Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore

Abstract

Introduction: To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. Methods: This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. Results: Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25–35.99; 6.30, 95% CI 1.15–34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. Conclusion: The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease. Keywords: COVID-19, critical illness, energy intake, enteral nutrition, nutrition support, protein intake

Challenges and considerations in delivering nutritional therapy in the ICU during COVID-19 pandemic

“…10 Nutritional support practices in the ICU and post-ICU. Late initiation of enteral nutrition (>36 hours) has been found by Lew et al 1 to increase mortality by 9-fold. However, approximately 96% of the patients in the study were initiated on enteral nutrition within 36 hours of ICU admission, in line with existing guidelines (<48 hours).…”

“…Firstly, due to COVID-19, none of the study sites performed nutritional assessment as physical examination for the patients was required. 1 Secondly, refeeding hypophosphataemia, a potentially serious complication, was found in 6% of the cohort. Thirdly, prone therapy was not associated with a higher incidence of high gastric residual volume (GRV) in patients on enteral tube feeding.…”

“…The median ICU and hospital length of stay (LOS) was 11.0 days (interquartile range [IQR] 7.0-21.8) and 31.0 days (IQR 19.3-44.0), respectively, for patients who recovered from COVID-19. 1 In this editorial, we discuss how the results from Lew et al have implications on nutritional support practices and future research direction in Singapore.…”

“…Providing clinical nutrition and metabolic care to patients with COVID-19 has been highly challenging. In this issue of the Annals, Lew et al 1 reported the results of a multicentre retrospective observational study on critically ill patients with COVID-19 in the intensive care unit (ICU). The authors found that more than 25% of these patients lived with obesity and/or diabetes, and a large majority have received neuromuscular blockade (70%), prone therapy (45%) and dialysis (37%).…”

“…2 The generally used weight-based predictive equations are considered less accurate, while indirect calorimetry-a gold standard for measuring energy needs-was deemed impractical due to the difficulty in ensuring sterility. 2,3 Nutritional assessment was not considered an essential aspect of nutritional therapy during the pandemic due to the difficulty in performing a physical assessment, as shown by Lew et al 1 One of the general concerns in the ICU is the determination of caloric and protein requirements of critically ill patients. 2,4 To overcome this, the authors suggested that nutritional screening tools that do not involve physical assessment could be used in the ICU; alternatively, clinicians could focus on risk factors such as age, length of time with minimal intake before initiation of nutritional intervention, and specific metabolic disturbances (e.g.…”