Evolution of the nutritional status of COVID-19 critically-ill patients: A prospective observational study from ICU admission to three months after ICU discharge

Glycine by enteral route does not improve major clinical outcomes in severe COVID-19: a randomized clinical pilot trial

There is a worrying scarcity of drug options for patients with severe COVID-19. Glycine possesses anti-inflammatory, cytoprotective, endothelium-protective, and platelet-antiaggregant properties, so its use in these patients seems promising. In this open label, controlled clinical trial, inpatients with severe COVID-19 requiring mechanical ventilation randomly received usual care (control group) or usual care plus 0.5 g/kg/day glycine by the enteral route (experimental group). Major outcomes included mortality, time to weaning from mechanical ventilation, total time on mechanical ventilation, and time from study recruitment to death. Secondary outcomes included laboratory tests and serum cytokines. Patients from experimental (n = 33) and control groups (n = 23) did not differ in basal characteristics. There were no differences in mortality (glycine group, 63.6% vs control group, 52.2%, p = 0.60) nor in any other major outcome. Glycine intake was associated with lower fibrinogen levels, either evaluated per week of follow-up (p < 0.05 at weeks 1, 2, and 4) or as weighted mean during the whole hospitalization (608.7 ± 17.7 mg/dl vs control 712.2 ± 25.0 mg/dl, p = 0.001), but did not modify any other laboratory test or cytokine concentration. In summary, in severe COVID-19 glycine was unable to modify major clinical outcomes, serum cytokines or most laboratory tests, but was associated with lower serum fibrinogen concentration.Registration: ClinicalTrials.gov NCT04443673, 23/06/2020.

Individualised energy and protein targets achieved during intensive care admission are associated with lower mortality in mechanically ventilated COVID-19 patients: The COFEED-19 study

BACKGROUND & AIMS

Malnutrition is prevalent among COVID-19 patients admitted to the intensive care unit (ICU) and it is associated with poor survival. Customized nutrition plays a vital role in enhancing outcomes for this patient population. This study explores the association between energy and protein intake and 90-day mortality in invasively mechanically ventilated COVID-19 patients, utilizing fat-free mass (FFM) and actual body weight (ABW) for nutritional requirements. Furthermore, the study investigates the occurrence of gastrointestinal (GI) intolerance in critically ill COVID-19 patients in relation to their nutritional intake and survival.

METHODS

A retrospective study was undertaken at a university-affiliated teaching hospital, focusing on COVID-19 patients on invasive mechanical ventilation admitted to the ICU between March 2020 and December 2021. The study collected demographic and clinical data, along with cumulative energy and protein goals, and recorded cumulative intake on days 4, 7, and throughout the ICU stay. Univariate and multivariable Cox regression analyses were conducted to evaluate associations between energy and protein deficits and the 90-day all-cause mortality.

RESULTS

The study included 85 patients, of whom 67 (78 %) survived 90 days after ICU admission. There were no significant differences in body composition between survivors and non-survivors. Reaching ≥70 % of the energy goal based on both ABW and FFM during the ICU stay was associated with decreased 90-day mortality (HR 0.22, 95 % CI 0.08-0.60 and HR 0.28, 95 % CI 0.09-0.85, respectively). Similarly, achieving ≥80 % of the protein target based on FFM was associated with decreased 90-day mortality (HR 0.26, 95 % CI 0.07-0.94), whereas no significant association was found for reaching protein targets based on ABW (HR 0.03, 95 % CI 0.00-3.40). Patients who reached both their energy and protein goal based on FFM during ICU admission showed a lower risk of all-cause 90-day mortality compared to those who received <70 % of the energy goal and <80 % of protein based on FFM after adjusting for age (aHR 0.12, 95 % CI 0.03-0.50). No differences in GI intolerance related symptoms between COVID-19 survivors and non-survivors were observed.

CONCLUSIONS

This study underscores the significance of providing adequate nutritional therapy to COVID-19 ICU patients who require IMV. Meeting over 80 % of the protein goals based on BIA-derived FFM was associated with lower mortality rates, which emphasizes the need for further investigation into the role of FFM in establishing nutritional targets.

In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay

BACKGROUND

Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight.

METHODS

This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay.

RESULTS

One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013).

CONCLUSION

In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.

Long-term outcomes in critically ill patients who survived COVID-19: The NUTRICOVID observational cohort study

BACKGROUND & AIMS

Malnutrition and sarcopenia may last beyond hospital discharge, especially in patients admitted to intensive care units (ICU), having a negative impact on patient recovery and leading to disability, poor quality of life, and additional morbidity. No prior evidence is available for post-ICU management and follow-up of coronavirus disease 2019 (COVID-19) patients and their long-term evolution. This study reports on the one-year-long evolution of a cohort of COVID-19 survivors after ICU discharge, in terms of nutritional and functional status as well as health-related quality of life (HRQoL).

