ended questions were used to assess reasons for participant self-ratings.

Results

A total of 76 dietitians, nutritionists, students, and interns completed the survey. For EN, self-efficacy scores were lowest for the calculation of enteral goal rate, and goal volume (mean 3.20 ± 1.27), and writing of EN prescriptions (mean 3.07 ± 1.29). Self-efficacy scores for the formulation of alternative formulas in lieu of commercial formula were the highest (3.63 ± 1.36). For PN, self-efficacy scores for all domains were lower than 3, with the lowest scores observed for writing PN prescriptions (2.19 ± 1.14) and determining micronutrient additives (2.12 ± 1.04). We identified limited training and lack of practical exposure to NS, limited ability to effectively monitor tube feeds, and prohibitive cost and limited availability of EN and PN formula among the barriers impacting self-efficacy scores.

Conclusion

Given the vital role that CNPs play in the delivery of EN and PN, it is important to develop professional training programs especially focused on PN to bridge knowledge and practice gaps.

Nutritional status efficacy of early nutritional support in gastrointestinal care: A systematic review and meta-analysis

BACKGROUND

Gastrointestinal surgery is a complicated process used to treat many gastrointestinal diseases, and it is associated with a large trauma: Most patients often have different degrees of malnutrition and immune dysfunction before surgery and are prone to various infectious complications during postoperative recovery, thus affecting the efficacy of surgical treatment. Therefore, early postoperative nutritional support can provide essential nutritional supply, restore the intestinal barrier and reduce complication occurrence. However, different studies have shown different conclusions.

AIM

To assess whether early postoperative nutritional support can improve the nutritional status of patients based on literature search and meta-analysis.

METHODS

Articles comparing the effect of early nutritional support and delayed nutritional support were retrieved from PubMed, EMBASE, Springer Link, Ovid, China National Knowledge Infrastructure, China Biology Medicine databases. Notably, only randomized controlled trial articles were retrieved from the databases (from establishment date to October 2022). The risk of bias of the included articles was determined using Cochrane Risk of Bias V2.0. The outcome indicators, such as albumin, prealbumin, and total protein, after statistical intervention were combined.

RESULTS

Fourteen literatures with 2145 adult patients undergoing gastrointestinal surgery (1138 patients (53.1%) receiving early postoperative nutritional support and 1007 patients (46.9%) receiving traditional nutritional support or delayed nutritional support) were included in this study. Seven of the 14 studies assessed early enteral nutrition while the other seven studies assessed early oral feeding. Furthermore, six literatures had "some risk of bias," and eight literatures had "low risk". The overall quality of the included studies was good. Meta-analysis showed that patients receiving early nutritional support had slightly higher serum albumin levels, than patients receiving delayed nutritional support [MD (mean difference) = 3.51, 95%CI: -0.05 to 7.07, Z = 1.93, P = 0.05]. Also, patients receiving early nutritional support had shorter hospital stay (MD = -2.29, 95%CI: -2.89 to -1.69), Z = -7.46, P < 0.0001) shorter first defecation time (MD = -1.00, 95%CI: -1.37 to -0.64), Z = -5.42, P < 0.0001), and fewer complications (Odd ratio = 0.61, 95%CI: 0.50 to 0.76, Z = -4.52, P < 0.0001) than patients receiving delayed nutritional support.

CONCLUSION

Early enteral nutritional support can slightly shorten the defecation time and overall hospital stay, reduce complication incidence, and accelerate the rehabilitation process of patients undergoing gastrointestinal surgery.

[The clinical impact of implementation of a nutritional treatment protocol in critically ill adults with SARS-CoV-2 infection]

Introduction

The critical patient affected by SARS-CoV-2 is at risk of malnutrition. The need to avoid volume overload and manoeuvres that delay reaching nutritional requirements such as pronation make the nutritional approach to these patients complex. To ensure adequate treatment, a nutritional support protocol was developed as a clinical practice guideline adapted to the COVID-19 patient.

Objective

To describe and analyse the results of introducing a nutritional support protocol aimed at SARS-CoV-2 patients admitted to the intensive care unit (ICU) of the Consorcio Hospital General Universitario de Valencia (CHGUV) from March to May 2020.

Material and methods

Observational, descriptive, retrospective and longitudinal design to evaluate compliance with a nutritional support protocol.

