key: cord-0964242-f262de91 authors: Hinkelmann, Jéssica Viana; de Oliveira, Natália Alves; Marcato, Daniela Falcão; Costa, Allana Rúbio Ramos Oliveira; Ferreira, Arícia Mendes; Tomaz, Marcilene; Rodrigues, Thalita Jhennyfer; Mendes, Anangelly Paula title: Nutritional Support Protocol for patients with COVID-19 date: 2022-03-11 journal: Clin Nutr ESPEN DOI: 10.1016/j.clnesp.2022.03.002 sha: 9921bd2cbded64da6c45c97a13fb219d1d8865a0 doc_id: 964242 cord_uid: f262de91 Background & aims Covid-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and worse clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19. Methods A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients. Results The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge. Conclusion Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses. 5 hours in the ICU (3) . We suggest using the Nutritional Risk Screening (NRS-2002) to identify noncritically ill patients at nutritional risk (11) , since this has been related to the increased incidence of intestinal and renal failure, respiratory and urinary tract infections, hyperglycemia, morbidity, and mortality in hospitalized patients (11) , also presenting high sensitivity and good predictive validity in elderly people with COVID-19 (12, 13) . It is worth mentioning that factors such as body temperature and a dose of corticosteroids should be considered when scoring the severity of the disease (10). As recommended by the European Society of Parental and Enteral Nutrition (ESPEN), we suggest that all critically ill patients with more than 48 hours of admission to the Intensive Care Unit (ICU) should be considered at nutritional risk. Information regarding the history of the current disease, comorbidities, laboratory tests, and medicines of nutritional relevance can be collected from the electronic medical record. If nutrition professionals cannot perform the nutritional assessment in person, teleservice with the patient and intermediation with members of the interprofessional team who are already at the bedside are supported (14, 15) . Information on weight loss before hospital admission and reduction of food intake of patients in the ICU bed can be obtained through the psychological and medical staff with the patient's family members. To prevent the spread of COVID-19 and ensure the safety of patients and professionals, physical contact with infected patients should be avoided (14, 15) . Thus, in the case of lucid and oriented patients, we suggest that the weight and height should be reported for the later calculation of the Body Mass Index (BMI) to be classified according to specific cutoff points for adults and the elderly (16, 17) . In the case of those bedridden or on an ICU bed, the weight and height must be estimated using the formula proposed by Chumlea et al. (1988) , employing the knee height (KH) and arm J o u r n a l P r e -p r o o f circumference (AC), which are taken with the aid of a tape measure for individual use or disposable to avoid in-hospital contamination (18) . The AC should be performed weekly to monitor the patient's nutritional status. Secondary sarcopenia is defined as loss of strength, mass, and muscle performance caused regardless of the individual's age. Low muscle strength likely indicates sarcopenia, and the diagnosis is confirmed when there is low muscle quality and quantity (19) . Individuals infected with COVID-19 are at risk due to the inflammatory process (that influences muscle protein synthesis), by reducing physical activity and anorexia (mainly with reduced protein intake) (20) (21) (22) . Thus, we suggest that the assessment of muscle mass depletion should be carried out based on measurements of the calf circumference (CC), and that of muscle strength should be based on the measurement of handgrip strength with the aid of a manual digital dynamometer (19, 23, 24) . Individuals with COVID-19 should be questioned at the time of the nutritional screening and during hospitalization about the presence of nasosinusal and gastrointestinal symptoms that influence food consumption (5) (6) (7) 25) . Instruments for investigating food consumption are used to estimate whether the intake is appropriate or inappropriate, providing subsidies for the development and implementation of nutritional plans. The 24-hour recall (24h-R) and the journal or food record are the most used instruments in hospital environments to assess current consumption and estimate absolute or relative values of energy and nutrient intake. The food record is preferred in our institution, and consists of descriptions of the food and the quantities consumed in 24 hours, and an illustrated form adapted to the portions used in the food service can be employed (26) . It is worth mentioning