helping empower recovery the online series (heros) · helping empower recovery the online series...

©2020 Baxter Healthcare Corporation

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Helping Empower Recovery

The Online Series (Heros)

Part 3:

Early Nutritional Supplementation in

Non-ICU Hospitalized Covid-19 Patients

April 23, 2020

GLBL/MG17/20-0016 04/2020 ©2020 Baxter Healthcare Corporation 1

• Support for this program is provided by Baxter International Inc.

• This program is not an accredited continuing education (CE) program

• Today’s presentation slides and on-demand viewing of this program will be available by 30-April at:

– https://www.baxterglobal.com/nutrition_hero_series

Program Disclosure

2GLBL/MG17/20-0016 04/2020 ©2020 Baxter Healthcare Corporation

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https://www.baxterglobal.com/nutrition_hero_series


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Faculty

Alessandro Laviano, MD

Associate Professor of Internal Medicine

Department of Translational and Precision Medicine

Sapienza University

Rome, Italy

Riccardo Caccialanza, MD

Director of UOC Dietetics and Clinical Nutrition

Fondazione IRCCS Policlinico San Matteo

Pavia, Italy


Disclosures

*honoraria for advisory boards, activities as a speaker,

travel grants, research grants

Potential conflicts of interest*:

Akern Fresenius Kabi

Angelini Ipsen

Baxter Mylan

B. Braun Nestlé Health Science

Boehringer Ingelheim Nutricia

Eli Lilly

Alessandro Laviano, MD

Riccardo Caccialanza, MD

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Potential conflicts of interest:

Abbott Nestlé Health Science

Baxter Nutricia

B. Braun Smartfish

Fresenius Kabi

GLBL/MG17/20-0016 04/2020 ©2020 Baxter Healthcare Corporation

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• Address the nutritional requirements of COVID-19 patients

• Discuss the role of delivery and monitoring of nutrition support in the COVID-19 ICU patient

• Review of best practices experienced in treating COVID-19 patients

Objectives


Dipartimento di Medicina

Traslazionale e di Precisione

[email protected]

Nutrition in the Time of COVID-19Alessandro Laviano


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CORONAVIRUS DISEASE 2019


Rabi FA, et al. Pathogens 2020;9(3):231.


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Zheng J. Int J Biol Sci. 2020;16(10):1678-1685.

Key Events in the Early Stage of SARS-CoV-2 Outbreak


Data exist to support the notion that SARS-CoVand MERS-CoV are viable in environmental conditions that could facilitate faecal-oral transmission. SARS-CoV RNA was found in the sewage water of two hospitals in Beijing treating patients with SARS1. When SARS-CoV was seeded into sewage water obtained from the hospitals in a separate experiment, the virus was found to remain infectious for 14 days at 4°C, but for only 2 days at 20°C1.

Charleen Yeo, Sanghvi Kaushal, *Danson [email protected]

Enteric Involvement of Coronaviruses: Is Faecal-Oral Transmission of SARS-CoV-2 Possible?

1. Initial genome release of novel coronavirus. http://virological.org/t/initial-genome-release-of-novel-coronavirus/319?from=groupmessage. (Accessed on 18 Feb 2020).

www.thelancet.xom/gastrohep. Vol 5, April 2020


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Gibney E. Nature. 2020;580:176-177.

Coronavirus Lockdowns Have Changed the Way Earth Moves

SEISMIC NOISEIn Belgium, vibrations caused by human activity have fallen by about one-third since coronavirus containment measures were introduced.


Confirmed Cases and Deaths by Country, Territory, or Conveyance (as of 22 April 2020)

https://www.worldometers.info/coronavirus/?#countries


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Unmet Needs and Unanswered Questions


The Mystery of the Mayan

Calendar.

WAS IT

2012OR IS IT

2020?

©Dave Granlund. www.davegranlund.com


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1. Covinsky K, Katz M. Supplemental nutrition assistance program – Do not take the food out of patients’ mouth. JAMA Intern Med 2020. https://doi.org/10.1001/jamainternmed. 2019.7151. [Epub ahead of print, Accessed March 9,2020].

Nutrition support in the time of SARS-CoV-2 (COVID-19)

Nutrition is a key determinant of health1. More importantly, nutrition is part of the treatment regimen for acute and chronic diseases and applies particularly to ailments for which an etiologic treatment has not yet been discovered and validated.

2020

Laviano A, Koverech A, Zanetti M.