Results

Thirty-one consecutive patients were included but nutritional follow-up could not be performed in eight. Of the remaining 23 patients, only eight reached 80% of caloric requirements before the tenth day after starting treatment (good compliance group) and 15 after the eleventh day (poor compliance group). In the group with «good compliance» 75% (n = 6) were discharged and 25% died (n = 2), compared to the group with «bad compliance» where 53% (n = 8) were discharged and 47% (n = 7) died (Chi square test, p-value = 0.019). Those patients who reached 80% of caloric needs during ICU stay had a shorter length of stay compared to those who did not (median days of admission = 14, IQR = 10-16 and median days of admission = 22, IQR = 13-39, p-value = 0.025).

Conclusions

Introducing a nutritional protocol during the first weeks of the SARS-CoV-2 pandemic could improve clinical outcomes by promoting healing and reducing associated complications.

Prevalence and mortality risk of low skeletal muscle mass in critically ill patients: an updated systematic review and meta-analysis

Background

Patients with critical illness often develop low skeletal muscle mass (LSMM) for multiple reasons. Numerous studies have explored the association between LSMM and mortality. The prevalence of LSMM and its association with mortality are unclear. This systematic review and meta-analysis was performed to examine the prevalence and mortality risk of LSMM among critically ill patients.

Methods

Three internet databases (Embase, PubMed, and Web of Science) were searched by two independent investigators to identify relevant studies. A random-effects model was used to pool the prevalence of LSMM and its association with mortality. The GRADE assessment tool was used to assess the overall quality of evidence.

Results

In total, 1,582 records were initially identified in our search, and 38 studies involving 6,891 patients were included in the final quantitative analysis. The pooled prevalence of LSMM was 51.0% [95% confidence interval (CI), 44.5-57.5%]. The subgroup analysis showed that the prevalence of LSMM in patients with and without mechanical ventilation was 53.4% (95% CI, 43.2-63.6%) and 48.9% (95% CI, 39.7-58.1%), respectively (P-value for difference = 0.44). The pooled results showed that critically ill patients with LSMM had a higher risk of mortality than those without LSMM, with a pooled odds ratio of 2.35 (95% CI, 1.91-2.89). The subgroup analysis based on the muscle mass assessment tool showed that critically ill patients with LSMM had a higher risk of mortality than those with normal skeletal muscle mass regardless of the different assessment tools used. In addition, the association between LSMM and mortality was statistically significant, independent of the different types of mortality.

Conclusion

Our study revealed that critically ill patients had a high prevalence of LSMM and that critically ill patients with LSMM had a higher risk of mortality than those without LSMM. However, large-scale and high-quality prospective cohort studies, especially those based on muscle ultrasound, are required to validate these findings.

Systematic review registration

http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022379200.

Enteral nutrition product formulations: A review of available products and indications for use

When oral nutrition is not feasible, enteral nutrition (EN) therapy is often considered the preferred route of nutrition support to meet the nutrient needs of individuals with a functional gastrointestinal tract across multiple levels of care (critical care, acute care, and home care). Enteral formulations have progressively evolved over the last 50 years from the simple blending of hospital food thin enough to run through a feeding tube, to the development of commercial standard formulas, followed by specialized formulas with immune-modulating and disease-specific qualities, to the most recent shift to food-based or blenderized EN composed of natural, whole foods with perceived health benefits. With the vast number of enteral formulations on the market, clinicians may be overwhelmed trying to determine proven vs theoretical benefits. This review is intended to explore differences in enteral formulations, identify implications for clinical practice, and review evidenced-based clinical guidelines to assist clinicians in enteral formula selection.

Mechanical ventilation in snake envenomation of dogs and cats

Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.

Effect of Dietary Supplements with ω-3 Fatty Acids, Ascorbic Acid, and Polyphenolic Antioxidant Flavonoid on Gene Expression, Organ Failure, and Mortality in Endotoxemia-Induced Septic Rats

