With thousands of patients across the country hospitalized due to COVID-19, the RD’s role in acute care—from assessing patients’ nutrition status to preventing malnutrition—is more important than ever.
While COVID-19 can lead to death even among otherwise healthy patients, the Centers for Disease Control and Prevention reports that it’s more prevalent in those with underlying health conditions, many of which have a nutrition component; early data estimate that 90% of patients hospitalized with COVID-19 also have obesity, hypertension, diabetes, or CVD.
Furthermore, there’s evidence that nutrition therapy results in better outcomes for many COVID-19 patients, improving and preserving nutrition status. This blog summarizes the numerous complex factors RDs working in acute care must take into account when assessing and treating patients with COVID-19, focusing on treating malnutrition through enteral nutrition.
Assessing Nutrition Status
For COVID-19 care, dietitians should follow nutrition assessment guidelines from the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition. COVID-19 patients who require hospitalization may experience loss of taste and smell and gastrointestinal issues resulting from the virus, possibly stemming from a loss of appetite and/or poor tolerance of solid foods. Some are acutely malnourished upon hospital admission.
In addition, COVID-19 can result in acute respiratory distress syndrome, which leads to an inflammatory response associated with muscle breakdown and widespread inflammation.
As a result, muscles weaken and breathing ability is decreased; these patients often require mechanical ventilation. When ventilated, nutrition support is initiated to prevent the loss of lean body mass and deterioration of respiratory muscle strength, mitigate already present nutrition deficits, and prevent malnutrition.
Colleen Topper, MS, RDN, a clinical dietitian at Montefiore Medical Center in The Bronx, New York, explains that she assesses “not only calorie, protein, electrolyte, and fluid needs, but also when alternate means of nutrition, such as enteral or parenteral nutrition, might be necessary” in COVID-19 patients. While this blog focuses on enteral feeding, note that parenteral nutrition, either peripheral or total, may be used to treat COVID-19 patients who can’t meet their nutrient needs via oral or enteral feeding.
Enteral feeding is indicated when a patient can’t eat by mouth or their solid food intake is unlikely to meet increased nutrient needs. Often, when COVID-19 patients are too weak or are experiencing respiratory distress, enteral nutrition, wherein a small feeding tube is placed through the nose into the stomach to provide supplemental or all nutrition, is appropriate.
Rachel Gilwit, RD, CNSC, CDE, is a critical care dietitian at UC San Diego Medical Center who manages patients in the ICU and knows firsthand the importance of enteral feedings. In some COVID-19 patients, “I advocate for early placement of an NGT (nasogastric tube), even while they are on a diet, and especially reinforce keeping it in place after they are removed from the ventilator because of factors which limit their food intake,” she says.
However, RDs must consider several variables, including the following, when determining whether enteral nutrition is the best feeding approach for a patient:
Diuresis: If a patient has a history of congestive heart failure or is experiencing pneumonia secondary to COVID-19, often a diuretic is used to ensure that fluid doesn’t build up around the heart, lungs, and between cells. This may require the use of a fluid-restricted tube feeding or calorically dense oral supplements.
Hemodynamic stability/vasopressors: If blood pressure is critically low, a patient may be too unstable for enteral nutrition. Insufficient blood flow to organs can result in gut ischemia when feeding is introduced, although this is rare. “We typically look at a patient’s mean arterial pressure to assess [hemodynamic stability],” Topper says. “Medications called vasopressors are then used to increase blood pressure.” ASPEN guidelines state that enteral nutrition is safe to administer in the presence of consistent, stable, and low doses of vasopressors, and when mean arterial pressure is >50 mm Hg. For most patients in the ICU setting, a standard polymeric isotonic or near-isotonic 1- to 1.5-kcal/mL formula is appropriate and will be well tolerated.
Glycemic control: Keeping blood glucose under control is key for the COVID-19 population, as stress-induced hyperglycemia may be present in patients with non–insulin-dependent diabetes, possibly requiring treatment with insulin during the illness. When patients are first admitted, maintaining glycemic control is more important than using a specialized formula. Once patients are more stable, a low-carbohydrate formula may aid in blood glucose management.
Sedation: In patients on ventilators receiving enteral nutrition, the commonly used sedative propofol is administered as part of a lipid emulsion that provides 1.1 kcal/mL from fat. At high rates, it may provide significant calories, so the tube feeding rate must be reduced to prevent overfeeding. In this case, a low dose of a low-calorie, high-protein formula needs to be used in addition to modular protein supplements and other additives to make up for their macronutrient needs.
Prone positioning: Placing a patient in the prone position (ie, on the stomach) while on a ventilator is used to improve ventilation and oxygen exchange. COVID-19 patients require prone positioning due to acute respiratory syndrome as a result of bilateral lung pneumonia. “We are finding there is a misconception that enteral feeding needs to be [withdrawn] while patients are undergoing proning,” Gilwit says, “partially due to the belief that, while on the stomach undergoing paralysis, enteral feeding may not be best tolerated. Yet, in spite of paralysis, the gut is still undergoing peristalsis, and the gastrointestinal tract is still capable of moving and absorbing nutrients.” Furthermore, research shows that gastric feeding in this position—including full-volume tube feeds—is safe and isn’t associated with increased aspiration risk; in addition, small bowel or post pyloric feeding tube placement isn’t necessarily indicated.
Extracorporeal membrane oxygenations: In this therapy, also referred to as ECMO, a machine takes over the work of the heart and lungs to add oxygen to a patient’s blood. This is especially important for COVID-19 patients with severe acute respiratory distress syndrome. Enteral nutrition can be safely administered within 24 hours of initiating ECMO, with slow advancement to the goal rate within the first week of critical illness.
This blog is an attempt to not only provide a small window into what clinical RDs do each day during the COVID-19 pandemic but also to celebrate their difficult and complex roles in ensuring patients have the best outcomes possible.
I’m so proud of my colleagues who advocate for these vulnerable patients. In short: Your work matters. You are health care heroes!
Additional COVID-19 Resources for RDs
- National Institutes of Health: www.nih.gov/health-information/coronavirus
- Academy of Nutrition and Dietetics: www.eatrightpro.org/coronavirus-resources; www.eatrightpro.org/news-center/member-updates/coronavirus-updates/during-covid19-emergency-cms-gives-green-light-to-mnt-via-telehealth-for-medicare-beneficiaries
- Centers for Disease Control and Prevention: www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
- American Society for Parenteral and Enteral Nutrition: www.nutritioncare.org/Covid19Resources; www.youtube.com/watch?v=dNmMW3ybXdY
- Society of Critical Care Medicine: www.sccm.org/COVID19RapidResources/Resources/Nutrition-Therapy-in-the-Patient-with-COVID-19-Dis
— Laurie Block, MS, RDN, CDE, is a registered dietitian and certified diabetes educator with more than 25 years of experience in nutrition to promote health and prevent disease. She enjoys writing on the ever-changing science of nutrition. Laurie practices in New York City and San Diego. She’s the author of The Type 1 Diabetes Cookbook and a big supporter of Marjorie’s Fund, a global initiative to empower people living with type 1 diabetes.