Clinical Case Report: Nutritional Management of Covid - 19

Daniel Lokic

April 9th 2023

Queens College Dietetic Internship

Queens Hospital Clinical Rotation

Abstract

This case is on a 71 y/o patient that was admitted for shortness of breath which turned out

to be Covid-19. Covid-19 is a highly contagious viral illness that can spread through infected

peoples mouths or noses through small liquid particles.1 Can cause mild to moderate respiratory

illness without requiring special treatment. However can become severe or critical and may

require medical attention. Some risk factors affecting the severity of the illness are severe

obesity, chronic kidney disease, diabetes, obesity, hypertension, asthma, age, sex, and race.2 This

patient is non-verbal with cerebral palsy and came in with a peg tube. She had a few

comorbidities of diabetes, hypoxia, septic shock, pneumonia, and pressure ulcers. She developed

several pressure injuries and went into septic shock and has been in the hospital for around 3

months now. She is placed on a continuous Glucerna feed with supplementation of prostat and

Juven daily. Her lab values are trending in a good direction and showing stability.

Disease Description

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) or more commonly

known as Covid-19 is a highly contagious illness that has been rapidly spreading around the

world for the past 4 years. It has affected over 750 million people of all ages, 6.8 million known

deaths have been documented.3 Its ability to mutate within our body has created several variants

throughout the 4 years. Alpha was the first variant discovered in the United Kingdom in late

December 2020, Beta was the first reported in South Africa in December 2020, Delta was the

first reported in India in December 2020, Gamma was the first reported in Brazil in early January

2021, and Omicron was first reported in South Africa in November 2021.4 These are some of the

most notable COVID-19 variants throughout the past few years. Each one has slightly different
symptoms and infectivity rates. Every variant can affect individuals differently based on their

genetics, age, race, comorbidities, and other factors.

Pathophysiology

The virus infects our body by entering through the respiratory tract and attaching to cells

in the airways and lungs. It reproduces itself, which leads to cell damage and death.5 This also

causes inflammation and fluid accumulation within the lungs, potentially leading to pneumonia,

acute respiratory distress syndrome (ARDS), and potentially, respiratory failure. 80% of Covid-

19 cases lead to some symptoms though primarily subside over the course of 10-14 days.6 For

more severe to critical cases the pathophysiology of the virus begins with it migrating from the

upper respiratory tract to the lower respiratory tract. There then is an infection of the Type 2

pulmonary alveolar epithelial cells, which leads to either a cytokine storm or continued viral

replication of the virus leading to apoptosis of the host cells.6 A cytokine storm is the release of

various types of cytokines listed in Appendix A, which play a role in maintaining our immune

system’s health. This then progresses to chemo-attraction of neutrophils which originally have a

role in dealing with inflammation and more production of anti-inflammatory cells to protect the

body.6 If the virus reaches this stage it has a possibility to reach Acute Respiratory Distress

Syndrome (ARDS), which can be fatal.6 If a cytokine storm does not occur, there is a replication

of viral particles that lead to cell death, which leads to more infection and replication in the

lungs, ultimately leading to the same end result of ARDS.6

Signs and Symptoms

 As mentioned before, there are several risk factors that influence the severity of Covid-19

which impact the signs and symptoms experienced. Appendix B displays the classification of

Covid-19 patients from asymptomatic all the way to critical. Asymptomatic patients display a

positive test although no clinical signs and symptoms along with normal chest imaging.5 Mild

patients display both acute respiratory tract infection and digestive system symptoms.5 These can

vary from fever, fatigue, myalgia, cough, sore throat, runny nose, sneezing, nausea, vomiting,

abdominal pain, or diarrhea. Moderate patients experience pneumonia with frequent fever and

cough, but no obvious hypoxemia and chest CT with lesions.5 Severe patients show pneumonia

with hypoxemia with an oxygen saturation of under 92%.5 Critical patients may have shock,

encephalopathy, myocardial injury, heart failure, coagulation dysfunction, acute kidney injury,

and ARDS.5

Risk factors

In a study involving over 5400 patients infected with Covid-19, hospitalization rates were