METHODS

A multicenter, ambispective, observational cohort study (NUTRICOVID study) was conducted in 16 public hospitals located in the Community of Madrid with COVID-19 survivors who were admitted to ICU during the first outbreak. Retrospective and prospective data were collected from hospital admission to one year after discharge. At hospital discharge and at 3, 6 and 12 months post-discharge, the following outcomes were recorded: weight, risk of malnutrition (MUST) and sarcopenia (SARC-F), medical nutrition therapy (MNT), functional status (Barthel index), and HRQoL (EQ-5D-5L).

RESULTS

A total of 199 patients (70.4% male, mean age [SD] of 60.7 [10.1]) were included in the study. At hospital discharge, mean weight loss was 16.4% (8.0%), whereas most patients gained weight after discharge with an increase of 16.5% (14.0%) at 12 months. The proportion of patients at high risk of malnutrition decreased from 83.2% at hospital discharge to 2.1% at 12 months. The proportion at risk of sarcopenia decreased from 86.9% at hospital discharge to 13.4% at 12 months. At hospital discharge, 69 patients received MNT by means of oral nutritional supplements (ONS) while two patients required enteral nutrition (EN). At 12 months, only 12 patients continued taking ONS, with no patients taking EN. Regarding functional status, 72.9% of patients were moderately or severely dependent at hospital discharge, whereas 87.2% showed low dependency or independency after 12 months. The EQ-VAS values increased from hospital discharge (39 [21.2]) to 6 months post-discharge and remained steady up to 12 months (72.7 [19.0]). The mean health value improved from hospital discharge (0.25 [0.41]) to 6 months post-discharge (0.80 [0.24]) and was maintained thereafter.

CONCLUSIONS

Patients' nutritional and functional impairment at hospital discharge was high, with high dependency status and low HRQoL; however, their situation improved progressively during the 12 months following hospital discharge. Nevertheless, there is a need to define early strategies to optimize the nutritional and functional recovery of COVID-19 patients.

Feasibility and criterion validity of the GLIM criteria in the critically ill: A prospective cohort study

BACKGROUND

This study aimed to evaluate the feasibility and validity of the Global Leadership Initiative on Malnutrition (GLIM) criteria in the intensive care unit (ICU).

METHODS

This was a cohort study involving critically ill patients. Diagnoses of malnutrition by the Subjective Global Assessment (SGA) and GLIM criteria within 24 h after ICU admission were prospectively performed. Patients were followed up until hospital discharge to assess the hospital/ICU length of stay (LOS), mechanical ventilation duration, ICU readmission, and hospital/ICU mortality. Three months after discharge, the patients were contacted to record outcomes (readmission and death). Agreement and accuracy tests and regression analyses were performed.

RESULTS

GLIM criteria could be applied to 377 (83.7%) of 450 patients (64 [54-71] years old, 52.2% men). Malnutrition prevalence was 47.8% (n = 180) by SGA and 65.5% (n = 247) by GLIM criteria, presenting an area under the curve equal to 0.835 (95% confidence interval [CI], 0.790-0.880), sensitivity of 96.6%, and specificity of 70.3%. Malnutrition by GLIM criteria increased the odds of prolonged ICU LOS by 1.75 times (95% CI, 1.08-2.82) and ICU readmission by 2.66 times (95% CI, 1.15-6.14). Malnutrition by SGA also increased the odds of ICU readmission and the risk of ICU and hospital death more than twice.

CONCLUSION

The GLIM criteria were highly feasible and presented high sensitivity, moderate specificity, and substantial agreement with the SGA in critically ill patients. It was an independent predictor of prolonged ICU LOS and ICU readmission, but it was not associated with death such as malnutrition diagnosed by SGA.

Inadequate Energy Delivery Is Frequent among COVID-19 Patients Requiring ECMO Support and Associated with Increased ICU Mortality

BACKGROUND

Patients receiving extracorporeal membrane oxygenation (ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for coronavirus disease 2019 (COVID-19) patients during ECMO therapy.

METHODS

We conducted a retrospective analysis of COVID-19 patients requiring venovenous ECMO support at a large tertiary hospital center. Nutrition goals were calculated using 25 kcal/kg body weight (BW)/day. Associations between nutrition support and outcome were evaluated using Kaplan-Meier and multivariable Cox regression analyses.

RESULTS

Overall, 102 patients accounted for a total of 2344 nutrition support days during ECMO therapy. On 40.6% of these days, nutrition goals were met. Undernutrition was found in 40.8%. Mean daily calorie delivery was 73.7% of calculated requirements, mean daily protein delivery was 0.7 g/kg BW/d. Mean energy intake of ≥70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity at ECMO start and body mass index (adjusted hazard ratio: 0.372, p = 0.007).

CONCLUSIONS

Patients with a mean energy delivery of ≥70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.

Nutrition support practices across the care continuum in a single centre critical care unit during the first surge of the COVID-19 pandemic - A comparison of VV-ECMO and non-ECMO patients

BACKGROUND & AIMS

Critically ill patients with COVID-19 are at high nutrition risk. This study aimed to describe the nutrition support practices in a single centre critical care unit during the initial surge of the COVID-19 pandemic. Practices were explored from ICU admission to post-ICU follow-up clinic and patients who received veno-venous extra-corporeal membrane oxygenation (VV-ECMO) were compared to those who did not.

