Summarizing ASPEN’s nutrition recommendations for patients with COVID-19
ASPEN has recently published a fact sheet with eight recommendations for nutrition care for patients with COVID-19. We’ve summarized the recommendations in easy-to-understand terms.
In an effort to conserve PPE, dietitians may not be permitted to enter isolation rooms or complete nutrition-focused physical exams. Now’s the time to get creative—call patients or family members, talk with members of the interdisciplinary team, and dig a little deeper into the chart. If you are unable to speak with the patient directly, document in your assessment note how you obtained the information.
When to feed.
Early enteral feeding is recommended for all critical care patients, including those with COVID-19. How early is “early?” Within 36 hours of ICU admission or within 12 hours of initiation of mechanical ventilation. The same rules regarding hypotension, shock, and escalating vasopressor use still apply. If enteral nutrition is not feasible, go ahead with parenteral nutrition, especially with nutritionally high-risk patients.
Logistics of enteral feeding.
Larger bore nasogastric (NG) or orogastric (OG) tubes are preferred for COVID-positive patients for a few reasons. First, they are easier to successfully place and require less clinician exposure time to the patient. Second, due to their size, they are less likely to clog and need replacement. Third, they do not require a trip to interventional radiology or the endoscopy suite, potentially complicating airborne precautions. Once GI access is obtained, continuous feeding is recommended, as it minimizes clinician interaction with the patient. When tube feeding pumps are scarce, prioritize pumps for patients with a small bowel feeding tube or those with poor tolerance to gravity or bolus feeding.
Meeting calorie and protein needs.
Enteral nutrition regimens should aim to meet 70% to 80% of a patient’s estimated calorie needs (15 to 20 kcal/kg actual weight) and 1.2 to 2 grams of protein/kg of actual weight. Indirect calorimetry is not recommended in order to limit clinician’s interaction with the patient. If the patient proves to be intolerant of enteral nutrition, begin parenteral nutrition.
Selecting a formula and administering modulars.
Standard high-protein, fiber-free, polymeric enteral formulas should be the first choice for this patient population. Immune-modulating formulas may provide additional benefit, but there is insufficient research to support widespread use of this type of specialty formula. When protein modulars or fiber supplements are needed, these should be administered once daily to limit clinician exposure to the patient. When parenteral nutrition is used, soy-based lipids should be held according to current guidelines.
Monitoring tolerance to feeding.
All current recommendations for monitoring tolerance to enteral nutrition regimens still apply. Be aware that COVID-19 may manifest with GI-related symptoms, particularly in those with more serious illness.
Feeding while prone.
If COVID-19 progresses to acute respiratory distress syndrome (ARDS), patients may be placed in a prone position to improve oxygenation. Enteral feeding in this position is safe and does not specifically increase the risks of ventilator-associated pneumonia. To reduce clinician exposure, gastric feeding should be trialed; post-pyloric feeding tubes should only be placed if gastric feeding while prone is not tolerated. To improve tolerance, elevate the head of bed by 10 to 20 degrees (reverse Trendelenburg position) while the patient is prone.
Feeding during ECMO.
Extracorporeal membrane oxygenation (ECMO) may be used for patients who are unable to achieve appropriate oxygenation through mechanical ventilation alone. Patients receiving this therapy can be fed enterally, but advance feeding cautiously. Some patients may experience increased levels of intolerance, so slow advancement to goal is recommended.
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Martindale R, Patel JJ, Warren M, McClave SA. Nutrition Therapy in the Patient with COVID-19 Disease Requiring ICU Care. Published online at nutritioncare.org. Updated April 1, 2020. Accessed 23, 2020.
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