Enteral nutrition during prone-position in COVID-19

patientsBy Emily Tewksbury, Dietetic Intern

Objectives● Describe the characteristics of COVID-19 and ARDS and their

methods of treatment● Explore the prone position and the benefits and risk factors● Discuss enteral nutrition in the prone position for severe lung

injuries, weighing the risks and benefits of feeding during prone position

● Look at current published literature for enteral nutrition and feeding during prone position for the COVID-19 critically ill patient

● Summarize findings and draw educated conclusion for EN in the prone position

COVID-19: What we know

From a large family of viruses

SARS-CoV-2

● Originate from bats● Known for their

crown-like spikes on their surface

● Commonly causes mild-upper respiratory tract illnesses

Longer latency period

Incubation period: up to 2 weeks (14 days)

● Aerosolized droplet transmission

● Asymptomatic shedding period

Takes over host cells metabolic machinery

Single-stranded positive-sense RNA

● Acts as a molecular message, instructing our host cell translate into new proteins which make up new virus particles

ARDSAcute Respiratory Distress

Syndrome

● Result of lung injury○ Small blood vessels in the alveoli

leak → lungs become smaller, stiffer → difficult to breath → amount of oxygen falls → hypoxia occurs

● ARDS patients need help opening closed airways

○ Mechanical Ventilation used to increase oxygen flow into the blood

● Severity Classification:○ MILD: 27% mortality○ MODERATE: 32% mortality○ SEVERE: 47% mortality

Benefit of proning a mechanically ventilated

patient

Prone Position Benefits● Improved oxygenation and drainage of bronchial secretions ● Decreased ventilator-induced lung injury● Increased survival in patients with severe acute lung injury● Inexpensive● Redistributed blood flow

Feeding the critically ill: ASPEN Recommendations

ASPEN Recommendations● Suggest EN over PN be used in critically ill

patients who require nutrition support. B2● Recommend nutrition support therapy in

the form of early EN should be initiated in 24-48 hours in the patient who is unable to maintain volitional intake. B1

● Suggest patients at high nutrition risk or severely malnourished should be advanced to goal feeding as quickly as tolerated over 24-48 hours.

● Goal is to provide > 80% of estimated protein and energy requirements over the first 48-72 hours. C3

● Suggest patients be monitored for tolerance of EN and inappropriate cessation of EN be avoided. D1 Suggest avoiding holds on EN for gastric residual volumes <500 mL in the absence of other signs of intolerance. D2b

● Risk of aspiration -- following steps should be proactively taken:

○ Recommend diverting to postpyloric access in those not tolerating gastric EN. B4a

○ Elevating head of bed 30-45 degrees. D4d○ Suggest prokinetic agents be initiated in

patients at high risk of aspiration and where clinically feasible. D4c

● In ARDS, recommend the use of a fluid restricted formula and the goals are to minimize overfeeding.

Benefits of early EN in the ICU setting

● Improvement in gut mucosal integrity● Immune function● Glycemic control● Fewer infections● Lower cost of management

EN within 24-48 hours is associated with:● Higher energy intake● Lower rate of infections● Shorter length of stay

Why are providers hesitant to enterally feed prone patients?

● Many critically ill patients experience poor tolerance of early EN because of impaired gastric motility with delayed gastric emptying

● High residual gastric volumes increase the risk of

○ Gastroesophageal reflux○ Vomiting ○ Aspiration○ Ventilator-associated pneumonia

● If a patient is hemodynamically unstable (MAP <50), is initiating pressors or is requiring increasing amounts of pressors, it is recommended to withhold TF until the patient is hemodynamically stable

Case StudyPatient Name: MC

Rotation: Medical Intensive Care Unit (MICU)

02/15/21

Pt presents to ED for SOB and trouble breathing. Found to be tachycardic, tachypneic, acidotic in DKA.

02/15/21

Pt COVID-19 positive. Admitted to regional UH ICU for COVID-19 pneumonia.

02/18/21

Seen by RDN at regional campus ICU. No nutritional implications at the time. Eating 100% diabetic diet.

03/4/21

Pt began to struggle breathing. Transferred to UHCMC MICU d/t no further improvements and frequent desaturations. CT scan indicative of ARDS. Pt intubated, OGT placed, and placed in prone position.

03/5/21

Made supine at 6AM. RDN screened for nutrition assessment/enteral nutrition recs.

Important Patient Information ● Patient name: MC

○ 47 year old Male○ Height= 175.2cm, Weight= 83.6kg, BMI= 27.2kg/m2○ Admission weight (2/15/21)= 86.1kg

○ Blood Glucose:■ 199 mg/dL H, 261 mg/dL H, 215 mg/dL H, 283 mg/dL H, 223 mg/dL H, 212 mg/dL H

○ HbA1c: 13.0%

● COVID recovered upon admission to the MICU● Sedated with fentanyl and propofol @ 24.7mls/hr. Insulin drip and paralytic agent drip (Nimbex)● Bowel regimen: Senokot and miralax daily● Wife states UBW= 205# (93.2kg) → significant wt loss d/t loss of appetite with COVID-19 infection.