Sepsis syndrome develops through enhanced secretion of pro-inflammatory cytokines and the generation of reactive oxygen species (ROS). Sepsis syndrome is characterized by vascular hyperpermeability, hypotension, multiple organ dysfunction syndrome (MODS), and increased mortality, among others. Endotoxemia-derived sepsis is an important cause of sepsis syndrome. During endotoxemia, circulating endotoxin interacts with endothelial cells (ECs), inducing detrimental effects on endothelium function. The endotoxin induces the conversion of ECs into fibroblasts, which are characterized by a massive change in the endothelial gene-expression pattern. This downregulates the endothelial markers and upregulates fibrotic proteins, mesenchymal transcription factors, and extracellular matrix proteins, producing endothelial fibrosis. Sepsis progression is modulated by the consumption of specific nutrients, including ω-3 fatty acids, ascorbic acid, and polyphenolic antioxidant flavonoids. However, the underlying mechanism is poorly described. The notion that gene expression is modulated during inflammatory conditions by nutrient consumption has been reported. However, it is not known whether nutrient consumption modulates the fibrotic endothelial gene-expression pattern during sepsis as a mechanism to decrease vascular hyperpermeability, hypotension, MODS, and mortality. Therefore, the aim of this study was to investigate the impact of the consumption of dietary ω-3 fatty acids, ascorbic acid, and polyphenolic antioxidant flavonoid supplements on the modulation of fibrotic endothelial gene-expression patterns during sepsis and to determine the effects on sepsis outcomes. Our results indicate that the consumption of supplements based on ω-3 fatty acids and polyphenolic antioxidant flavonoids was effective for improving endotoxemia outcomes through prophylactic ingestion and therapeutic usage. Thus, our findings indicated that specific nutrient consumption improves sepsis outcomes and should be considered in treatment.

[Fistuloclysis - A useful tool in patients with intestinal failure]

Introduction

Introduction: fistuloclysis is a technique described by Teubner et al. whereby a fistula is used as a route of nutritional administration. This procedure is an alternative to the management of patients with intestinal failure receiving parenteral nutritional support. Case reports: we present two clinical cases of patients with different medical histories but who coincided in malnutrition, abdominal sepsis with fistulas, and their awaiting intestinal reconnection. In both cases nutritional support was administered with parenteral nutrition and enteral nutrition through fistuloclysis. Discussion: enteral nutrition through fistuloclysis improves function of the intestinal barrier, reduces the rate of intrahospital infection in critically ill patients, improves immune function, prevents atrophy of the intestinal mucosa, and that is why as soon as an enteral access is located we must take advantage of this route so that our patients may experience the benefits of fistuloclysis regardless of caloric intake.

Care practices for patients requiring mechanical ventilation more than seven days in Swedish intensive care units: A national survey

OBJECTIVE

To identify care practices in Swedish intensive care units specific to patients requiring mechanical ventilation for >7 days.

RESEARCH METHODOLOGY

We conducted a national cross-sectional survey inviting all adult Swedish ICUs (n = 79). Nurse managers were invited by email to complete a questionnaire by telephone. The questionnaire included seven domains: ventilator weaning, mobilisation, communication, nutrition, symptom assessment, psychosocial support and organisational characteristics.

RESULTS

We received responses from 77 units (response rate, 97%). Weaning protocols were available in 42 (55%) units, 52 (68%) used individualised weaning strategies and 50 (65%) involved physicians and nurses in collaborative decision making. In 48 units (62%), early mobilisation was prioritised using bed cycling but only 26 (34%) units had mobilisation protocols. Most of the intensive care units (74, 96%) had nutrition protocols but only 2 (3%) had dedicated dieticians. Delirium screening tools were available in 49 (64%) ICUs, 3 (4%) assessed anxiety and none assessed dyspnoea. Nineteen (25%) units employed a primary nursing model and 11 (14%) indicated person-centred care policies. Regular case conferences, including family participation, were held by 39 (51%) units.

CONCLUSION

We found that an individualised approach to ventilator weaning, decided by physicians and nurses in collaboration, was the predominant approach, although weaning protocols were available in some intensive care units. Most units prioritised early mobilisation, though few used protocols. Nutritional protocols were widely adopted, as few units had a dedicated dietician.

Effect of abdominal massage on feeding intolerance in patients receiving enteral nutrition: A systematic review and meta‐analysis

AIM

This study aimed to evaluate the effect of abdominal massage (AM) on feeding intolerance (FI) in patients receiving enteral nutrition (EN).

DESIGN

A systematic review and meta-analysis.

METHODS

We searched seven electronic databases to September 2021. STATA and RevMan were used to analyse the data.

RESULTS

Eleven studies were included. The results revealed that AM could significantly reduce gastric residual volume and abdominal circumference difference, and reduce the incidence of gastric retention, vomiting, abdominal distention (all p < 0.001), diarrhoea (p = 0.02) and constipation (p = 0.002) in the experimental group. One study reported the incidence of aspiration in the control group was higher, but this was not statistically significant (p = 0.07). The meta-regression analysis showed there was a statistically significant correlation between intervention personnel and gastric residual volume (p = 0.035).

CONCLUSION

AM could reduce the amount and incidence of gastric retention and the changes in abdominal circumference, and significantly reduce the incidence of gastrointestinal symptoms, without increasing the incidence of aspiration for EN patients. No Patient or Public Contribution.

