(Courtesy of Afford Medical Technologies Pvt Ltd.

Meike Maya S
 Fig 3
Metabolic Changes During Stress

The liver produces large amounts of

glucose, from glycogenesis and
neoglucogenesis. Glucose will be
mainly used by non-insulin-
dependent organs,.

FFA released by lipolysis are highly

susceptible to peroxidation by the
ROS massively released after stress-
induced mitochondrial dysfunction.
Glycerol released from lipolysis will
be regenerated by the liver into
glucose.

Muscular proteolysis will release

amino acids that will be recycled into
glucose (mainly alanine and
glutamine) or degraded into urea or
ammonium.

Lactate generated in hypoxic areas

will be used by the liver to generate
glucose by the Cori cycle

British (10.1093/bja/aeu187)
British Journal of Anaesthesia 2014 113, 945-954DOI: Journal of Anaesthesia 2014 113, 945-954DOI: (10.1093/bja/aeu187)
 Fig 4

Illustrative example of the EE and use of the type of energy substrates used
during the early, the late, and the recovery phases
Metabolic Response To Stress

Ebb
• Occuring immediately
after injury ↓cardiac
output, oxygen

phase consumption, body

temperature

• ↑cardiac output, oxygen

Flow consumption, body
temperature, energy

phase
expenditure, total body
protein catabolism
 COVID 19

Respiratory Failure

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2)

Requiring ICU Care

Risk Factor for ICU Admission

25-40% have at least

comorbidity
Older (≥60 years)
(hypertension, DM,
HD, COPD)

75% overweight and

obese
Clinical course and risk
factors for mortality of adult
inpatients with COVID-19 in
Wuhan, China: a
retrospective cohort study
(Zhou, F et al., 2020)
Nutrition Screening
 Nutrition Screening

British
Australia/
Dietetics ESPEN ASPEN
New Zealand
Association
• No • High • Use MUST/ • No
Recommendation recomendation
nutrition NRS 2002
risk criteria
stated

Chapple, L.A.S., et al., (2020)

Nutrition Assessment
COVID 19 Patient Requiring ICU Care
Nutritional management = any other ICU
patient admitted with pulmonary compromise

Nutrition Assessment

• Use of personal protective equipment/ APD sesuai

panduan tim viral airborne
• With limited APD supply many dietitians are not entering
ICUs/ patient room
• Not performing a nutrition focused physical examination
(relying on other healthcare providers)
• Calling the patient or family, using telehealth visits (virtual
and telephone)
• Collaborate an coordinate with medical team A safe
nutrition care plan
Martindale, R., et al., (2020)
 Clinical features and nutrition management
for patients with COVID-19 in ICU

Nutrition management
Clinical features Nutritional implication
strategies
Insulin resistance Blood glucose control
Metabolism alterations
Protein catabolism Higher protein EN
Bedside practices limited
Remote consults
Staff sickness
Highly transmittable virus Team planning
Impact on food service and
Upskill non-ICU dietitians
menu selection
Nutrition Diagnosis
Inadequate oral food and beverage intake
Nutrition
Inadequate or excessive intake from EN or PN infusion Diagnosis is
Inappropriate infusion of EN or PN
commonly
used in the ICU
Inadequate or excessive fluid intake

Increased nutrient needs

Excessive carbohydrate intake

Abnormal nutrition-related laboratory values

Altered gastrointestinal

Malnutrition

Mahan LK & Raymond JL., (2017)

Nutrition Intervention
Nutrition Requirement
CALORIE PRESCRIPTION
British Australia/New ESPEN ASPEN
Dietetics Zealand • IC if safely • No IC
Association • No IC available • Hypocaloric
• As per current • Algorithm first 5 • Hypocaloric (<70% feeding
local practice d (approximately of EE) progressive to 15-
20-25kcal/kg) with increments to 20 kcal/
• 25-30 kcal/kg/d 80-100% kg/day (~70-80%
after after day 3 caloric
5d requirements)
Body weight used in equations

Use actual body Use actual weight

Actual body weight
weight or or adjusted weight No
ideal weight if if overweight/ recommendation
unavailable obese

IC : indirect calorimetry

Chapple, L.A.S., et al., (2020)

 PROTEIN PRESCRIPTION
British Australia/New ESPEN ASPEN
Dietetics Zealand • -1.3 g/kg/d • 1.2-2.0 g/kg/d
Association • -≥1.2g/kg/d delivered
• As per current progressively to
local practice target by
day 3-5

Chapple, L.A.S., et al., (2020)

>>If undergoing CRRT , increased loss protein via the filtarition process 
protein 2- 2.5 g/ kgABW/day
>> Serum protein markers (albumin, prealbumin, transferin, CRP) not
validated for determining adequacy of protein provision
Carbohydrate
Should provide 60 – 70% calories

40-50% (patients with mechanical

ventilation) or hipercapnea

Blood glucose levels should be

monitored and nutrition regimen and
insulin adjusted to maintain glucose
 Can be used to provide needed energy and
Fat essential fatty acids

Should provide 15 – 40% of calories

Limit to 2.5g/kg/day or possibly 1

g/kg/day IV*

Caution with use of fats in stressed &

trauma pts

• There is evidence that high fat feedings

(especially LCT) cause immunosuppression
• New formulas focus on omega-3s
 Estimated at 1 ml of water
Fluid per kilocalorie consumed, or
30 to 35 ml/kg of usual
body weight.

