Nutrition in the Critically Ill with COVID-19

We can always count on the ASPEN team to come through for us regarding nutritional recommendations for our patients with COVID-19. A hat tip to them. A hat tip also to my pharmacist teammate, Amanda, for sending this to me (and many other literature goodies). This is free so download your own copy and don't trust me.

Let's take a look. First of all, to make one thing clear, there's no RCT on how to provide nutrition particularly to COVID patients. These recommendations need to be extrapolated from other data. This document was updated today. I enjoyed how they took into account preserving PPE in their recs.

The recs:

- start EN within 24-36 hours of admission to the ICU or within 12h of intubation.

- start with trickle/trophic feeds and ramp it up as stated in the document.

- use weight based equations for the correct amount of nutrition

- trophic feeds if patients are on vasopressors (not if increasing VP doses, though). My understanding is that most of these patients are hemodynamically stable. If the patient is getting sicker, do not feed.

- no recommendations regarding patients on paralytics.

- start with gastric feeds, if this fails, try prokinetics, if this fails, feed post-pyloric. I know there are logistical issues with this at different institutions. They also recommend against post-pyloric feeding tubes needing fluoro for placement due to limiting exposure to HCW.

- continuous feeds recommended over bolus feeds (less PPE)

- they make recommendations about TPN that I won't mention here

- they recommend checking triglyceride levels in patients on propofol within the first 24 hours due to a subset of patients who develop secondary HLH. Not going down this road right now.

- they do not recommend checking gastric residuals. This is something I've covered in the past and it will save PPE.

- feeding proned patients: you could feed the gastric chamber. This is something that I have been asked.

It's only an 8 page document. Check it out for yourself!

-EJ

Link to Abstract

Link to FULL FREE PDF

Nutrition and Gut Health in the ICU: Citations

References to the Enteral Nutrition Lecture

Lambell KJ, Tatucu-Babet OA, Chapple LA, Gantner D, Ridley EJ. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care. 2020;24(1):35. Published 2020 Feb 4. doi:10.1186/s13054-020-2739-4

McClave SA, Martindale RG, Rice TW, Heyland DK. Feeding the critically ill patient. Crit Care Med. 2014;42(12):2600–2610. doi:10.1097/CCM.0000000000000654

McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) [published correction appears in JPEN J Parenter Enteral Nutr. 2016 Nov;40(8):1200]. JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. doi:10.1177/0148607115621863

Nguyen NQ, Besanko LK, Burgstad C, et al. Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients. Crit Care Med. 2012;40(1):50–54. doi:10.1097/CCM.0b013e31822d71a6

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307(8):795–803. doi:10.1001/jama.2012.137

Arabi YM, Aldawood AS, Haddad SH, et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults [published correction appears in N Engl J Med. 2015 Sep 24;373(13):1281]. N Engl J Med. 2015;372(25):2398–2408. doi:10.1056/NEJMoa1502826

Arabi YM, Aldawood AS, Al-Dorzi HM, et al. Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial. Am J Respir Crit Care Med. 2017;195(5):652–662. doi:10.1164/rccm.201605-1012OC

Al-Dorzi HM, Albarrak A, Ferwana M, Murad MH, Arabi YM. Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. Crit Care. 2016;20(1):358. Published 2016 Nov 4. doi:10.1186/s13054-016-1539-3

Allingstrup MJ, Kondrup J, Wiis J, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med. 2017;43(11):1637–1647. doi:10.1007/s00134-017-4880-3

Harvey SE, Parrott F, Harrison DA, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014;371(18):1673–1684. doi:10.1056/NEJMoa1409860

Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013;309(20):2130–2138. doi:10.1001/jama.2013.5124

Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365(6):506–517. doi:10.1056/NEJMoa1102662

Halpern SD, Becker D, Curtis JR, et al. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med. 2014;190(7):818–826. doi:10.1164/rccm.201407-1317ST

Reignier J, Boisramé-Helms J, Brisard L, et al. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2018;391(10116):133–143. doi:10.1016/S0140-6736(17)32146-3