Fasting practices of enteral nutrition delivery for airway procedures in critically ill adult patients: A scoping review

BACKGROUND

There is limited understanding of fasting practices and reported safety concerns for airway procedures in critically ill adults.

OBJECTIVE

To describe fasting practices including safety concerns for airway procedures in critically ill adult patients in the reported literature.

INCLUSION CRITERIA

Studies conducted in adult critically ill patients receiving enteral nutrition (EN) and undergoing an airway procedure (endotracheal intubation, endotracheal extubation, and tracheostomy) were included if EN fasting practices and/or prespecified nutrition and clinical outcomes were reported.

METHODS

A scoping review using the Joanna Briggs Institute methodology was conducted. MEDLINE, Embase, and CINAHL were searched from 2000 to January 19, 2022. Results are presented via narrative synthesis.

RESULTS

Fourteen studies were included, with only one randomised control trial (RCT). Twelve studies reported on fasting practices with varied EN fasting durations (0-34 h) and two reported data on nutrition adequacy. Three studies investigated continued EN in one study arm and four studies minimised fasting duration by including gastric suctioning prior to the airway procedure. Safety concerns primarily related to aspiration events (61%) were reported in nine studies.

CONCLUSION

In the reported literature, there is wide variation in EN fasting practices for airway procedures in critically ill patients with limited evidence to inform practice.

Effect of Early Low-Calorie Enteral Nutrition Support in Critically Ill Patients: A Systematic Review and Meta-analysis

Objective

The purpose of this research was to rigorously assess the impact of early low-fever enteral feeding supplementation in critically sick patients.

Methods

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database were searched for randomized controlled trials related to enteral nutrition support of critically ill patients (retrieval time was limited to June 30, 2021); data were extracted after screening the literature, and the quality of meta-analysis was evaluated.

Results

When compared to adequate caloric enteral nutrition support, early low caloric enteral nutrition support reduces the incidence of intolerance to nutrition support (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13) and the insulin dose during enteral nutrition support (MD = -17.21, 95 percent CI: -19.91 to -14.51, P = 0.00001). However, it had no effect on intensive care unit (ICU) treatment duration (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13), in-hospital mortality (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13), or infection incidence (OR = 1.00, 95 percent CI: 0.85, 1.19, P = 0.98).

Conclusion

When compared to sufficient caloric enteral nutrition support, early low-calorie enteral nutrition support lowers the risk of severe illness. The rate of intolerance to nutritional assistance and the decrease in insulin dosage supplied had no effect on the length of ICU therapy, patient death, or infection incidence.

Comparison of nutritional risk status assessment tools in predicting 30-day survival in critically ill COVID-19 pneumonia patients

BACKGROUND

Few clinical studies have addressed nutritional risk assessment in patients with COVID-19 pneumonia admitted to the intensive care unit (ICU).

OBJECTIVES

Assess the nutritional risk status of the critically ill COVID-19 pneumonia patients admitted to the ICU, and compare the nutritional risk screening tools.

DESIGN

Medical record review SETTING: Tertiary critical care unit PATIENTS AND METHODS: We included adult (age >18 years) PCR-confirmed critically ill COVID-19 pneumonia cases admitted to the ICU between August 2020 and September 2021. Scoring systems were used to assess COVID-19 severity and nutritional status (mNUTRIC: modified Nutrition Risk in Critically Ill, NRS2002: Nutritional Risk Screening 2002). The 30-day mortality prediction performance of nutritional scores and survival comparisons between clinical and demographic factors were assessed.

MAIN OUTCOME MEASURES

Compare the nutrition risk tools SAMPLE SIZE: 281 patients with a mean (SD) age of 64.3 (13.3) years; 143 (50.8%) were 65 years and older.

RESULTS

The mean mNUTRIC score of the cases was 3.81 (1.66) and the mean NRS-2002 score was 3.21 (0.84.), and 101 (35.9%) were at high risk of malnutrition according to the mNUTRIC score and 229 (81.4%) according to the NRS 2002 score. In cases at high risk of malnutrition by the mNUTRIC score there was a greater need for invasive mechanical ventilation, vasopressors, and renal replacement therapy (P<.001 for all comparisons). The mNUTRIC score was superior to the NRS-2002 score in estimating 30-day mortality. In patients who died within 30 days, the mNUTRIC score and NRS-2002 score on the day of hospitalization were significantly higher (P<.001), and the proportion of patients with NRS-2002 score ≥3 and mNUTRIC score ≥5 was significantly higher in the non-surviving group (P<.001). In addition, patients with a high risk of malnutrition had a shorter survival time. The mNUTRIC score was an independent and important prognostic factor for 30-day mortality, and patients with an mNUTRIC score ≥5 had a 6.26-fold risk for 30-day mortality in the multivariate Cox regression.

