Position of Parenteral Therapy in Patients with Severe COVID-19 Disease

Introduction

Respiratory complications in the form of acute respiratory distress syndrome (ARDS) requiring ventilatory and hemodynamic support are the most common reason for admission to intensive care in patients with COVID-19. The development of ARDS is the main cause of morbidity and mortality in these patients. Intensive therapy is associated with a high risk of malnutrition, the etiology of which is complex. Severe malnutrition worsens not only the short-term prognosis of patients but also the overall treatment outcomes during the recovery period.

According to current guidelines by the European Society for Clinical Nutrition and Metabolism (ESPEN), enteral therapy is preferred in the first line in accordance with recommendations for treating patients requiring intensive care. Parenteral therapy also plays an important role, particularly in cases where enteral therapy is contraindicated or insufficient.

Current Recommendations for Parenteral Nutrition

Parenteral therapy is indicated in patients with severe COVID-19 disease when enteral therapy is contraindicated or insufficient. The indication for parenteral therapy should be assessed on a case-by-case basis. Parenteral nutrition can be administered as a full form of nutrient substitution or as a supplement to enteral therapy. In addition to general contraindications to enteral therapy, specific situations for considering parenteral nutrition in COVID-19 patients are described.

In patients on non-invasive ventilation, enteral therapy may cause air leaks around the mask or gastric dilation with diaphragm dysfunction, reducing the effectiveness of non-invasive ventilation. In such patients, parenteral therapy should be considered if malnutrition is imminent. Providing enteral nutrition to patients on high-flow nasal oxygen with a risk of malnutrition can also be challenging; in this case, Thibault et al. advocate for the use of parenteral therapy, arguing that any form of nutrition is better than none. Another specific situation for considering parenteral therapy includes vomiting in patients ventilated in the prone position, severe hypoxemia with FiO₂ > 80%, or bowel dysfunction.

Parenteral nutrition should generally not be initiated before the 4th day of therapy in the intensive care unit. When administering parenteral nutrition, the simultaneous supply of vitamins and trace elements should be ensured. Current study results do not confirm the effect of routine administration of these substances in supratherapeutic doses on improving prognosis; experts recommend administering these substances according to individual needs. In patients on full parenteral nutrition or those staying more than 10 days in the intensive care unit (ICU), indirect calorimetry should be considered due to the risk of overfeeding syndrome.

Conclusion

Parenteral nutrition is one of the modalities of comprehensive therapy in patients with severe COVID-19 disease and the risk of severe malnutrition. The initiation of parenteral therapy depends on various factors and should be assessed on a case-by-case basis. Indication criteria primarily include insufficiency or contraindication of enteral therapy.

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Sources:
1. Thibault R., Seguin P., Tamion F. et al. Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance. Crit Care 2020 Jul 19; 24 (1): 447, doi: 10.1186/s13054-020-03159-z.
2. Barazzoni R., Bischoff S. C., Breda J. et al.; endorsed by the ESPEN Council. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clin Nutr 2020 Jun; 39 (6): 1631–1638, doi: 10.1016/j.clnu.2020.03.022.