Recommendations for nutrition therapy in critically ill COVID-19 patients

Nutrition Management in Critically Ill Project Team, Chinese Nutrition Society for Clinical Nutrition

Abstract: At present, fighting against the novel coronavirus pneumonia (COVID-19) epidemic is entering the
decisive stage, and nutritional treatment of critically ill patients is a key measure to reduce the mortality.
This paper aims to provide recommendations to improve the effect of nutrition therapy among the critically
ill COVID-19 patients. Taken the front-line clinical experience and metabolic characteristics of critically ill
patients into consideration, we have made recommendations on characteristics of nutritional metabolism,
nutrition screening, nutritional requirements, choice of nutrition programs and approaches, and monitoring
method of nutrition during the treatment for critically ill COVID-19 patients.

Key words: COVID-19 critically ill patients nutrition therapy enteral nutrition parenteral nutrition

Changes of metabolism in convid-19 patient:

1. Reduced glucose oxidative energy supply, increased glycolysis, increased gluconeogenesis, insulin
resistance, increased blood sugar
2. Increased protein breakdown, increased protein synthesis in the acute phase, decreased muscle
protein synthesis, and altered amino acid profile: such as decreased branched chain amino acid
(BCAA) concentrations
3. Increased fat mobilization and breakdown
4. Increased consumption of multivitamins and trace elements

Malnutrition due to imbalance of supply and demand of the energy requirement

1. Increased energy consumption due to factors such as fever, increased work of breathing muscles,
mechanical ventilation. Energy consumption increases, and therefore demand for energy also
increases.
2. Metabolic disorders. Impaired glucose utilization, increased protein and fat catabolism, causes
negative nitrogen balance in the body
3. Inadequate intake and malabsorption of nutrients. Loss of appetite, dyspnea, mechanical ventilation,
disturbance of consciousness are the factors of bedridden patient causing inadequate intake of
nutrient required. coronavirus can directly attack the gastrointestinal tract, drug treatment or
enteral nutrition intolerance can cause diarrhea, nausea, vomiting and other gastrointestinal
dysfunction, which can lead to malabsorption and increased loss of nutrients

NUTRITIONAL ASSESSMENT

- suggested to use NRS 2002, or modified NUTRIC score

- NRS 2002 ≥3, patient is at risk of malnutrition; NRS 2002 ≥5 or NUTRIC score≥5, patient is at high risk
of malnutrition, early nutrition intervention is required
- Those at low risk are advised to repeat assessment after 3 days

NUTRITION INTERVENTION for COVID-19

1.1 nutrition requirements
1.1.1 energy requirement
- energy requirement calculation using VCO 2 : REE(kcal)=VCO2×8.19
- energy requirement calculation from weight estimation:
o non obese group: 25-30 kcal/kg (ideal body weight)
 ideal body weight estimation:
 male – ideal weight, kg = height, cm – 105
 female – ideal weight, kg = (height, cm – 100) ×0.85
o obsess group BMI 30-50 kg/m2: 11-14 kcal/kg (current body weight)
o morbid obese BMI > 50 kg/m2: 22-25 kcal/kg (ideal body weight)
- energy counting factor:
o medication that contain glucose, ex D-glucose: 3.4 kcal/g, glycerol / glycerol: 4.3 kcal/g
o contain fatty acid propofol 1.1kcal/ml
- In the early stages of stress such as infection, feeding should be started at a low rate, and the
nutritional supply should not exceed 70% of the target amount, can also try to allow permissive low
calories (≤50% of the target feeding amount/ 10-15kcal/kg/day). Energy intake should be gradually
increased to the target amount within 3 to 7 days after patient stabilized.

