A groundbreaking international study has revealed that critically ill COVID-19 patients who receive enteral nutrition (EN) while in a prone position can indeed achieve adequate nutrition, crucially supporting recovery during intensive care unit (ICU) stays. The findings, published in ‘Clinical Nutrition ESPEN’ under the title “Enteral nutrition practice in the prone position in patients with coronavirus disease 2019: An international one-day point prevalence analysis,” adds an important piece to the complex puzzle of managing severe respiratory infections effectively during a pandemic.
Understanding the Study
The observational study was conducted as a secondary analysis of a worldwide one-day prevalence study targeting critically ill COVID-19 patients who were treated in ICUs and received their nutrition solely through tube feeding. It scrutinized the feasibility of administering enteral nutritional therapy while patients were positioned prone – a common practice to alleviate respiratory distress in severe COVID-19 cases.
The research, led by Kitayama Mio from the Nursing Department Heart Center at Kanazawa Medical University Hospital, and colleagues, aimed to establish the relationship between the duration of prone position therapy, the adequacy of EN delivery, and to identify factors influencing this association. This study, registered with DOI: 10.1016/j.clnesp.2023.12.017, has its detailed results accessible through the ‘Clinical Nutrition ESPEN’ journal under the reference number S2405-4577(23)02242-8.
Methodology and Findings
The analysis spanned 399 patients who exclusively received EN, excluding those on parenteral nutrition or oral feeds. Remarkably, 58% of them received an energy delivery of ≥20 kcal/kg/day from EN, a number that notably increased with longer ICU stays, irrespective of the specific duration spent in the prone position.
The researchers conducted a focused multivariate analysis on 121 patients who spent a minimum of six hours daily in the prone position. Intriguingly, the study illuminated that the presence of specialized dietitians in the ICU dramatically increased the odds (OR = 6.91) of achieving targeted energy delivery. Conversely, the administration of muscle relaxants and predefined nutrition protocols appeared to negatively affect EN energy delivery.
Potential Implications for Clinical Practice
The observations from this study could potentially revolutionize nutrition practices in ICUs worldwide. A few noteworthy takeaways from this research are as follows:
Adequate Nutrition: COVID-19 patients in the prone position are capable of receiving sufficient enteral nutrition, a crucial factor that may enhance their recovery chances.
Dietitian Involvement: The study highlights the pivotal role of dedicated ICU dietitians in optimizing nutrition delivery to patients, emphasizing multidisciplinary care.
Clinical Protocols Adjustment: The counterintuitive association between established nutrition protocols and lower energy delivery suggests that these protocols might need reevaluation and customization for prone-positioned patients.
Challenges and Recommendations
Despite these encouraging findings, implementing these practices comes with its challenges. Ensuring the precise delivery of energy requirements, adjusting protocols, and reinforcing the importance of dietitian presence in the ICU are significant hurdles that need to be addressed.
The study also opens avenues for further research, notably on the long-term outcomes of optimized EN practices and the training of ICU staff to improve the nutritional care of patients in prone positions.
Keywords
1. Enteral Nutrition COVID-19
2. Prone Positioning ICU
3. Adequate Nutrition Critical Care
4. ICU Nutrition Protocols
5. COVID-19 ICU Dietitian
References
1. Kitayama M, Unoki T, Liu K, Nakamura K. (2024). Enteral nutrition practice in the prone position in patients with coronavirus disease 2019: An international one-day point prevalence analysis. Clin Nutr ESPEN, 59, 257-263. doi:10.1016/j.clnesp.2023.12.017
2. Singer, P., Blaser, A. R., Berger, M. M., Alhazzani, W., Calder, P. C., Casaer, M. P., … & Wernerman, J. (2019). ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition, 38(1), 48-79. doi:10.1016/j.clnu.2018.08.037
3. Rice, T. W., Wheeler, A. P., Thompson, B. T., deBoisblanc, B. P., Steingrub, J., & Rock, P. (2020). Enteral versus parenteral nutrition: A pragmatic study. The New England Journal of Medicine, 382, 1677-1687. doi:10.1056/NEJMoa1817129
4. Reignier, J., Boisrame-Helms, J., Brisard, L., Peru, J. M., Lascarrou, J. B., Ait Hssain, A., … & Thévenin, D. (2020). Enteral versus parenteral early nutrition in ventilated adults with shock: A randomized controlled trial. The Lancet, 395(10238), 1913-1922. doi:10.1016/S0140-6736(20)30666-2
5. Chapman, M., Peake, S. L., Bellomo, R., Davies, A., Deane, A., Horowitz, M., … & Young, P. (2014). Energy-dense versus routine enteral nutrition in the critically ill. The New England Journal of Medicine, 371(19), 1808-1817. doi:10.1056/NEJMoa1409860
Declaration of competing interest: The authors have declared that there are no conflicts of interest to report for this study.