Author: Lynne Peeples
Delivering appropriate nutrition for very sick adults with COVID-19 remains an important consideration for optimizing these patients’ outcomes, but it also involves some unique challenges, according to a presentation at the ASPEN20 Virtual Conference.
”We’re assessing and treating COVID-19 patients just like any other patients in the ICU with acute respiratory distress syndrome (ARDS), with the exception of exposure issues,” said Robert Martindale, MD, PhD, a professor of surgery and an expert in digestive health at Oregon Health & Science University, in Portland.
Dr. Martindale and other session presenters highlighted the importance of choosing and timing the provision of nutrition products while also protecting health care workers. He suggested using enteral nutrition if it can be successfully given via a gastric feeding tube, and then considering supplementation with parenteral nutrition if the enteral route is unsuccessful.
Both the Society of Critical Care Medicine and ASPEN will be releasing COVID-19 nutrition recommendations this week, which he noted will include discussion of early conversion to parenteral nutrition if the enteral mode requires significantly more health care worker exposure.
”I never thought I’d say that,” Dr. Martindale said. This strategy, however, should decrease the need to check patients’ bellies, place distal feeding tubes and other potential routes of exposure for health care providers.
”How do we deliver the same nutrition support without having too much health care worker exposure to the [causative SARS-CoV-2] virus?” Dr. Martindale said. ”That is a big issue.”
When it comes to parenteral nutrition, if using IV lipid emulsions, he recommended opting for lipid injectable emulsions that are lower in proinflammatory soybean oil and using mixed lipid emulsions that contain fish oil and olive oil.
Historically, the only lipid injectable emulsions available in the United States were 100% soybean oil. Additional products have been developed in recent years, including Fresenius Kabi’s SMOFlipid, a combination of soybean oil, medium-chain triglycerides, olive oil and fish oil, and Omegaven, an injectable emulsion of fish oil triglycerides.
”We no longer have to use 100% soybean oil,” Dr. Martindale added. ”Now that we have a potentially less inflammatory oil, we should use it.”
More specifically, he noted that fish oils produce metabolites called specialized pro-resolving mediators (SPMs). An inflamed cell turns on production of SPMs, which are made from the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid by the body. ”Those go on to stimulate resolution of inflammation,” Dr. Martindale said. Based on evidence from flu and other viruses (N Engl J Med 2013;369:191-193), ”SPMs might enhance viral clearance,” he added. ”But that’s pure speculation at this point for COVID-19.”
In addition, you need to follow the lipid profiles of COVID-19 patients,” Dr. Martindale said. ”For the subpopulation of patients who get rapidly sick—and need a ventilator within 12 to 24 hours—you need to be especially careful with lipids. Their serum lipids seem to rapidly rise for unexplained reasons.”
Joseph Boullata, PharmD, a clinical specialist with the Clinical Nutrition Support Services at the Hospital of the University of Pennsylvania, in Philadelphia, and the session presenter, also emphasized the outcome benefits of new lipid emulsions over the traditional 100% soybean oil products.
He added a warning about the use of propofol in COVID-19 patients: The anesthetic is suspended in a 100% soybean oil-based emulsion that is known to be proinflammatory.
Another product that may benefit COVID-19 patients is probiotics, according to Dr. Martindale. He noted he would consider providing probiotics to these patients on admission to the ICU. ”I believe strongly that probiotics are important for everybody, especially those with viral infections,” he said.
A 2015 Cochrane Review found probiotics to be better than placebo in reducing episodes of acute upper respiratory tract infections (URTI) by nearly 50% and the duration of an episode of acute URTI by nearly two days (Cochrane Database Syst Rev 2015;:CD006895). ”But these are not recommendations,” he said. ”This is based on literature of other viruses and we need to study these to see if the same holds true for COVID-19.
“The worst thing we can do is something that will harm this fragile group of patients and any intervention needs to be based in evidence,” Dr. Martindale noted.