the importance of J o u r n a l P r e -p r o o f training members of the multi-professional team to properly register the food and volumes consumed. In the case of patients on enteral or parenteral nutritional support, the total volume of diet administered on the day must be recorded. The nutritional approach must be established after a complete nutritional assessment, considering not only COVID-19 but also the comorbidities and injuries presented by the patient, the number of hospitalization days before the ICU, the energy balance since hospital admission, and the risk for refeeding syndrome (27, 28) . The oral feeding route should be preferred in patients able to consume 70% of their needs between the third and the seventh day of hospitalization, considering the nutritional needs presented in session 3 (Nutritional Needs), without risk of vomiting or aspiration (27) . If meeting the nutritional needs is not possible, or the patient presents nutritional risk through screening, oral supplements should be used (29) . The meals provided by the hospital must consist of unprocessed or minimally processed foods, including culinary preparations using them as a base and all food groups, so as to ensure an appropriate supply of macronutrients and micronutrients, which has been associated with good results in the treatment of COVID-19 and the complications resulting from symptoms disease, as well as better prognosis, given the relevant role of nutrition in strengthening the immune system (2, 30) J o u r n a l P r e -p r o o f Appropriate nutritional support in terms of micronutrients, vitamins (mainly A, C, E, D, and the B complex), omega-3, and trace elements (such as selenium, zinc, and iron), helps the immune system's general functioning, control of inflammatory processes, oxidative stress, and nutritional status (1, 2, 31). These nutrients' main role is through their action in the differentiation, proliferation, maturation, and function of the cells that make up the immune system, in addition to the development and maintenance of physical barriers such as mucus. However, studies on supplementation in the prevention or treatment of COVID-19 are still controversial, of low quality, and without proven safety, with the risk of reducing or suppressing the immune and antiinflammatory response (32) (33) (34) . Considering the relationship between nutrients and their metabolism, it is important to offer these nutrients and trace elements through foods (32) . Thus, patients on an oral diet should receive 4 or more servings of fruits and vegetables per day (sources of antioxidants, vitamins, minerals, and phytochemicals), 2 to 4 servings of fish per week, as well as an appropriate supply of whole grains, dairy products, poultry, and beef (1). Water intake should also be monitored, especially in cases of hydroelectrolytic imbalances and gastrointestinal symptoms such as diarrhea and vomiting (35) . A systematic screening of hypovitaminosis D must be performed for individuals at risk for it, such as obese and elderly people, and those with chronic non-communicable diseases and long hospital stays since the deficiency of this vitamin makes these patients more susceptible to infection by COVID-19 and to developing the severe form of the disease (36, 37) . In addition to its immunomodulatory and anti-inflammatory potential, the vitamin has a neuroprotective effect and can prevent neurological complications related to the disease (37, 38) . Individuals with 25hydroxyvitamin D <12 ng/mL should receive a single dose of 500,000 IU cholecalciferol (27) . Those with values <20 ng/mL should be supplemented with 50,000 IU/week, and if ≥ 20 and < 30 ng/mL with 25,000 IU/week (29) . It is noteworthy that studies on vitamin D supplementation in the prevention of COVID-19 or better clinical prognosis of those individuals already infected are J o u r n a l P r e -p r o o f limited and controversial, and it is important to assess the ratio of costs and benefits before administering the supplement, especially in patients with hypovitaminosis D and in the group of risk for disability (39) (40) (41) . Patients with caloric intakes below 60% of their nutritional needs and those at nutritional risk should receive nutritional supplements orally (29, 42) . Those malnourished, sarcopenic, with insufficient protein intake, or in the post-ICU rehabilitation phase may need protein supplements to meet the needs of this macronutrient (35) . Considering the available literature, whey protein supplements are suggested to increase protein intake, as it has anabolic, immunomodulating, antioxidants, and high digestibility properties (29) . In the case of patients feeding orally, it is important to favor a balanced diet. The intake of simple