Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Nutrition intake in critically ill patients with coronavirus disease (COVID-19): A nationwide, multicentre, observational study in Argentina

INTRODUCTION

In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with coronavirus disease (COVID-19) patients.

METHODS

A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March and October 2020.

INCLUSION CRITERIA

Adult ICU patients>18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48h. Statistical analysis was carried out using IBM-SPSS© 24 programme.

RESULTS

One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97g/kg/day (CI 0.95-0.99), P<0.001), and lower caloric intake than those who survived (12.94kcal/kg/day (CI 12.48-13.39) vs 16.47kcal/kg/day (CI 16.09-16.8), P<0.001). A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II>18.

CONCLUSIONS

Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.

[Nutrition Intake in Critically Ill Patients with Coronavirus Disease (Covid-19): A Nationwide, Multicentre, Observational Study in Argentina]

INTRODUCTION

In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with Coronavirus Disease (COVID-19) patients.

METHODS

A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March-October 2020.

INCLUSION CRITERIA

Adult ICU patients >18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48hs. Statistical analysis was carried out using IBM-SPSS© 24 program.

RESULTS

One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73 g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97 g/kg/day (CI 0.95-0.99), P <0.001), and lower caloric intake than those who survived (12.94 kcal/kg/day (CI 12.48-13.39) vs 16.47 kcal/kg/day (CI 16.09-16.8), P <0.001).A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II >18.

CONCLUSIONS

Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.[[[es]]]RESUMENIntroducción: En 2020, la pandemia provocada por el SARS-COV-2, demandó una enorme cantidad de recursos sanitarios para garantizar el tratamiento y apoyo adecuado a estos pacientes. Este estudio tiene como objetivo evaluar la ingesta de calorías/proteínas y evaluar sus asociaciones con resultados clínicos relevantes en pacientes críticamente enfermos con enfermedad por coronavirus (COVID-19).Métodos: Se realizó un estudio observacional prospectivo multicéntrico a nivel nacional que incluyó 12 unidades de cuidados intensivos (UCI) argentinas entre marzo y octubre de 2020. Criterios de inclusión: pacientes adultos de la UCI > 18 años ingresados en la UCI con diagnóstico de COVID-19 y ventilación mecánica durante al menos 48 horas. El análisis estadístico se realizó mediante el programa IBM-SPSS© 24.

RESULTADOS

En el presente estudio se incluyeron 185 pacientes. Entre los que fallecieron se observó un aporte proteico más bajo (0,73 g/kg/día (intervalo de confianza (IC) del 95 % 0,70-0,75 frente a 0,97 g/kg/día (IC 0,95-0,99), P < 0,001), y menor aporte calórico que los que sobrevivieron (12,94 kcal/kg/día (IC 12,48-13,39) vs 16,47 kcal/kg/día (IC 16,09-16,8), P < 0,001).Se construyó un modelo de regresión logística para analizar qué factores estaban asociados con la probabilidad de lograrlos objetivos calóricos/proteicos. Se observo una mayor probabilidad de lograr dichos objetivos cuando el inicio del soporte nutricional era precoz, el puntaje NUTRIC modificado era superior a 5 puntos y el paciente tenía diagnóstico de desnutrición mediante la Evaluación Global Subjetiva(B o C). Por otra parte, en los pacientes que necesitaron ventilación mecánica en decúbito prono se observó menor aporte calórico y proteico, situación similar en aquellos con APACHE II > 18.

CONCLUSIONES

Los pacientes críticos con insuficiencia respiratoria asociada a la enfermedad por COVID-19 que requerían ventilación mecánica y que fallecieron en la UCI tuvieron una ingesta calórica y proteica menor que los que sobrevivieron. El inicio temprano del soporte nutricional y la desnutrición aumentaron la posibilidad de alcanzar los objetivos calóricos y proteicos, mientras que la gravedad de la enfermedad y la ventilación mecánica en decúbito prono disminuyeron la posibilidad de alcanzar los objetivos calóricos y proteicos.