1.1.2 protein
- protein intake: 25-30% Energy Intake
- intake requirement based on weight
o non-obese group: 1.2-2.0 g/kg (ideal body weight)
o obsess group BMI 30-40 kg/m2: 2 g/kg (ideal body weight)
o morbid obese BMI > 40 kg/m2: 2.5 g/kg (ideal body weight)
o kidney failure without CRRT patient: reduced on protein intake
o kidney failure with CRRT patient: 1.2-2.0 g/kg
- increase HBV protein and BCAA: HBV include whey protein and protein from animal sources (50% of
protein requirement), helps to reduce muscle wasting, enhance respiratory muscle strength,
promote cough and expectoration
- advised to supplement BCAA up to 35%, not only significantly inhibit muscle breakdown, but also
improve insulin resistance and enhance the efficacy of interferon
- Non-protein thermal energy / nitrogen ratio:
o Recommended to reduce non-protein energy / nitrogen ratio (100 ~ 150 kcal): 1 g
1.1.3 Fat
- Fat intake: 25-30% energy intake
- For patients with covid-19 who are critically ill with parenteral nutrition, due to changes in fat
absorption and metabolism, excessive intravenous injection of fat can lead to lipid overload and
toxicity, causing hypertriglyceridemia and abnormal liver function. Glycerol concentration levels
correlate with improved survival
- Recommended intravenous lipid 1g/kg, not more than 1.5g/kg, adjust dose according to individual
tolerance
- Types of fat:
o For critically ill patients who can eat orally, increase the intake of essential fatty acids
through a variety of cooking vegetable oils, especially monounsaturated fatty acid vegetable
oils
 o For critically ill patients with parenteral nutrition, the use of medium and long chain fatty
acids is preferred, as compared with long chain fatty acids, the oxidative utilization of fatty
acids higher, but usage of soybean oil I.V fat emulsion is not recommended
o the use of omega-3 fatty acids in critically ill patients has a lower risk of infection and death,
and a shorter hospital stay, so it is recommended to increase the proportion of fish oil
(mainly omega-3 fatty acids)
o Omega-9 fatty acids have an immune-neutral effect and have less interference with
hemodynamics, endothelial cell function, immune function and liver function, so it is
recommended to increase the proportion of olive oil (mainly omega-9 fatty acids)

1.1.4 Glucose-lipid ratio

- Increased endogenous glucose production in critically ill patients with insulin resistance
- Too much glucose can lead to blood sugar increase, increase CO 2 production, increase fat synthesis,
and increase insulin requirements
- Suggest to reduce glucose:lipid ratio to (50-70):(50-30)
- Minimum carbohydrate intake: glucose 2g/kg
- For critically ill patients with covid-19, continuous dynamic monitoring of blood glucose levels should
be performed, and the target blood glucose value should be controlled between 7.8 and 10.0
mmol/L
- Hyperglycemia (blood glucose level> 10 mmol / L) will increase patient mortality and infection
complications and should be avoided
- If blood glucose is consistently greater than 20 mmol/L, insulin infusion pump is recommended

1.1.5 fluid requirement

- 30~40 mL/kg for stable patient
- Minimize fluid intake based on nutrient requirement and output
- For every 1°C increase in body temperature, supplement 3 ~ 5 mL/kg (calculated as 4 mL/kg)
- IO balance is important in covid-19 patient as most of them suffering with pulmonary edema and
fluid accumulation, prevent fluid overload especially from IV drip

1.1.6 trace elements

- vitamins and minerals intake based on RNI
- Patients with impaired liver and kidney function, gastrointestinal complications, refeeding syndrome
or electrolyte disorders should be adjusted according to the actual situation.
- Recently multiple studies shown that high dose of i.v. vitamin C (3-10g/day) can reduce mortality in
critically ill patients, reduce drug usage and ventilation period, also effective in treating acute
respiratory distress syndrome (ARDS) caused by viral infection
- Vitamin D deficiency is common in critically ill patients and is associated with adverse clinical
outcomes, including higher mortality and infection rates, longer hospital stays, and longer
mechanical ventilation. Therefore, if the 25-OH vitamin D level of critically ill patients is lower than
12.5 ng/mL or 50 nmol/L, vitamin D3 should be supplemented. Large doses of vitamins D3 (500 000
UI) can be given at one time after one week of admission in intensive care unit.
- Hypophosphatemia often occurs in critically ill patients, such as blood phosphorus ≤0.5 mmol/L,
need to be observed on the presence of refeeding syndrome. Therefore, it is recommended to
closely monitor the serum phosphate concentration and to give appropriate phosphate supplements
if necessary

Minerals Recommendation Trace elements Recommendation

 Sodium/potassium 1-2 mmol/kg Chromium < 1mg
Calcium 10-15 mEq Copper 0.3-0.5 mg
Magnesium 8-20 mEq Manganese 55 mcg
Phosphate 20-40 mmol Selenium 60-100 mcg
Zinc 3-5 mg

Vitamins Recommendation Vitamins Recommendation

Vitamin B1 6 mg Vitamin C 200 mg
Vitamin B2 3.6 mg Vitamin A 990 mcg
Vitamin B3 40 mg Vitamin D 5 mcg
Folate 600 mcg Vitamin E 10 mg
Vitamin B5 15 mg Vitamin K 150 mcg
Vitamin B6 6 mg
Vitamin B12 5 mcg
Biotin 60 mcg

1.2 Nutrition education counseling, ONS, EN, PN

1.2.1 Oral intake / Oral Nutrition Support
- For patient who are able to eat, without risk of vomiting or aspiration, oral intake should be targeted
to meet 70% of nutritional requirement within 3 to 7 days
- Encourage orally, small and frequent meal suggested
- If oral intake does not meet the patient's requirement, ONS should be prioritized, followed by EN
- Energy of 400 ~ 600 kcal from ONS is suggested.
- For patients with dysphagia, try to reduce the risk of aspiration by changing food properties (texture)
or other methods. If the dysphagia worsens, EN should be given.