METHODS

This retrospective observational study included COVID-19 positive, adult ICU patients who were mechanically ventilated for ≥72 h. Data were collected from ICU admission until the time of post-ICU clinic. For in-ICU data, results are compared between patients who did and did not receive VV-ECMO.

RESULTS

252 patients were included (VV-ECMO n = 58). Adequate energy and protein was delivered in 193 (76.6%) patients during their ICU admission with no differences between those who did and did not receive VV-ECMO (44 (75.9%) vs. 149 (76.8%)). Parenteral nutrition only being required in 12 (4.8%) patients. Following stepdown to the ward 77 (70%) patients required ongoing enteral nutrition support, and 74 (66.7%) required a texture modified diet or were NBM. Following hospital discharge, nearly a third of ICU survivors (28.4%) were referred for dietetic input. The most common referral reason was loss of weight. Breathlessness and fatigue were the most commonly reported nutrition impact symptoms experienced following hospital discharge.

CONCLUSION

Results show it is possible to reach nutritional adequacy for most patients and that neither VV-ECMO nor proning were barriers to nutritional adequacy. Nutritional issues for patients who were critically ill with COVID-19 persist following stepdown to ward level and into the community and strategies to manage this require further investigation.

Dénutrition et COVID-19

L’infection par le severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), ou maladie à coronavirus 2019 (COVID-19), est une pathologie associée à un risque élevé de dénutrition. La prévalence de la dénutrition chez les personnes hospitalisées pour COVID-19 s’élève à 40 %, et jusqu’à plus de 70 % dans les unités de soins intensifs. Les mécanismes expliquant la dénutrition sont multiples, associant baisse des ingesta, augmentation des pertes énergétiques et augmentation des besoins énergétiques. La dénutrition est associée à la sévérité de la COVID-19. Son dépistage et sa prise en charge en sont donc une priorité. Le dépistage de la dénutrition repose sur les critères de la Haute Autorité de santé (HAS), associant un critère phénotypique (perte de poids, indice de masse corporelle bas, perte de masse et/ou de force musculaire), et un critère étiologique (toujours présent dans la COVID-19). La prise en charge suit les recommandations de la Société Francophone de Nutrition Clinique et Métabolisme (SFNCM) publiées en mai 2020, reposant sur une alimentation adaptée au statut nutritionnel (enrichissement, compléments nutritionnels oraux, nutrition artificielle), la prévention du syndrome de renutrition inappropriée, et la kinésithérapie de renforcement musculaire. La prise en charge nutritionnelle doit également se poursuivre à distance de la phase aiguë de la COVID-19 pour lutter contre la sarcopénie.

Does Route of Full Feeding Affect Outcome among Ventilated Critically Ill COVID-19 Patients: A Prospective Observational Study

The outbreak of the new coronavirus strain SARS-CoV-2 (COVID-19) highlighted the need for appropriate feeding practices among critically ill patients admitted to the intensive care unit (ICU). This study aimed to describe feeding practices of intubated COVID-19 patients during their second week of hospitalization in the First Department of Critical Care Medicine, Evaggelismos General Hospital, and evaluate potential associations with all cause 30-day mortality, length of hospital stay, and duration of mechanical ventilation. We enrolled adult intubated COVID-19 patients admitted to the ICU between September 2020 and July 2021 and prospectively monitored until their hospital discharge. Of the 162 patients analyzed (52.8% men, 51.6% overweight/obese, mean age 63.2 ± 11.9 years), 27.2% of patients used parenteral nutrition, while the rest were fed enterally. By 30 days, 34.2% of the patients in the parenteral group had died compared to 32.7% of the patients in the enteral group (relative risk (RR) for the group receiving enteral nutrition = 0.97, 95% confidence interval = 0.88–1.06, p = 0.120). Those in the enteral group demonstrated a lower duration of hospital stay (RR = 0.91, 95% CI = 0.85-0.97, p = 0.036) as well as mechanical ventilation support (RR = 0.94, 95% CI = 0.89–0.99, p = 0.043). Enteral feeding during second week of ICU hospitalization may be associated with a shorter duration of hospitalization and stay in mechanical ventilation support among critically ill intubated patients with COVID-19.

Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives

Intensive care unit survivors experience prolonged physical impairments, cognitive impairments, and mental health problems, commonly referred to as post-intensive care syndrome (PICS). Previous studies reported the prevalence, assessment, and prevention of PICS, including the ABCDEF bundle approach. Although the management of PICS has been advanced, the outbreak of coronavirus disease 2019 (COVID-19) posed an additional challenge to PICS. The prevalence of PICS after COVID-19 extensively varied with 28-87% of cases pertaining to physical impairments, 20-57% pertaining to cognitive impairments, and 6-60% pertaining to mental health problems after 1-6 months after discharge. Each component of the ABCDEF bundle is not sufficiently provided from 16% to 52% owing to the highly transmissible nature of the virus. However, new data are emerging about analgesia, sedation, delirium care, nursing care, early mobilization, nutrition, and family support. In this review, we summarize the recent data on PICS and its new challenge in PICS after COVID-19 infection.