Thread by @RD_Catherine

Official guidance from #ESPEN about nutritional management of #COVIDー19 clinicalnutritionjournal.com/article/S0261-…
A useful summary of nutrition/malnutrition, immune function and critical care.
But in reality, #ICU is different... FWIW a personal interpretation of limited experience thus far..

Assume every patient with #COVID19 is at high risk of malnutrition, whether co-morbidities exist, or not. Difficulties in breathing (DIB) compromises oral intake whether or not non-invasive ventilation (NIV) is used. Plus patients are being admitted well along the disease pathway

Use a feed protocol where possible. Most #ICU have one. Ours follows a 4-hourly escalation in NG feed rate tempered for patients on high level vasopressors. Protocols inform unfamiliar staff with normal ICU practices when ventilated numbers escalate.

Use indirect calorimetry to estimate REE in #COVID-19 patients? Clinically irrelevant. Potential #AGP risk. High FiO2 >0.6/ high inflation pressures/ PEEP >10 typical of patient management and beyond capabilities of IC. Altered V/Q with proning/NA alters lung function. DON'T.

Estimating energy needs of #COVID19 patient is clinically relevant. Aggressive attempts to meet energy needs in the first week of #ICU is irrelevant and may worsen outcome. Less (approx 60% predicted REE) is more. Rest easy. Just start some feed.

Not sure about that? Here's the outcome of the 'INTACT' trial of feeding patients with acute lung injury (ALI) ncbi.nlm.nih.gov/pmc/articles/P…. There's plenty more trials that show similar.

Don't leave your obese #COVIDー19 patient behind. Discard any personal prejudice that this respiratory patient has 'sufficient stores'. (I've heard you say it) Because sarcopenia is increasingly common as BMI increases. And sarcopenia in #ICU patients increases mortality risk...

Whatever the BMI of your #COVID19 patient, they need protein. We have absolutely 0 protein stores - a bit of an evolutionary oversight. But we'll cannibalise muscle protein from day 1 to mobile amino acids to areas of high need if there's nothing incoming....

Hopefully your #COVIDー19 patient will sustain only a single organ failure during admission, so protein losses during Week 1 remain modest... Protein losses accelerate as multi-organ failure develops (and organ support may increase losses, too. eg -ve 20g protein/24h on CVVHF)

AVOID high protein intake during week 1. Catabolism is teleological 'housekeeping' to remove damage - not something to be 'offset'. Don't blunt the response with ultra-high protein intakes. Use a standard feed. Koekkoek's work beautifully demonstrates this:

Note #COVID19 patients on #ICU are frequently run dry. Aggressively so. Offloading lung fluid (via PEEP/ diuretics) is a theme. Hypernatraemia and uraemia far more likely in these patients. The time for higher protein intakes is when stabilised, on the weaning pathway -not Week1

Nasogastric feeding is tolerated in the proned #ICU patient. No worries. journals.sagepub.com/doi/pdf/10.117…
Gastric emptying is related to osmotic load per unit time. Suggest start with 1kcal/ml feed. Then 'flip' to energy dense feed to match fluid restrictions once emptying established

Dysphagia more likely in these extubated patients. Your #SLT is invaluable in swallowing assessment. #oneteam That premature removal of the NGT is not a 'great step forward' - it removes your ability to bolus feed, overnight feed, or decompress the stomach with NIV air-swallowing

Consider active contact portal for patients on discharge - either phone or online. Your #COVIDー19 patient has been in isolation. Family/carers have not witnessed their experience. Superfast discharge away from the acute unit is key. There is no narrative as to how to recover....

Consider nutrition for recovery/ rehab in the midst of food shortages/ insecurity. Recommend a 'food first' approach as availability of commercial products may become limited by demand. Help patients to ignore the clamour of the nutritionally illiterate and their opinions. 💙