Nutritional management and clinical outcome of critically ill patients with COVID-19: A retrospective study in a tertiary hospital

BACKGROUND & AIMS

Severe COVID-19 infection is characterized by an inflammatory response and lung injury that can evolve into an acute respiratory distress syndrome that needs support treatment in intensive care unit. Nutritional treatment is an important component of the management of critically ill patients and should be started in the first 48 h of ICU admission to avoid malnutrition. This study describes the characteristics of the patients treated in a tertiary hospital in Madrid during the months of March-May 2020 (first wave), the medical nutrition treatment employed and its influence in the clinical outcome of these patients.

METHODS

This is a retrospective study including COVID-19 patients admitted in ICU that needed medical nutrition treatment (MNT). Collected variables included sex, age, BMI, underlying diseases, time from hospitalisation to ICU admission, type of respiratory support (invasive mechanical ventilation (IMV) or high flow nasal cannula (HFNC) or non-invasive ventilation (non-IMV)), caloric and protein requirements (25 kcal/kg adjusted body weight (ABW), 1.3 g/kg ABW/day), MNT type (enteral nutrition (EN), parenteral nutrition (PN), mixed EN + PN), total calories (including propofol) and proteins administered, percentage of caloric and protein goal in ICU day 4th and 7th, metabolic complications, acute kidney failure (AKF), length of stay (LOS) and mortality. Data are expressed as mean ± SD, median (IQR) or frequencies. Statistical analysis was performed with the IBM SPSS Statistics for Windows, Version 25.0. p < 0.05 were considered statistically significant.

RESULTS

A total of 176 patients were included (72.7% male), 60.1 ± 13.5 years, BMI 29.9 ± 5.4 kg/m². Underlying diseases included 47.4% overweight, 39.8% obesity, 49.1% hypertension, 41.4% dyslipidaemia. 88.6% of patients needed IMV, 89.1% prone position, 2.9% ECMO. Time to ICU admission: 2 (4.75) days. Estimated caloric and protein requirements were 1775 ± 202 kcal and 92.4 ± 10.3 g. Calories and proteins administered at days 4th and 7th were 1425 ± 577 kcal and 66 ± 26 g and 1574 ± 555 and 74 ± 37, respectively. Most of the patients received PN (alone or complementary to EN) to cover nutritional requirements (82.4% at day 4th and 77.9% at day 7th). IVM patients received more calories and proteins during the first week of ICU admission. Complications included 77.8% hyperglycaemia, 13.2% hypoglycaemia, 83.8% hypertriglyceridemia, and 35.1% AKF. ICU LOS was 20.5 (26) days. The mortality rate was 36.4%.

CONCLUSIONS

In our series, the majority of patients reached energy and protein requirements in the first week of ICU admission due to the use of PN (total or complementary to EN). Patients with HFNC or non-IMV may be at risk of malnutrition if total or complementary PN to oral diet/ONS/tube feeding is not used to cover nutritional requirements. Therefore, if EN is not possible or insufficient, PN can be safely used in critically ill patients with COVID-19 with a close monitoring of metabolic complications.

[Poor premorbid adjustment linked to deterioration in theory of mind skills: a study in stabilised schizophrenic patients]

INTRODUCTION

Previous studies suggest that there is a deficit in theory of mind (ToM) in stabilised schizophrenic patients. More specifically, it has been claimed that poor premorbid adjustment covaries with the abnormalities in ToM skills detected in such patients. It has also been suggested that this deficit could be a trait marker for schizophrenic disorders.

PATIENTS AND METHODS

The aim of this study was to examine the performance in mentalistic skills in 36 stabilised schizophrenic patients in comparison to a standard control group. We also sought to examine the relation between ToM skills and premorbid adjustment in our target sample. Premorbid adjustment was evaluated using the modified Cannon-Spoor premorbid adjustment scale, and ToM measurements were obtained by means of first- and second-order verbal experimental tasks.

RESULTS

Schizophrenic patients presented statistically significant poorer performances in first- and second-order ToM tasks, although no differences were observed between these patients and the control sample as regards overall cognitive acuity. Poor premorbid adjustment in areas of social functioning in the patients was also associated with statistically significant poorer performance in both ToM tasks.