Evolution of nutrition support in patients with COVID-19 disease admitted in the Intensive Care Unit

INTRODUCTION

Nutritional support in patients with COVID19 can influence the mean stay and complications in the patient in Intensive Care Unit (ICU).

AIMS

To evaluate the selection of enteral nutritional treatment in the COVID-19 patient admitted to the ICU. To know the development of dysphagia and its treatment. To evaluate the adjustment to the requirements and its relationship with the patient's complications.

MATERIAL AND METHODS

One-center longitudinal retrospective study in 71 patients admitted to the ICU with COVID19 infection and complete enteral nutrition between March and April 2020. Clinical variables were collected: length of stay in ICU, mean stay and rate of complications; and estimated anthropometric variables.

RESULTS

The mean age was 61.84 (13.68) years. Among the patients analyzed, 33 (46.5%) died. The median stay in the ICU was 20 (15.75-32) days and the mean stay was 37 (26.75-63) days. The type of formula most prescribed was normoprotein 24 (35.3%) and diabetes-specific 23 (33.8%) depending on the prescribed formula. There was no difference in mean stay (p = 0.39) or death rate (p = 0.35). The percentage of achievement of the estimated protein requirements was 50 (34.38-68.76). At discharge, 8 (21%) of the patients had dysphagia. A relationship was observed between the mean ICU stay and the probability of developing dysphagia (OR: 1.035 (1.004-1.07); p = 0.02).

CONCLUSIONS

In the patient with COVID19 disease admitted to the ICU, only half of the necessary protein requirements were reached. The presence of dysphagia at discharge was related to the length of time the patient was in the ICU.

Nutrition therapy in the intensive care unit during the COVID-19 pandemic: Findings from the ISIIC point prevalence study

BACKGROUND & AIMS

Nutrition therapy for Intensive Care Unit (ICU) patients involves complex decision-making, especially during the COVID-19 pandemic. We investigated the use of nutrition therapy in ICU patients with and without COVID-19 infections.

METHODS

Nutrition therapy was evaluated during a world-wide one-day prevalence study focused on implementation of the ABCDEF bundle (A: regular pain assessment, B: both spontaneous awakening and breathing trials, C: regular sedation assessment, D: regular delirium assessment, E: early mobility and exercise, and F: family engagement and empowerment) during the COVID-19 pandemic. Basic ICU and patient demographics including nutrition therapy delivery were collected on the survey day. Physical activity for patients with and without COVID infections was categorized using the ICU mobility scale (IMS). Multivariable regression analysis of nutrition was conducted using ICU parameters.

RESULTS

The survey included 627 non-COVID and 602 COVID patients. A higher proportion of COVID-19 patients received energy ≥20 kcal/kg/day (55% vs. 45%; p = 0.0007) and protein ≥1.2 g/kg/day (45% vs. 35%; p = 0.0011) compared to non-COVID patients. Enteral nutrition was provided to most COVID patients even with prone positioning (91%). Despite nutrition therapy, IMS was extremely low in both groups; median IMS was 1 in non-COVID patients and 0 in COVID patients. The rate of energy delivery ≥20 kcal/kg/day was significantly higher in patients with COVID-19 infections in the subgroup of ICU days ≤5 days and IMS ≤2. Having a dedicated ICU nutritionist/dietitian was significantly associated with appropriate energy delivery in patients both with and without COVID-19 infections, but not with protein delivery.

CONCLUSION

During the COVID-19 pandemic, patients with COVID-19 infections received higher energy and protein delivery. Generally low mobility levels highlight the need to optimize early mobilization with nutrition therapy in all ICU patients.

