Practical Approach on Feeding theCritically Ill of COVID-19: focus ICU

STOP COVID - 19SAVE LIVES

Frans JV PangalilaJakarta

Disease spectrum of COVID-19

Zunjou Wu et al. JAMA 2020

81% were mild statuso no pneumonia or mild pneumonia

5% were severe statuso dyspnea or respiratory rate ≥ 30/min or

SpO2 < 93% or PaO2 /FiO2 < 300 mmHg

14% were critical ill statuso needs mechanical ventilationo shocko multi-organ failure→ require ICU admission

Penyakit Kritis: COVID-19

Injury / Sepsis-COVID-19

Acute Stress Response

Immune Response NeuroendocrineResponse

Metabolic response

Release mediator and reaction Stress hormon release

ditandai:o peningkatan “ resting energy expenditure “ (REE) atau

hipermetabolik: meningkatkan kebutuhan energi-kalorio akselerasi “ whole body proteolysis “ atau hiperkatabolik

dan lipolisis

Tampilan ditemukan:- Klinis: demam, takikardi, takipnea

- Laktat darah - asidosis (hipoperfusi)

- Hiperglikemia- Negative Nitrogen balance : ekskresi N urin- C reactive protein (CRP) meningkat - hipoalbumin

Autophagy and Nutrient in Critically ill

Endothel

Pro

tein

me

tab

olis

mLi

pid

me

tab

olis

m

Amino Acid Lipid / Fat Glucose

Glu

cose

me

tabo

lism

Lysosome

Protein synthesis

Lipid droplets

Fatty Acid

Energy Glycogen

Energy

Energy

Autophagy• trigger : starvation• suppress : overfeeding /hyperglycemia and insulin

Airway managementBreathing control

Tissue oxygenationFluid managementCirculatory support

AntibioticNutrition delivery

Old Paradigm : Nutrition as a Supporthad been shift to

New Paradigm : Nutrition as a Therapy

Step 1: who are the patients requiring nutritionalsupport ?

“ all patients ICU are at risk of MALNUTRITION if stay > 2 days “

→ Nutrition assessment: identified malnutrition

ICU: NUTRIC Score and Subjective Global Assessment (SGA) more reliable

NUTRIC Score

Nutric Score without IL-6

Step 2: estimate Energy (calories) requirements

o tools: • Indirect calorimetry (ideal)• Harris- Benedict equation with longs modification

(time consuming and not validated in ICU)• etc

“ Rule of Thumb “ : 25 – 30 kcal/kg IBW meet patientsneeds, start: 8 – 10 kcal/kg/day

ESPEN: 27 kcal/kg/day in polymorbid older adult (> 65 yrs)30 kcal/kg/day , severely underweight polymorbid

ASPEN/SCCM: 15 – 20 kcal/kg ABW/day ≈ 70 – 80% ofcaloric requirements

o nutrition requirements should take into consideration the useof Propofol in terms of lipid calories and total calories needed

Step 3: estimate Protein (nitrogen) requirements

“ Rule of Thumb “ : 1.5 – 2 g /kg IBW meet patients needs

ESPEN: 1.0 gr/kg/day in older adults→progressive deliveryof 1.3 gr/kg in polymorbid COVID-19

ASPEN/SCCM: 1.2 – 2.0 kcal/kg ABW/day

- During ACUTE PHASE : 0.7 – 0.8 gr/kg protein (to avoid suppressingAUTOPHAGY)

o protein intake should not be calculated as calorie sourceo non protein calorie (NPC): nitrogen ratio

- 150 cal (NPC) : 1 g nitrogen- 6.25 g of protein = 1 g nitrogen

Step 4: estimate Fluid, Electrolyte requirementand supplement Micronutrient

o Rule of the “ thumbs “ 1 ml/kcal is the minimum requirement of fluid to deliver isocaloric feed BUT avoiding fluid balance ++

o electrolyte should be tailored to individuals requirement

ESPEN Recommendation:

➢ provision of vitamins and trace elements is required to maximize anti –infection nutritional defense• Vitamins A, D, E, B6 and B12

• Micronutrients zinc, selenium and iron• Omega-3 fatty acids with Enteral or Parenteral Nutrition

- metabolites of Arachidonic acid (AA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are known to suppress inflammation, ↓ microbial load,augment phagocytosis of macrophages /other immunocytes , ↑ woundhealing (based on case reports)

Step 5: when should we start and which route ?

2018

2016

Enteral Nutrition (EN) : technical and access

2016

2018

Algoritme Pilihan Akses Enteral Nutrisi (EN)

Indikasi EN (+)

Risiko Aspirasi

(+)Risiko Aspirasi

(-)Risiko Aspirasi

(-)Risiko Aspirasi

(+)

EN jangka pendek(< 4-6 minggu)

EN jangka panjang(> 4-6 minggu)

Nasoduodenalatau

Nasojejunal tubeNasogastric tube

Jejunostomi atauGastro-

jejunostomi tubeGastrotomi tube

Risiko Aspirasi

• riwayat aspirasi• kesadaran menurun• gangguan menelan• GERD *• gastroparesis• gastric outlet obstruc

tion

Calorie Targeted (%)

20

40

60

80

100

1 3 542 6 7 8 9

Days

Enteral Nutrisi

PN + EN

Caloric Debt

↑ Caloric debt associated with↑ ICU stay↑ days on MV↑ complications↑ mortality

Rubinson et al CCM 2004 Villet et al Clin Nutr 2005

Dvir et Clin Nutr 2006 Petros et al Clin Nutr 2006

Step 5: when we start to think to give ParenteralNutrition (PN)?