Wt loss of 9.6kg (10.2% wt change) in <1 month.● NFPE findings:

○ Muscle loss evident in the temporal, clavicle, shoulder, bicep/triceps, quadriceps, and calf region.○ Fat loss evident in the tricep and chest region○ No edema present○ Skin WNL

ASPEN Malnutrition CriteriaWhich criteria does MC meet?

Nutrition Diagnosis

● Change in metabolic demand? YES - associated with critical illness related to COVID-19 pneumonia and ARDS requiring mechanical ventilation.

● Malnutrition present? Severe Protein Calorie Malnutrition● Nutrition Diagnosis: Severe Protein Calorie Malnutrition related to acute

illness associated with COVID-19 infection and ARDS as evidenced by </= 50% of estimated energy requirement for >/= 5 days, >10.2% wt loss in the past </= 1 month, moderate muscle and subcutaneous fat loss evident upon NFPE.

Literature ReviewBefore–after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position

Background and Aims● To evaluate an intervention for improving the delivery of early enteral nutrition

(EN) in patients receiving mechanical ventilation with prone positioning (PP).● Current guidelines about feeding of critically ill patients fail to consider the

potential specific problems raised by prone positioning, and no strategies for improving the delivery of early EN in patients managed with prone positioning have been reported.

● The aim was to improve EN delivery without increasing the residual gastric volume, vomiting, or ventilator-associated pneumonia, by increasing the acceleration to target feeding rate, using erythromycin as a prokinetic agent, and elevating the head of the bed.

Methods● Study Design: Prospective before-and-after study● Setting: 12-bed medical-surgical adult ICU of the District Hospital Center in La

Roche-sur-Yon, France● Subjects: Eligible patients treated between January 2003 and June 2004 were

compared to all eligible patients treated between July 2004 and December 2005.○ Inclusion criteria: if they received endotracheal mechanical ventilation, EN via a nasogastric tube

started within 48 h after initiation of endotracheal mechanical ventilation, and prone positioning during the first 5 days of EN.

○ Exclusion criteria: ■ a history of esophageal or gastric surgery■ acute abdominal disease■ administration of prokinetic agents within 48 h before starting EN■ EN via a jejunostomy or gastrostomy■ pregnancy

Early Enteral Nutrition

● Polymeric solution (Isosource): 105 kcal, 4.1 g protein, 3.5 g lipid, 14.2 g CHO per 100 mL

● 14-F nasogastric tube● Tolerance of EN was assessed

by measuring the residual gastric volume and recording emesis episodes

● Residual gastric volume was measured at 6-h intervals (6am, noon, 6pm, midnight)

● Initiated soon after endotracheal ventilation → prone to supine q6hrs

Subject Groups● Control phase (control group): EN was

administered at a continuous rate for 18 hours/day from 6pm to noon the following day.

○ Delivery rate @ 30 ml/hr on the first day and was increased everyday by 30 ml/hr until the 4th day.

○ EN was discontinued if residual gastric volume exceeded 250 ml or the patient vomited.

○ After discontinuation, prokinetic treatment (erythromycin, 25 mg IV q6hrs) was started. EN was reintroduced 6 hours later at previous tolerated rate.

○ In the prone position, the bed was horizontal.

● Intervention phase (intervention group): Nutrition was delivered continuously for a 24-hr cycle

○ Delivery rate @ 25 ml/hr, increased by 25 ml/hr q6hr until up to 85 ml/hr for all patients.

○ Erythromycin (250 mg IV q6hr) was given routinely starting at the first turn in the prone position.

○ In the event of intolerance, the delivery rate was decreased to the previously tolerated rate.

○ In the prone position, the entire bed was tilted to ensure 25 degrees of head elevation.

Ventilator-Associated Pneumonia

● New and persistent or progressive infiltrates on the chest radiograph with at least two of the following criteria:

○ Peripheral leukocytosis (>10,000/mm3) or leukopenia (4000/mm3)

○ Body temperature >/= 38.5C and purulent tracheal aspirates

● If suspected, underwent bronchoscopy with protected distal bronchial sampling.

● Diagnosis confirmed with quantitative culture from bronchial sample.

Data Collection

● Age, Sex, McCabe Score, weight, Simplified Acute Physiology Score (SAPS) II, diagnosis, Sequential Organ Failure Assessment (SOFA) score, vital signs, lab values, rate of EN, residual gastric volume, and vomiting episodes

Following criteria were recorded during the 5-day period

Statistical Analysis

● Continuous data was analyzed using Student’s t-test● Categorical data was analyzed using a chi-square test● Demographic data was collected and analyzed by means +/- SD● The Mann-Whitney test was used to compare the supine and prone positions

regarding:○ Median residual gastric volume○ Median EN volume○ # of vomiting episodes

● P values < 0.05 were considered significant

Results

● 64 patients were in the prone position in the control group; 34 patients included in the study

● 69 patients were in the prone position in the intervention group; 38 patients included in the study