sugars and refined carbohydrates, with a high glycemic index, must be restricted, given that these individuals may have hyperglycemia and hyperinsulinemia induced by medicines, infectious processes and/or comorbidities (36) . Electrolytes, such as sodium, potassium, magnesium, and calcium, should be monitored frequently as they are associated with the severity of the disease, and nutritional therapy must be adjusted according to the serum values (43, 44) . Oxygen supplementation is needed due to hypoxemia, ventilator failure, or both, which may occur in an invasive or non-invasive way depending on the severity and cause of the respiratory failure. Whenever possible, non-invasive respiratory support should be the method of choice, and it can be provided by low-flow (LFNC) or high-flow (HFNC) nasal cannulas, face masks (simple, Venturini, without rebreather), and non-invasive positive pressure ventilation (NIPPV) (45, 46) . However, tolerance to the non-rebreather mask can be negative due to the discomfort and feeling of claustrophobia, leading to its frequent removal and interruption of treatment, in addition to J o u r n a l P r e -p r o o f influencing food consumption (45) . Patients who need mechanical ventilatory support and orotracheal intubation require specific nutritional care after extubation. About 10 to 67% of these patients present swallowing disorders, which are associated with reintubation, pneumonia, longer hospital stays, and increased mortality (27, 47) . The evolution of weaning from the enteral to oral diet after extubation requires attention, given the possibility of dysphagia and odynophagia. Therefore, a speech-language assessment of swallowing (deglutition screening) must be performed post-extubation to safely resume the oral diet, even in patients intubated for less than 48 hours, since there is a risk of silent aspiration, that is, the lack of a cough reflex (48, 49) . It is up to the nutritionist to adjust the characteristics of the diet according to the consistency allowed by the speech therapist, pre-existing comorbidities, or electrolyte disorders (2, 27) . Patients must be kept on enteral nutritional therapy until oral intake provides at least 75% of nutritional needs for 3 consecutive days (50) . In the presence of dysphagia and, therefore, the immediate contraindication of the oral diet, the enteral nutrition must be maintained, and risk assessment for aspiration must be carried out. If there is a high risk of aspiration, the positioning of the post-pyloric enteral catheter is indicated or, in case of intolerance to the enteral nutrition or hardship in attaining the goals, parenteral nutrition is suggested (2, 27) . Thus, nutritional therapy and the consistency of the diet may vary according to the type of oxygen support required (Table 1) . Neglecting the proper administration of calories and proteins can result in worsening the nutritional status and its correlations (2, 51). J o u r n a l P r e -p r o o f In the case of patients who are not able to eat orally for more than 3 days, or those with an oral intake below 50% of their energy needs for more than one week, enteral nutritional therapy should be applied. Gastric positioning is recommended, as it is more physiological and reduces the exposure of health professionals to the virus, the post pyloric route being preferable in cases of high J o u r n a l P r e -p r o o f gastric residual volume (> 500 mL) (2) . Parenteral nutrition should be used if the gastrointestinal tract is contraindicated or unable to adjust the nutritional goals (2) . Patients in the ICU should receive nutritional support within 24 to 36 hours of admission to the sector or 12 hours after orotracheal intubation and the beginning of mechanical ventilation (2, 14) . Enteral nutrition should be offered continuously, reducing the risk of diarrhea and the exposure of health professionals to the virus (14) . Absent in the literature was a standardization of the enteral diet interruption time before and after extubation, with studies suggesting that the most important thing is the assessment of symptoms and breathing patterns, with or without the need for reintubation (48, 53) . Segaran et al. (2016) suggest that the enteral diet be paused 4 hours before and after airway procedures, such as making a tracheostomy and extubation (54) . However, in our hospital, the medical and physiotherapeutic teams defined the interruption of the enteral diet 1 hour before extubation as a protocol, returning after 1 hour or stabilizing the respiratory condition at full volume. The enteral diet formula must be polymeric and hyperproteic (>20% protein) in the initial phase of critical illness. Fiber free formulas may be better tolerated in patients with gastrointestinal dysfunction. Protein, fiber, and probiotic modules can be used when necessary and indicated. Soy oil should be used with caution in critically ill patients receiving parenteral nutrition, in view of the risk of hypertriglyceridemia, especially in those patients using propofol (14). In the case of individuals infected with SARS-Cov-2 who are in the ICU, propofol (2.6 diisopropylphenol) has been used for deep and continuous sedation, and to perform the endotracheal J o u r n a l P r e -p r o o f intubation procedure (55) . Due to the lipids used to emulsify the drug, it is classified as a supplier of non-nutritional calories, since lipid emulsions based on 10% soy oil provide 1.1 kcal/mL (56) . Thus, this infused energy must be counted and properly adjusted to the nutritional plan of patients undergoing enteral and parenteral nutritional therapy, minimizing the risk of hyperlipidemia and hyperalimentation (57, 58) . Furthermore, we suggest performing serum triglyceride measurements every 72 hours. Current guidelines have recommended the prone position in patients with COVID-19 and acute respiratory distress syndrome, aiming to improve oxygenation and increase the clearance of bronchial secretions, with reduced lung injury and increased survival rates. The establishment of protocols for the administration and monitoring of nutritional therapy helps improve tolerance to diets, thus contributing to a better clinical and nutritional prognosis (14, 42) . The prone position does not contraindicate or limit enteral nutrition and it is not associated with gastrointestinal and pulmonary complications. However, it is recommended that the administration of the diet happens continuously through an infusion pump and, in patients with gastric feeding intolerance, it may be necessary to have a fixed prescription of prokinetics (2, 27, 42) . The diet should be started after the first hour the patient is in a prone position and maintained for up to 1 hour before returning to the supine position. The bedhead should be kept elevated, between 25 to 30 degrees (reverse Trendelenburg), to reduce the risk of bronchoaspiration, facial edema, and intra-abdominal hypertension (14, 42, 59) . The progression of the enteral diet infusion rate must be according to the patient's tolerance, providing at least 75% of the caloric needs until the 3 rd day of the nutritional therapy (Table 2) . Oligomeric formulas should be preferable only in cases of severe J o u r n a l P r e -p r o o f gastrointestinal disorders, and if these persist, making it impossible to provide at least 60% of energy needs in the first 10 days of the ICU, parenteral nutrition is recommended. (2, 42, 60) . Caloric and protein needs should be adjusted per age, nutritional status, disease severity, gastrointestinal tolerance. Recent guidelines recommend that the energy needs of patients with non-critical COVID-19 and undergoing rehabilitation should be performed using indirect calorimetry. However, given the risk of infection and the unavailability of equipment in most hospitals, the use of predictive equations is recommended (2, 15 Refeeding Syndrome (RS) is characterized by metabolic and electrolytic changes that occur after the reintroduction of nutritional support or increase in caloric supply after a long period of fasting, with serum reduction of phosphorus, potassium, and/or magnesium; thiamine deficiency may also occur (63) . The consequences of the syndrome include hypercapnia (and consequent difficulty in patient independence from mechanical ventilation), hyperglycemia, and liver failure (57, 58) . Individuals with COVID-19 may be at risk for RS, given the reduced food intake due to olfactory dysfunction and gastrointestinal symptoms, with consequent weight loss, of both adipose tissue and muscle mass, in addition to the presence of hydroelectrolytic disorders (5-7, 14, 25, 35, 63) . In the initial phase of the critical illness, endogenous energy production associated with an inadequate caloric supply could also contribute to RS (4, 64) . Recent guidelines suggest that in patients at risk for RS, nutritional therapy should be started, with an offer of 10 to 20 kcal/kg in the first 24 hours, progressing 33% of the target every 1 to 2 days, with progression or onset being suspended until reversal of hydroelectrolytic disorders and thiamine supplementation (100 mg/day for 5 to 7 days) in patients with severe starvation, chronic alcoholism, and signs of deficiency of this vitamin (63) . The American Society of Parenteral and Enteral Nutrition (ASPEN) and ESPEN recommend that the caloric and protein targets for critically ill patients with COVID-19 be the same as those for J o u r n a l P r e -p r o o f other patients admitted to the ICU, starting