Nutrition support practices across the care continuum in a single centre critical care unit during the first surge of the COVID-19 pandemic - A comparison of VV-ECMO and non-ECMO patients

BACKGROUND & AIMS

Critically ill patients with COVID-19 are at high nutrition risk. This study aimed to describe the nutrition support practices in a single centre critical care unit during the initial surge of the COVID-19 pandemic. Practices were explored from ICU admission to post-ICU follow-up clinic and patients who received veno-venous extra-corporeal membrane oxygenation (VV-ECMO) were compared to those who did not.

METHODS

This retrospective observational study included COVID-19 positive, adult ICU patients who were mechanically ventilated for ≥72 h. Data were collected from ICU admission until the time of post-ICU clinic. For in-ICU data, results are compared between patients who did and did not receive VV-ECMO.

RESULTS

252 patients were included (VV-ECMO n = 58). Adequate energy and protein was delivered in 193 (76.6%) patients during their ICU admission with no differences between those who did and did not receive VV-ECMO (44 (75.9%) vs. 149 (76.8%)). Parenteral nutrition only being required in 12 (4.8%) patients. Following stepdown to the ward 77 (70%) patients required ongoing enteral nutrition support, and 74 (66.7%) required a texture modified diet or were NBM. Following hospital discharge, nearly a third of ICU survivors (28.4%) were referred for dietetic input. The most common referral reason was loss of weight. Breathlessness and fatigue were the most commonly reported nutrition impact symptoms experienced following hospital discharge.

CONCLUSION

Results show it is possible to reach nutritional adequacy for most patients and that neither VV-ECMO nor proning were barriers to nutritional adequacy. Nutritional issues for patients who were critically ill with COVID-19 persist following stepdown to ward level and into the community and strategies to manage this require further investigation.

Sensitivity analysis of COVID-19 with quarantine and vaccination: A fractal-fractional model

To eradicate most infectious diseases, mathematical modelling of contagious diseases has revealed that a combination of quarantine, vaccination, and cure is frequently required. However, eradicating the disease will remain a difficult task if they aren't provided at the appropriate time and in the right quantity. Control analysis has been shown to be an effective way for discovering the best approaches to preventing the spread of contagious diseases through the development of disease preventive interventions. The method comprises reducing the cost of infection, implementing control measures, or both. In order to gain a better understanding of COVID-19′s future dynamics, this study presents a compartmental mathematical model. The problem is modelled as a highly nonlinear coupled system of classical order ODEs, which is then generalised using the Mittag-Leffler kernel's fractal-fractional derivative. The uniqueness of the fractional model under discussion has also been demonstrated. The boundedness and non-negativity of the considered model are also established. The next generation technique is used to examine basic reproduction, and disease free and endemic equilibrium. We used reported cases from Australia in this investigation due to the high risk of infection. The reported cases are considered between 1st July 2021 and 20th August 2021. On the basis of previous data, the spread of infection is predicted for the next 600 days which is shown through different graphs. The graphical solution of the considered nonlinear model is obtained via numerical scheme by implementing the MATLAB software. Based on the fitted values of parameters, the basic reproduction number R0 is calculated as R0≈1.58276. Furthermore, the impact of fractional and fractal parameter on the disease spread among different classes is demonstrated. In addition, the impact of quarantine and vaccination on infected people is dramatically depicted. It's been argued that public awareness of the quarantine and effective vaccination can drastically reduce infection rates in the population.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

COVID-19 and Nutrition: Summary of Official Recommendations

Medical nutrition therapy may have a key role in the COVID-19 pandemic. Given the spread of misinformation, the present review organizes and summarizes nutrition recommendations regarding COVID-19, serving as a reference guide for health professionals. Nineteen official recommendations were included of international, US, Asian, European, Canadian, and Australian origin on (i) lactation, (ii) nutrition during quarantine, (iii) nutrition in high-risk groups, (iv) nutrition for recovery at home, and (v) nutrition in hospital. Breastfeeding is encouraged, and the role of hydration and the adoption of a healthy diet during quarantine are emphasized. Older people and/or people with comorbidities should be checked for malnutrition and follow a healthy diet. For patients recovering at home, hydration, protein, and energy intake should be ensured. For hospitalized patients, early feeding with a priority on enteral route is recommended.