NEWS 10 April 2020Amy Maxmen

For Ebola in the Democratic

Republic of the Congo,

the end will have to wait

Just days before announcing the

official end of a devastating

outbreak, a new case emerges.


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Saving Lives Without New Drugs

Callahan is helping an international team develop guidelines dubbed Maximum Use

of Supportive Therapy (MUST), aimed at keeping more patients alive. It includes intravenous

(IV) drips to replace massive fluid loss from diarrhea and vomiting, a risk factor for shock;

balancing of electrolytes such as calcium or potassium, which prevents kidney and heart

failure; nasogastric tubes for feeding; and testing and treatment of secondary infections such

as malaria. Introducing MUST will also make it easier to study new treatments, Callahan says:

Randomized controlled trials—ethically fraught because only some patients get the novel

treatment (see main story, p. 908)—will be much more acceptable if everyone receives

high-level care. In addition, MUST might reveal side effects of new drugs that would otherwise

be masked by Ebola symptoms, and it could reduce the rate of complications that might be

incorrectly blamed on a drug.

2014;346(6212):91. DOI: 10.1126/science.346.6212.911Jon Cohen


Bah EI, et al. N Engl J Med 2015; 372:40-47.

Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea

The case fatality rate that we observed in this cohort in the capital city of Conakry was lower than the rate reported in most studies of previous

EVD outbreaks (although not in all studies) and was lower than the rate in most other regions in Guinea at that point in the epidemic. Clinical

care at the main isolation facility near Donka Hospital was jointly provided by the Ministry of Heath, Médecins sans Frontières, and the WHO

during the study period. Adherence to new guidelines promoting increased medical interventions, particularly related to the use of oral and

intravenous fluids and electrolyte replacement, appropriate antibiotics, and targeted clinical laboratory testing, may have contributed to the

reduced case fatality rate, as compared with past outbreaks.

Figure 1. Kaplan–Meier Estimate of the Probability of Survival among Patients with Ebola Virus Disease, According to Age

Table 2. Therapies Received by 37 Patients Hospitalized for EVD


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Obesity (Silver Spring) 2020 (epub ahead of print)

BRIEF CUTTING EDGE REPORTS

High prevalence of obesity in severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) requiring invasive mechanical ventilationSimonnet A, Chetboun M, Poissy J, Raverdy V, Noulette J, Duhamel A, Labreuche J, Mathieu D, Pattou F, Jourdain M

First published: 09 April 2020 https://doi.org/10.1002/oby.22831

All PatientsN=124

InvasiveMechanical

Ventilation N=85

No InvasiveMechanical

Ventilation N=39

Male 90 (73) 64 (75) 26 (67)

Age (years) 60 (51-70) 60 (51-69) 60 (50-72)

Height (cm) 172 (166-178) 172 (166-178) 172 (165-180)

Weight (kg) 88 (80-108) 95 (81-112) 81 (75-94)

Body Mass Index (kg/m2) 29.6 (26.4-36.4) 31.1 (27.3-37.5) 27 (25.3-30.8)

Diabetes 28 (23) 23 (27) 5 (13)

Hypertension 60 (49) 48 (56) 12 (32)

Dyslipidemia 34 (28) 24 (28) 10 (26)

Table 1: Baseline characteristics of 124 patients admitted in intensive care for SARS-CoV-2, who required invasive mechanical ventilation (n=85) and those who did not (n=39).Results are expressed as median (IQR) for continuous variables and as frequency (percentage) for categorical variables.


*The denominators of patients who were included in the analysis are provided if they differed from the overall numbers in the group. Percentages may not total 100 because of rounding.†The primary composite end point was admission to an intensive care unit, the use of mechanical ventilation, or death.¶The presence of hepatitis B infection was defined as a positive result on testing for hepatitis B surface antigen with or without elevated levels of alanine or aspartate aminotransferase.||Included in this category is any type of cancer.

W Guan, et al. N Engl J Med. 2020. DOI: 10.1056/NEJMoa2002032.

Clinical Characteristics of Coronavirus Disease 2019 in China

Table 1. Clinical Characteristics of the Study Patients, According to Disease Severity and the Presence or Absence of the Primary Composite End Point.


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Zhou F, et al. Lancet 2020;395:1054-1062.

Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: A Retrospective Cohort Study

Demographics and Clinical Characteristics

Total

(n=191)

Non-survivor

(n=54)

Survivor

(n=137) P Value

Age, Years56·0

(46·0–67·0)

69·0

(63·0–76·0)

52·0

(45·0–58·0)<0·0001

Sex — — — 0·15

Female 72 (38%) 16 (30%) 56 (41%) —

Male 119 (62%) 38 (70%) 81 (59%) —

Exposure History 73 (38%) 14 (26%) 59 (43%) 0·028

Current Smoker 11 (6%) 5 (9%) 6 (4%) 0·21

Comorbidity 91 (48%) 36 (67%) 55 (40%) 0·0010

Hypertension 58 (30%) 26 (48%) 32 (23%) 0·0008

Diabetes 36 (19%) 17 (31%) 19 (14%) 0·0051

Coronary Heart

Disease15 (8%) 13 (24%) 2 (1%) <0·0001

Chronic Obstructive

Lung Disease6 (3%) 4 (7%) 2 (1%) 0·047

Carcinoma 2 (1%) 0 2 (1%) 0·37

Chronic Kidney

Disease2 (1%) 2 (4%) 0 0·024

Other 22 (12%) 11 (20%) 11 (8%) 0·016

Laboratory Findings

Total

(n=191)

Non-survivor

(n=54)

Survivor

(n=137) P Value

White Blood Cell

Count, × 10⁹ per L

6·2

(4·5–9·5)

9·8

(6·9–13·9)

5·2

(4·3–7·7)<0·0001

<4 32 (17%) 5 (9%) 27 (20%) <0·0001*

4–10 119 (62%) 24 (44%) 95 (69%) —

>10 40 (21%) 25 (46%) 15 (11%) —

Lymphocyte Count,

× 10⁹ per L

1·0

(0·6–1·3)

0·6

(0·5–0·8)

1·1

(0·8–1·5)<0·0001

<0·8 77 (40%) 41 (76%) 36 (26%) <0·0001

Haemoglobin, g/L128·0

(119·0–140·0)

126·0

(115·0–138·0)

128·0

(120·0–140·0)0·30

Albumin, g/L32·3

(29·1–35·8)

29·1

(26·5–31·3)

33·6

(30·6–36·4)<0·0001

ICU Admission 50 (26%) 39 (72%) 11 (8%) <0·0001

ICU Length of Stay,

Days8·0 (4·0–12·0) 8·0 (4·0–12·0) 7·0 (2·0–9·0) 0.41


Zhou F, et al. Lancet 2020;395:1054-1062.

Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: A Retrospective Cohort Study


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Wu C, et al. JAMA Int Med. 2020 (epub ahead of print)

Initial prealbumin levels are lower in patients who developed ARDS vs

patients who did not.

Is this a sign of acute malnutrition

or increased inflammatory response?

Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China


Table 3. Complications, Treatments, and Clinical Outcomes

Guan W, et al. N Engl J Med. 2020


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Lin L, et al. Gut 2020 (epub head of print)

Gastrointestinal Symptoms of 95 Cases with SARS-CoV-2 Infection


Zheng J. Int J Biol Sci. 2020;16(10):1678-1685.

Gastrointestinal Symptoms of 95 Cases with SARS-CoV-2 Infection

Figure 1. Gastroscopy of the oesophagus in a severe patient with SARS-CoV-2 infection. A and B were different parts of the oesophagus under the endoscopy.

(A) A round ulcer (4–6 mm in size) was covered with white moss.

(B) Some ulcers were fused into pieces with a small amount of bleeding.


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GI

Symptoms

(n=74)

GI

Symptoms

(n=577) P value

>38,5° C 39% 17% <0,001

Lymphocytes

(x109/L)0,97 1,2 0,001

CRP (mg/L) 15,6 7,9 0,003

Shortness

of Breath10,8% 3,3% 0,007

Fatigue 31% 16% 0,004

Headache 21% 8% 0,002

Jin X, et al. Gut 2020 (epub ahead of print)

Epidemiological, clinical and virological Characteristics of 74 Cases of Coronavirus-infected Disease 2019 (COVID-19) with Gastrointestinal Symptoms Table 1. Demographic and epidemiological characteristics

of patients with COVID-19 with and without GI symptoms

Data are presented as medians (IQR), n (%) and n/N (%). COPD=chronic obstructive pulmonary disease


2. General Treatment

2.1. Letting patients rest in bed and strengthening support therapy;

ensuring sufficient caloric intake for patients; monitoring their water

and electrolyte balance to maintain internal environment stability;

closely monitoring vital signs and oxygen saturation.

