key: cord-0959878-adg964l9 authors: Chapple, Lee-anne S.; Tatucu-Babet, Oana; Lambell, Kate J.; Fetterplace, Kate; Ridley, Emma J. title: Nutrition guidelines for critically ill adults admitted with COVID-19: Is there consensus? date: 2021-05-25 journal: Clin Nutr ESPEN DOI: 10.1016/j.clnesp.2021.05.003 sha: 665b5c6fd652f20d36800e3213b6af6cf4513011 doc_id: 959878 cord_uid: adg964l9 Introduction The Coronavirus Disease 2019 (COVID-19) pandemic has overwhelmed hospital systems globally, resulting in less experienced staff caring for critically ill patients within the intensive care unit (ICU). Many guidelines have been developed to guide nutrition care. Aim To identify key guidelines or practice recommendations for nutrition support practices in critically ill adults admitted with COVID-19, to describe similarities and differences between recommendations, and to discuss implications for clinical practice. Methods A literature review was conducted to identify guidelines affiliated with or endorsed by international nutrition societies or dietetic associations which included recommendations for the nutritional management of critically ill adult patients with COVID-19. Data were extracted on pre-defined key aspects of nutritional care including nutrition prescription, delivery, monitoring and workforce recommendations, and key similarities and discrepancies, as well as implications for clinical practice were summarized. Results Ten clinical practice guidelines were identified. Similar recommendations included: the use of high protein, volume restricted enteral formula delivered gastrically and commenced early in ICU and introduced gradually, while taking into consideration non-nutritional calories to avoid overfeeding. Specific advice for patients in the prone position was common, and non-intubated patients were highlighted as a population at high nutritional risk. Major discrepancies included the use of indirect calorimetry to guide energy targets and advice around using gastric residual volumes (GRVs) to monitor feeding tolerance. Conclusion Overall, common recommendations around formula type and route of feeding exist, with major discrepancies being around the use of indirect calorimetry and GRVs, which reflect international ICU nutrition guidelines. January 2021 to identify further relevant guidelines that were published in scientific journals. Search strings included terms related to 1) intensive care; 2) nutrition support; and 3) guidelines/practice recommendations. The search strategy was based on two previously published search strategies from an affiliated institution 12, 13 and is shown in the Supplemental Table S1 . The Guidelines and practice recommendations were included if they met all of the below inclusion criteria and none of the exclusion criteria: Inclusion: 1. Included recommendations for the nutritional management of patients with COVID-19. 2. Contained recommendations for critically ill adults. 3. Related to care provided directly within the ICU setting. 4 . Were affiliated with an international nutrition or dietetic society. 1. Were an opinion piece, narrative or systematic review. intervention; recommendations for specific patient populations or conditions and; recommendations on service provision such as equipment considerations and workforce. Key similarities and discrepancies, as well as implications for clinical practice are discussed. Seven guidelines were known to authors at commencement of the review and were included. To identify further guidelines unknown to authors, a database search was conducted which identified 229 non-duplicate articles of which two met all inclusion criteria and none of the exclusion criteria, and a final guideline was identified through searching the websites of the International Confederation of Dietetic Associations (CONSORT diagram in Figure 1 ). Overall, 10 guidelines were included in this review from the following associations: American Society For Parenteral and Enteral Nutrition (ASPEN) 14 ; Australian Society For Parenteral and Enteral Nutrition (AuSPEN) 15 ; Brazilian Society of Parenteral and Enteral Nutrition (BRASPEN) 16 ; British Dietetic Association (BDA) 17 20 and; NUTRIC (ATID) 21 . A further two state specific patient populations that should be considered at higher nutritional risk: ASPEN recommend identifying pre-existing malnutrition or risk factors for re-feeding syndrome 14 and AuSPEN provide specific criteria to categorize patients as high or low nutritional risk to target early intervention 15 . In addition, two (AuSPEN and BRASPEN) acknowledge that the safety of staff must be considered while completing nutrition risk screening in a pandemic setting 15, 16 . -Guidelines state nutritional risk screening is important to identify high risk patients requiring intervention -There is no agreement between guidelines as to which nutrition risk screening tool should be implemented -Guidelines recommend that the conduct of nutrition risk screening considers the safety of staff and reduction of bedside assessments, using coordinated care and remote working arrangements Five guidelines discuss the use of indirect calorimetry for measuring energy expenditure and one (ESPEN) recommends that indirect calorimetry is used where safely available 18 . Three recommend J o u r n a l P r e -p r o o f against the use of indirect calorimetry due to risk of staff exposure to the virus (ASPEN, AuSPEN), potential spread of disease (BRASPEN, ASPEN), and/or workforce related demands (AuSPEN) [14] [15] [16] . The ATID guideline did not provide an explicit recommendation on the use of indirect calorimetry but mentioned the use of indirect calorimetry when considering energy prescription 21 . The majority of guidelines (eight of the 10) provide recommendations on the prescription of energy and protein in patients with COVID-19 using a predictive equation. All eight guidelines support the slow and progressive delivery of energy and protein during the first 5-7 days of critical illness, although approaches to this vary ( 24, 25 . Two guidelines (ASPEN and IDA) discuss timing of initiation in patients with sepsis or circulatory shock, recommending early EN at a trophic rate 14, 19 . The ASPEN guideline states COVID-19 should not be considered a contraindication to early trophic EN, unless combined with escalating vasopressor use and EN intolerance 14 . The remaining three guidelines do not provide specific recommendations for the timing of Initiation of EN 17, 22, 23 , with the TDA referring to "early