Various Aspects of Non-Invasive Ventilation in COVID-19 Patients: A Narrative Review

Non-invasive ventilation (NIV) is primarily used to treat acute respiratory failure. However, it has broad applications to manage a range of other diseases successfully. The main advantage of NIV lies in its capability to provide the same physiological effects as invasive ventilation while avoiding the placement of an artificial airway and its associated life-threatening complications.

The war on the COVID-19 pandemic is far from over. The present narrative review aimed at identifying various aspects of NIV usage, in COVID-19 and other patients, such as the onset time, mode, setting, positioning, sedation, and types of interface. A search for articles published from May 2020 to April 2021 was conducted using MEDLINE, PMC central, Scopus, Web of Science, Cochrane Library, and Embase databases. Of the initially identified 5,450 articles, 73 studies and 24 guidelines on the use of NIV were included. The search was limited to studies involving human cases and English language articles. Despite several reported benefits of NIV, the evidence on the use of NIV in COVID-19 patients does not yet fully support its routine use.

Formulation of the Menu of a General Hospital After Its Conversion to a “COVID Hospital”: A Nutrient Analysis of 28-Day Menus

Aim

The aim of the present study was to modify the hospital menu to increase energy and protein provision in COVID-19 patients.

Methods

After the conversion of our hospital to a COVID-19 hospital, eggs, and comfort foods such as vanilla pudding were added to the menu to boost energy and protein intake of patients. All meals of the standard menu of the hospital, i.e., breakfast, lunch, and dinner were recorded for 14 consecutive days during two periods: pre-COVID-19 and after being converted to a “COVID hospital.” The menus were analyzed with the use of the USDA database.

Results

The total content of energy (1,873 ± 87 vs. 2,489 ± 137 Kcal), protein (97 ± 11 vs. 126.4 ± 18.7 g), fat (55 ± 9 vs. 74.1 ± 12.8 g), and carbohydrate (241.0 ± 16.0 vs. 323.0 ± 16.0 g) of the provided menus was increased in the COVID-19 period compared to the pre-COVID period. The leucine provision was also increased (4.8 ± 1.08 vs. 7.2 ± 1.3 g). Changes in protein and leucine were greater for breakfast (10 vs. 21 g protein and 0.8 vs. 1.7 g of leucine). The menu during COVID-29 provided more vitamin C (69.5 vs. 109.4 mg), thiamine (1.5 vs. 1.6 mg), riboflavin (2.1 vs. 2.6 mg), niacin (20.6 vs. 27.2 mg), pantothenic Acid (5.7 vs. 7.9 mg), vitamin B6 (2 vs. 2.6 mg), folate (274 vs. 334 μg), B₁₂ (4.8 vs. 6.2 μg), choline (296 vs. 458 mg) as well as vitamins A (8,564 vs. 21,258 IU), D (3.9 vs. 4.7 μg), and K (59.3-111.5 μg). As far as micronutrients are concerned, the provisions of calcium (972 vs. 1375 mg), iron (10.2-12.8 mg), magnesium (236 vs. 294 mg), phosphorus (1,325 vs. 1,807 mg), copper (1.0 vs. 1.3 mg), manganese (2.1 vs. 2.4 mg) and selenium (148 vs. 183 μg) were increased during the COVID-19 period.

Conclusion

Simple menu changes and addition of comfort foods can substantially boost the nutrient content of a hospital diet, which in concert with provision of oral nutritional supplements could have an impact on patients’ nutritional status.

