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4/7/20 This Photo by Unknown Author is NUTRITION MANAGEMENT FOR licensed under CC BY-SA CRITICALLY ILL PATIENTS WITH COVID-19 Dr Emma Ridley, PhD, MPH, BNutDietet, APD Senior Research Fellow, Lead, Nutrition Program ANZIC-RC Monash University, Melbourne, Australia Senior ICU Dietitian, The Alfred, Melbourne, Australia @ICUNutrition and @INTENTnutrition 1 THANK YOU 2 THANK YOU 3 1

4/7/20 DISCLAIMERS • This is changing all the time- some guidance will be out of date quickly • Be mindful of the data • There are many of you listening- some of what I say may not work in your setting • The ideas presented here are based on best evidence and my clinical experience (and have not been influenced by any sponsor) • I have received honorarium for speaking from Baxter Healthcare Corporation (US), Baxter Healthcare Australia and Nutricia • I have an unrestricted research grant from Baxter Healthcare Corporation (US) for work unrelated to COVID-19 4 OUTLINE 1. A crash course in COVID-19 and ICU 2. Data from other countries This Photo by Unknown Author is licensed under CC BY-SA 3. A crash course in the COVID-19 response and safety during a pandemic 4. Medical management for COVID-19 5. Nutrition management for COVID-19 6. ANZ COVID-19 Nutrition Guideline 5 TERMINOLOGY • Coronovirus: A term for many virus that cause mild colds, with some severe • This virus is actually SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) • COVID-19 is the illness caused by SARS-CoV-2 (ie HIV gives you AIDS) • In severe cases, it leads to acute respiratory distress syndrome (ARDS) 6 2

4/7/20 THE DATA SO FAR • The experiences around the world appear to be different • In UK and US Obesity is a major risk factor for poor outcome- not seen as much in China • Different onsets: 1. Fast onset like flu 2. Mild symptoms 3. Severe respiratory failure • Fever- impact on metabolic rate (38.1-39 ℃ most common) • GI symptoms- variable reports: nausea, diarrhoea This Photoby Unknown Author is licensed under CC BY-SA 7 https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19 This Photo by Unknown Author is licensed under CC BY-SA THE UK 8 https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19 THE UK 9 3

4/7/20 https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19 THE UK 10 THE UK 11 THE UK 12 4

4/7/20 This Photo by Unknown Author is licensed under CC BY-SA Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID -19 in This Photo by Unknown Author is licensed under CC BY-SA Italy. JAM A. Published online M arch 23, 2020. doi:10.1001/jam a.2020.4683 13 Grasselli G, Zangrillo A, Zanella A, et al. JAM A. Published online April 06, 2020. doi:10.1001/jam a.2020.5394 14 TO SUMMARISE • Patients that come to ICU are very unwell • If they get intubated they are very very unwell 15 5

4/7/20 THE COVID-19 RESPONSE AND A CRASH COURSE IN SAFETY This Photoby Unknown Author is licensed under CC BY-SA 16 THE PHASED PANDEMIC PLAN IN ANZ https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf 17 HAZARD CONTROL AND SAFETY 18 6

4/7/20 https://en.wikipedia.org/wiki/Hierarchy_of_hazard_controls 19 Social distancing Isolation of cases Remote working Reduce number people with patient contact LEAST EFFECTIVE- Therefore use other strategies first 20 PRECAUTIONS 21 7

4/7/20 TYPES OF PRECAUTIONS BASED ON TRANSMISSION 1. Contact- apply to all 2. Droplet 3. Airborne *If you are from outside of ANZ there may be slight differences in terminology and recommendations- check local guidance 22 Airborne Precautions: P2/N95 mask, protective eyewear, gown, Droplet gloves. Precautions: Note that the N95 mask be fit- Surgical mask, protective checked on eyewear, gown, application to gloves ensure no air leakage; an N95 mask will not fit well with facial hair 23 COVID-19 AND SPREAD IN HEALTHCARE This Photo by Unknown Author is licensed under CC BY-SA • Emerging data indicates that SARS-CoV-2 (COVID-19) is primarily spread via respiratory droplets produced when an infected person coughs or sneezes and has a “significant association with aerosol generating procedures (AGPs)” • Healthcare workers may be exposed to these particles through the inhalation of droplets, conjunctival/mucosal contact, and touch contamination https://appliedradiology.com /articles/sir-provides-aerosol-generating-procedures-for-interventional-radiologists 24 8

