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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,

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4/7/20 1

NUTRITION MANAGEMENT FOR 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

This Photo by Unknown Author is licensed under CC BY-SA

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THANK YOU

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THANK YOU

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4/7/20 2

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  • This is changing all the time- some guidance will be out of date quickly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

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OUTLINE

1. A crash course in COVID-19 and ICU 2. Data from other countries 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

This Photo by Unknown Author is licensed under CC BY-SA

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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)

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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
  • utcome- 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

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THE UK

This Photo by Unknown Author is licensed under CC BY-SA

https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19

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THE UK

https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19

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THE UK

https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19

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THE UK

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THE UK

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This Photo by Unknown Author is licensed under CC BY-SA 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

  • Italy. JAM A. Published online M arch 23, 2020. doi:10.1001/jam a.2020.4683

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Grasselli G, Zangrillo A, Zanella A, et al. JAM A. Published online April 06, 2020. doi:10.1001/jam a.2020.5394

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TO SUMMARISE

  • Patients that come to ICU are very unwell
  • If they get intubated they are very very unwell

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THE COVID-19 RESPONSE AND A CRASH COURSE IN SAFETY

This Photoby Unknown Author is licensed under CC BY-SA

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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

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https://en.wikipedia.org/wiki/Hierarchy_of_hazard_controls

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Social distancing Isolation of cases Remote working Reduce number people with patient contact LEAST EFFECTIVE- Therefore use other strategies first

20 PRECAUTIONS 21

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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

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Droplet Precautions: Surgical mask, protective eyewear, gown, gloves Airborne Precautions: P2/N95 mask, protective eyewear, gown, gloves. Note that the N95 mask be fit- checked on application to ensure no air leakage; an N95 mask will not fit well with facial hair

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COVID-19 AND SPREAD IN HEALTHCARE

  • 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 This Photo by Unknown Author is licensed under CC BY-SA

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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

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.

Feeding tube insertion and/or change

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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.

? Feeding tube insertion and/or change

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ANZICS COVID-19 GUIDELINE

https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf

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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

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MEDICAL MANAGEMENT FOR COVID-19

This Photoby Unknown Author is licensed under CC BY-SA

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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)

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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
  • ?ECMO

Rescue therapies

https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30127-2/fulltext

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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

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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)
  • Venous stasis (e.g. facial oedema)

This Photoby Unknown Author is licensed under CC BY-NC-ND

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ACUTE RESPIRATORY LUNG DISEASE (ARDS)

  • Mechanical ventilation buys time for the illness to resolve (or not)

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OUTCOMES IN ARDS PATIENTS

  • They are bad!

Herridge etal. N Engl J Med 2003; 348:683-693

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OTHER MEDICAL MANAGEMENT IN COVID-19

  • Restricted fluid management strategy to reduce extravascular lung water

37 NUTRITION MANAGEMENT FOR COVID-19 38

THE BASICS STILL APPLY!

1. Start EN early 2. Gradual introduction, increasing to target by days 3-5 3. Manage intolerance 4. If going to survive, more aggressive nutrition care after day 5 5. Prokinetics 6. Minimise interruptions 7. NJ feeding 8. Supp PN or sole PN

THE BASICS STILL APPLY!

1. Start EN early 2. Gradual introduction, increasing to target by days 3-5 3. Manage intolerance 4. If going to survive, more aggressive nutrition care after day 5 5. Prokinetics 6. Minimise interruptions 7. NJ feeding 8. Supp PN or sole PN

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WHAT HAVE WE SEEN FROM OVERSEAS?

  • Intolerance
  • High BGLs

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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

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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

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VENTILATED

  • Start early (within 24 hours) but don’t worry too much about how much you get in
  • Polymeric formula is fine
  • Build up to reach target rate by 3-5 days (pending tolerance, clinical situation)
  • If going to survive, more aggressive approach to nutrition after the initial severity of

illness is managed

  • Deep sedation- increased intolerance possible

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PRONE

1. Pause EN prior to re-positioning, aspirate NGT 2. Restart EN after re-position 3. Continue to monitor GRVs (with a threshold < 300ml) 4. Increased intolerance can be observed 5. I don’t recommend prophylactic prokinetics (personal opinion) 6. NJ feeds are used as routine in prone position in some units

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MANAGEMENT OF INTOLERANCE

  • Increased gastric intolerance= more severely unwell (in COVID-19 and general)
  • Patients receiving a lot of sedation (and sometimes paralysis)= increased intolerance
  • ? An other mechanism related to the virus

1. Use a GRV cut off off 300-500ml 2. Dual prokinetics if you get into trouble (not before) 3. Do not concentrate EN- may delay gastric emptying further. If anything, less concentrated is better for intolerance 4. NJ or supp PN if it doesn’t resolve

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RESTRICTED FLUID REQUESTS

  • These patients are very sick- medical treatment to help them improve takes priority
  • If it appears the patient is going to survive and you are not happy with the feeding

regime, that is the time to raise a plan to transition to one that you are happy about