Dietetic-Led Nutrition Interventions in Patients with COVID-19 during Intensive Care and Ward-Based Rehabilitation: A Single-Center Observational Study

Background: In this study, a report of dietitian-led nutrition interventions for patients with COVID-19 during ICU and ward-based rehabilitation is provided. As knowledge of COVID-19 and its medical treatments evolved through the course of the pandemic, dietetic-led interventions were compared between surge 1 (S1) and surge 2 (S2). Methods: A prospective observational study was conducted of patients admitted to the ICU service in a large academic hospital (London, UK). Clinical and nutrition data were collected during the first surge (March–June 2020; n = 200) and the second surge (November 2020–March 2021; n = 253) of COVID-19. Results: A total of 453 patients were recruited. All required individualized dietetic-led interventions during ICU admission as the ICU nutrition protocol did not meet nutritional needs. Feed adjustments for deranged renal function (p = 0.001) and propofol calories (p = 0.001) were more common in S1, whereas adjustment for gastrointestinal dysfunction was more common in S2 (p = 0.001). One-third of all patients were malnourished on ICU admission, and all lost weight in ICU, with a mean (SD) total percentage loss of 8.8% (6.9%). Further weight loss was prevented over the remaining hospital stay with continued dietetic-led interventions. Conclusions: COVID-19 patients have complex nutritional needs due to malnutrition on admission and ongoing weight loss. Disease complexity and evolving nature of medical management required multifaceted dietetic-led nutritional strategies, which differed between surges.

[Evolution of nutrition support in patients with covid19 disease admitted in the intensive care unit]

Introducción

El soporte nutricional en el enfermo COVID-19 ingresado en Unidad de Cuidados Intensivos (UCI) puede influir en la evolución durante la hospitalización y al alta.

Objetivos

Evaluar la selección del tratamiento nutricional enteral en el paciente con infección COVID-19 ingresado en UCI. Conocer el desarrollo de disfagia y su tratamiento. Evaluar el ajuste a los requerimientos y su relación con las complicaciones del paciente.

Material y métodos

Estudio retrospectivo longitudinal unicéntrico en 71 pacientes ingresados en UCI con infección COVID que recibieron nutrición enteral total entre marzo y abril de 2020. Se recogieron datos de estancia en UCI, estancia media y tasa de complicaciones; variables antropométricas estimadas y diagnóstico de disfagia.

Resultados

La edad media fue de 61,84 (13,68) años. Entre los pacientes analizados fallecieron 33 (46,5%). La mediana de estancia en UCI fue de 20 (15,75-32) días y la estancia media fue de 37 (26,75-63) días.

El tipo de fórmula más prescrita fue la normoproteica (24 [35,3%]) y la específica de diabetes (23 [33,8%]). No hubo diferencia en la estancia media (p = 0,39) o en la tasa de éxitus (p = 0,35) en función de la fórmula prescrita. El porcentaje de consecución de los requerimientos proteicos estimados fue del 50% (34,38-68,76).

Al alta, 8 (21%) de los pacientes tenían disfagia. Se observó un aumento en el riesgo de disfagia en función de la estancia media en UCI (OR: 1,035 [1,004-1,07]; p = 0,02).

Conclusiones

En el paciente con infección COVID-19 en UCI únicamente se alcanzaron la mitad de los requerimientos proteicos necesarios en una situación de estrés. La presencia de disfagia al alta se relacionó con el tiempo que el paciente estuvo en la UCI.

Nutritional risk and clinical outcomes in critically ill adult patients with COVID-19

INTRODUCTION

the COVID-19 pandemic put the world's population at risk. As the relationship between nutritional risk and clinical outcomes in critically ill patients with COVID-19 is still poorly understood, a multidisciplinary research team of the Argentine Society of Intensive Care (SATI) conducted a multicenter study aimed to define nutritional features, and to evaluate the relationship between nutritional risk and relevant clinical outcomes for COVID-19 patients in an intensive care unit (ICU).

METHODS

a multicenter, prospective, observational study including twelve Argentinian ICUs was conducted between March and October 2020. Inclusion criteria were: adult patients older than 18 years who were admitted to the ICU with a COVID-19 diagnosis were included. Clinical data included comorbidities scores, and nutritional screening tools such as the Subjective Global Assessment (SGA), the Nutritional Risk Screening (NRS) 2002, and the modified NUTRIC score (mNUTRIC SCORE) were used. In addition, clinical outcomes including overall mortality, mechanical ventilation (MV) days, and ICU and hospital length of stay (LOS) were recorded.