● EN intolerance did not differ between groups● Mean ICU stay was (20 +/- 13 days, 23 +/- 13 days) P= 0.56● Mean LOS was (28 +/- 21, 34 +/- 29 days) P= 0.31● Intervention group had significantly lower rates of ICU mortality and hospital

mortality

ResultsMedian Enteral Nutrition:

● Median daily EN volumes were greater in the intervention group compared to the control group

Median Gastric Residual Volume:

● No difference between the intervention and control group

Vomiting Episodes:

● Recorded in 9 of the intervention patients and 12 of the control patients

Erythromycin Intake:

● Median cumulative erythromycin dose over the 5-day period was higher in the intervention group than the control group (P < 0.001)

Ventilator-Associated Pneumonia Incidence:

● No increase in VAP between the control and intervention groups

Conclusion● Early, advanced rate of EN may decrease

rate of underfeeding in CMV patients● Despite the larger feeding volumes, there

was no significant difference in residual gastric volume, episodes of vomiting, or VAP between groups

● Intolerance to EN occurred in 71% of the control group and 63% of the intervention group (P= 0.5)

● Erythromycin may be administered prior to potential GRV for increased motility in prone patients

Limitations

● Due to the study design (observational, nonrandomized), unable to determine a causal relationship

● The study was performed in a single ICU and cannot be generalized to the entire population

○ However, the demographic characteristics and rates of EN were similar to previous studies○ The intervention was based on guidelines intended for usage in all ICUs

● The target volume for EN was not calculated for each individual patient. Therefore, a mismatch could have occurred between daily energy requirements and daily intake

○ Goal to increase EN rate among severely hypoxic mechanically ventilated patients w/o increasing risk for side effects such as ventilator-associated pneumonia

Does our treatment for MC match the literature?

Nutrition Recommendations● Estimated Needs:

○ Kcals/day: ~1600 (Penn State, MV=7.3, REE=1700 kcals)

○ 110+ (~1.5 grams protein per kg IBW (72.7kg))

○ Fluids: per MD● Additional Information for the team: D/t

ARDS and critical illness requiring CMV and recent prone positioning, pt would benefit from Peptamen AF for anti-inflammatory factors and semi-elemental nature of TF.

1. Glucose levels <200 mg/dL before initiating TF regimen.

2. Once BG consistently <200 mg/dL initiate Peptamen AF @ 15mls/hr + Prostat BID.

3. If pt is tolerating TF and BG remain stable, advance TF to 25mls/hr x 24hrs + Prostat BID (While on propofol).

a. Flushes per team

→ Once pt is off of propofol, advance Peptamen AF to goal rate @ 55 mls/hr + 1 Prostat.

4. Supplement Vitamin D liquid 8,000 IU daily for 6-8 weeks.

5. If pt is proned again, will need to administer prokinetic agent. Can do Erythromycin 250 mgs IV q6hrs with TF. Or Reglan 5-10 mgs enterally given q8hrs.

Where is MC now?

03/7/21

TF and Prostat recommendations were taken. Pt self-extubated and DHT was removed by pt, started on Airvo at 30%. Failed swallow evaluation so DHT was replaced.

03/11/21

Pt passed MBSS. Follow-up with RDN for PO diabetic diet order. Adjusted needs to 2100-2300 kcals (MSJ), 95-110 grams of protein (1.3-1.5gms/kg IBW). Pt transferred to floor.

03/12/21

Given insulin education for self-administration to prevent glucose rise postprandial.

03/13/21

Pt discharged from UHCMC.

03/30/21

Follow-up with family medicine. Pt weighing 185.2#s (84.1kg), voice improving, A1C 11% (decreased from initial 13%)

Thank you to Melissa McQuillen for all her help

and wealth of knowledge! I appreciate you!

Resources1. Matthay, Michael A., et al. “Acute Respiratory Distress Syndrome.” Nature Reviews. Disease Primers, vol. 5, no. 1, 2019.

PubMed Central, doi:10.1038/s41572-019-0069-0.

2. McClave, Stephen A., et al. “Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult

Critically Ill Patient.” Journal of Parenteral and Enteral Nutrition, vol. 40, no. 2, 2016, pp. 159–211. Wiley Online Library,

doi:https://doi.org/10.1177/0148607115621863.

3. Reignier, Jean, et al. “Before–after Study of a Standardized ICU Protocol for Early Enteral Feeding in Patients Turned in the

Prone Position.” Clinical Nutrition, vol. 29, no. 2, Apr. 2010, pp. 210–16. ScienceDirect, doi:10.1016/j.clnu.2009.08.004.

4. Reintam Blaser, Annika, et al. “Early Enteral Nutrition in Critically Ill Patients: ESICM Clinical Practice Guidelines.” Intensive

Care Medicine, vol. 43, no. 3, 2017, pp. 380–98. PubMed Central, doi:10.1007/s00134-016-4665-0.

5. Tsatsakis, Aristides, et al. “SARS-CoV-2 Pathophysiology and Its Clinical Implications: An Integrative Overview of the

Pharmacotherapeutic Management of COVID-19.” Food and Chemical Toxicology, vol. 146, Dec. 2020, p. 111769. PubMed

Central, doi:10.1016/j.fct.2020.111769.