Pandemic spurs nutrition gap in ICUs

Most critically ill COVID-19 patients are not having their nutrition needs fully met, according to a new survey. Fortunately, this management gap can be filled by enlisting the aid of non-nutrition support clinicians and other staffing strategies, according to several experts who spoke during a webinar convened during the American Society for Parenteral and Enteral Nutrition (ASPEN) Malnutrition Awareness Week, held Oct. 4-8, 2021.

Only 9% of the nearly 200 respondents, who included dietitians and physicians, reported that COVID-19 patients met their full nutritional support needs in the ICU, and 63% reported that these patients typically received less than 60% of their energy/protein goals (JPEN J Parenter Enteral Nutr 2021 Sep 5. doi:10.1002/jpen.2263).

“We’ve had multiple patients who are having difficulty tolerating enteral nutrition [EN] for a variety of reasons,” said Sarah Cogle, PharmD, BCNSP, an associate clinical professor at Auburn University Harrison School of Pharmacy, in Alabama. “Many have severe acute respiratory distress syndrome, and are on different therapies like proning and

continuous or intermittent neuromuscular blockade. Many have issues with hypotension and aren’t getting good perfusion. In some, all these things are going on at once. We’re still trying to feed enterally, but we’re seeing a lot more intolerance of feeding via the enteral route among these patients.”

The decision on when to begin parenteral nutrition (PN) in a patient who had been enterally fed can be a challenging one, particularly in the context of COVID-19. For nutrition support clinicians, it’s one that requires close collaboration with clinical colleagues outside the specialty.

“We don’t have a lot of specific, clear evidence as to when we should switch,” Dr. Cogle said. She noted that supplemental COVID-19 guidelines issued by ASPEN and the Society of Critical Care Medicine in 2020 recommend that the threshold for switching to PN in this population should be lower than in typical ICU patients (JPEN J Parenter Enteral Nutr 2020;44:1174-1184).

Patients of particular concern are those with septic shock and/or requiring high-pressure respiratory support, she noted. “It’s currently suggested that after a week or so, if you’re not at target with enteral nutrition, to consider supplemental PN. Some studies have started PN a little sooner for patients who were not receiving target feeds around day 3” (Clin Nutr 2019;38[5]:2408-2416).

But in the survey, 24% of clinicians said they would use PN in COVID-19 patients only if there were noticeable malnutrition, weight loss or the presence of severe disease. Moreover, 17% said they would not use supplemental PN under any circumstances in patients already receiving EN.

The biggest concerns conveyed by non-nutrition support clinicians, Dr. Cogle said, is that they believe moving to PN will produce worse outcomes, including higher mortality rates and increased rates of infection. “Recent trials have not shown that,” she said. “We haven’t seen major improvements in mortality outcomes, but outcomes

have not been worse either. While supplemental PN may not be for everyone, there are certain patients who are perhaps at more nutritional risk who may be appropriate.”

Earlier trials, such as the 2011 EPaNIC study, found increased infections and longer ICU length of stay with early PN initiation (N Engl J Med 2011;365[6]:506-517), Dr. Cogle noted, but several more recent trials have found no differences in mortality, functional outcomes or infectious complications (N Engl J Med 2014;371[18]:1673-1684; Lancet 2018;391:133-143; Crit Care 2017;21[1]:142).

“These studies found that patients who got supplemental PN received more calories and protein, but they didn’t necessarily see a difference in outcomes,” Dr. Cogle said. “But many of these trials didn’t focus on functional outcomes. A 2021 review of the literature hypothesized that EN plus PN may be associated with a trend toward lower mortality in patients at higher nutrition risk, and the authors recommended that a focus on functional outcomes may be appropriate in future trials” (JPEN JParenter Enteral Nutr 2021 Apr 26. doi:10.1002/jpen.2125).

Most prescribers are big believers in EN, Dr. Cogle said. “I am, too, but a lot of the concern with PN stems from older data with higher infection and complication rates and worse outcomes. We need to be an educational resource for our teams, providing education about the shift, listening to the concerns of non-nutrition support clinicians and providing information about factors that have led to better outcomes, such as the fact that we do a much better job managing PN now, and central line care is much better.”

Another reason for recent improvements in outcomes is elimination of hyperalimentation. “With past practices, sometimes we were literally overfeeding people, which led to much higher rates of infection,” Dr. Cogle said. “Make sure that your non-nutrition support colleagues are aware that today we do a much better job at writing and managing these orders and achieving glycemic control. We can adjust the formula every day to be sure we are not overfeeding.”

Deciding when to move from EN to PN, whether in a complex COVID-19 patient or any patient, should be individualized, Dr. Cogle said. “You may first want to focus on optimizing EN if at all possible, particularly with patients who are on so many other continuous drips.” She recommended using validated nutrition risk assessment scores recommended by ASPEN, such as the NUTRIC score, for critically ill patients.

“Don’t rely on weight alone to detect malnutrition,” agreed Carol McGinnis, DNP, APRN-CNS, CNSC, a clinical nurse specialist in nutrition support at Sanford USD Medical Center, in Sioux Falls, S.D. “If you look only at height, weight and body mass index, you’re not necessarily considering how sick the patient is now, or other preexisting factors that may be putting the patient at risk for malnutrition.”

Don’t just look at what has been ordered in terms of a patient’s nutrition; also pay attention to what they have actually received over a several-day period, according to Dr. Cogle. “There may be interruptions in feeding; for example, if a patient vomits and [feeding is withheld] for the rest of the day, the feeding was ordered but not received,” Dr. Cogle said. “Or if a patient goes to surgery and that surgery is postponed, their feeds may be held longer. Work with your non-nutrition support colleagues, such as nurses, to keep track of what the patient is actually getting.”

“The best nutritional outcomes, including patient safety, depend on the synergy of a high-functioning team where contribution of each member is valued and solicited,” Dr. McGinnis said.

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‘With past practices, sometimes we were literally overfeeding people, which led to much higher rates of infection. Make sure that your non-nutrition support colleagues are aware that today we do a much better job at writing and managing these orders and achieving glycemic control.’ —Sarah Cogle, PharmD ‘If you look only at height, weight and body mass index [to detect malnutrition], you’re not necessarily considering how sick the patient is now, or other preexisting factors that may be putting the patient at risk for malnutrition.’

—Carol McGinnis, DNP

—Gina Shaw