RESULTS

a total of 285 ICU patients met our inclusion criteria. Mean age was 61.24 (SD = 14.6) years; APACHE-II, 14.2 (SD = 6.6); Charlson Comorbidity Index (CCI), 2.3 (SD = 2.3). Most patients were admitted from the emergency room to the ICU. Hypertension, obesity, and diabetes were the most common comorbidities. Nutritional assessment showed that 36.9 % were SGA B+C, and 46 % were obese. Mean ICU LOS was 22.2 (SD = 19.5), and hospital LOS was 28.1 (SD = 21.9) days. Of all patients, 90.2 % underwent MV, and MV days were 20.6 (SD = 15.6). The univariate and multivariate analyses showed that risk factors for COVID-19 mortality were (odds ratio [95 % confidence interval]): SGA score of B or C: 2.13 [1.11-4.06], and NRS 2002 ≥ 3: 2.25 [1.01-5.01].

CONCLUSIONS

in the present study, nutritional status (SGA) and NRS 2002 were major mortality risk factors for CODIV-19 patients in the ICU.

Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives

Intensive care unit survivors experience prolonged physical impairments, cognitive impairments, and mental health problems, commonly referred to as post-intensive care syndrome (PICS). Previous studies reported the prevalence, assessment, and prevention of PICS, including the ABCDEF bundle approach. Although the management of PICS has been advanced, the outbreak of coronavirus disease 2019 (COVID-19) posed an additional challenge to PICS. The prevalence of PICS after COVID-19 extensively varied with 28-87% of cases pertaining to physical impairments, 20-57% pertaining to cognitive impairments, and 6-60% pertaining to mental health problems after 1-6 months after discharge. Each component of the ABCDEF bundle is not sufficiently provided from 16% to 52% owing to the highly transmissible nature of the virus. However, new data are emerging about analgesia, sedation, delirium care, nursing care, early mobilization, nutrition, and family support. In this review, we summarize the recent data on PICS and its new challenge in PICS after COVID-19 infection.

Nutritional and metabolic management of COVID-19 intensive care patients

Nutritional and metabolic disturbances are observed in patients critically ill with Coronavirus disease 19 (COVID-19) patients. The aim of this review is to describe these disturbances during the progression of the disease, from the pre-intubation phase through the ventilated condition to the post extubation phase. The analysis of new data describing the prevalence of malnutrition, the modifications in energy expenditure and body composition are guiding medical nutritional therapy to prevent patients from experiencing severe energy deficit and muscle loss. Rehabilitation may be extremely prolonged and therefore, nutrition is mandatory to decrease this recondition period. This review also comments on the European Society of Parenteral and Enteral Nutrition (ESPEN) nutritional statements.

Skeletal Muscle Damage in COVID-19: A Call for Action

Both laboratory investigations and body composition quantification measures (e.g., computed tomography, CT) portray muscle loss in symptomatic Coronavirus disease 2019 (COVID-19) patients. Muscle loss is associated with a poor prognosis of the disease. The exact mechanism of muscle damage in COVID-19 patients, as well as the long-term consequences of muscle injury in disease survivors, are unclear. The current review briefly summarizes the literature for mechanisms, assessment measures, and interventions relevant to skeletal muscle insult in COVID-19 patients. Muscle injury is likely to be attributed to the cytokine storm, disease severity, malnutrition, prolonged physical inactivity during intensive care unit (ICU) stays, mechanical ventilation, and myotoxic drugs (e.g., dexamethasone). It has been assessed by imaging and non-imaging techniques (e.g., CT and electromyography), physical performance tests (e.g., six-minute walk test), anthropometric measures (e.g., calf circumference), and biomarkers of muscle dystrophy (e.g., creatine kinase). Interventions directed toward minimizing muscle loss among COVID-19 patients are lacking. However, limited evidence shows that respiratory rehabilitation improves respiratory function, muscle strength, quality of life, and anxiety symptoms in recovering older COVID-19 patients. Neuromuscular electrical stimulation may restore muscle condition in ICU-admitted patients, albeit empirical evidence is needed. Given the contribution of malnutrition to disease severity and muscle damage, providing proper nutritional management for emaciated patients may be one of the key issues to achieve a better prognosis and prevent the after-effects of the disease. Considerable attention to longer-term consequences of muscle injury in recovering COVID-19 patients is necessary.