Diagnosis and Treatment Protocol for Novel Coronavirus PneumoniaTrial Version 7. Released by National Health Commission & State Administration of Traditional Chinese Medicine on March 3, 2020


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Volume 5, ISSUE 5, P426-428, May 01, 2020

Mao R, Liang J, Shen J, Ghosh S, Zhu L, Yang H, Wu K, Chen M

Implications of COVID-19 for patients with pre-existing digestive diseases

Medication for Patients with IBD

• Continue current treatment if disease is stable, and contact your doctor for suitable medicine if disease has flared

• Use of mesalamine should be continued and should not increase the risk of infection

• Corticosteroid use can be continued, but be cautious of possible side-effects

• A new prescription of immunosuppressant or increase in dose of an ongoing immunosuppressant is not recommended in epidemic areas.

• Use of biologics such as the anti-TNFs infliximab or adalimumab should be continued

• If infliximab infusion is not accessible, switching to adalimumab injection at home is encouraged

• Vedolizumab use can be continued due to the specificity of the drug for the intestine

• Ustekinumab use can be continued, but starting ustekinumab requires infusion centre visits and therefore is not encouraged

• Enteral nutrition might be used if biologics are not accessible

• Tofacitinib should not be newly prescribed in epidemic areas unless there are no other alternatives


Journals Intensive Care Medicine (ICM) and Critical Care Medicine (CCM). DOI: 10.1007/s00134-020-06022-5

© European Society of Intensive Care Medicine and the Society of Critical Care Medicine 2020

Surviving Sepsis Campaign: Guidelines on the Management

of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Alhazzani W, Hylander Møller M, Arabi YM, Loeb M, Ng Gong M, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A,

Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M,

Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti J, Citerio G, Baw B,

Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A.


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Clinical Nutrition, https://doi.org/10.1016/j.clnu.2020.03.022

ESPEN Expert Statements and Practical Guidance for Nutritional Management of Individuals with SARS-CoV-2 Infection

Barazzoni R, Bischoff SC, Krznaric Z, Pirlich M, Singer P,

endorsed by the ESPEN Council


Merker M, et al. JAMA Netw Open. 2020;3(3):e200663. doi:10.1001/jamanetworkopen.2020.0663

Association of Baseline Inflammation with Effectiveness of Nutritional Support Among Patients with Disease-related MalnutritionA Secondary Analysis of a Randomized Clinical Trial

Figure 2. Kaplan-Meier Estimate for Time to Death Within 30 Days According to Inflammatory Status

A) 30-Day Mortality in Overall Population

C) 30-Day Mortality Among Patients with Moderate Inflammation

D) 30-Day Mortality Among Patients with High Inflammation

B) 30-Day Mortality Among Patients with Low Inflammation


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Unmet Needs and Unanswered Questions


Early Nutritional Supplementation in Non-critically Ill Patients Hospitalized for the 2019 Novel Coronavirus

Disease (COVID-19): Rationale and Feasibility of a Shared Pragmatic Protocol

Riccardo CaccialanzaUOC Dietetica e Nutrizione Clinica

Fondazione IRCCS Policlinico

San Matteo

[email protected]


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• Changes in intestinal barrier

• Reduction in glomerular filtration

• Alterations in cardiac function

• Altered drug pharmacokinetics

• Delayed wound healing

• Increased surgical complications

• Increased treatment toxicity

• Impaired immunity

• Increase in length of hospital stay

• Increased hospital readmissions

• Increased mortality

• Increased treatment costs

• Impaired quality of life and functional status

Malnutrition/Cachexia: Consequences

Butterworth CE Jr. Nutrition Today 1974;9:4–8.


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It is based on the observation that most patients present at admission with severe inflammation and anorexia leading

to the drastic reduction of food intake, and that a substantial percentage develops respiratory failure requiring

non-invasive ventilation or even continuous positive airway pressure.

Early Nutritional Supplementation in Non-critically Ill Patients Hospitalized for the 2019 Novel

Coronavirus Disease (COVID-19): Rationale and Feasibility of a Shared Pragmatic Protocol

Riccardo Caccialanza, M.D.; Alessandro Laviano, M.D, Ph.D.; Federica Lobascio, M.D; Elisabetta Montagna RD; Raffaele Bruno, M.D.; Serena Ludovisi, M.D.;

Angelo Guido Corsico, M.D., Ph.D.; Antonio Di Sabatino, M.D.; Mirko Belliato, M.D.; Monica Calvi Pharm.D.; Isabella Iacona, Pharm.D.; Giuseppina Grugnetti, R.N.;

Elisa Bonadeo, M.D.; Alba Muzzi, M.D.; Emanuele Cereda, M.D., Ph.D.