1.2.2 Enteral Nutrition

- Contraindication for EN: Including uncontrolled shock, uncontrolled hypoxemia and acidosis, upper
gastrointestinal bleeding, intestinal ischemia, intestinal obstruction, abdominal compartment
syndrome, and enterocutaneous fistula
- Indication for EN: Enteral nutrition can maintain the integrity of the intestinal function, prevent
gastrointestinal complications in patients with mechanical ventilation, promote intestinal immune
function
- Early EN within 24 to 48 hours should be given to critically ill patients with covid-19 who can not
tolerate orally and has no contraindications to EN
- Early EN is also recommended for patients receiving extracorporeal membrane oxygenation (ECMO)
- Trophic feeding: 10-20ml/hour or 10-20kcal/hour, can prevent intestinal mucosal atrophy and
maintain intestinal integrity, therefore for patients who are not tolerating on EN or unable to step up
feeding, trophic feeding should be encourage if allowed
- continuous feeding helps in reducing risk of causing diarrhea compared to bolus feeding, thus
continuous feeding (feeding pump) is preferred if condition allowed. Feeding initiated with 20-
30ml/hour, if there is no aspiration after 2 hours, allowed to increase rate by 10ml/hour until 60-
100ml/hour
- intubated patient should prop up by 30-45° to reduce the risk of aspiration pneumonia, cleaning the
mouth with chlorhexidine mouth wash twice a day is suggested. If prone ventilation used, enteral
nutrition should be withhold at least half an hour to one hour before the action, check on gastric
 residual to prevent complications such as aspiration and suffocation due to reflux or vomiting during
the inversion
- EN formula:
o Standard polymeric formula: suitable for patients with covid-19 without underlying disease
such as elevated blood glucose and renal insufficiency, and normal gastrointestinal function.
However, since the demand for protein in critically ill patients is higher than that for energy,
standard formula preparations may not achieve protein requirement, and modular protein
can be added if necessary
o Diabetic friendly formula: for patients with diabetes or associated with elevated blood sugar
o Kidney related formula: for patient with renal failure
o Energy dense formula (1.5-2kcal): for patient with fluid restriction
o High dietary fiber formula: for patients with persistent diarrhea without intestinal ischemia
or severe gastrointestinal dysfunction. Soluble dietary fiber (fructo-oligosaccharide, inulin,
etc.) can also be added to the standard formula, 10-20g per day.
o Short chain peptide formula: suitable for patients who give EN by nasal jejunal tube route or
diarrhea due to gastrointestinal malabsorption
o Pulmonary disease specific formula (high fat/low carbohydrate): the use of high fat / low
carbohydrate formula for ventilated patient is still controversial. It has been thought that the
use of this formula can reduce CO2 production and reduce respiratory entropy. However
there are studies showing as long as there is no overfeeding, energy intake approximately
equal to energy expenditure, the composition ratio of macronutrients does not affect
production of CO2. In addition, the high content of omega-6 fatty acids in this formula may
be proinflammatory. Therefore, it is not recommended to use this formula for patients
o Formula for immunomodulation: such as formulas that added with omega-3, γ-linolenic acid,
glutamine, etc. In view of limited research studies with conflict results, it is not
recommended for covid-19 patients
- Gastrointestinal complications of EN: the use of antiviral drugs, sedatives and mechanical ventilation
can give direct impact on gastrointestinal tract causing bloating, vomiting, diarrhea and other
gastrointestinal complications, some severe cases require withhold of EN
o Vomit & bloating/abdominal distention: use of prokinetic agent, such as metoclopramide
10mg or erythromycin 3-7mg/kg for 3 to 4 times a day. Domperidone is not recommended
as it may cause severe tachycardia as well other symptoms. If prokinetic agent does not
work, pyloric feeding is recommended.
o Diarrhea: slow down feeding rate, dilute EN formula to reduce osmotic pressure, or try on
high dietary fiber formula or short chain peptide formula and check on temperature of the
prepared formula.
- It is not recommended to stop EN completely due to feeding intolerance, try on trophic feeding
1.2.3 Parenteral Nutrition