Approaches to Nutritional Screening in Patients with Coronavirus Disease 2019 (COVID-19)

Malnutrition is common among severe patients with coronavirus disease 2019 (COVID-19), mainly elderly adults and patients with comorbidities. It is also associated with atypical presentation of the disease. Despite the possible contribution of malnutrition to the acquisition and severity of COVID-19, it is not clear which nutritional screening measures may best diagnose malnutrition in these patients at early stages. This is of crucial importance given the urgency and rapid progression of the disease in vulnerable groups. Accordingly, this review examines the available literature for different nutritional screening approaches implemented among COVID-19 patients, with a special focus on elderly adults. After a literature search, we selected and scrutinized 14 studies assessing malnutrition among COVID-19 patients. The Nutrition Risk Screening 2002 (NRS-2002) has demonstrated superior sensitivity to other traditional screening measures. The controlling nutritional status (CONUT) score, which comprises serum albumin level, cholesterol level, and lymphocytes count, as well as a combined CONUT-lactate dehydrogenase-C-reactive protein score expressed a predictive capacity even superior to that of NRS-2002 (0.81% and 0.92% vs. 0.79%) in midlife and elder COVID-19 patients. Therefore, simple measures based on routinely conducted laboratory investigations such as the CONUT score may be timely, cheap, and valuable alternatives for identifying COVID-19 patients with high nutritional risk. Mini Nutritional Assessment (MNA) was the only measure used to detect residual malnutrition and high malnutrition risk in remitting patients-MNA scores correlated with hypoalbuminemia, hypercytokinemia, and weight loss. Older males with severe inflammation, gastrointestinal symptoms, and pre-existing comorbidities (diabetes, obesity, or hypertension) are more prone to malnutrition and subsequently poor COVID-19 prognosis both during the acute phase and during convalescence. Thus, they are in need of frequent nutritional monitoring and support while detecting and treating malnutrition in the general public might be necessary to increase resilience against COVID-19.

Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations

The use of indirect calorimetry is strongly recommended to guide nutrition therapy in critically ill patients, preventing the detrimental effects of under- and overfeeding. However, the course of energy expenditure is complex, and clinical studies on indirect calorimetry during critical illness and convalescence are scarce. Energy expenditure is influenced by many individual and iatrogenic factors and different metabolic phases of critical illness and convalescence. In the first days, energy production from endogenous sources appears to be increased due to a catabolic state and is likely near-sufficient to meet energy requirements. Full nutrition support in this phase may lead to overfeeding as exogenous nutrition cannot abolish this endogenous energy production, and mitochondria are unable to process the excess substrate. However, energy expenditure is reported to increase hereafter and is still shown to be elevated 3 weeks after ICU admission, when endogenous energy production is reduced, and exogenous nutrition support is indispensable. Indirect calorimetry is the gold standard for bedside calculation of energy expenditure. However, the superiority of IC-guided nutritional therapy has not yet been unequivocally proven in clinical trials and many practical aspects and pitfalls should be taken into account when measuring energy expenditure in critically ill patients. Furthermore, the contribution of endogenously produced energy cannot be measured. Nevertheless, routine use of indirect calorimetry to aid personalized nutrition has strong potential to improve nutritional status and consequently, the long-term outcome of critically ill patients.

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and individualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic.