Medical Nutrition Therapy for COVID Patients

Additional Info

• Audio File:uab/ua182.mp3
• Doctors:Dupont, Steve
• Featured Speaker:Steve Dupont, MS, RD, LD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4493
• Guest Bio:Steve Dupont, MS, RD, LD is a Clinical Dietitian. 
  
  Release Date: January 22, 2021
  Expiration Date: January 22, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Steven T. Dupont, MS, RD, LD
  Dietitian, Food & Nutrition Sciences
  
  Steven Dupont has no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host):  Welcome to UAB Med Cast. I'm Melanie Cole and I invite you to listen as we discuss medical nutrition therapy for COVID patients. Joining me is Steve Dupont. He's a Clinical Dietician with UAB Medicine. Steve, I'm so glad to have you with us today. And this is a great topic. And one that I think is under-discussed. So, let's dig into this a little bit. In the big picture, how has the COVID pandemic changed your clinical practice? Let's start there.
  
  Steve Dupont, MS, RD, LD (Guest): Well, first of all, Melanie, thanks for having me on. I'm excited to be here. I wish I could say something really positive to start off about practicing in this COVID world that we're in. I've been spending a lot of time at my desk actually, which I don't particularly like to do because I really like to get out into the hospital and talk to patients face to face, talk to their families and really get a deeper sense of you know who they are and why they're here. So, that's been a little bit of a challenge. On the positive side, if I had to come up with something, I would say that looking out at so many unfortunate people out there who have been laid off and everything like that, I'm so, so, thankful and grateful to have sort of relative job security here in the healthcare field.
  
  Host: So, what specific challenges are you facing with COVID patients in the hospital? Speak about some of the things that you've been seeing, medical nutrition needs. Tell us what you're seeing.
  
  Steve: The big thing really is like I alluded to before is the physical distancing between the patients because of limitations on PPE and things like that. I'm not going and seeing these COVID even the ones that are able to talk. I'm not going to see them face to face. I may talk to them on the phone. But usually I'm not laying eyes on them, which when you're talking about malnutrition, it's not always obvious just by looking at somebody's medical record, whether or not they're malnourished or not. For example, you might have a patient that weighs 300 pounds and your first instinct is to think oh, well, they're perfectly, well-nourished or over nourished. Right?
  
  But you may find out if you were to actually talk to that person or their family that, oh, by the way, two months ago they weighed 375 pounds. And they've lost all that weight and they have not been eating or whatever it is. Just being able to see people, being able to ask them questions, even talking to patients on the phone, sometimes, well it's hard to get people on the phone because either the phone's across the room or they're too weak to pick it up or whatever like that.
  
  Or even if you do get them on the phone, of course, COVID patients tend to be kind of fighting for every breath. So, you don't want to necessarily be taxing them too much and put them into a code event or something like that, based on the fact that you're just peppering them with questions. So, you have to be a little bit careful there. And then of course there's obvious thing about appetite. I mean the, one of the main symptoms of COVID tends to be complete loss of taste and smell. So, you can imagine what that would do to your appetite. And then another thing I could mention would be a lot of these patients are on steroids as part of their therapy. So, you get some challenges there, mainly with respect to hyperglycemia and some other things that kind of get a little wacky with their lab values and stuff like that.
  
  Host: So, are you allowed in the room? How have the concepts and what you've been discussing had implications for nutrition support? Tell us how you are providing this service.
  
  Steve: Yeah, like I said really not going in the room. If push came to shove, I suppose, I could probably get myself into the room, but based on the guidelines that we've been issued, we're trying to conserve PPE as much as we can. So, providers such as dietitians, who technically don't have to lay hands on a patient we're kind of expected to do as much as we can remotely. So, I'm relying on, if I can't talk to the patient, I'm trying to get a hold of the nurse on the phone or somebody on the unit who knows what's going on with the patient so I can get a little more information. Sometimes I might have a phone number in the record of a next of kin or family member or something like that, that I can call and ask questions if I need to. But the less people that I have to bother, unless I feel like it's really a medically essential thing, I'm usually just trying to assess that person from the medical record and then trying to fill in as many of the gaps as I can.
  
  Host: What about nutrition needs during prone positioning? How's that work?
  
  Steve: Yeah, a lot of the patients you're referring to the, when they're laying prone stomach, a lot of the patients in the ICU are prone like that. I mean, I've not seen anything. And even in theory, I don't think that should really change your nutritional needs a whole lot. Now there's a lot of other things that I'll talk about with the ICU patient that kind of changes nutritional needs, but the prone positioning itself, now I think it does affect the GI function a little bit and the GI motility, because when you're flipped over the other way, it's obviously not a natural position to say, have a bowel movement. So, it stands to reason. And I have seen this, that those patients can be a little bit more likely to be constipated. So, usually a pretty aggressive bowel regimen is called for and sometimes, you have to use rectal tube or some sort of bowel management system to, from a practical standpoint to make it easier to keep the bowel maintenance underway as they're being treated.
  
