Up to 10% of COVID-19 patients require respiratory and hemodynamic support in the ICU and are at an increased risk of malnutrition (1). Where enteral nutrition is impossible, contraindicated, or insufficient then parenteral nutrition (PN) is warranted, and considered safe in the critically ill cohort (2, 3). We report the characteristics and outcomes for ventilated patients with COVID-19 who received PN on ICU.
A retrospective observational study was undertaken of COVID-19 ICU patients between March-April 2020 (“wave1”) and December-March 2021 (“wave2”). Nutritional risk was calculated using The NUTRIC score (4). Data was analysed in Microsoft Excel.
In total, 17 patients with COVID-19 (7 in “wave1”, 10 in “wave2”) received PN for an average of 8.6 ± 4 (range 4-16) days during their admission.
1. Patient characteristics (n=17)
| Age (mean ± SD (range)) | 60 ±12 (28-78) | APACHE (mean (range)) | 15 (12-24) |
|---|---|---|---|
| Male/Female | 15/2 | SOFA (mean (range)) | 10 (6-14) |
| BMI kg/m2 | 29.7 ±6 (21-35) | Proning | 13 (76%) |
| I+V | 17 (100%) | 30-day mortality | 12 (70%) |
| Nasogastric tube in situ | 17 (100%) | Time to PN from I+V (mean SD ± (range)) | 8.9 ±4 (2-18) |
Legend: BMI – Body Mass Index, I+V – intubated and ventilated, APACHE - Acute Physiology And Chronic Health Evaluation, SOFA – Sequential Organ Failure Assessment
Indications for PN were high gastric residual volumes (GRVs) (70%), haemodynamic instability and impaired feed delivery. In wave 2, bedside Naso-jejunal tube (NJT) placement was available. Six patients had successful NJT insertion, all of which subsequently achieved nutritional targets enterally, and PN was discontinued. 35% of patients had a NUTRIC score ≥5 and required longer on PN (mean 10.5 days) versus those with a NUTRIC score <4 (mean 7.1 days). Biochemical refeeding was seen in 50% of patients.
In conclusion, ventilated COVID-19 patients on the ICU who required PN had complex nutritional needs, and significant levels of refeeding. Accrued nutritional deficit due to high GRV’s was our primary indication for PN commencement. They had a high mortality rate, when compared to national ICNARC mortality data (5), suggesting PN was provided at the point of worsening multi-organ failure.
1. Thibault R, Seguin P, Tamion F, et al. Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance. Crit Care 2020; 24: 447.
2. Harvey S E, Parrott F, Harrison D A, et al. Trial of the route of early nutrition support in critically ill adults. N Engl J Med 2014; 371: 1673-1684.
3. Singer P, Blaser A, Berger M, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019; 38: 48-79.
4. Heyland D K, Dhaliwal R, Jiang X, et al. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011; 15: R268.
5. ICNARC report on COVID-19 in critical care: England, Wales and Northern Ireland 3 June 2021 (Accessed June 14, 2021, at https://www.icnarc.org/our-audit/audits/cmp/reports)