Case Study: Pulmonary Disease

[ARDS COVID-19]

By: Christa Justice

NUTR 563
June 15, 2020
 Abstract/Introduction
 Novel coronavirus disease (COVID-19)
 Mild to severe symptoms: fever, sore throat, coughing, SOB, GI
issues (1)
 High risk for respiratory infections or respiratory failure
 Acute Respiratory Distress Syndrome (ARDS)
 Consulted for intubation > 24 hours
 ASPEN: Initiate EN or TPN within 12 hours of intubation (2)

https://www.medscape.com/viewarticle/928605
Assessment – Mr. N
 56 YOM
 5’10” 134 lb (61 kg)
 IBW: 73.18 kg
 BMI: 19.25 kg/m²
 Admitting Dx: ARDS due to COVID-19
 PMH: DM and HTN. No PSH.
 Required intubation and sedation d/t worsening respiratory failure.
 Propofol 18.3 ml/hr (483 kcal/day)
 AKI
 EN indicated
 Trickle TF of Pivot 1.5 (immune enhancing TF) at 10 ml/hr, 30 ml
water flush q 4 hrs.
 Unable to complete malnutrition assessment

This Photo by Unknown Author is licensed

under CC BY-NC-ND
 Laboratory Values
Reference range Lab value Significance
Sodium 135-145 mEq/L 151 (H) Diabetes, HTN, dehydration

Glucose 70-100 mg/dL 145 (H) Diabetes

BUN 6-20 mg/dL 116 (H) Shock, hypovolemia, excess protein in the
GI tract
Creatinine 0.6-1.3 mg/dL 2.78 (H) Dehydration, diabetic nephropathy, shock

Potassium 3.5-5.5 mEq/L 5.0 Acidosis, anemia, hypoventilation, renal

failure
Magnesium 1.7-2.2 mg/dL 2.9 (H) Dehydration, oliguria,

Chloride 96-108 mEq/L 119 (H) Respiratory alkalosis, dehydration, fever

Phosphorus 2.4-4.1 mg/dL 5.0 (H) Laxatives or medicines that contain

phosphate, renal failure
AST 10-34 U/L 76 (H) Mononucleosis, acute pancreatitis or
hepatitis
Triglycerides <150 mg/dL 661 (H) High fat in the blood, propofol
 Medications
Scheduled: Nutritional Implications: IVF/Drips: Nutritional Implications:
Pepcid Anti-ulcer, anti-gerd, may Fentanyl Dry mouth, N/V/C/D,
caused reduced absorption of dyspepsia
fe & vitamin B12, N/V/C/D
Levophed at 4 Hemodynamic instability,
Hydrocortis Can increase appetite/weight,
mcg/min possible intestinal ischemia
one may cause N/V, bloating,
with EN
esophagitis
Periostat Antibiotic, may cause N/V/D, Vasopressin at Hemodynamic instability,
cramps 2 units/hr possible intestinal ischemia
with EN
Lantus 15 Blood glucose control
units AM Propofol at Sedative, provided 1.1 kcal of
Versed Sedative, may cause 18.3 ml/hr lipids per mL
N/V/C/D, wt change (483 kcal/day)

Heparin N/V/C, black tarry stools,

Kayexalate Anti-hyperkalemia, may cause caution w/ diabetes;
N/V/C/D, gastric irritation hyperkalemia
Estimated Nutritional Needs

915 - 1220 calories/day (15-

20 kcal/kg Current BW)

79 - 122 g protein/day (1.3-2.0g

pro/kg Current BW)

Based on current ASPEN

recommendations for mechanically
ventilated COVID-19 patients.
Diagnosis (PES Statement)

Inadequate protein energy intake and

inadequate enteral nutrition
infusion related to hemodynamic
instability as evidenced by trickle TF
meeting <50% of estimated energy
needs
Intervention – Tube Feeding
 ChangeTF to Vital HP at 10 ml/hr. When
hemodynamically stable, advance to 30
ml/hr. (provides 720 kcal, 63 g protein, 602 ml free
water, with 483 kcal/day from propofol).

 If propofol d/c, recommend TF of Vital AF 1.2 advance to

goal rate 45 ml/hr (provides 1296 kcal, 81 g protein,
876 ml free water).

 If K/Phos continue to trend up, recommend Novosource

Renal 2.0 at 15 ml/hr (provides 720 kcal, 33 g pro, 258
ml free water, with 483 kcal/day from propofol).

 If propofol d/c and K/Phos continue to trend up,

recommend Novosource Renal 2.0 at goal rate 25 ml/hr
+ prosource BID (provides 1320 kcal, 85 g pro, 430 ml
free water).
https://abbottnutrition.com/vital-hp
https://www.nestlenutritionstore.com/novasource-renal.html
Monitoring and Evaluation

Total energy intake, Total protein

intake, Formula/Solution, Nutrition Goal: Patient will
Enteral rate/composition/route, meet 75-100% of estimated
IV fluids, Prescription needs by follow up
medication and Weight change
Discussion
Initiate enteral nutrition support within 12 hours of intubation or parenteral
nutrition if gastric enteral nutrition is not an option. (3)

Hyper catabolism or break down of lean body mass occurs in the early acute
phase of critically ill patients. (4)

Meeting estimated nutritional needs: goal of 70%-80%

Early enteral nutrition support - reduced mortality, morbidity, infections,

or complications in the ICU. (5)

Dense formulas should be avoided with patients in prone positioning as this

can promote enteral feeding intolerance. (3)
Conclusion
• Enteral nutrition support: effectively provided adequate protein and
energy calories on the ventilator without overfeeding or enteral feeding
intolerance

• Individualized formula selection

• Monitored laboratory values, medications with potential nutrient

interactions, IV fluids and IV medications, bowels, input/output, and
mean arterial pressure

• Future research is determining appropriate tube feed formulas. Disease-

specific formulas may not be necessary as it is more important to not
overfeed the patient. (4)
References:
1. Coronavirus Disease 2019 (COVID-19). Symptoms. Centers for Disease Control and
Prevention. Accessed June 7, 2020. https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html
2. ASPEN Report on Nutrition Support Practice Processes with COVID-19: The First
Response. May 2020. Diana Wells Mulherin, PharmD, BCNSP; Renee Walker, MS,
RDN, LD, CNSC, FAND; Beverly Holcombe, PharmD, BCNSP, FASHP, FASPEN;
Peggi Guenter, PhD, RN, FAAN, FASPEN; and the ASPEN Clinical Practice
Committee. Accessed June 9, 2020.
3. Dina AL Muharib, MSc, Nada AlMohaisen, MSc. Medical Nutrition Therapy for
COVID-19-Quick Guide. Page 1-3. Accessed June 9, 2020.
http://www.efad.org/media/1975/medical-nutrition-therapy-covid-19.pdf
4. Mehta Y., Sunavala J. D., Kadhe G. Practice Guidelines for Nutrition in Critically Ill
Patients: A Relook for Indian Scenario. Page 36. Page 50. Accessed June 10, 2020.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930530/
5. Evidence Analysis Library. Critical Illness (CI) Guideline (2012) Executive Summary
of Recommendations 2012. Accessed June 7, 2020
https://www.andeal.org/topic.cfm?menu=5302&cat=4840