intestinal nutrition" but providing no further guidance 23 . -The early initiation of EN within 48 hours of admission is recommended in seven of 10 guidelines -The use of early trophic EN in patients with sepsis or circulatory shock (if not combined with increasing vasopressor needs or EN intolerance) is recommended in two guidelines All of the included guidelines recommend the enteral route (oral or EN) in preference of PN for nutrition therapy [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] . Four (ASPEN, AuSPEN, BDA, ESPEN) guidelines recommend the commencement of EN via the nasogastric (NG) route 14, 15, 17, 18 . One guideline (TDA) recommends postpyloric EN as the first line feeding route, stating that critically ill patients often experience GI intolerance 23 . In the four guidelines where NG feeding is recommended, progression to post-pyloric EN is not recommended unless adequate management of GI intolerance is first attempted (such as the use of prokinetics) due to the risk to staff with tube insertions 14, 15, 17, 18 . The remaining five guidelines recommended nutrition via the EN route but do specify whether delivery should be via a NG or post-pyloric tube 16, [19] [20] [21] [22] patients develop a cytokine storm that resembles hemophagocytichistiocytosis (secondary HLH) 14 , and this may be the cause of hypertriglyceridemia (rather than propofol-induced) 26 . To prevent under-or over-feeding, the majority of guidelines recommend close monitoring of nutrition adequacy (energy and protein delivery compared to estimated or measured requirements) [14] [15] [16] [17] [18] [19] [20] [21] [22] . Five guidelines (ASPEN, AuSPEN, BDA, INDI, ATID) highlight the importance of monitoring the delivery of non-nutritional calories (e.g. glucose, propofol) 14, 15, 17, 20, 21 . pyloric tubes should be considered as necessary [14] [15] [16] [17] 21 . Three guidelines (AuSPEN, ASPEN, ATID) make specific recommendations for patients receiving extracorporeal membrane oxygenation (ECMO) 15, 17, 23 . Two (ASPEN, ATID) specifically recommend early EN in this patient group 14, 21 . The AuSPEN and ATID guidelines highlight that patients on ECMO are likely to have high metabolic needs (e.g. after ICU day 5 up to 30kcal/kg and 1.5 -2g protein/kg day in normal-weight individuals) 15, 21 . The ASPEN guideline highlights that in the past there was concern about lipid infiltration into the oxygenator when patients were receiving PN; however, with newer ECMO circuits it is stated that this is no longer a concern 14 . Seven guidelines make recommendations for non-intubated patients 15, 17, 18, [20] [21] [22] [23] . The overarching theme is that these patients are at high nutrition risk (e.g. due to poor appetite, fatigue, difficulty breathing, dysphagia) and that a high energy and high protein diet and oral nutrition supplements should be provided. Escalation to enteral nutrition should occur if energy and protein intakes are inadequate (e.g. meeting <50-65% targets after 5 days). Three guidelines (AuSPEN, BDA, ATID) specifically recommend avoiding early removal of nasogastric tubes post extubation 15, 17, 21 . risks and consider what is acceptable within their unit. All guideline recommendations need to be considered in the context of a lack of specific data and are predominately based on expert opinion rather than high level evidence, and it is hence reasonable to adapt them to the local context. It should be recognized that the included guidelines were developed early in the pandemic (March-September 2020) and; therefore, may not reflect the most recently available evidence for managing patients with COVID-19 in ICU. New data is rapidly emerging to guide nutrition clinical care and should be considered 29, 30 . In addition, as hospital systems become more coordinated, and patient numbers more manageable, the ability to safely implement higher-level practices to provide optimal nutrition care will improve, and these practices may be able to be reintroduced. For example, while the use of indirect calorimetry was not recommended early in the pandemic, primarily due to the increased risk of staff exposure to the virus. However, studies using indirect calorimetry have since been conducted safely as the pandemic and management strategies have progressed 29 . Reintroduction of these higher risk procedures should be considered based on site capacities, levels of expertise, and follow best practice recommendations 31 . Limitations of the review include that only guidelines available in the English language were included, as it is likely that a number of country-specific associations would have guidelines in their native language only. Similarly, only websites of nutrition or dietetic societies that are members of the International Confederation of Dietetics were searched; however, it should be recognized that medical or intensive care specific societies may also have practice guidelines that incorporate a section on nutrition management. Clinical recommendations for patients with COVID-19 were similar across guidelines and to those in the general ICU population including the use high protein, volume restricted enteral formula delivered gastrically and commenced early in ICU, while taking into consideration non-nutritional calories to avoid overfeeding. A number of discrepancies exist, including the use of IC to determine energy prescriptions, and monitoring of GI intolerance using GRVs, with these discrepancies also existing within international ICU nutrition guidelines. Further evidence generation is required to support many of the recommendations. There are no conflicts of interest to declare. All authors (LC, OTB, KL, KF, ER) contributed to conceptualization; data curation; formal analysis; investigation; methodology; writing-original draft and writing-review & editing. 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Turkish Dietetic Association Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S ESPEN guideline on clinical nutrition in the intensive care unit Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S ESPEN guideline on clinical nutrition in the intensive care unit Early caloric deficit is associated with a higher risk of death in invasive ventilated COVID-19 patients Practical guidance for the use of indirect calorimetry during COVID 19 pandemic Authors would like to thank Matthew Summers, Rhea Louis, and Sarah McEwen for their assistance with figure preparation and International Confederation of Dietetic Associations website searches. Nil to declare