assessed based on risk factors of each individual.2 Hospitalization rates were higher among those

with greater than three underlying conditions including obesity, severe obesity, diabetes,

hypertension, and asthma.2 They were also increased if adults were aged 45-64, a greater risk if

they were above the age of 64, if they were males, and if they were non-hispanic black vs non-

hispanic white.2

Evidenced Based MNT Recommendations and Treatment

A literature review of nutritional support protocol for patients with Covid-19 discusses

some of the latest evidenced based medical nutrition therapy recommendations and treatment.
Appendix C & D discuss the nutritional recommendations according to the type of respiratory

support in patients with Covid-19 and the nutritional needs at different stages of critical illness.

In Appendix C, under ambient air, bi-nasal catheter, and non-rebreather mask oxygen support,

the nutritional support would be a preferred oral diet that includes a high calorie and/or high

protein supplementation.7 For mechanical ventilation oxygen support, early enteral nutrition is

recommended.7 For patients with extubation oxygen support, assessing dysphagia and providing

an oral diet if possible, though if it is not possible enteral is recommended.7 In Appendix D, it

shows a table discussing initial and late stage nutritional recommendations. There is a risk of

refeeding, so patients should aim to only reach 10-20 kcal/kg in the first 24 hours and then

increase it by 25% of their caloric needs every 24 hours after that, reaching a goal of 25-35

kg/kcal/day.7

In terms of protein, a goal of 0.8-1.0 g/kg for the first two days and 1.2-2g/kg between

the 3rd and 4th day.7 Overall, oral feeding and supplementation is always preferred if patients

have the ability to meet over 70% of nutritional needs between the 3rd and 7th day of

hospitalization.7 The enteral feeding formula must be polymeric if possible, with a greater than

20% protein composition in the initial phase of critical illness.7 It is also recommended that the

patient meets their recommended daily amounts of vitamin A, C, D, E, B-complex, omega 3,

selenium, zinc, and iron to promote adequate immune system functions.7 The link between

vitamin D deficiency and Covid-19 has been greatly studied and correlations seen between them.

Although unlikely for repeated vitamin D deficiency labs to be taken in a clinical setting, it is

recommended to monitor the patient's lab in order to properly supplement them. If the patient has

below 12 ng/mL the recommended dose is 500,000 IU once, when the patient reaches 20-30
ng/mL, the dose is 50,000 IU/week, and once the patient reaches 30+ ng/mL the dose is 25,000

IU/week until showing stable levels.7

Comorbidities

Diabetes

Type 2 diabetes is characterized by the body's difficulty in utilizing insulin effectively, a

hormone produced by the pancreas to regulate blood glucose levels. This is due to resistance to

insulin, which if it persists, the pancreas becomes unable to produce enough insulin, leading to

high blood sugar levels.8 The hemoglobin A1c is a test measuring average blood sugar level over

the past 3 months. The marker indicates whether the patient is at risk of developing T2DM or

how severe their diabetes has gotten. The risk factors can include genetic factors like family

history of diabetes, older age, obesity, intra abdominal obesity, physical inactivity, prior

diagnosis of gestational diabetes, smoking, diet, PCOS, prediabetes, race or ethnicity.8 Among

many people diagnosed with type 2 diabetes, it can be a misconception that avoiding

carbohydrates is necessary in order to help the problem. A proper keto diet can work if done

correctly though it is extremely hard to follow and many people will not experience a good

quality of life while on it. Carbohydrates themselves are not inherently bad to those with type 2

diabetes. Although carbohydrates do raise blood sugar levels, this is normal with almost every

person. Carbohydrates become a problem once blood glucose levels and A1c specifically reach

above the 5.6% threshold.8 Even then they will not pose a problem if handled correctly,

sometimes if necessary, insulin will need to be supplemented alongside an adequate

carbohydrate intake. Carbohydrates with proper portion control are recommended because some

may contain fiber which is beneficial in decreasing blood glucose.9

 Making sure the amount of carbohydrates in a single serving is below the individual