4/7/20 AEROSOL GENERATING PROCEDURES AND RISK • Medical procedures that have the potential to create aerosols in addition to those that patients regularly form from breathing, coughing, sneezing, or talking are AGPs • APGs can be grouped into 2 categories: 1. Procedures that create and disperse aerosols and 2. Procedures that induce the patient to produce aerosols Feeding tube insertion and/or change Judson, S.D.; M unster, V.J. Nosocom ial Transm ission of Em erging Viruses via Aerosol- Generating M edical Procedures. Viruses 2019 , 11 , 940. 25 ? Feeding tube insertion and/or change Judson, S.D.; M unster, V.J. Nosocom ial Transm ission of Em erging Viruses via Aerosol- Generating M edical Procedures. Viruses 2019 , 11 , 940. 26 ANZICS COVID-19 GUIDELINE https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf 27 9

4/7/20 ANZICS COVID-19 GUIDELINE • We recommend that all intensive care personnel (medical, nursing, allied health, cleaning and ward assistants) receive training in infection control and personal protection equipment. • We suggest N95 fit testing, if available, recognising that the evidence for fit testing effectiveness is limited and that the variation and supply of N95 mask types will make any recommendation on fit testing difficult to implement from a practical perspective. • Application of PPE • We recommend that when a unit is caring for a confirmed or suspected COVID-19 patient that all donning and doffing are supervised by an additional appropriately trained staff member. https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf 28 MEDICAL MANAGEMENT FOR COVID-19 This Photoby Unknown Author is licensed under CC BY-SA 29 GENERAL MANAGEMENT • Supportive care like any other patient with respiratory issues (but isolated!) • Majority are going to be ventilated • Some will receive other organ support (ie CVVHD) 30 10

4/7/20 RESPIRATORY MANAGEMENT OF THE CRITICALLY ILL COVID19 PATIENT • Trial of HIFLO nasal oxygen • Early intubation with a lung protective strategy • Severe hypoxemia- increase peep • Deep sedation to improve ventilation • Prone position (usually 12-16 hours) • ? Recruitment manoeuvres • ?NO Rescue therapies • ?ECMO https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30127-2/fulltext 31 PRONING • A strategy used to improve oxygenation in ARDS • Decision to prone should be made early for best response • Obesity (BMI > 40 kg/m2) can be a contraindication • It is resource intensive • Generally occurs for around 16 hours per day with 8 hours supine This Photoby Unknown Author is licensed under CC BY-NC-ND 32 PRONING Complications (from Alfred Health Guideline) • Loss of airway • Tracheal tube obstruction • Tracheal tube dislodgment • Nerve compression (e.g. brachial plexus injury) • Crush injuries • Dislodging vascular catheters or drainage tubes • Corneal damage and loss of vision • Pressure sores (e.g. face, bony prominences) This Photoby Unknown Author is licensed under CC BY-NC-ND • Venous stasis (e.g. facial oedema) 33 11

4/7/20 34 ACUTE RESPIRATORY LUNG DISEASE (ARDS) • Mechanical ventilation buys time for the illness to resolve (or not) 35 OUTCOMES IN ARDS PATIENTS • They are bad! Herridge etal. N Engl J Med 2003; 348:683-693 36 12

4/7/20 OTHER MEDICAL MANAGEMENT IN COVID-19 • Restricted fluid management strategy to reduce extravascular lung water 37 NUTRITION MANAGEMENT FOR COVID-19 38 1. Start EN early 1. Start EN early 2. 2. Gradual introduction, increasing to target by days 3-5 Gradual introduction, increasing to target by days 3-5 3. 3. Manage intolerance Manage intolerance THE BASICS THE BASICS 4. 4. If going to survive, more aggressive nutrition care after If going to survive, more aggressive nutrition care after STILL STILL day 5 day 5 APPLY! 5. Prokinetics APPLY! 5. Prokinetics 6. 6. Minimise interruptions Minimise interruptions 7. NJ feeding 7. NJ feeding 8. Supp PN or sole PN 8. Supp PN or sole PN 39 13

4/7/20 WHAT HAVE WE SEEN FROM OVERSEAS? • Intolerance • High BGLs 40 ORAL/EATING • A high energy high protein diet should be standard • Oral supplements should be standard This Photo by Unknown Author is licensed under CC BY-SA 41 HIFLO • Can dry and irritate the mucosa • Unwell patient so appetite, nausea, ability to eat can be an issue • Fluids generally well tolerated https://www.ham ilton-m edical.com /en_US/Solutions/high-flow-oxygen- therapy.htm l 42 14