https://abs.twimg.com/emoji/v2/... draggable="false" alt="🚨" title="Police cars revolving light" aria-label="Emoji: Police cars revolving light">https://abs.twimg.com/emoji/v2/... draggable="false" alt="📢" title="Public address loudspeaker" aria-label="Emoji: Public address loudspeaker"> #Tweetorial on #ICU nutritional management in #COVID19 – disclaimer this is from my own insights having worked as an ICU #dietitian & working as a #juniordoctor #Hammersmith ICU resources will be tagged at the end - WARNING it’s long - so grab a https://abs.twimg.com/emoji/v2/... draggable="false" alt="☕️" title="Hot beverage" aria-label="Emoji: Hot beverage"> 1/13

Calculating requirements (Energy)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">If BMI>25 therefore opt for AIBW/IBW
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Many with single organ failure, ventilated & febrile +
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Equations to help – PENN STATE & Mifflin St Jeor – factors temp/vent settings OR if in doubt or time limits ASPEN BMI>30 11-14kcal/kg/ABW/day 2/13

Calculating requirements (Energy)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">We anticipate most pt’s will receive only 70% of feed due to variety of issues (proning, aspiration risk/placement delays)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Don’t despair but prioritise tolerance and build up feed and https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow"> protein provision 3/13

Calculating requirements (Protein)
Protein in Overweight/Obese: NOT protein malnourished
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">1.3g/kgAdjBW & 2g/kgIBW (BMI 30-40kg/m2)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Factor in filter/AKI as we are aiming –ve fluid balancehttps://abs.twimg.com/emoji/v2/... draggable="false" alt="💦" title="Splashing sweat symbol" aria-label="Emoji: Splashing sweat symbol">
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow">use of furosemide (monitor e-) & filtration both to aid respiratory function 4/13

Calculating requirements (Protein)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">On filter: 1.5-2g/kg
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Off filter (with AKI / CKD / low eGFR): 1-1.2g/kg

**Hypocaloric/https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow">protein feeds optimal in overweight/obese may require additional protein supps e.g. Prosource TF** 5/13

Factors effecting feed choice
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square"> Young #ICU patients require https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow"> amounts of sedation – fentanyl/propofol -> therefore factor this in to your provision (if receiving >200mg/hr~1kcal/ml
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Look at fluid target – most will be aiming –ve 500ml to 1L -> opt for 1.5-2kcal/ml feeds 6/13

Factors effecting feed choice
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Interrupted feeds (a/w CXR, nil aspirates, proning) opt high conc. feeds
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Role for peptide feed aiding GI tolerance 2° effects of analgesia/sedation/Norad
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Familarise yourself with your new local protocols! 7/13

Issues with Feed
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Delayed gastric emptying https://abs.twimg.com/emoji/v2/... draggable="false" alt="🚨" title="Police cars revolving light" aria-label="Emoji: Police cars revolving light">as patients on https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow"> fent/propofol/norad slowing gastric emptying https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Ventilation may require full paralysis https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Rightwards arrow" aria-label="Emoji: Rightwards arrow"> atracurium impacting GI motility
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Advocate for prokinetics early e.g. metoclopramide/erythromycin & role of peptide feeds 8/13

Feed & Proning
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">We’ve proned ~70% of our patients https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Rightwards arrow" aria-label="Emoji: Rightwards arrow"> so be familiar!
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Usually 16h proned -> 8h unproned ->repeat
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">This will interrupt feeds & slow rate down – that’s ok -> we need to optimise the lungs aiding shunting & V/Q mismatch
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Check local protocols
9/13

Feed & Proning
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Reduce rates of feed during prone position e.g. concentrated feed @20ml/h with slow increments up when unproned (helps prevent aspiration)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Reduce threshold of GRVs 300ml max (vs 500ml as normal) 10/13

Novel Therapies & Feeding
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">High Vit C - Trial phase NOT for clinical practice
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Low carb feeds – NONE of the current feeds exceed glucose oxidation rates of individuals so unlikely to impact vent settings. Remember UNLIKELY to meet full feed https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Rightwards arrow" aria-label="Emoji: Rightwards arrow"> prioritise kcal/protein
11/13

Novel Therapies & Feeding
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Hypocaloric and https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow"> protein as per ASPEN/ESPEN to help support muscle preservation & cytokine storm
https://abs.twimg.com/emoji/v2/... draggable="false" alt="▪️" title="Black small square" aria-label="Emoji: Black small square">Fish oil/Antioxidants https://abs.twimg.com/emoji/v2/... draggable="false" alt="🐟" title="Fish" aria-label="Emoji: Fish">https://abs.twimg.com/emoji/v2/... draggable="false" alt="💊" title="Pill" aria-label="Emoji: Pill"> in the words of a pro in this field @RD_Catherine – it’s complicated!
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012041.pub2/information
12/13">https://www.cochranelibrary.com/cdsr/doi/...

Resources Available
Sorry for the length but hope this has been some interest/help. Massive thanks to @BDACriticalCare @ICS_updates & all individuals involved who produced superb resources at unprecedented speeds 13/13 #trustadietitian #ICU #nutrition https://www.bda.uk.com/resource/critical-care-dietetics-guidance-covid-19.html">https://www.bda.uk.com/resource/...