“ increased caloric debt associated with worseoutcome “

⓿ Consider PN if EN is not indicated or unable to reach targetcalories:- when GI symptoms is prominent (to reduce droplet aerosol)- hemodynamic instability requiring vasopressor at high or de escalation

dose or requiring high pressure respiratory support

ASPEN/SCCM Recommendation (2020):

⓿ Consider use of multi-chamber bag PN products, particularlyif standard PN components are in shortage

⓿ in case of Dysphagia after extubating consider temporary PN

⓿ Prone positioning (refractory hypoxemia)o to improve oxygenation and increase bronchial secretion clearanceo head of the bead elevated (reverse Trendelenburg) ≈10 - 25 degrees o delivered into stomach (post-pyloric placement)

Bagaimana PN diberikan ??

memerlukan PN > 5 hari dan atau > 1000 kalori

ya tidak

PN akses periferMemerlukan > 2 cairan dan atau obat / bahan iritan (vasopresor, kemoterapi)

Ya

Kateter multi-lumen

Tidak Kateter single lumen

Step 6: MONITORING ?

Pemantauan : identifikasi dini !!

Refeeding Syndrome (RFS)

• terjadi pergeseran cairan ,elektrolit (phosphat, magnesium, kalium) dan mineral akibat pemberian nutrisi yang aktif

• petanda khas : HYPHOPHOSPHATEMIA (prediktor hipoalbumin)• didasari : aktifitas hormon INSULIN dan GLUCAGON

Manifestasi Klinis

mual – muntahdeliriumgagal napasaritmiahipotensi - gagal jantungkoma - kematian

Risiko RFS

anoreksia nervosamalnutrisikronik alkoholismeusia lanjutNIDDM (poorly control)kristaloid berlebihan

Pemantauan : identifikasi dini !!

Overfeeding Syndrome

❑ KARBOHIDRAT : > 5 mg/kg/menit

❑ LEMAK : > 2 gr/kg/hari

❑ PROTEIN : > 2 gr/kg/hari

Gagal Napas - hipercapnea

Hiperglikemia

Hiperinsulinemia

Gangguan fagositosis

Perlemakan hati

Hipertrigliseridemia

Ureagenesis – gangguanfungsi ginjal

Enteral Nutrition (EN) : monitoringPulmonary Aspiration is potentially lethal

o don’t discontinue enteral feeding for GRV < 500 ml

o GRV > 500 ml: withhold feeding GRV > 250 ml: use prokinetic agent

Enteral Nutrition( 20 – 40 ml/hour )

“ aspirate at 6 hours “

Aspirate < 250

↑ rate by 20 ml/hour or continue until maximal

Aspirate > 250

↓ rate half or minimum 20 ml /hour but don’t STOP to feed and use prokineticagent

⓿ Head of the Bed 30○ to 45○

⓿ Monitoring Gastric Residual Volume (GRV)

Pasien Dalam Pemantauan (PDP) atau konfirmasi “COVID 19”

“ Risiko tinggi “o Usia lanjut (≥ 50 thn)o laki lakio co morbid: hipertensi, diabeteso temperatur ≥ 37.8○Co lama keluhan ≥ 6 hario netrofil-limfosit rasio > 5o CRP > 50o d dimer ≥ 0.7µg/ml atau > 3 kali

nilai awalo CT thoraks: pneumonia (+)

(+)

suplemen oksigen• simpel mask atau NRM

(pemantauan ketat)

(-)

standar oksigen• nasal kanul (02 NK 2-3 l)(pemantauan 2 x perhari)

RR > 30/menit SpO2 < 93% HR > 120/menit

Intensive Care Unit (ICU)

Rawat bangsal(PDP)

Diet oral atauSuplemen nutrisi oral danatau Parenteral nutrisi dini

Intensive Care Unit (ICU)

o nilai SOFA ≥ 5 atau ∆ > 2atau

o disertai satu gagal organatau

o P/f rasio < 200

RR > 30 / menit SpO2 < 93 % HR > 120 /menit

(+)(-)

• Non Invasive Ventilation• High Flow Nasal Cannula

Oxygen

• awake prone position• restriksi cairan

Sp02 < 95% 3 - 5 jam Invasive ventilation

Rawat ICU

Enteral nutrisi dan atauParenteral nutrisi

Practical approach nutrition during the phase Critical illness and Convalescence

Acute phaseDay 1 - 4

Post Acute ICU phase> Day 5

Post ICU phase

Day 125%

Day 480 - 85%Day 3

75%

Target 1

ICU discharge

Post ICU

Target 2Progressive feeding(avoid overfeeding)

• monitor phosphate (P)• stay at 25% of caloric target for 48 hour

if phosphate drop• prevent very early high protein intake

protein: 0.7 – 0.8 g/kg

Target 1o calories 85% of calculated targetso proteins 1.3 g/kg/day

Target 2o calories 30 – 35 kcal / kg/dayo proteins 1.5 – 2.5 g/kg

• patients are at risk for reductionsin caloric and protein intake aftercessation of enteral nutrition(after feeding tube removal)

Cal

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kcal

/ d

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Pro

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/kg

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Zanten AR et al Crit Care 2019 (modified)

Take Home Point

⓿ Identifikasi dini : MALNUTRISI

⓿ Fase Akut penyakit kritis: HINDARI sindroma Re-Feedingdan Over-feeding

⓿ Unit Rawat Intesif: multidisiplin-multispesialis perlunya:→ Penyusunan/konsensus penatalaksanaan bersama

NUTRISI

⓿ Nutrisi Enteral berikan secara dini → simptom GI ++nutrisi Parenteral dini dipertimbangkan

⓿ Integrated post discharge hospital center COVID-19- post ICU discharge- usia lanjut- pendataan