CONCLUSIONS

Deficient premorbid adjustment in schizophrenia may be linked to a ToM deficit that can be assessed with simple tasks.

[Lumbosacral polyradiculomyelitis caused by herpes simplex virus (HSV) in a patient with AIDS]

To our knowledge this is the first description of lumbosacral polyradiculopathy produced by herpes simplex virus (HSV) without coinfection by cytomegalovirus (CMV) in a patient with HIV infection. The acute lumbosacral polyradiculomyelitis (ALP) in patients with AIDS is a well defined nosologic entity and classically associated to CMV infection. However, this pathology can be due to others etiologies as toxoplasmosis, syphilis, lymphoma, tuberculosis, cryptococcus, varicella-zoster virus fVZV), Epstein-Barr virus (EBT) and HSV associated CMV. The case report was documented with findings in cerebrospinal fluid, magnetic resonance imaging and was confirmed by detection of HSV DNA by polymerase chain reaction. CMV DNA was not detected and no clinical features of CMV disease was seen. Therapy with foscarnet was successful. This drug without gancyclovir associated has rarely been employed in the treatment of ALP. We believe that foscarnet may be a valuable alternative therapy for cases of ALP of suspected acyclovir-resistant herpes virus infection.

[Invasive fungal infections in liver transplant recipients: analysis of 21 cases]

BACKGROUND

Invasive fungal infections (IFI) are one of the most important causes of mortality in liver transplant (LT) recipients. The aim of this study was to describe the characteristics of IFI in the LT program of our institution with an special emphasis in the differences between Candida infections (CI) and that caused by other fungi (NCI).

PATIENTS AND METHODS

Retrospective analysis of the hospital charts of 21 patients who underwent a LT from February 1987 to December 1995. The diagnosis of IFI required the histological evidence of tissue invasion or a positive culture in a tissue sample or in an usually sterile fluid. Esophageal candidiasis was not considered as IFI. Antifungal prophylaxis was performed either with nystatin or fluconazole.

RESULTS

Twenty-one of 356 patients (6%) developed a total of 23 episodes of IFI. Pathogens were Candida spp. (n = 10), Aspergillus (n = 8), Zygomicetes (n = 4) and Cryptococcus (n = 1). Fifty-seven percent of the episodes of IFI (80% of those caused by Candida and 38% of those produced by other fungi; p < 0.05) developed in the first 3 months after transplantation and only 5 episodes appeared after the sixth month. The diagnosis of IFI was done at autopsy in 6 patients (29%). Overall, NCI (13 episodes) predominated over CI (10 episodes), being the later the cause of the 54% of the episodes in the first 178 recipients but only the 30% in the last 178 patients (p = 0.09). No differences were found in the distribution of the risk factors amongst those patients with CI or NCI. Seventeen of the 21 patients (71%) died and 15 of these deaths (72%) were attributable to fungi; 15 patients who died either did not receive amphotericin (n = 6) or received a cumulative dose lower than 500 mg. Six patients received a cumulative dose of more than 1.5 g (mean, 3.2 g) and four of them were cured. Mortality in the nonfungal infection group was 26% (p < 0.001).

CONCLUSIONS

IFI was a rare but severe complication in our LT recipients. The relative frequency of CI was progressively decreasing during the study period, being NCI the predominant infections. Amphotericin therapy was effective only when a high cumulative dose could be administered.

[Human babesiosis in a patient after splenectomy]

A case of human babesiosis in a 34-year-old male patient with previous splenectomy is reported. This is the first description of babesiosis in a splenectomized patient in Spain. The clinical picture was mainly characterized by the presence of fever and hemolysis. The findings of a reactive hemophagocytic syndrome and lymph node enlargement, the description of which is exception in this entity are of note. The therapeutic aspects are reported emphasizing the good response to treatment with clindamycin and quinine sulphate which is unusual in the splenectomized cases reported in Europe. The diagnostic tods as well as the epidemiologic implications of the description of this zoonosis in Spain are discussed.