TARGET Investigators, for the ANZICS Clinical Trials Group, Chapman M, Peake SL, et al. Energy-Dense versus Routine Enteral Nutrition in the Critically Ill. N Engl J Med. 2018;379(19):1823–1834. doi:10.1056/NEJMoa1811687

Wischmeyer PE. Enteral Nutrition Can Be Given to Patients on Vasopressors. Crit Care Med. 2020;48(1):122–125. doi:10.1097/CCM.0000000000003965

Doig GS, Simpson F, Heighes PT, et al. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med. 2015;3(12):943–952. doi:10.1016/S2213-2600(15)00418-X

Lambell, K.J., Tatucu-Babet, O.A., Chapple, L. et al. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care 24, 35 (2020).

van Niekerk G, Meaker C, Engelbrecht AM. Nutritional support in sepsis: when less may be more. Crit Care. 2020;24(1):53. Published 2020 Feb 14. doi:10.1186/s13054-020-2771-4

Wischmeyer PE, McDonald D, Knight R. Role of the microbiome, probiotics, and 'dysbiosis therapy' in critical illness. Curr Opin Crit Care. 2016;22(4):347–353. doi:10.1097/MCC.0000000000000321

Fay KT, Klingensmith NJ, Chen CW, et al. The gut microbiome alters immunophenotype and survival from sepsis. FASEB J. 2019;33(10):11258–11269. doi:10.1096/fj.201802188R

Robinson CM, Pfeiffer JK. Viruses and the Microbiota. Annu Rev Virol. 2014;1:55–69. doi:10.1146/annurev-virology-031413-085550

Lozupone CA, Stombaugh JI, Gordon JI, Jansson JK, Knight R. Diversity, stability and resilience of the human gut microbiota. Nature. 2012;489(7415):220–230. doi:10.1038/nature11550

Clark JA, Coopersmith CM. Intestinal crosstalk: a new paradigm for understanding the gut as the "motor" of critical illness. Shock. 2007;28(4):384–393. doi:10.1097/shk.0b013e31805569df

Zhao L, Luo L, Jia W, et al. Serum diamine oxidase as a hemorrhagic shock biomarker in a rabbit model. PLoS One. 2014;9(8):e102285. Published 2014 Aug 21. doi:10.1371/journal.pone.0102285

Lankelma JM, van Vught LA, Belzer C, et al. Critically ill patients demonstrate large interpersonal variation in intestinal microbiota dysregulation: a pilot study. Intensive Care Med. 2017;43(1):59–68. doi:10.1007/s00134-016-4613-z

McDonald D, Ackermann G, Khailova L, et al. Extreme Dysbiosis of the Microbiome in Critical Illness. mSphere. 2016;1(4):e00199-16. Published 2016 Aug 31. doi:10.1128/mSphere.00199-16

Shimizu K, Ogura H, Goto M, et al. Altered gut flora and environment in patients with severe SIRS. J Trauma. 2006;60(1):126–133. doi:10.1097/01.ta.0000197374.99755.fe

Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012;307(18):1959–1969. doi:10.1001/jama.2012.3507

Weng H, Li JG, Mao Z, et al. Probiotics for Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated Patients: A Meta-Analysis with Trial Sequential Analysis. Front Pharmacol. 2017;8:717. Published 2017 Oct 9. doi:10.3389/fphar.2017.00717

Manzanares W, Lemieux M, Langlois PL, Wischmeyer PE. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis [published correction appears in Crit Care. 2017 Feb 27;21(1):42]. Crit Care. 2016;19:262. Published 2016 Aug 19. doi:10.1186/s13054-016-1434-y

Goldenberg JZ, Yap C, Lytvyn L, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017;12(12):CD006095. Published 2017 Dec 19. doi:10.1002/14651858.CD006095.pub4

Yelin I, Flett KB, Merakou C, et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat Med. 2019;25(11):1728–1732. doi:10.1038/s41591-019-0626-9

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Gaines S, Alverdy JC. Fecal Micobiota Transplantation to Treat Sepsis of Unclear Etiology. Crit Care Med. 2017;45(6):1106–1107. doi:10.1097/CCM.0000000000002382