person's threshold is not exceeded. This is typically calculated by using the person's height,

weight, and meal frequency. In carbohydrate counting, food portions are split up into 15 grams

for easier counting. Using the diabetes carbohydrate food list, the foods are categorized based on

carbohydrates like starches, fruits, milk, sweets, deserts and other carbohydrates, and non-starchy

vegetables; meat and meat substitute; fats; and free foods.8 There is vast amounts of research

regarding benefits of a high fiber intake for a person with type 2 diabetes. Around 25–30 grams

of fiber a day is recommended to aid in controlling diabetes.9

Hypoxia

Hypoxia is a disease in which oxygen is not available in sufficient amounts to maintain

homeostasis, which can result from either low blood supply or low oxygen in the blood.10

Hypoxia can vary in intensity from mild to severe and can present in acute, chronic, or acute and

chronic forms. Hypoxia can be seen very frequently in the hospital as it can occur from various

respiratory related issues. Most interventions for hypoxia would be medical as the primary step is

to control the person's oxygen saturation and regular breathing patterns.10 Aside from that,

assessing dysphagia and the ability to maintain an oral diet is important for nutrition

interventions.10 Getting a speech pathology exam may be beneficial depending on the patient to

make sure they are receiving the correct food consistency. If oral diet is not possible for the

patient, ensuring they receive adequate enteral tube feeding.

Sepsis
 Sepsis is a potentially life threatening condition that is caused by an infection in the body

that causes damage to its own organs. It causes a dysregulated immune response, alterations in

blood flow, and disruption of normal physiological processes, which can lead to multi-organ

dysfunction and potentially death.11 About 1.7 million hospitalizations a year occur due to

sepsis with the primary population being elderly due to weakened immune systems.11 A primary

part of the medical nutrition therapy of sepsis is malnutrition screening. Making sure the patient

is eating over 75% of their meals, not losing significant weight in a short period of time, not

having fluid accumulation, or not observing fat or muscle wasting. Because of the inflammation

caused by sepsis, the body may lose a lot of lean body mass and require much greater amounts of

energy for the first 7-10 days.12 The recommended protein requirement for patients with sepsis is

1.2 - 2.0 g/kg/day along with 25-30 kcal/day to prevent muscle deterioration. Enteral or

parenteral should be used if the patient is not meeting above 75% oral intake.

Pneumonia

This patient came into the intensive care unit with pneumonia secondary to Covid-19.

Pneumonia is an inflammation of the air sacs in the lungs and the surrounding tissue, it can

generally be treated with antibiotics.13 It can cause various signs and symptoms, some more

common ones are respiratory symptoms like cough, dyspnoea, sputum production, and chest

pain.13 Yearly, there are about 46.5 per 10,000 people hospitalized with pneumonia in the United

States.13 It is important to monitor signs of malnutrition like adequate food intake and

maintenance of lean body mass. With increased inflammation within the body, our nutrient needs

may go up depending on the severity, so it is important for dietitians to maintain regular contact

to patients with pneumonia.

Pressure Ulcer

Pressure Ulcers develop through the breakdown of skin due to prolonged contact or

"pressure" to a single point on the body. There are an annual 60,000 deaths each year in the

United States from pressure injuries with an annual cost of $11 billion.14 Around 9% of patients

will develop a pressure ulcer upon admission to a hospital.14 They are categorized in 4 stages

depending on the severity of the wound and how deep it is. This patient had four different

pressure ulcers: Stage 3 coccyx, Stage 2 right buttock, jaw (BIPAP), and anterior neck. It is

important to maintain adequate calorie and protein intake to promote healing, they should receive

around 25-35 kcal/kg calories and up to 1.2-2.0 g/kg protein.14 It is very important to regularly

assess malnutrition as it can easily bring high morbidity and mortality rates. Without the

adequate protein and calorie needs met, the body’s ability to fight off diseases will have a

significant impact.

