Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support

Several guidance documents have been released with specific recommendations for nutrition for

patients with COVID-19 admitted to the ICU (https://www.nutritioncare.org/COVID19/). General

recommendations from critical care nutrition guidelines (JPEN J Parenter Enteral Nutr 2016;40:159-211;

Clin Nutr 2023;42:1671-89) are still applicable with an emphasis on preserving resources, clustering

of care, and modifying clinical practices for prevention of transmission. Of note, these guidelines are

primarily based on expert opinion, and many recommendations were made with the consideration

of minimizing the risk to hospital staff. Publication of these recommendations also predates vaccine

availability, and the guidelines may represent a risk-benefit perspective that warrants reconsideration as

further knowledge is gained about the care of critically ill patients with COVID-19.

(JPEN J Parenter Enteral Nutr 2021; 45:32-42.). Therefore, close monitoring of their nutritional adequacy

is essential.

Enteral nutrition

Bedside enteral tube placement is preferred, and some guidance documents recommend that

complicated feeding tube placements (involving radiology or endoscopy) should be avoided.

Continuous EN is preferred over bolus EN regimens.

Supplements to EN (i.e., protein or fiber) should be scheduled once daily instead of more frequent

dosing.

for indirect calorimetry. However, ongoing research suggests a persistence of hypermetabolism

for up to 3 weeks after intubation in some patients with COVID-19, in which case weight-based

Prone positioning is not a contraindication to EN. Early EN practices should continue in this setting,

with initiation at trophic doses and advancement as tolerated. The head of the bed should be elevated

to at least 10 to 25 degrees.

Parenteral nutrition

PN should be considered earlier if practical or clinical barriers to EN are present and prevent

adequate nutrition delivery.

Gastrointestinal involvement of COVID-19 may result in intolerance to EN and warrant initiation

of PN.

PN formulas should be formulated with the minimum volume, especially in the presence of Acute

Respiratory Distress Syndrome or volume overload.

severe hypertriglyceridemia in patients with COVID-19.