Alagna L, Haak BW, Gori A. Fecal microbiota transplantation in the ICU: perspectives on future implementations. Intensive Care Med. 2019;45(7):998–1001. doi:10.1007/s00134-019-05645-7

Dai M, Liu Y, Chen W, et al. Rescue fecal microbiota transplantation for antibiotic-associated diarrhea in critically ill patients. Crit Care. 2019;23(1):324. Published 2019 Oct 21. doi:10.1186/s13054-019-2604-5

Wurm P, Spindelboeck W, Krause R, et al. Antibiotic-Associated Apoptotic Enterocolitis in the Absence of a Defined Pathogen: The Role of Intestinal Microbiota Depletion. Crit Care Med. 2017;45(6):e600–e606. doi:10.1097/CCM.0000000000002310

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Nutrition in Critical Illness

I’m writing a lecture on Nutrition for the ICU patient population. It’s been quite tough to find substantial data because of the many nuances and the vast heterogeneity of the patient population. That being said, this review article came out a few days ago and it provides a guide of sorts to provide our patients with nutrition during their different phases in the ICU. My understanding is that the ASPEN group shall be meeting towards the end of March. I am looking forward to whatever guidance they can provide so I can better care for my patients.

Fortunately this article is free! A hat tip for the authors.

Lambell, K.J., Tatucu-Babet, O.A., Chapple, L. et al. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care 24, 35 (2020).

Link to article

Link to FREE PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Why we should NOT be checking for residual tube feeds

Do you as a nurse spend any part of your day checking for residuals on your patients who are on mechanical ventilation and receiving tube feeds/enteral feeding? Did you know that since 2016, the ASPEN guidelines have recommended against this? Now may be your opportunity to present this data to the powers that be and let you have your time back so you can "play cards" (obvious joke) and do more important things in patient care. It's 2019, think of all the time you've spent partaking in this practice. Sigh. Okay don't think about it. We NEED you at the bedside. In the McClave study there was no support for using residual volumes as a marker for the risk of aspiration. the frequency was 21.6% vs 22.6%. The Poulard study from 2010 was calling checking residual gastric volume "standard practice". I guess that's why some institutions are still doing it. They wanted to do the study because there was no data to find a correlation between residuals and adverse events. Know what they found? That not checking residuals allowed for a greater daily volume of enteric feeds. No difference in vomiting between the two groups nor was there a difference in ventilator associated pneumonia. Worth it to check residuals? Still not convinced? Lets look at more data then. Last but definitely not least, the Reignier study in 2013, 3 years after the 2010 study showed that there wasn't a benefit to checking residuals (in all fairness the study took place in 2010) looked at ventilator associate pneumonia as the primary endpoint. Did they find a difference? They found a whole bunch of NOPE. Does that settle the argument in your mind? Yes, I know that we all had that ONE patient who aspirated and got sick. It's not perfect. But the data is there, actually, right here. Three articles that you can obtain on my website. A little literature review from me, if you will. Hope you got something out of it and your time will now be saved. Share this with your nurse managers, dietitian teams, and fellow nurses so everyone can benefit.

I'm sorry that I can't get you these articles as they are hidden behind the dreaded paywall but the ASPEN guidelines are free.


-EJ














Link to Article

Reignier, J. (2013). Effect of Not Monitoring Residual Gastric Volume on Risk of Ventilator-Associated Pneumonia in Adults Receiving Mechanical Ventilation and Early Enteral Feeding. JAMA, 309(3), 249.



Link to Article

McClave, S. A., Lukan, J. K., Stefater, J. A., Lowen, C. C., Looney, S. W., Matheson, P. J., … Spain, D. A. (2005). Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients*. Critical Care Medicine, 33(2), 324–330.



Link to Abstract

Poulard, F., Dimet, J., Martin-Lefevre, L., Bontemps, F., Fiancette, M., Clementi, E., … Reignier, J. (2009). Impact of Not Measuring Residual Gastric Volume in Mechanically Ventilated Patients Receiving Early Enteral Feeding. Journal of Parenteral and Enteral Nutrition, 34(2), 125–130.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Can early enteral nutrition decrease mortality?

