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#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 
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Calculating requirements (Energy)
If BMI>25 therefore opt for AIBW/IBW
Many with single organ failure, ventilated & febrile +
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
If BMI>25 therefore opt for AIBW/IBWMany with single organ failure, ventilated & febrile +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)
We anticipate most pt’s will receive only 70% of feed due to variety of issues (proning, aspiration risk/placement delays)
Don’t despair but prioritise tolerance and build up feed and 
protein provision 3/13
We anticipate most pt’s will receive only 70% of feed due to variety of issues (proning, aspiration risk/placement delays) Don’t despair but prioritise tolerance and build up feed and protein provision 3/13
Calculating requirements (Protein)
Protein in Overweight/Obese: NOT protein malnourished
1.3g/kgAdjBW & 2g/kgIBW (BMI 30-40kg/m2)
Factor in filter/AKI as we are aiming –ve fluid balance
use of furosemide (monitor e-) & filtration both to aid respiratory function 4/13
Protein in Overweight/Obese: NOT protein malnourished
1.3g/kgAdjBW & 2g/kgIBW (BMI 30-40kg/m2)Factor in filter/AKI as we are aiming –ve fluid balanceuse of furosemide (monitor e-) & filtration both to aid respiratory function 4/13
Calculating requirements (Protein)
On filter: 1.5-2g/kg
Off filter (with AKI / CKD / low eGFR): 1-1.2g/kg
**Hypocaloric/protein feeds optimal in overweight/obese may require additional protein supps e.g. Prosource TF** 5/13
On filter: 1.5-2g/kgOff filter (with AKI / CKD / low eGFR): 1-1.2g/kg**Hypocaloric/
protein feeds optimal in overweight/obese may require additional protein supps e.g. Prosource TF** 5/13
Factors effecting feed choice
Young #ICU patients require amounts of sedation – fentanyl/propofol -> therefore factor this in to your provision (if receiving >200mg/hr~1kcal/ml
Look at fluid target – most will be aiming –ve 500ml to 1L -> opt for 1.5-2kcal/ml feeds 6/13
Young #ICU patients require amounts of sedation – fentanyl/propofol -> therefore factor this in to your provision (if receiving >200mg/hr~1kcal/mlLook at fluid target – most will be aiming –ve 500ml to 1L -> opt for 1.5-2kcal/ml feeds 6/13
Factors effecting feed choice
Interrupted feeds (a/w CXR, nil aspirates, proning) opt high conc. feeds
Role for peptide feed aiding GI tolerance 2° effects of analgesia/sedation/Norad
Familarise yourself with your new local protocols! 7/13
Interrupted feeds (a/w CXR, nil aspirates, proning) opt high conc. feedsRole for peptide feed aiding GI tolerance 2° effects of analgesia/sedation/NoradFamilarise yourself with your new local protocols! 7/13
Issues with Feed
Delayed gastric emptying as patients on fent/propofol/norad slowing gastric emptying Ventilation may require full paralysis 
atracurium impacting GI motility
Advocate for prokinetics early e.g. metoclopramide/erythromycin & role of peptide feeds 8/13
Delayed gastric emptying as patients on fent/propofol/norad slowing gastric emptying Ventilation may require full paralysis atracurium impacting GI motilityAdvocate for prokinetics early e.g. metoclopramide/erythromycin & role of peptide feeds 8/13
Feed & Proning
We’ve proned ~70% of our patients so be familiar!
Usually 16h proned -> 8h unproned ->repeat
This will interrupt feeds & slow rate down – that’s ok -> we need to optimise the lungs aiding shunting & V/Q mismatch
Check local protocols
9/13
We’ve proned ~70% of our patients so be familiar!Usually 16h proned -> 8h unproned ->repeatThis will interrupt feeds & slow rate down – that’s ok -> we need to optimise the lungs aiding shunting & V/Q mismatch Check local protocols 9/13
Feed & Proning
Reduce rates of feed during prone position e.g. concentrated feed @20ml/h with slow increments up when unproned (helps prevent aspiration)
Reduce threshold of GRVs 300ml max (vs 500ml as normal) 10/13
Reduce rates of feed during prone position e.g. concentrated feed @20ml/h with slow increments up when unproned (helps prevent aspiration)Reduce threshold of GRVs 300ml max (vs 500ml as normal) 10/13
Novel Therapies & Feeding
High Vit C - Trial phase NOT for clinical practice
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 prioritise kcal/protein
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High Vit C - Trial phase NOT for clinical practiceLow 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 prioritise kcal/protein11/13
Novel Therapies & Feeding
Hypocaloric and protein as per ASPEN/ESPEN to help support muscle preservation & cytokine storm
Fish oil/Antioxidants 
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
Hypocaloric and protein as per ASPEN/ESPEN to help support muscle preservation & cytokine stormFish oil/Antioxidants 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
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
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