  Host: Well, then tell us Steve, how the critically ill COVID patient is different from the typical ICU patients you might see.
  
  Steve: Yeah. So, all ICU patients are a little bit tenuous, right? I mean, that's an in a lot of cases, why they're in the ICU to begin with. But I think most clinicians would probably agree that the COVID patient in particular is just very unpredictable. I mean, we've all heard those stories or seen them firsthand of a person who one minute they're sitting there breathing room air and they're eating and drinking, whatever else. And the next thing you know, they're on the ventilator because they've just completely collapsed. I've heard it compared to a person who's been treading water for a long time. And you just don't know at what point they're going to run out of energy and kind of dip below the surface. A lot of the patients that are on ventilators are requiring very heavy sedation. And the sedative of choice tends to be propafol, which is a medication that is in a lipid emulsion. So it has 1.1 calories per milliliter. So, for example, I've seen patients on as much as 50 milliliters per hour of propafol, meaning that they're getting about 1300 calories a day.
  
  Now, if those were well-rounded calories, that would be wonderful. But unfortunately, that's just fat calories. Okay. So, there's not protein, there's no vitamins and minerals. There's nothing else. So, in the process of trying to kind of fit in all those other pieces, it can be difficult to do and be kind of tricky sometimes without just completely overshooting on the total number of calories that you're giving the patient and you really don't want to overfeed any patient who's critically ill and, on a ventilator, and especially a COVID patient, just because it makes breathing even more difficult. But another one that we're seeing an awful lot is kidney failure.
  
  These COVID patients are really having kidney failure at a much higher rate than the average ICU patient. And there's a number of theories as to why that's the case from cytokines that are produced from the infection, to blood clots and other theories as well. But from a practical standpoint that you're seeing a lot of people having to end up going onto dialysis, and usually in the ICU, that would be like a continuous dialysis or CRRT for short. And that, once you go from not being on dialysis to continuous dialysis, that does change your nutritional needs quite a bit. Your protein needs are drastically increased. Your electrolyte needs are drastically increased.
  
  So, usually at that point, you're switching from a renal specialty formula to more of standard high protein formula for critically ill patients. And then the other thing I was going to mention was with the prone position, and we already kind of touched on that.
  
  Host: This is really, like I said, a very good topic. Now, Steve, as we wrap up, for other providers that are counseling their patients on COVID at home or working with patients that are not on ventilators, and as you said, in prone position, are there any particular ways we can help treat or prevent COVID with nutrition? What do you as a clinical nutritionist recommend for COVID patients? And this one can really apply to any of us that are learning more about what we still don't know about this situation.
  
  Steve: If you're the average person who is at home dealing with COVID and I actually have a colleague who's at home right now who's dealing with it. I mean, it kind of is staggering how much it can affect a person. You know, this is a colleague who's a young person, much younger than me. And she was saying the other day that she was so weak, that she could barely eat or drink. So, just trying to do the best that you can, especially to drink, to stay hydrated. Cause like I mentioned before with the kidney affects, the last thing you want to do is to get severely dehydrated.
  
  So, personally, if it was me or somebody that I knew I'd be really forcing fluids. And if you got to the point where you couldn't take any fluids, then that would really be a junction where you would want to think about going to the Emergency Department to get some IV fluids. Apart from that, there are some associations between micronutrients, like there hasn't been a lot of research yet, of course, but we're looking at vitamin D status, looking at zinc status and things like that. I mean, you certainly don't want to be deficient in anything.
  
  So, taking a multivitamin or something like that would certainly be appropriate. I don't think there's any evidence that taking additional amounts of any particular nutrient on top of what you know, a normal adequate intake is going to make much of a difference. So, really the only other things in terms of prevention would be you know, there's a lot of links to obesity, diabetes, hypertension, other chronic diseases. So, if you have one of those diseases or if you have several of them then the best advice would be to manage them as best you can. Keep them well managed. And if you don't have one of those conditions, then certainly do everything in your power to prevent from getting there.
  
  Because it seems like COVID is going to be around for some time. I mean, even with the vaccine, it's just there's just no telling, I mean, probably going to be mutations that will evade the vaccines where it's going to be kind of a whack-a-mole affair so.
  
  Host: Well, it certainly does. And thank you so much, Steve, for joining us today and really offering up your best advice and information for providers about clinical nutrition therapy and medical nutrition therapy for COVID patients. Thank you again. And a community physician can refer a patient to UAB medicine by calling the mist line at 1-800-UAB-MIST.
  
  And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
  
  
• Hosts:Melanie Cole, MS