Management of Fluid and Nutrition

Support for COVID-19 Patients

PRASENOHADI

Department of Pulmonology and Respiratory Medicine

Faculty of Medicine - Universitas Indonesia
Persahabatan Hospital – National Respiratory Referral Center
JAKARTA
INTRODUCTION

• The viral epidemic caused by the new coronavirus SARS-CoV-

2 is responsible for the new coronavirus disease 2019
(COVID-19).
• Up to 30% of the COVID-19 patients with ARDS  respiratory
and hemodynamic support in the ICU.
• The coronavirus SARS-CoV-2 is colonizing the respiratory
tract but may also invade the gastrointestinal (GI) tract,
neurological system, and kidneys.
Critical Care (2020) 24:447.
INTRODUCTION

• SARS-CoV-2  angiotensin-converting enzyme 2 receptor

(lymphocytes, monocytes, lung alveolar type 2 cells, esophagus
epithelial cells, enterocytes, and colonocytes)  rapid viral
replication and cell damage  induce huge inflammation and
increased cytokine secretion  cytokine storm
• The nutritional assessment and the early nutritional care
management of COVID-19 patients must be integrated into the
overall therapeutic strategy, as with any critical illness and
rehabilitation program.
Critical Care (2020) 24:447.
Nutritional Consequences of COVID-19 Disease

• Severe respiratory infections induce inflammatory syndrome and

hypercatabolism  increased energy expenditure linked to
ventilatory work, in turn responsible for increased energy and protein
requirements.
• Food intake is very reduced by several factors: anorexia secondary to
infection, dyspnea, dysosmia, dysgeusia, stress, confinement, and
organizational problems limiting attendance at meals  high risk of
malnutrition.
• Infection, hypermetabolism, and physical immobilization expose to
rapid muscle wasting.
A representation of the inflammatory
molecules involved in infection and how
certain dietary components may interact
with them.

Nutrients 2020, 12, 1466; doi:10.3390/nu12051466.

Schematic diagram showing interactions
between selected dietary constituents,
the immune system, and viral infection.

Nutrients 2020, 12, 1562; doi:10.3390/nu12061562.

Deleterious effects of the
anti-COVID-19 strategy
(RED) can impact the base
of the Mediterranean diet
pyramid.
An increase in polyphenol
uptake and substitution of
meat with legume-derived
proteins can help prevent
chronic inflammation, and
reduction of caloric intake
may compensate for the
reduction in physical
activity.
Alcohol consumption is
discouraged for healthy
people and is detrimental
for patients, even in the
absence of clinical
symptoms.
Front. Immunol. 11:944. doi:
10.3389/fimmu.2020.00944
Common Problems in Infectious Hospitalized
Patiens

Dehydration

Anorexia

Fatigue
What is Maintenance Fluid Therapy?

1. Dehydration but hemodynamically stable

2. No serious electrolyte abnormality
3. Provision of water, electrolytes based on
normal daily requirement

TODAY

On top of basic electrolytes, add

microminerals,glucose, amino acids
Clinical Nutrition. 2020;39:1631–8.
Medical nutrition therapy
for critically ill patient

Eur Rev Med Pharmacol Sci. 2020;24:4035-9.

Critical Care. 2020;24:447.
INDIKASI NUTRISI Penilaian Nutrisi 
ENTERAL DAN Keputusan untuk memulai Dukungan Nutrisi Khusus
PARENTERAL Fungsi Saluran Pencernaan

Ya Tidak

Nutrisi Enteral Nutrisi Parenteral

Jangka panjang Jangka pendek
Gastrostomi Nasogastrik
Jejunostomi Nasoduodenall Jangka panjang atau
Jangka pendek
Nasojejunal Pembatasan cairan
 
Fungsi Sal Cerna Nutrisi Nutrisi
Parenteral Perifer Parenteral Total
Normal Compromised