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.


Link to Abstract

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.

In my quest for sort out the answer of when to initiate enteral nutrition in my critically ill ICU patients, the data leans toward starting early. In this meta-analysis that was published in 2009, despite the sample sizes being very small, they were able to find a benefit regarding mortality and pneumonias when you start feeding patients within 24 hours. How small you ask? Well, 234 in the group that determined a benefit in mortality and just 80 in the group that determined a benefit towards pneumonia of early feeding. We need larger studies. All these authors admit this. We need some super ambitious RD's out there to take this bull by the horns and definitely answer these questions for us! A 🎩 tip to the authors!

-EJ

Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials. Intensive Care Med. 2009;35(12): 2018-2027.

Enteral Nutrition: When should we start in our mechanically ventilated patients? Day 1 or 4?

Link to Abstract

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patient.

When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5... on and on. This study shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1. The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be "start at day 1 vs day 2" or "start at day 1 vs day 3"? We do not know those answers yet. 

A 🎩 tip to the authors! 

- EJ

Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M., … Fraser, R. J. L. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients*. Critical Care Medicine, 40(1), 50–54. 

Enteral nutrition in the ICU: How we should be feeding our critically ill patients.

Link to Article

Link to PDF

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

These are the ASPEN guidelines that were published in 2016. They were created to assist us in providing patients with appropriate nutrition while they recover from critical illness. This paper is free and although the 53 pages seem intimidating, the last 11 pages are the references. Also, the font is large and the format is easy to digest as it is laid out in a question/answer type format. I honestly look forward to the updated guidelines but these have a bunch of goodies that I do not feel the vast majority of my colleagues are aware of. I must admit, the majority of the recommendations are based on consensus rather than solid data. If that's what we have, though, we must make do while asking healthy questions.

Fun facts I've picked up on re-reading these guidelines that I had missed out on previous reads and that I may or may not have known:
- clear liquid diet is not necessary after post-op. Patients can be provided with solid food.
- patients should be getting 1.2-2.0g/kg of body weight of protein/ day. Some standard tube feeds may not reach this target in certain patients.
- I knew this but it begs reminding: DO NOT CHECK RESIDUALS!
- fancy formulas may be more confusing that practical for a standard patient in the MICU at the time of this publication.
- they made no recommendations for probiotics but I have found data stating otherwise.
- don't bother with high-fat low carb formulations for reps failure
- check phosphorus levels regularly in respiratory failure patients. That was you can replace the K with K/Phos instead of compartmentalizing the electrolytes.
A 🎩 tip to the many contributors to this guideline.

That's enough for today
-EJ


 

Enteral Nutrition Can Be Given to Patients on Vasopressors

Link to Article (Not Free)

I have always been interested in the nutritional status of our patients in the ICU and I don't quite have my mind made up regarding a lot of things. Actually, within the next few months I am going to be asking my registered dietician colleagues here for help with a number of clinical questions.
Truth is that there is a void of solid data regarding nutrition, when to start, how much, how much protein, etc. I understand the ASPEN guidelines have provided some consensus, but much of it is expert opinion rather than actual data. I digress. A topic for another day.
Regarding this article that was published yesterday, the author detailed the vasopressors doses at which one should start feeds (or not start, norepinephrine > 0.3-0.5mcg/kg/min is a no-no), resuscitation markers that should make us feel more comfortable with starting feeds such as decreasing downtrending vasopressor doses.  He also describes the feeding strategy of starting with tropic feeds at 10-20cc/hr.  Lastly, he describes signs of intolerance including residuals > 500cc, note, not 250, not 300... 500.
I have some honest questions for which I personally do not know the answer, though. I need help with this if someone knows the answer. From an evolutionary standpoint, we do not eat when we are ill. Just remember your appetite for a big delicious meal when you last had a significant viral illness. Should we really start to immediately feed these patients? Also, I do not feel that our bodies are accustomed to this whole continuous feeds phenomenon. We normally bolus feed ourselves. Are we shocking the system by doing continuous feeds? See? This is why I need help from some badass registered dietitians.
A 🎩 tip to the author!

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.