Holiday Segar Method

• 0 -10 kg : 100 cc/ kg

• 10-20 kg : 1000cc+50 cc/kg for each
kg over 10 kg
• 20kg and up : 1500 cc+20 cc/kg
each kg over 20 kg
 FORMULA

British Dietetics Australia/New ESPEN ASPEN

Association Zealand • No • Standard high
• Consider protein
supplements if
• 1.25-1.5 kcal/ml recommendation protein (>20%
unable to meet • Avoid 2 kcal/ml protein)
targets EN polymeric
• Volume isosmotic enteral
restricted/low elec formula
trolyte EN if fluid • Fibre can be
restricted considered
• Consider 1.3/1.5 once stable
kcal/ml
feeds if prone

EN: Enteral Nutrition

 Timing of Nutrition Delivery
Goal : Early enteral nutrition (24-36 hours of
admision to ICU/12 hours of intubation and
placementon mechanical ventilation)

Majority patient with sepsis/ circulatory

shock tolerate early EN at a trophic rate

Early parenteral nutrition (PN)  high risk

patient for whom early gastric EN is not
feasible

Recommendation Guidelines

British Dietetics Australia/New ESPEN ASPEN

Association Zealand • ‘Early phase’ • Commence
• No • Commence feeding- not within 24-48
recommendation within 24h further specified h of ICU
• Goal rate within • Goal rate within admission
5d 3-5 d • Goal rate within
first week
NPO: Nil Per OS/ nothing by mouth
IVF : intravenous fluid
Mahan and Raymond (2017)
 Access/ Routes
of Feeding
Graphic source:
Oral Feeding http://www.rxkinetics.com/tpnt
utorial/1_4.html

Enteral Feeding

• Oral Gastric Tube (OGT)

• Naso Gastric Tube (NGT)
• Naso Jejunal Tube
• PEG/ PEJ (Percutaneous Endoscopic
Gastrostomy/ Jejunostomy)

Graphic source:
Parenteral Nutrisi (PPN / TPN) http://www.rxkinetics.com/tpntutorial/1_4.html
Determining optimal route of nutrition support
 Route of Feeding
British Dietetics Australia/New ESPEN ASPEN
Association Zealand • Gastric • Gastric
• Gastric • Gastric • Post-pyloric if not • PN if gastric
• Post-pyloric if poor • Post-pyloric or PN if tolerating contraindicated
tolerance not or at high aspiration
• PN if post-pyloric not tolerating risk
available • PN if not tolerating
for 1
week
Chapple, L.A.S., et al., (2020)

EN is preferred to PN

If gastric feeding is unsuccessful (EN intolerance) prokinetic agent

If fail  use post pyloric feeding tube to limiting exposure do not require use of endoscopy or
fluoroscopic guidance

Continous rather than bolus EN

Patient COVID 19 with GI problems : early PN transitioning to EN when GI subside

If refeeding syndrome is present start at approximately 25% of caloric goal (EN/ PN fed) &
monitoring of serum Potassium, Magnesium, Phosphate. Calories are slowly increased

Martindale, et al., (2020)

 Nutrition Dose

EN start with low dose/ hypocaloric/ trophic

Advancing to full dose EN slowly over the first week

(energy goal 15-20 kcal/ kg actual body weight)

If PN  conservative dextrose content and volume in

early phase, slowly advancing

if patient give propofol (contain calories from lipid) 

nutrition requirement should be consideration

Martindale, et al., (2020)

 Formula Selection

Early acute phaseA standard high protein

(≥20 protein), poymeric isosmotic formula

Addition of fiber?

• If patient’s status improves

• GI dysfuntion  a fiber free formula

If PN required

• Patient who receive propofol/ IV lipid emulsions early witin

24 hours monitor serum triglyceride levels

Martindale, et al., (2020)

Monitor EN Level of pain
Tolerance
Abdominal distention

Passage of flatus and stool

Physical examination

Diarrhea-assess cause infectious

diarrhea, intake hyperosmolar, broad
spectrum antibiotics

Recording of the percent of calories

and protein delivered should be
Martindale, et al., (2020)
recorded for both EN and PN.
 Gastrointestinal management

British Dietetics Australia/New ESPEN ASPEN

Association Zealand • No • No GRV
• GRV monitoring • GRV cut-off recommendation monitoring
as per usual <300ml, • Prokinetics
practice, or GRV monitor 8 hourly. • Post-pyloric
cut-off Cease feeding if all
<300ml, monitor measures if other measures
4 hourly GRVs <300ml not successful
if prone for >48h in
• Early/prophylact patients who
ic proki are not prone
netics in patients
with high
GRVs
Be careful...