CONCLUSION

One third of critical COVID-19 pneumonia cases hospitalized in the ICU due to acute respiratory failure have a high risk of malnutrition, and a high mNUTRIC score is associated with increased mortality.

LIMITATIONS

Single center retrospective study.

CONFLICT OF INTEREST

None.

Enteral Nutrition: Based on the Combination of Nutrison Fibre and TPF-DM with A Marine Biological-Based Active Polysaccharide Preparation

Good nutrition is essential for human growth, wound healing, and spiritual vitality. However, some individuals are unable to eat or experience gastrointestinal problems such as severe diarrhea, vomiting, gastric retention, and even gastrointestinal bleeding for a variety of causes. Therefore, it has important clinical significance to provide patients with required nutrients and maintain the integrity of the body’s tissues and organs through enteral nutrition. Based on this, this work uses a dual carrier of polylactic acid (PLA) and polyvinyl alcohol (PVA) to carry marine biopolysaccharides combined with sodium alginate (PSS) and successfully obtains the intestinal tract based on marine bioactive polysaccharides. Nutritional oral biological preparations (PSS-PLA/PVA) also cooperate with enteral nutritional suspension (diabetes) (TPF-DM) and Nutrison fibre to provide enteral nutritional support for critically ill patients. PSS-PLA/PVA has been shown in clinical studies to increase the effect of enteral nutrition support, the function of intestinal T lymphatic tissue, and the ability to control immunological function, indicating that it is worthy of further clinical development.

A Two-Stage Bedside Intubation Method to Improve Success Rate of Post-pyloric Placement of Spiral Nasoenteric Tubes in Critically Ill Patients: A Multi-Center, Prospective Study

Backgrounds

Prokinetic agents could improve the success rate of post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs), and bedside blind technique might apply as a rescue therapy subsequent to spontaneous transpyloric migration failure. The objective of this study was to investigated the validity and safety of these two bedside intubation methods as a sequential procedure for post-pyloric placement of spiral NETs in critically ill patients.

Methods

The multicenter, prospective study was conducted in intensive care units of four tertiary hospitals (June 2020 to January 2021). Eligible patients received self-propelled spiral NET placements, promoted by prokinetic agents (Stage 1). An abdominal X-ray performed 24 h post-intubation confirmed the position of the tube tip. Patients with a failed transpyloric migration entered Stage 2, where beside blind intubation was conducted (reconfirmed by X-ray). The primary end point was the overall success rate of post-pyloric placement.

Results

The overall success rate of post-pyloric placement of the spiral NET was 91.1% (73.4% in the third portion of the duodenum [D3] or beyond). The total adverse event rate was 21.0%, without any serious adverse events. In Stage 1, 55.6% of participants achieved transpyloric migration, of these, 44.4% migrated to D3 or beyond. The median time from decision to intubate to the initiation of enteral nutrition (EN) was 25 h. In Stage 2, 83.0% of patients had successful post-pyloric intubation (67.9% in D3 or beyond). The median time from decision to EN initiation after the two-stage process was 36 h.

Conclusions

Prokinetic agents-assisted self-propelled intubation and remedial bedside blind technique as a sequential procedure for post-pyloric placement of spiral NETs were effective and safe, and this two-stage process did not affect the implementation of early EN in critically ill patients.

Trial Registration

Chinese Clinical Trial Registry, ChiCTR1900026381. Registered on 6 October 2019.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Enteral Nutrition in Critically Ill Patients Under Vasoactive Drug Therapy. The NUTRIVAD Study

BACKGROUND

Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients.

METHODS

This prospective observational study was conducted in 23 ICUs over 30 months. Inclusion criteria were a need for VAD and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for at least 48 h of mechanical ventilation, an estimated life expectancy longer than 72 h, and at least 72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy and safety data were collected. An independent research group conducted the statistical analysis.

RESULTS

Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 μg/kg/min (95%CI: 0.63-0.8) targeting a mean arterial pressure of 68 mmHg (95%CI: 67-70) during the first 48 h. EN was started 34 h (95%CI: 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 Kcal (95%CI: 1098-1220) and 55.6 g (52.4-58.7) respectively. Daily energy balance during EN/patient/day was -432 (95%CI: -496 to -368). 154 (77%) patients experienced EN-related complications. However, severe complications such as mesenteric ischemia were recorded in only 1 patient (0.5%).