Nutrition Care Process: Assessment

Client History

This patient is a 71 year old female from the Dominican Republic, who was transferred to

the intensive care unit upon admission to the hospital. She was admitted from a nursing home for

shortness of breath, and her diagnosis was Covid-19, Pneumonia, and Septic Shock. Some of her

comorbidities include diabetes, urinary tract infection, hypoxia, septic shock, pneumonia, and

pressure ulcers. She has altered mental status (AMS) due to being non-verbal and she also has

cerebral palsy. She has been in the nursing home system for the past 9 years and she has no

related caretakers. The city provides her with a caretaker that can make informed decisions on
her behalf. Her medical and surgical history included cerebral palsy, chest congestion and

hypoxia at the nursing home and receiving a tracheostomy in 2019. She has no significant family

history and her social history includes living in the nursing home.

Food Nutrition/Related History

This patient has been in a nursing home since 2014 and a majority of her related history

was documented from speaking with the nursing home staff. Due to this patient's altered mental

status, her feeding ability is total dependance. She has a PEG tube and the reason for her tube

feeding is the tracheostomy and her altered mental status. This patient has no food allergies or

intolerances. In the nursing home, the patient was on Glucerna 1.5, continuous, 40 ml/hr for 24

hours with 800 ml total water flushes.

Medications & Food Drug Interactions

The medications the patient was taking can be seen in Appendix E. The only significant

interactions are with Budesonide and Grapefruit.15

Nutrition Focused Physical Exam

The Nutrition-Focused Physical Exam (NFPE) is a tool used to measure the nutritional

status of a person in order to determine whether or not they are showing signs of malnutrition.16

For patients that come in with overweight or obesity weight classifications, malnutrition may not

be an immediate concern. If the patient needs to be weighed, the dietitian will do so and compare

to their previous weights listed in Epic, a software used by the hospital. If there is limited, or no

previous weight history, we will ask the patient of their usual weight to try and gauge whether or
not there has been drastic weight changes. According to the guidelines set by A.S.P.E.N,, a

minimum of 2 of the 6 criteria have to be met to achieve an appropriate diagnosis of

malnutrition.16 This patient has total dependance feeding ability, with an enteral feed of Glucerna

1.5 continuously on a PEG tube, so she met her nutrition needs. There was no significant weight

loss noted during her stay in the nursing home or her 4 months at the hospital or muscle or fat

wasting.

Anthropometric Measurements

Upon initial assessment, the patient weighed 125 pounds on 01/03/23. Upon

reassessment, 60 days later the patient weighed 119 pounds, recording a 6 pound loss. The

patient is 4 feet and 9 inches, which would place her BMI at 25.7 and an overweight

classification. Because this patient has cerebral palsy, using the body mass index is not the most

accurate use of calculating height to weight ratio. The body mass index is a great way to roughly

estimate the general population's risk for diseases and health risk by understanding their height to

weight ratio. For someone who has cerebral palsy, there could be a difference in growth as a

child which would not give an accurate representation of developing health risks17. The

evidenced based way to measure the height for those diagnosed with cerebral palsy is shown in

Appendix F.18 This figure shows that ulna, knee, and tibia length are the best markers for height.

An alternative measure for identifying possible health risks for those diagnosed with cerebral

palsy is using waist to hip ratio.18 This removes the height aspect and gives a better

understanding of subcutaneous fat in the abdominal area and if it is at higher risk of developing

conditions related. This is a little bit concerning due to her height of 4’9”, though it does not fall

within the risk of severe weight loss so it is not categorized as a sign of malnutrition. This is a
good sign to be aware and continue to monitor her weight as a dietitian to make sure there is no

drastic change.

Biochemical Data, Medical Tests, and Procedures

The results of her labs over the course of 3 months can be seen in Appendix G.

Interpretation of Abnormal Lab Values19

Hemoglobin A1c: Classified as a diabetic and she is given Glucerna 1.5 for this reason.

Glucose: Elevated glucose levels are seen but are considered within normal limits for someone

who has diabetes.

Sodium: Previously elevated sodium may have been due to dehydration or prolonged use of

diuretics.