• Re-feeding syndrome

• Underfeeding

• Overfeeding
Overfeeding,
harmful!
Intake of 50% to 65%
of goal calories during the first
week of hospitalization is
thought to be sufficient to
achieve the clinical benefit of
EN
1) Excess calories
• hyperglycemia,
• hepatic steatosis,
• Excess CO2 which can exacerbate
respiratory insufficiency or prolong
weaning from mechanical ventilation.
2) Overfeeding protein can result
in uraemia, dehydration, and
metabolic acidosis.
3) Overfeeding fat can result in
hypertriglyceridemia, and
compromise immunity
 Medical Management, Nutritional Implications and Suggested
Nutrition Management Strategies for Patients with COVID-19
in ICU
Nutrition management
Medical Management Nutritional implication
strategies
Dry mouth
High energy/high protein
Shortness of breath
High flow nasal oxygen diet
Fatigue
therapy Oral nutrition supplements
Fasting for potential
Early escalation to EN
intubation
1.25-1.5kcal/ml EN
Prokinetics for GI intolerance
Post-pyloric feeding or PN
Delayed gastric emptying
Account for propofol calories
Non-nutrition calorie
Deep sedation in nutrition
contribution from
prescription if >110% is
propofol
being provided
by nutrition and non-
nutrition calories
Delayed gastric emptying
Lower GRV threshold
Increased regurgitation and
Prone 1.25-1.5 kcal/ml EN
vomiting
Post-pyloric feeding or PN
Feeding interruptions
Energy-dense formula
Respiratory failure Restricted fluid input Potential compromised
protein intake
Monitoring and Evaluation
Commonly Used
Nutrition Enteral or parenteral nutrition
intake
Monitoring &
Evaluation Energy intake
Domains
Digestive system

Vitamin profile

Weight or weight change

Electrolyte and renal profile

Food intake
 Dietetic Practices/Resourcing

British Dietetics Australia/New ESPEN ASPEN

Association Zealand
• Remote reviews • Remote reviews • No • Bundling clinical
• Upskill non-ICU • Consider team recommendation care
dietitians structure • Remote reviews
• Stock levels of • Train on PPE • Stock levels of
EN formula, • Utilise Allied EN formula,
pumps & Health Assistants pumps &
ancillaries • Review food ancillaries
• Review service
communication systems
pathways • Stock levels of
EN formula,
pumps &
ancillaries
 COLLABORATION

Doctor

Dietician,
Physiotherapy
Nutrisionist

Pharmacist Nurses
 REFERENCES
Beaumont Hospital’s Intensive Care Units. 2009. Multidisciplinary Nutrition Support Guidelines: Adults
Hoffer LJ and Bistrian BR. Nutrition in critical illness: a current conundrum [version 1; referees: 2
approved] . F1000Research 2016, 5(F1000 Faculty Rev):2531
Barazzoni R, Bischoff SC, Krznaric Z, Pirlich M, Singer
P endorsed by the ESPEN Council. (2020) ESPEN expert
statements and practical guidance for nutritional
management of individuals with SARS-CoV-2 infection.
Clinical Nutrition, E-pub ahead of print: doi.org/10.1016/j.
clnu.2020.03.022
Chapple, L.A.S., Fetterplace, K., Ridley, E.J. 2020. Nutrition for Critically Ill Patients with COVID-19. ICU
Management & Practice, Volume 20 - Issue 1. Australia
Mahan LK & Raymond JL. 2017. Krause’s Food & The Nutrition Care Process. Elsevier : Missouri
Pirlich M. 2016. Approach to Oral and Enteral Nutrition in Adults. Germany: ESPEN LLL Programme
Preiser JC, Ichai C, Orban JC, Groeneveld ABJ. Metabolic response to the stress of critical illness. British
Journal of Anaesthesia 2014 113, 945-954DOI: (10.1093/bja/aeu187
Simon C, Faut CE, Wooley, JA. Lessons Learned in Applying the Nutrition Care Process to Critically Ill
Patients. Support Line 2009, Volume 31 No. 2
Martindale R, Patel JJ, Taylor B, Warren M, McClave SA (2020) Nutrition therapy in the patient with
COVID-19 disease requiring ICU care. Available from sccm.org/getattachment/Disaster/Nutrition-
Therapy-COVID-19- SCCM-ASPEN.pdf?lang=en-US
Zhou F., Yu T., Fan G., Liu Y., et al. 2020.Clinical course and risk factors for mortality of adult inpatients
with COVID-19 in Wuhan, China: a retrospective cohort study. www.thelancet.com Vol 395 March 28,
2020