We are aware that our straight approach may be debatable. However, in order to cope with the current emergency

crisis, its aim is to promptly and pragmatically implement nutritional care in COVID-19 patients, which would risk to be

overlooked in spite of being potentially beneficial to clinical outcomes and effective in preventing the consequences

of malnutrition in this patient population.

39GLBL/MG17/20-0016(1) 04/2020 ©2020 Baxter Healthcare Corporation

Simplified nutritional risk screening§ Yes No

1 Is BMI <22 kg/m2?

2 Did the patient loose weight in the last 3 months?

3 Did the patient reduce food intake or is expected to reduce it in the next few days?

§If any answer is «Yes», start supplementation (between or straight after meals) with high-protein, high-calorie oral nutritional supplements (ONS; 2-3 bottles [125/200 ml each] providing 600-900 kcal and 35-55 grams of proteins).

*Use referred or estimated values if scales are not available or cannot be used due to hygienical reasons.

**Albumin, transferrin, prealbumin, glucose, kidney (creatinine and blood urea nitrogen) and liver (cholinesterase, aspartate amino-transferase, alanine amino-transferase, gamma glutamyl transferase) function, electrolytes (Na, K, Cl, Ca, P, Mg), triglyceride, folic acid, vitamina B12, 25-hydroxyvitamin D, C-reactive protein.

***Recommended dietary allowance.

Start Systematic Supplementation With:

• Whey proteins 20 g/day (in one or two occasions, preferably during meals)

• Daily infusion of RDA*** tailored multivitamin, multimineral and trace elements solutions (eg, in 100/250 mL of physiological saline solution)

• Cholecalciferol - 50.000 UI or 25.000 UI/week if 25-hydroxyvitamin D is <20 ng/mL or ≥20 <30 ng/mL, respectively.

If patients don’t tolerate ONS (ie, less than 2 bottles/day are consumed for 2 consecutive days) or respiratory conditions worsen, contact the Clinical Nutrition and Dietetics Unit for the prescription of parenteral nutrition or start it implementing strict biochemical monitoring**

DURING THE HOSPITAL STAY

Monitor food/supplements intake with the aid of local healthcare professionals.

Protocol for Early Nutritional Supplementation in Non-critically Ill COVID-19 Patients AT ADMISSION

Record:

• Body weight and height*

• Relevant biochemical parameters**


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Cholecalciferol

50.000 UI/week if 25-OH vitamin D <20 ng/mL

25.000 UI/week if 25-OH vitamin D ≥20 <30 ng/mL

McPherson RA, et al. Curr Opin Clin Nutr Metab Care. 2011;14:562‐568; Rondanelli M, et al. Nutrition. 2020;72:110667; Teixeira FJ, et al. PharmacolRes. 2019;144:245-256; Cereda E, et al. Cancer Med. 2019; 8:6923-6932; Cross ML, et al. British J Nutr. 2000;84:S81‐S89; Ng TB, et al. Appl Microbiol Biotechnol. 2015;99:6997-7008; Olsen MF, et al. BMJ. 2014;348:g3187.

Systematic supplementation with:

Whey proteins 20 g/day (in one or two occasions, preferably

during meals)

• Anabolic and antioxidant properties + high digestibility

• Potential clinical benefits in cancer cachexia

• Immunomodulatory properties

• Potential antiviral activity

• Improved immune recovery in patients with HIV during ART

Daily e.v. infusion of RDA tailored multivitamin,

multimineral and trace elements solutions (eg, in 100/250 mL of

physiological saline solution)

• Anti-oxidant properties

• Specific vitamin and micronutrient deficits harmful during viral infections

• Approach is not precise (not available single nutrient dosage)

