key: cord-0954606-b4vnkwpa
authors: Berger, Mette M
title: Editorial ‐ Nutritional Status Affects COVID‐19 Patient Outcomes
date: 2020-07-01
journal: JPEN J Parenter Enteral Nutr
DOI: 10.1002/jpen.1954
sha: 66e697f560506d15550f030438d65e9cf66230a0
doc_id: 954606
cord_uid: b4vnkwpa

nan

The authors used the NRS score to evaluate their patients as recommended by the Chinese and European societies of clinical nutrition (5) . The NRS score has the enormous advantage of being easy to collect, and not to require any laboratory determination. The score ranges from zero to seven assessing nutrition (max 3 points), severity of illness (max 3 points) and age (max 1 point). The nutritional part reports on weight loss, body mass index, and food ingestion during the last days. Two cut-offs have been validated that should trigger a nutritional intervention: NRS scores >3 for inpatients, and >5 points for critically ill patients (5 presented with a very high risk (>5 points), a proportion that increased to 62% in the critically ill. Only 4% of the NRS 3-4 patients died. Mortality of the entire cohort was 9%:

in patients with NRS>5 the mortality was 43%.

Before the actual pandemic, the high >5 NRS score was shown to be able to identify the patients with higher mortality, as in a Lausanne ICU cohort of persistent critically ill patients: in these patients nutrition therapy requires fine-tuning (6). Zhao et al confirm the importance of this threshold in COVID-19 patients.

Screening and scoring is a good start, and reflects good care! But screening is only the first step of nutrition therapy! Only 25% of the 371 patients received a form of nutritional support, and 121 (33%) patients received probiotics, as treatment of diarrhoea. Feeding was defined as a delivery >10 kcal/kg/day. The proportion of fed patients was lowest (20%) in the "severe" patients, and a little higher 46% in the critically ill! Among the later, enteral nutrition was attempted, 31% received PN, and 8% combined EN+PN. This means that 54% of the critically ill patients were not fed. This is likely to have contributed to the mortality, the more so that 62% of the patients had high admission NRS scores.

The authors humbly recognize that were not able to do better. But these findings might well be universal.

Could it have been different? Could a higher proportion of patients have been fed, probably contributing to mortality reduction? The answer is "potentially yes", as the nutrition therapy could have been more efficient. In the Nutrition Day survey, not being fed on the study day was associated with an 8 fold increase in mortality (4) . The presence of standard operating procedures (SOP) might have made a difference. In chaos conditions with limited human and material resources, procedures must be simple.

One of the important aim of SOPs is exactly that: define how to proceed when everything is too much, and good willing caregivers lack training. In the Lausanne COVID-19 cohort of 117 critically ill patients, the median NRS was 5 points, and the median score for food intake component was 2 (of a maximum 3), contributing heavily to the NRS in addition to critical illness (2-3 points): as in the Wuhan cohort, weight loss or low BMI were rare (unpublished data). But the majority of Lausanne patients were fed by the enteral route initiated within 24 hours, nearly straight after intubation: ICU mortality was 13%. Why were they fed, while an important proportion of physicians and nurses were not ICU trained? Because there are SOP that were used to orient the untrained ICU personnel during the crisis. In the SOPs, intubation translates into initiating enteral nutrition right away in absence of severe shock or other major instability. How much? 20 kcal/kg to be increased over 3 days. Which product?

The standard high protein with fibre product -there is only one available. Micronutrients? one multi-vitamin and multi-trace element vial + 100 mg thiamine per day for 6 days.

Simple.

There are many contributors to mortality, but malnutrition is one of them, and refeeding syndrome is another: the patients were exposed to both. There are of course epidemiological factors explaining the higher mortality in Wuhan compared to European settings. Wuhan medical teams were discovering the disease and the treatments to apply, while we were 2-3 months later taking advantage of this very recent knowledge to orient the treatments. But nutrition matters, and is cornerstone to an adequate immune response. Interestingly the procalcitonin value was significantly correlated with the NRS score. As is the rule in COVID-19 patients, inflammation was present, but it was not massive (median CRP 69 mg/l) in the critically ill, but prealbumin, which as visceral marker and an acute phase protein, was deeply depressed (median 0.10 mg/l: normal 0.2-0.4 g/l) reflecting a devastating ongoing catabolic process.

The relation between malnutrition (acute or chronic) and infection is complex (7) but has repeatedly been shown to be a reality, being long recognized at the level of the World Health Organisation. It is important to note, that acute recent underfeeding seemed to matter most, as the medical history does not show any chronic malnutrition. But 60% of patients had not been able to eat normally for the last days before admission in the Wuhan COVID-19 cohort. No chronic malnutrition was responsible for the disease, but acute underfeeding did compromise the immune defences and contributed to rapid loss of lean body mass, which we know is linked to immunity and outcome. Acute underfeeding (a few days) has a direct impact on the inflammatory response and on the cellular immunity and can be counteracted by individualized feeding using combined enteral and parenteral nutrition (8) . 

Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical and nutritional charactersitics of severe and critically ill cases infected with 2019-nCoV

Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective

ESPEN Guidelines: Nutrition in the ICU

Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients

Malnutrition and infection: complex mechanisms and global impacts

Supplemental parenteral nutrition improves immunity with unchanged carbohydrate and protein metabolism in critically ill patients: The SPN2 randomized tracer study