Nutrisi Lengkap Formula Khusus  Fungsi saluran

cerna membaik
Nutrients
Tolerance 
Mencukupi Mencukupi Tidak
Tidak mencukupi Ya
Berlanjut ke Diet yg lebih
Makanan Nutrisi parenteral Kompleks dan
Sebagai suplemen Sumber: ASPEN Board of Directors
Oral Makanan oral
Guidelines for the use of Parenteral and
Sesuai dengan
Enteral Nutrition in adult and pediatric
penerimaan
Dilanjutkan ke nutrisi Patients. JPEN 1993: 17.
Enteral total
Nutritional management in individuals at risk
for severe COVID-19, in subjects suffering
from COVID-19, and in COVID-19 ICU patients
requiring ventilation

Clinical Nutrition 39 (2020) 1631–8.

 Fakta maintenance :

• RL/NS
• 5% Dextrose
• RL/D5%
• NS/D5%
Masih digunakan secara luas untuk
Terapi cairan maintenance*****
Ilustrasi BB Dewasa (Org Indonesia) : ± 50 kg
Kebutuhan Air 2000 mL RL 2L KAEN 3B / BFLUID®
Natrium 50 – 100 mEq 260 mEq 100/70 mEq
Kalium 50 mEq 8 mEq 40 mEq

Infus RL bukan
Untuk Terapi Rumatan
 BFLUID®

Glucose Amino acids

7.5 ％ 3%

BFLUID

Electrolytes
Added (Na, K, Cl, Mg, Ca, P)
Thiamin ＋ Zinc
 Manfaat Pemberian Asam Amino

Peran Asam Amino Kehilangan obligat dari nitrogen (FAO/WHO)

Bahan baku untuk sintesis protein 　　　　　　　　　　　　　　　　　　　　
Memperbaiki imbang nitrogen
mg N/kg/hari
　　　 Total loss
Meningkatkan metabolisme Urine 37
protein 54 mg/kg/hari
Tinja 12
Sesuai dengan
Kulit 3 31 .6 g AA/hari
●Mencegah penyulit post op
● Memperbaiki prognosis
Lain-lain 2 Pada orang 60-kg ※

※:
0.054 (g) ×7.5*×60 （ kg ） ×1.3** ＝ 31.6 (g)
*: Conversion of nitrogen to amino acid (6.25×1.2 ）
**: Increased by 30%, considering individual difference.
FAO: Food and Agriculture Organization (United Nations)
 Penya-kit
Gastro-

Infeksi akut/
intestinal DBD Pada sepsis  kebutuhan AA 1.5-2 g/kg BB/hari
Demam

Bfluid perlu ditambahkan

Hiper-emesis
Gravida-rum
Aminofluid
Neurologi

Diabetes
Mellitus
Post
operatif
Sepsis

Total Calorie 25 kcal/kg

AA 1.5 g/kg

Misal 1 L Bfluid + 500 ml Amparen : NPC 300 kcal + AA 80 g

Jika perlu extra kalori bisa ditambahkan emulsi lemak atau KH atau Nutrisi Enteral

Yuichi Imai: Practice of Clinical Training, 2004; 1 (5): 6-13.

 Neomune 

1 sachet 5 sachet
Arginine 2,24 g 11,20 g
Glutamine 0,87 g 4,35 g
Fish oil 1,11 g 5,55 g
Casein 8,89 g 44,45 g
Carbohydrate 21,2 g 106,0 g
Vitamins
Minerals

NPC 128 kcal/sachet; Protein 12,0 g/sachet

20
 Stress and Cytokines
Stress
Immune Cells
Lymphocytes Macrophages PMNs

Glutamine

TNF, IL-1, IL-2, IL-10, Interferon

Host Defense Organ Injury

21
SUMMARY

• At this time of the COVID-19 pandemic, given the huge sanitary cost and
human resource spending, attention to nutritional medical therapy and
nutritional status should be considered among the “basic vital signs” as
important as blood pressure and pulse oximetry.
• Optimized nutrition care of the ICU COVID-19 patients is important to
maintain GI tract function, sustain immune defenses, and avoid severe loss
of muscle mass and function.
Thank You