with a low-calorie diet (15-20 kcal/kg/day) in the initial phase of critical illness and reaching 100% of nutritional needs by the fourth day of nutritional therapy, when caloric goals should be recalculated to 25 to 30 kcal/kg/day (2, 65) . However, a recent study carrying out indirect calorimetry in this population showed hypermetabolism after the first week of the critical illness, with nutritional needs superior to those of other eutrophic and obese critically ill patients ( J o u r n a l P r e -p r o o f Those with sepsis or circulatory shock may receive trophic enteral feeding as tolerated, which is contraindicated only in cases of use of vasopressors in increasing doses and gastrointestinal intolerance (14) . Nutritional monitoring includes physical examination, anthropometric assessment, and gastrointestinal functioning, including the occurrence of diarrhea, intestinal constipation, and vomiting, as well as palpation and abdominal auscultation (69, 70) . The interpretation of laboratory tests must be performed daily (Table 3) . Albumin and C-reactive protein (CRP) can be used to assess systemic inflammation, with reassessment every 20 days (considering the half-life of albumin) (3, 27, 71) . Lactate and blood gases should be evaluated daily since tissue hypoperfusion indicated in hyperlactatemia and metabolic acidosis in blood gases contraindicate the initiation or progression of nutritional therapy (3). (3, 72) . The same should occur if the gastric residue is greater than 500 mL, or if it is less than this value, but associated with other signs of gastrointestinal intolerance (3). Patients with chronic non-communicable diseases are part of a risk group that has worse outcomes and higher mortality after the infection by COVID-19 due to the constant inflammatory state and altered innate immune system (2) . They are patients, therefore, who demand individualized nutritional guidance for adequate control of comorbidities and nutritional status after hospital discharge, modulating the immune, inflammatory, and oxidative process (32) . Among the characteristics associated with a diet that positively affects the immune response are proteins (glutamine, arginine, branched-chain amino acid -BCAA's), polyunsaturated fats, low sugar, high fiber, high intake of fruits and vegetables, and adequate consumption of all food group (1). Among the micronutrients, the most relevant in this scenario are vitamin A, vitamin D, vitamin C, vitamin E, vitamin K, B vitamins, zinc, iron, selenium, and copper. Emphasis should also be given to phytochemicals: polyphenols, carotenoids (32) . COVID-19 often leads to prolonged hospital stays, including in the ICU, with consequent deterioration of the nutritional status and sarcopenia, which influences the quality of life. Oral J o u r n a l P r e -p r o o f nutritional therapy has an important role as an effective treatment to reduce these complications, and better rehabilitation results, being recommended the offer of hypercaloric (400 kcal/day) and hyperproteic (30 grams of protein/day) nutritional supplements for at least 30 days after hospital discharge when food intake is not sufficient to achieve nutritional goals (2) . General recommendations are the increased fractioning of meals in case of anorexia, a greater intake of protein-rich foods, as well as those sources of the aforementioned vitamins and minerals, such as whole grains, fruits, and vegetables. At the time of hospital discharge, the patient should be instructed on eating habits that influence the signs and symptoms presented, such as xerostomia, anosmia, ageusia, nausea, and diarrhea, as well as on proper food hygiene. Quality indicators are used to accompany the characteristics of the monitored population, manage the care patients are offered, identify adverse events, and direct the training of the nutritional support staff. In our institution, we perform a monthly tabulation and analysis of the clinical data of patients hospitalized with COVID-19, as well as of the caloric goal and adequacy to that in the first 72 hours of nutritional therapy, way of feeding, and the use of formulas/modules/nutritional supplements during the hospitalization, gastrointestinal symptoms, and clinical outcome (hospital discharge or death). Regardless of their nutritional statuses at hospital admission, patients with COVID-19 are at nutritional risk. A complete nutritional assessment should include anthropometric, dietary, and laboratorial assessment, as well as a multidisciplinary discussion about the patient's clinical condition. In this way, it is possible to establish an individualized nutritional approach to contribute to better clinical and nutritional prognoses. 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