  • More concentrated EN can reduce gastric emptying further (increased intolerance)
  • Management of hypernatremia:
  • Free water is most effective in first instance (depends on cause of the hypernatraemia)
  • Conc formula often compromises nutrition provision (low protein, but is low sodium)
  • Low sodium specific formula as a last option if refractory

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ARDS SPECIFIC NUTRITION

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LOW CHO HIGH FAT EN

1. Avoid overfeeding (check maximal CHO infusion rates provided by the EN rate) 2. Increased CO2 production 3. Needs to be excreted (blown off) 4. Can prolong ventilation time 5. If you think you might be

  • verfeeding:

a. Critically assess your energy target b. reduce EN for a specified time (24-48 hours) and then re-discuss c. If not change in ventilation parameters/CO2- return to previous plan

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ANZ COVID19 NUTRITION GUIDELINE

This Photoby Unknown Author is licensed under CC BY-SA

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ANZ COVID19 NUTRITION GUIDELINE

  • Thank you to
  • Lee-anne Chapple and Kate Fetterplace
  • All other collaborators
  • We have summarized and synthesized current evidence into

practical recommendations in a very short period- it is not perfect! It will also evolve

  • 30 recommendations
  • Available: https://www.auspen.org.au/auspen-

news/2020/4/6/covid-19-information

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  • We recommend commencing enteral nutrition (EN) support using an algorithm

with a set rate for up to the first 5 days of ICU admission

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WHY?

Energy and protein targets:

  • We recommend commencing enteral nutrition (EN) support using an algorithm with a

set rate for up to the first 5 days of ICU admission

  • International guidelines recommend a slow increase to target in the early phase of illness (and

these patients are particularly unwell)

  • There is no evidence that early trophic feeding for up to 5 days leads to poor outcomes
  • Staff risk and staff workload
  • Reduced use of PPE
  • High mortality

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ANZ COVID19 NUTRITION GUIDELINE

Energy and protein targets:

  • We recommend providing 25 kcal/kg bodyweight/day after the first 5 days of illness (and up to

30 kcal/kg bodyweight/day for severely unwell patients or those who have a prolonged admission e.g. ECMO, CRRT, or length of MV >7days) and protein prescription of at least 1.2 g/kg bodyweight/day. Insertion of an enteral tube:

  • We recommend using PPE for full airborne precautions during the insertion of nasogastric tubes

(NGT) tubes, and unnecessary NGT changes avoided. Commencement of nutrition support:

  • We recommend the use of an energy-dense EN formula (1.25-1.5 kcal/ml).

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ANZ COVID19 NUTRITION GUIDELINE

Monitoring of gastric residual volumes (GRV):

  • We recommended continuing to measure GRVs in COVID-19 where appropriate PPE is available

(airborne precautions) but using a threshold of less than 300ml and measuring 8 hourly.

  • We recommend ceasing measurements when GRVs have been less than 300ml for > 48 hours in

patients who are not prone. Prone:

  • We recommend that EN is paused and the NGT be aspirated prior to any position changes EN should

be re-commence as soon as possible to avoid unnecessary interruption to feeding.

  • We recommend GRV monitoring continue 8 hourly while in the prone position, even if intolerance is

not an issue.

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ANZ COVID19 NUTRITION GUIDELINE

  • Continuing nutrition support
  • Dietetic assessment and reviews
  • Nutrition for non-ventilated patients and those receiving high flow nasal oxygen
  • Ward recommendations
  • Contingency planning and workforce considerations

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PANDEMIC DIETETICS VS IDEAL DIETETICS

  • Now is not the time for perfection
  • This is an unprecedented time
  • The bar must be lower
  • We are at risk too- PPE is the lowest form of hazard control

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STAGE 5- CRITICAL

  • We are going to develop a new plan
  • Triaging of workflow (including off-site workers)
  • Contingency for feed and equipment shortages

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READING AND RESOURCES

  • https://www.uptodate.com/contents/prone-ventilation-for-adult-patients-with-acute-respiratory-distress-

syndrome

  • Judson, S.D.; Munster, V.J. Nosocomial Transmission of Emerging Viruses via Aerosol-Generating

Medical Procedures. Viruses 2019, 11, 940. https://www.mdpi.com/1999-4915/11/10/940#cite

  • https://litfl.com/prone-position-and-mechanical-ventilation/ (see podcasts at bottom too).
  • https://litfl.com/coronavirus/ (includes link to The Alfred covid-19 resources)
  • Grasselli G, Zangrillo A, Zanella A, et al. Baseline Characteristics and Outcomes of 1591 Patients

Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. Published online April 06, 2020. doi:10.1001/jama.2020.5394

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READING AND RESOURCES

  • ASPEN
  • https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Resources_for_Clinici

ans_Caring_for_Patients_with_Coronavirus/

  • ESPEN: https://www.espen.org/guidelines-home
  • BDA CCSG: https://www.bda.uk.com/resource/critical-care-dietetics-guidance-covid-

19.html

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READING AND RESOURCES

  • https://covid19evidence.net.au/

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THANK YOU FOR YOUR TIME!

Website: https://www.monash.edu/medicine/sphpm/anzicrc/research/anzic-rc-nutrition-program Email: emma.ridley@monash.edu @ICUnutrition AND @INTENTnutrition

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