• May be beneficial with very limited risk of harm secondary to overdosing

Liu M, et al. Microbes Infect. 2017; 19:580-586; Beck MA. J Am Coll Nutr. 2001;20:384S-388S; Camini FC, et al. Arch Virol. 2017;162:907-917; Weger-Lucarelli J, et al. PLoS Pathog. 2019;15:e1008089; Evans P, et al. Br J Nutr. 2001;85:S67-74; Gupta S, et al. Cells. 2019;8(6); Beck MA. Nutr Rev. 1998;56:S140-6; Meyer M, et al. Am J Physiol Lung Cell Mol Physiol. 2015;308:L1189-201; Li Z, et al. Arch Virol. 2017;162:603-610; Baum MK, et al. JAMA. 2013;310:2154-63; Levett-Jones T. J Assoc Nurses AIDS Care. 2017;28:984-986; Tasca KI, et al. Oxid Med Cell Longev. 2017;2017:9834803; Isanaka S, et al. JAMA. 2012;308:1535-44; McGill JL, et al. Sci Rep. 2019;9:15157; Lee H, et al. Sci Rep. 2016;6:25835.

• Restoration to normal values in infected patients may improve immunologic recovery, reduce levels of inflammation and increase immunity against pathogens

Beard JA, et al. J Clin Virol. 2011;50:194-200; Teymoori-Rad M, et al. Rev Med Virol. 2019;29:e2032; Jiménez-Sousa MÁ, et al. Front Immunol. 2018;9:458; Havers F, et al. J Infect Dis. 2014;210:244-53; Gruber-Bzura BM. Int J Mol Sci. 2018;19. pii:E2419.

At Admission


§Referred or estimated weight & height values if scales are not available or cannot be used due to hygienical reasons.

*Albumin, transferrin, prealbumin, glucose, kidney (creatinine and blood urea nitrogen) and liver (cholinesterase, aspartate amino-transferase, alanine amino-transferase, gamma glutamyl transferase) function, electrolytes (Na, K, Cl, Ca, P, Mg), triglyceride, folic acid, vitamina B12, 25-hydroxyvitamin D, C-reactive protein.

Norman K, et al. Clin Nutr. 2008;27:5-15; Schuetz P, et al. Lancet. 2019;393:2312-2321; Gomes F, et al. Clin Nutr. 2018;37:336-353.

If any answer is «Yes»:

Start supplementation (between or straight after meals) with high-protein, high-calorie ONS (2-3 bottles [125/200 ml each] → 600-900 kcal /35-55 g proteins)

Relevant biochemical parameters collected*

At Admission

Simplified nutritional risk screening§ Yes No

1 Is BMI§ <22 kg/m2?

2 Did the patient loose weight in the last 3 months?

3 Did the patient reduce food intake or is expected to reduce it in the next few days?


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Monitor food/ONS intake with the aid of local healthcare professional (as available…)

If patients don’t tolerate ONS (ie, less than 2 bottles/day are consumed for 2 consecutive days) or respiratory conditions worsen, contact the Clinical Nutrition and Dietetics Unit for the prescription

of parenteral nutrition or start it implementing strict biochemical monitoring

• NGT may result in air leakage and compromise the effectiveness of NIV or CPAP

• Special NIV masks with a port for NGT may be hardly available

• Positive pressure ventilation through a face mask may also result in gastric distention, further compromising the respiratory conditions

• Receiving EN during NIV was associated with a significantly higher rate of airway complications and longer NIV duration

• There is currently no validated strategy to reduce the critical complications of EN among patients with NIV or CPAP

• Patients receiving ART, frequently diarrhea that can contribute to treatment interruption

• Gastrointestinal symptoms are frequently reported by COVID-19, which may increase the risk of EN intolerance

Singer P, et al. Crit Care. 2018;22:27; Kogo M, et al. Respir Care. 2017;62:459-467; Kogo M, et al. Respir Care. 2017;62:1119-1120; Doig GS, et al. JAMA. 2013;309:2130-2138; Dikman AE, et al. Dig Dis Sci. 2015;60:2236-2245; Bezabih YM, et al. BMC Infect Dis. 2019;19:537; Pan L, et al. Am J Gastroenterol. 2020 [Epub ahead of print].

During the Hospital Stay

Why not enteral nutrition


Results: One hundred eighteen patients (90.1%) completed the 7-day SPN support regimen and 102 of them (86.4%) were in advanced disease stage. SPN induced a significant improvement of phase angle (PhA, + 0.25 [95% CI 0.11, 0.39]; p=0.001), standardized phase angle (SPA, + 0.33 [95% CI 0.13, 0.53]; p=0.002), HG (+ 2.1 kg -95% CI 1.30, 2.81]; p<0.001), and PAB (+ 3.8 mg/dL [95% CI 2.1, 5.6]; p<0.001). In multivariable analysis, the effects on BIVA parameters were more pronounced in patients (N=90, 76.3%) in whom estimated protein and calorie requirements were both satisfied (adjusted difference: PhA, + 0.39 [95% CI 0.04, 0.73]; p=0.030; SPA, + 0.62 [95% CI 0.16, 1.09]; p=0.009).

