Thread by @GIdietitian

Top 10 key expert opinion recommendations for nutrition support for the critically ill patient with #COVID19 via @ASPENWEB.
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These recs are based on indirect evidence (2016 SCCM/ASPEN and 2019 EPSEN Guidelines), direct evidence from limited COVID19 trials, and expert opinion. 2/

Key Rec #1:
-Use wt based equations to determine energy & protein needs
-15-20 kcals/kg/d; 1.2-2 g protein/kg
-Do not use indirect calorimeter as this increases contamination risk
-Monitor for refeeding syndrome (monitor phos, mag, potassium)
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Key Rec #2:
-Start early EN (24-36 hrs of ICU admit, 12 hrs of intubation) as this improves mortality, reduces infection ncbi.nlm.nih.gov/pubmed/26771786 ncbi.nlm.nih.gov/pubmed/30348463
-EN is safe in those w sepsis/shock when pressors stable, no symptoms of ileus onlinelibrary.wiley.com/doi/full/10.10…
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Key Rec #3:
-EN preferred over PN
-Use gastric route for EN
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Key Rec #4:
-For EN, use isotonic 1ml/kcal, high protein, fiber free formula
-Trophic feeds (10-20ml/hr) in those w worsening hemodynamics (rising lactate, MAP<65 mmHg, pressor reqs increasing, high pressure resp support)
ncbi.nlm.nih.gov/pubmed/26773077
ncbi.nlm.nih.gov/pubmed/30134303
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Key Rec #5:
-Do not check gastric residuals! These are not reliable and may increase viral transmission.
ncbi.nlm.nih.gov/pubmed/23321763
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Key Rec #6:
-Gastric feeding rec'd over post-pyloric feeding
-GT is easily placed and often already existing in the intubated patient
-Feed via continuous drip; avoid bolus to help with GI tolerance, blood glucose control, reduce staff interaction ncbi.nlm.nih.gov/pubmed/30348463
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Key Rec #7:
-If EN not tolerated (ileus, increasing pressor requirement), switch to PN
ncbi.nlm.nih.gov/pubmed/30348463
ncbi.nlm.nih.gov/pubmed/26773077
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Key Rec #8:
-If PN needed, use alt lipid emulsion or limit soybean oil based IV fat emulsion in the first week as the omega-6 FA have proinflammatory potential
-Monitor TG levels
ncbi.nlm.nih.gov/pubmed/30348463
ncbi.nlm.nih.gov/pubmed/26773077
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Key Rec #9:
-In those in prone position, use EN w isotonic high protein formula at 10-20 ml/hr. No inc risk of GI or pulm complications in pts receiving EN in prone position ncbi.nlm.nih.gov/pubmed/25274497
-Keep HOB elev 10-25 degrees w gastric feeding rc.rcjournal.com/content/60/11/…
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Key Rec #10 (for ECMO pts):
-Those on ECMO w early feeding had improvement in 28 day mortality, no bowel ischemia ncbi.nlm.nih.gov/pubmed/30030574
-Those on ECMO w ⬆️nutrition intake had ⬇️ 90-day mortality
ncbi.nlm.nih.gov/pubmed/31839430
-Start slow gastric continuous EN; hold if unstable
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Consult the clinical #dietitian to help in the care of #COVID19 patients in need of #nutrition support. #whatRDsDo #nutritionmatters
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