Nutrition Therapy in Critically Ill Patients with Coronavirus Disease (COVID‐19)

Martindale, Robert; Patel, Jayshil J.; Taylor, Beth; Arabi, Yaseen M.; Warren, Malissa; McClave, Stephen A.

In the midst of a worldwide pandemic of the Coronavirus Disease 2019 (COVID‐19), a paucity of data precludes derivation of COVID‐19‐specific recommendations for nutritional therapy. Until more data are available, the focus needs to center on principles of critical care nutrition modified for the constraints of this disease process, i.e., COVID‐19‐relevant recommendations. Delivery of nutritional therapy must include strategies to reduce exposure and spread of the disease by providing clustered care, adequate protection of healthcare providers, and preservation of personal protective equipment. Enteral nutrition (EN) should be initiated early after admission to the intensive care unit (ICU) using a standard isosmolar polymeric formula, starting at trophic doses and advancing as tolerated while monitoring for gastrointestinal intolerance, hemodynamic instability, and metabolic derangements. Intragastric EN may be provided safely, even with use of prone positioning and extracorporeal membrane oxygenation. Clinicians, though, should have a lower threshold for switching to parenteral nutrition in cases of intolerance, high risk of aspiration, or escalating vasopressor support. While data extrapolated from experience in Acute Respiratory Distress Syndrome (ARDS) warrants use of fiber additives and probiotic organisms. The lack of demonstrated benefit precludes a recommendation for micronutrient supplementation. Practices which increase exposure or contamination of equipment, such as use of gastric residual volumes as a monitor, indirect calorimetry to calculate requirements, endoscopy or fluoroscopy to achieve enteral access, or transport out of the ICU for additional imaging should be avoided. At all times, strategies for nutritional therapy need to be assessed on a risk/benefit basis, paying attention to risk for both the patient and the healthcare provider. This article is protected by copyright. All rights reserved