Potassium: Previously low levels may be due to diuretics given from fluid fluctuations and

pneumonia secondary to Covid-19

Creatinine: Low creatinine levels may be due to older age or low muscle levels due to cerebral

palsy stunting growth along with having altered mental status.

Calcium: Low levels of calcium may be due to the medications she is taking. An anti-

inflammatory drug like rifampin was given to the patient.

Phosphorus: The sudden low levels of phosphorus may be due to prolonged use of diuretics and

recent respiratory alkalosis.

Iron: Low levels of iron may be due to patient dealing with several pressure ulcers

Nutrient Needs
Estimated Nutritional Requirements: Based on lowest weight since admission: 52kg (114 lb)

- Energy Needs: 1560 - 1820 kcal

- Based on 30-35 kcal/kg (Stage III and IV pressure ulcers)20,21

Initially if a patient comes in with severe to critical Covid-19 symptoms, taking into account risk

of reeding syndrome, this patient would receive 10kcal/kg (520-1040), or 25% of her needs. On

the second day she would receive 1040kcal, or 50% of her needs. On day three and four she

would receive between 1560-1820 kcal.

- Protein Needs: 78 - 104 gm

- Based on 1.5 - 2.0 gm/kg (Stage III and IV pressure ulcers)20,21

Because this patient developed her pressure ulcers during her hospital stay, she did not have

these nutrient requirements originally. For the first two days her requirement would be 0.8-1.0

(42-52 gm protein), then the next two days would be 1.0-1.2 (52-62 gm protein). Providing this

patient with juven 2x day and prostat for extra protein to promote wound healing would provide

20g of extra protein.

- Fluid Needs: 1560 - 1820 ml21

- Based on 1 mL/kcal

This patient was experiencing fluid loss and gain so the fluid recommendation would be up to

MD discretion.

Malnutrition identification

This patient was at risk of being malnourished during her hospitalization for several

reasons, which can be seen in Appendix H21. Her energy intake was always above her

recommended amount due to being on total dependence with a PEG tube. She is at risk of
malnutrition mainly due to her fluctuating weight. Her fluctuation in weight is due to fluid

accumulation and loss, not overall muscle or fat loss. She does not show any visible fat or

muscle wasting from appearance. She does have mild fluid accumulation although it is highly

fluctuating and does not consistently stay elevated. For her functional markers she has altered

mental status, but is it not declining at this time.

Nutrition Care Process: Diagnosis

PES Statement #1

Inadequate oral intake (NI-2.1) related to altered mental status and inability to self-feed as

evidenced by pt on enteral feeds via peg tube22

Nutrition Intervention #1 - Enteral Nutrition

Glucerna 1.5 tube feed via peg tube- Secondary to inability to self feed

Start at 10mL/hr increasing by 10mL/hr every hour to reach goal rate of 40mL/hr for

24hr/day with 200 ml water flush every 6 hours to receive 800ml/day

Order Provides: 960ml formula, 1700 kcal, 99g protein, 730ml water + 800 ml water flushes

Nutrition Intervention Explanation

The nutritional intervention of this PES statement is to provide enteral feed that meets the

patient’s recommended nutritional needs. Starting the feed at 10 ml/hr and reaching 40 ml/hr.

She is on Glucerna 1.5 due to her A1c of 6.5, classifying her as a diabetic. This formula is less

likely to give diabetic patients fluctuations in blood sugar due to including low-glycemic

response carbohydrates.
Medical Intervention #1

The medical intervention is displayed fully in Appendix I. The medical staff provided

pepcid every 12 hours via PEG tube to prevent any potential acid indigestion occuring. They set

up continuous enteral feeding with water flushes due to total feeding ability dependence.

PES Statement #2

Increased nutrient needs (NI-5.1) related to increased demand for nutrients for wound healing as

evidenced by loss of skin integrity and delayed wound healing22

PES Statement #3

Inadequate energy intake (NI-1.2) related to COVID - 19 as evidenced by hypoxia, shortness of

breath, chest congestion22

Nutrition Intervention #2 & 3 - Increase nutrients provided

Increase calorie needs to best meet increased needs20

- 30-35 kcal/kg

- 1.5-2.0 gm/kg

Provide Juven 2x/day (for wound healing)

Provide Prostat 1x/day (for greater protein needs)

Nutrition Intervention Explanation

 Due to the patient's four pressure ulcers, her nutrient needs were increased drastically to

30-35 kcal/kg and 1.5-2.0 gm/kg. An additional 2x Juven daily and 1 prostat daily were given to

provide adequate wound healing vitamins and minerals along with protein for muscle

maintenance.