CONCLUSIONS

EN in these patients seems feasible, safe and unrelated to serious complications. Reaching the energy target only through EN is difficult.

CLINICAL RELEVANCY STATEMENT

Enteral nutrition (EN) in critically ill patients requiring vasoactive drugs (VAD) is currently a subject of controversy. Factors such as when to start EN, dosing, monitoring, or whether to avoid EN altogether are a real challenge because of its link to a risk of bowel ischemia. We describe our experience with EN in 200 critically ill patients on mechanical ventilation and requiring VAD. Under adequate supervision, EN proved feasible and safe. Our findings require confirmation in clinical intervention trials. This article is protected by copyright. All rights reserved.

Effect of Early Enteral Nutrition Support Combined with Chemotherapy on Related Complications and Immune Function of Patients after Radical Gastrectomy

Objective

The purpose was to analyze the effect of early enteral nutrition (EEN) support combined with chemotherapy on related complications and immune function in patients after radical gastrectomy.

Methods

80 patients with gastric cancer treated in our hospital from March 2019 to March 2020 were selected as the research objects and divided into the experimental group and control group according to the random number table, with 40 cases in each group. The control group received chemotherapy only after surgery, while the experimental group received EEN on this basis. The total protein (TP), transferrin (TF), albumin (ALB), immune cells, and other indexes were measured in the two groups before and after treatment to analyze the effect of different treatment methods on the complications and immune function of patients after radical gastrectomy.

Results

There were no significant differences in gender ratio, average age, average BMI, pathological types, disease staging, and residence between the two groups (P > 0.05). The exhaust recovery time, total gastric tube drainage, fluid intake time, and hospitalization time in the experimental group were significantly lower than those in the control group (P < 0.05). There were no significant differences in the TP, TF, and ALB levels between the two groups before treatment (P > 0.05), and the TP, TF, and ALB levels in the experimental group were significantly higher than those in the control group after treatment (P < 0.05). The CD4⁺/CD8⁺, CD3⁺, and CD4⁺ levels in the experimental group after treatment were significantly higher than those in the control group (P < 0.001). After treatment, the growth hormone levels in both groups significantly increased (P < 0.001), and the growth hormone level in the experimental group was significantly higher than that in the control group (P < 0.001). There was no significant difference in the KPS scores between the two groups before treatment (P > 0.05), and the KPS score in the experimental group was significantly higher than that in the control group after treatment (P < 0.001). The incidence of postoperative complications in the experimental group was significantly lower than that in the control group (P < 0.05).

Conclusion

EEN combined with chemotherapy is a reliable method to improve the immune function of patients after radical gastrectomy for gastric cancer, which plays an important role in improving the physical state of patients and reducing the incidence of complications. Therefore, its further research will help to establish a better treatment plan for such patients.

Does Route of Full Feeding Affect Outcome among Ventilated Critically Ill COVID-19 Patients: A Prospective Observational Study

The outbreak of the new coronavirus strain SARS-CoV-2 (COVID-19) highlighted the need for appropriate feeding practices among critically ill patients admitted to the intensive care unit (ICU). This study aimed to describe feeding practices of intubated COVID-19 patients during their second week of hospitalization in the First Department of Critical Care Medicine, Evaggelismos General Hospital, and evaluate potential associations with all cause 30-day mortality, length of hospital stay, and duration of mechanical ventilation. We enrolled adult intubated COVID-19 patients admitted to the ICU between September 2020 and July 2021 and prospectively monitored until their hospital discharge. Of the 162 patients analyzed (52.8% men, 51.6% overweight/obese, mean age 63.2 ± 11.9 years), 27.2% of patients used parenteral nutrition, while the rest were fed enterally. By 30 days, 34.2% of the patients in the parenteral group had died compared to 32.7% of the patients in the enteral group (relative risk (RR) for the group receiving enteral nutrition = 0.97, 95% confidence interval = 0.88–1.06, p = 0.120). Those in the enteral group demonstrated a lower duration of hospital stay (RR = 0.91, 95% CI = 0.85-0.97, p = 0.036) as well as mechanical ventilation support (RR = 0.94, 95% CI = 0.89–0.99, p = 0.043). Enteral feeding during second week of ICU hospitalization may be associated with a shorter duration of hospitalization and stay in mechanical ventilation support among critically ill intubated patients with COVID-19.

