Thread by @TimothyEdenRD

🚨📢 #Tweetorial on #ICU nutritional management in #COVID19 – disclaimer this is from my own insights having worked as an ICU #dietitian & working as a #juniordoctor #Hammersmith ICU resources will be tagged at the end - WARNING it’s long - so grab a ☕️ 1/13

Calculating requirements (Energy)
▪️If BMI>25 therefore opt for AIBW/IBW
▪️Many with single organ failure, ventilated & febrile +
▪️Equations to help – PENN STATE & Mifflin St Jeor – factors temp/vent settings OR if in doubt or time limits ASPEN BMI>30 11-14kcal/kg/ABW/day 2/13

Calculating requirements (Energy)
▪️We anticipate most pt’s will receive only 70% of feed due to variety of issues (proning, aspiration risk/placement delays)
▪️Don’t despair but prioritise tolerance and build up feed and ⬆️ protein provision 3/13

Calculating requirements (Protein)
Protein in Overweight/Obese: NOT protein malnourished
▪️1.3g/kgAdjBW & 2g/kgIBW (BMI 30-40kg/m2)
▪️Factor in filter/AKI as we are aiming –ve fluid balance💦
▪️⬆️use of furosemide (monitor e-) & filtration both to aid respiratory function 4/13

Calculating requirements (Protein)
▪️On filter: 1.5-2g/kg
▪️Off filter (with AKI / CKD / low eGFR): 1-1.2g/kg

**Hypocaloric/⬆️protein feeds optimal in overweight/obese may require additional protein supps e.g. Prosource TF** 5/13

Factors effecting feed choice
▪️ Young #ICU patients require ⬆️ amounts of sedation – fentanyl/propofol -> therefore factor this in to your provision (if receiving >200mg/hr~1kcal/ml
▪️Look at fluid target – most will be aiming –ve 500ml to 1L -> opt for 1.5-2kcal/ml feeds 6/13

Factors effecting feed choice
▪️Interrupted feeds (a/w CXR, nil aspirates, proning) opt high conc. feeds
▪️Role for peptide feed aiding GI tolerance 2° effects of analgesia/sedation/Norad
▪️Familarise yourself with your new local protocols! 7/13

Issues with Feed
▪️Delayed gastric emptying 🚨as patients on ⬆️ fent/propofol/norad slowing gastric emptying ▪️Ventilation may require full paralysis ➡️ atracurium impacting GI motility
▪️Advocate for prokinetics early e.g. metoclopramide/erythromycin & role of peptide feeds 8/13

Feed & Proning
▪️We’ve proned ~70% of our patients ➡️ so be familiar!
▪️Usually 16h proned -> 8h unproned ->repeat
▪️This will interrupt feeds & slow rate down – that’s ok -> we need to optimise the lungs aiding shunting & V/Q mismatch
▪️Check local protocols
9/13

Feed & Proning
▪️Reduce rates of feed during prone position e.g. concentrated feed @20ml/h with slow increments up when unproned (helps prevent aspiration)
▪️Reduce threshold of GRVs 300ml max (vs 500ml as normal) 10/13

Novel Therapies & Feeding
▪️High Vit C - Trial phase NOT for clinical practice
▪️Low carb feeds – NONE of the current feeds exceed glucose oxidation rates of individuals so unlikely to impact vent settings. Remember UNLIKELY to meet full feed ➡️ prioritise kcal/protein
11/13

Novel Therapies & Feeding
▪️Hypocaloric and ⬆️ protein as per ASPEN/ESPEN to help support muscle preservation & cytokine storm
▪️Fish oil/Antioxidants 🐟💊 in the words of a pro in this field @RD_Catherine – it’s complicated!
cochranelibrary.com/cdsr/doi/10.10…
12/13

Resources Available
Sorry for the length but hope this has been some interest/help. Massive thanks to @BDACriticalCare @ICS_updates & all individuals involved who produced superb resources at unprecedented speeds 13/13 #trustadietitian #ICU #nutrition
bda.uk.com/resource/criti…