Medical Intervention

The medical intervention is displayed fully in Appendix I. Coming in with Acute

Respiratory Failure secondary to Covid-19, the medical intervention was providing medications

such as remdesivir, dexamethasone, and pantoprazole. Because she had hypoxia, her oxygen

saturation was lower and needed to be brought up so the medical staff provided saturated 96-

97% oxygen supplementation on 3L, down titrated from oxygen mask 15L.

Nutrition Care Process: Monitoring and Evaluation

Maintain and monitor current pt's tolerance to feed - every 3 days

- Enteral nutrition formula/solution FH-1.3.1.1 23

- Protein estimated intake from enteral nutrition in 24 hours FH-1.5.3.1.11 23

- Energy estimated intake from enteral nutrition in 24 hours FH-1.1.1.4 23

Track significant weight changes to identify possible malnutrition - every day

- Weight change percentage AD-1.1.4.3 23

Test glucose labs - 1x/day, monitor A1c value - 1x month

- Glucose, casual BD-1.5.2 23

- Hemoglobin A1c BD-1.5.3 23

Monitor wounds to ensure tube feeding is adequate for wound healing - every day
 - Impaired wound healing PD-1.1.17.2123

Ongoing Medical Issues

03/03/23

- Ileus

- S/P percutaneous endoscopic gastrostomy tube placement

- Indwelling Foley catheter present

- Hypokalemia

- Chronic respiratory failure requiring continuous mechanical ventilation through

tracheostomy

- Cerebral palsy

Follow up Status and Recommendations

03/03/23

- Patient with no new diagnoses

- Patient waiting for stabilization of lab values, edema, chest congestion

- On high alert to prevent any new pressure ulcers

- No plan for discharge at this moment

- No recommended referral to outpatient department

- Risk Level: High - reassessment of pt. every 3 days.

Conclusion
 Covid-19 discussions have subsided since the outbreak in 2020, although there are people

every day still impacted by it. Most cases show either asymptomatic, mild or moderate signs and

symptoms, but there are many that need to be hospitalized from it. It is important to minimize the

risk factors like hypertension, diabetes, obesity, chronic kidney disease, etc. Making sure

pressure ulcers from within hospitals get more awareness is important to minimize duration of

hospital stays and cost per patient. Dietitians play a big role when it comes to providing adequate

nutrient needs to those with greater risk for malnutrition and lean body mass loss. Increasing

needs for patients with Covid-19, pressure ulcers, sepsis, and other conditions is very important

for dietitians to do. Taking into account Covid-19 potential refeeding syndrome, high pressure

ulcer and sepsis calorie and protein needs is essential for patients to recover as fast as possible.

After assessments, if the patient's hospital stay is prolonged for various other reasons, it is

important to regularly check up on patients based on their risk level to assess if there should be

any changes made. Monitoring and evaluating the diet provided, supplements given, changing

labs, changing weights, integrity of skin and to make sure the patient is not malnourished.
 Appendix

Appendix A. Pathophysiology of Covid-19

Appendix B. Signs and Symptoms of Covid-19

Appendix C. Nutritional recommendations according to the type of respiratory support in

patients with covid-19

Appendix D. Nutritional needs at different stages of critical illness by Covid-19

Appendix E. List of medications patient was receiving at the time of 1/03/23

Appendix F. Cerebral Palsy Anthropometric Assessment

Appendix G. Biochemical Data, Medical Tests, Procedures. Green - Improvement or stable lab.

Orange - No improvement or no new lab test. Red - Declining lab

Appendix H. Malnutrition Identification

Appendix I. Medical Intervention

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