Joint Effort towards Preventing Nutritional Deficiencies at the Extremes of Life during COVID-19

The COVID-19 (Coronavirus disease 2019) pandemic is posing a threat to communities and healthcare systems worldwide. Malnutrition, in all its forms, may negatively impact the susceptibility and severity of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection in both children and older adults. Both undernutrition and obesity have been evoked as conditions associated with a higher susceptibility to the infection and poor prognosis. In turn, the COVID-19 infection may worsen the nutritional status through highly catabolic conditions, exposing individuals to the risk of malnutrition, muscle wasting, and nutritional deficiencies. Accordingly, the relationship between malnutrition and COVID-19 is likely to be bidirectional. Furthermore, the modification of nutritional behaviors and physical activity, required to limit the spread of the virus, are posing a challenge to health at both the extremes of life. Thus far, even the most advanced healthcare systems have failed to address the alarming consequences of malnutrition posed by this pandemic. If not properly addressed, we may run the risk that new and old generations will experience the consequences of COVID-19 related malnutrition.

Safety and tolerance of enteral nutrition in COVID-19 critically ill patients, a retrospective study

BACKGROUND

There is a lack of evidence about the tolerance of enteral nutrition (EN) in COVID-19 critically ill patients. However, several gastrointestinal manifestations related to COVID-19 have been described. The aims of this study were to analyze the incidence of gastrointestinal intolerance (GI) associated to EN (diarrhea, vomiting, gastroparesis and constipation) and to describe energy/protein provision along with biochemical alterations during the first week of EN.

METHODS

A retrospective cohort of COVID-19 critically ill patients under mechanical ventilation. We reported daily enteral nutrition infusion and gastrointestinal manifestations within the first week of intubation and enteral nutrition initiation.

RESULTS

Fifty-two patients were included; 40.3% were overweight and 46.2% were obese. During the first 7 days of EN, manifestations of GI intolerance such as vomiting, diarrhea and gastroparesis were present in 18 patients (32.4%). Hypernatremia (39%) was the most frequent electrolyte abnormality. Only Acute Kidney Injury (AKI) diagnosis was associated with a higher energy deficit on day 7. No associations between drug prescription and GI intolerance were observed. On day 4, 94.5% of patients were receiving more than 80% of energy requirements and 94.2% of protein requirements. Accumulated energy and protein deficits at day 3 were 2171.2 ± 945 kcal and 114.9 ± 49.2 g, respectively; and 2586.4 ± 1151 kcal, 133.3 ± 60.4 g at day 7.

CONCLUSION

Enteral nutrition is feasible and well-tolerated in COVID-19 patients with mechanical ventilation within the first week of enteral nutrition initiation. More studies are needed to elucidate the impact of nutritional therapy on infection course and outcomes.

COVID-19: general overview, pharmacological options and ventilatory support strategies

The novel coronavirus called "Severe Acute Respiratory Syndrome Coronavirus 2" (SARS-CoV-2) caused an outbreak in December 2019, starting from the Chinese city of Wuhan, in the Hubei province, and rapidly spreading to the rest of the world. Consequently, the World Health Organization (WHO) declared that the coronavirus disease of 2019 (COVID-19) can be characterized as a pandemic. During COVID-19 several immunological alterations have been observed: in plasma of severe patients, inflammatory cytokines are at a much higher concentration ("cytokine storm"). These aspects are associated with pulmonary inflammation and parenchymal infiltrates with an extensive lung tissue damage in COVID-19 patients. To date, clinical evidence and guidelines based on reliable data and randomized clinical trials (RCTs) for the treatment of COVID-19 are lacking. In the absence of definitive management protocols, many treatments are currently being evaluated worldwide. Some of these options were soon abandoned due to ineffectiveness, while others showed promising results. As for ventilatory strategies, at the moment there are still no consistent data published about the different approaches and how they may influence disease progression. What will probably represent the real solution to this pandemic is the identification of a safe and effective vaccine, for which enormous efforts and investments are being put in place. This review will summarize the state-of-the-art of COVID-19 current treatment options and those potentially available in the future, as well as high flow oxygen therapy and non-invasive mechanical ventilation approaches.