No significant changes in hydration status were detected and no severe metabolic or other complications occurred.

Conclusions: Early 7-day SPN resulted in improved body composition, HG and PAB levels in hypophagic, and hospitalized cancer patients at nutritional risk in the absence of any relevant clinical complications. Further trials, aimed at verifying the efficacy of this early nutritional intervention on mid- and long-term primary clinical endpoints in specific cancer types, are warranted.

Which Parenteral Nutrition (Ideally…)

Males

Females


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• Limited accuracy of nutritional assessment and support due to weight and height measurement hard or even impossible to perform, like body composition assessment and calorimetry.

• Underfeeding very hard to avoid for several reasons: constantly increasing number of admitted patients; impossibility to assist patients during meals; monitoring of food intake extremely difficult, if feasible at all.

PN support may only partially fit the needs of pre-ICU COVID-19 patients due to:

• Central infusion lines not always available outside the ICU wards; elevated energy requirements (severe acute inflammatory response and average high patients’ BMI); cardiovascular and pulmonary compliance limit PN volume.

• Clinical Nutrition Units not widespread in Italian hospitals, thus specific competences in nutritional care not always available.

• Potentially problematic timely provision and availability of ONS, EN formulas, PN bags, infusion pumps.

Critical Issues and Perspectives


Specific nutritional support issues:

• COVID-19 disease can suddenly require intensive care measures, including intubation → EN

• EN tolerance (gastric distention, erosive gastritis)

• Supplemental PN

• Specific high protein-calorie, highly digestible enteral formulas enriched in anti-inflammatory or immunomodulatory nutrients

• Use of omega-3 fatty acids (anti-inflammatory/immunosuppressive properties)

• Clinical research focused on nutritional issues in COVID-19 patients is hard, if not impossible to perform.

Critical Issues and Perspectives (cont.)


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However, any effort should be done to try to guarantee adequate nutritional support to hospitalized patients, as it may be potentially beneficial to clinical outcomes and effective in reducing or preventing the deleterious consequences of malnutrition in this patient population.

Conclusions

Implementing prompt and

appropriate nutritional care in

COVID-19 disease management

is a hard challenge due to the

current dramatic emergency

circumstances.


We are infinitively grateful to all the employees of the Fondazione IRCCS Policlinico San Matteo for their tremendous

and courageous efforts in struggling against the current tragic clinical and social COVID-19 emergency.

We are extremely grateful to all friends, medical nutrition industries and colleagues who will contribute to spread and share the challenge of implementing nutritional care in COVID-19 disease management.

Acknowledgments


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QUESTIONS49GLBL/MG17/20-0016 04/2020 ©2020 Baxter Healthcare Corporation

Baxter is a trademark of Baxter International Inc.

Thank you to all of those leading the fight against

COVID-19


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PLEASE REGISTER TODAY:https://www.baxterglobal.com/nutrition_hero_series

PART 4: ADDRESSING NUTRITIONAL CHALLENGES OF COVID-19 PATIENTS FROM ASSESSMENT TO DISCHARGE

Paul WischmeyerMD, EDIC, FASPEN, FCCMProfessor of Anesthesiology and Surgery

Associate Vice Chair for Clinical Research, Dept. of Anesthesiology

Physician Director, TPN/Nutrition Support Service, DUH

Duke University School of Medicine

Durham, NC, USA

FEATURING SPEAKER:

Thursday, April 30, 2020

at 08:00 PST/11:00 EST/16:00 BST/17:00 CEST

OBJECTIVES

• Define the best available guidance for nutritional requirements in COVID-19 patients using predictive equations and indirect calorimetry

• Describe strategies for managing nutritional challenges in paralysis, vasopressor use, prone position, CRRT, and ECMO

• Understand the role of early parenteral nutrition and supplemental parenteral nutrition in ICU and non-ICU COVID-19 patients

• Briefly discuss role of probiotics and Vitamin D to reduce risk and progression of COVID-19 infection


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helping empower recovery the online series (heros) · helping empower recovery the online series...

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