Comparison of Feeding Efficiency and Hospital Mortality between Small Bowel and Nasogastric Tube Feeding in Critically Ill Patients at High Nutritional Risk

Nasogastric tube enteral nutrition (NGEN) should be initiated within 48 h for patients at high nutritional risk. However, whether small bowel enteral nutrition (SBEN) should be routinely used instead of NGEN to improve hospital mortality remains unclear. We retrospectively analyzed 113 critically ill patients with modified Nutrition Risk in Critically Ill (mNUTRIC) score ≥ 5 and feeding volume < 750 mL/day in the first week of their stay in the intensive care unit (ICU). Age, sex, mNUTRIC score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were matched in the SBEN (n = 48) and NGEN (n = 65) groups. Through a univariate analysis, factors associated with hospital mortality were SBEN group (hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.31-1.00), Simplified Organ Failure Assessment (SOFA) score on day 7 (HR, 1.12; 95% CI, 1.03-1.22), and energy intake achievement rate < 65% (HR, 2.53; 95% CI, 1.25-5.11). A multivariate analysis indicated that energy intake achievement rate < 65% on the third follow-up day (HR, 2.29; 95% CI, 1.12-4.69) was the only factor independently associated with mortality. We suggest initiation of SBEN on the seventh ICU day before parenteral nutrition initiation for critically ill patients at high nutrition risk.

The modified NUTRIC score can be used for nutritional risk assessment as well as prognosis prediction in critically ill COVID-19 patients

Background & aims

In the newly emerged Coronavirus Disease 2019 (COVID-19) disaster, little is known about the nutritional risks for critically ill patients. It is also unknown whether the modified Nutrition Risk in the Critically ill (mNUTRIC) score is applicable for nutritional risk assessment in intensive care unit (ICU) COVID-19 patients. We set out to investigate the applicability of the mNUTRIC score for assessing nutritional risks and predicting outcomes for these critically ill COVID-19 patients.

Methods

This retrospective observational study was conducted in three ICUs which had been specially established and equipped for COVID-19 in Wuhan, China. The study population was critically ill COVID-19 patients who had been admitted to these ICUs between January 28 and February 21, 2020. Exclusion criteria were as follows: 1) patients of ＜18 years; 2) patients who were pregnant; 3) length of ICU stay of ＜24 h; 4) insufficient medical information available. Patients' characteristics and clinical information were obtained from electronic medical and nursing records. The nutritional risk for each patient was assessed at their ICU admission using the mNUTRIC score. A score of ≥5 indicated high nutritional risk. Mortality was calculated according to patients’ outcomes following 28 days of hospitalization in ICU.

Results

A total of 136 critically ill COVID-19 patients with a median age of 69 years (IQR: 57–77), 86 (63%) males and 50 (37%) females, were included in the study. Based on the mNUTRIC score at ICU admission, a high nutritional risk (≥5 points) was observed in 61% of the critically ill COVID-19 patients, while a low nutritional risk (<5 points) was observed in 39%. The mortality of ICU 28-day was significantly higher in the high nutritional risk group than in the low nutritional risk group (87% vs 49%, P ＜0.001). Patients in the high nutritional risk group exhibited significantly higher incidences of acute respiratory distress syndrome, acute myocardial injury, secondary infection, shock and use of vasopressors. Additionally, use of a multivariate Cox analysis showed that patients with high nutritional risk had a higher probability of death at ICU 28-day than those with low nutritional risk (adjusted HR = 2.01, 95% CI: 1.22–3.32, P = 0.006).

Conclusions

A large proportion of critically ill COVID-19 patients had a high nutritional risk, as revealed by their mNUTRIC score. Patients with high nutritional risk at ICU admission exhibited significantly higher mortality of ICU 28-day, as well as twice the probability of death at ICU 28-day than those with low nutritional risk. Therefore, the mNUTRIC score may be an appropriate tool for nutritional risk assessment and prognosis prediction for critically ill COVID-19 patients.

Nutritional Considerations in Frail Older Patients with COVID-19

The COVID-19 pandemic is posing an unprecedented challenge to healthcare systems worldwide. Older adults, which frequently present multiple chronic comorbidities, are more susceptible to COVID-19 and experience more likely negative outcomes, in terms of disease severity and mortality. However, chronological age per se may not entirely explain the dramatic scenario described among the frailest and oldest persons. Comorbidities and functional status may indeed play a relevant role. Patients at high risk of adverse clinical outcomes in COVID-19 infection are the same at risk of malnutrition, namely older adults and multimorbid individuals. In fact, COVID-19 can negatively impact on nutritional status, both in patients admitted to the hospital with the most severe manifestations of the infection, as well as in those who experience milder/asymptomatic forms of the disease. Despite being quite difficult in these emergency circumstances, nutritional status needs to be assessed in all COVID-19 patients upon admission and during hospital stay. Early nutritional support should be guaranteed in order to improve several malnutrition-related adverse outcomes. The evaluation of the nutritional status is today even more crucial than in normal times given the delicate status of older patients with COVID-19.