This presentation summarizes my effort of discussing the ASPEN and ESPEN guidelines in a Seminar for proper nutrition in all types of COVID19 patients. I am sharing this over the internet because It will allow healthcare providers to provide information for the provision of better nutrition and care among patients. This PPT is made open to all and all the details are taken from are from the mentioned respective studies and authors. As a scientific scholar and doctor, I am sharing the data mentioning their due references. All articles mentioned are open access and you may reach out and read them at length for any issues. Please do not use data without reference from these articles for copyright issues.

4. 0
1
0
2
0
3
0
4
1900
194
0
1960
NUTRITION = SUSTENANCE
Amount/Quantity of the feed was a concern
NUTRITION FOR SUSTENANCE
PROXIMATE PRINCIPLES OF
NUTRITION
Nutrition supports recovery. Nutrition was
adjusted as per disease. The concept of a proper
Diet Chart.
SUPPORTIVE EFFECT OF NUTRITION
IN HEALTH
Addition of Micronutrients separately came into being.
Here came the quality of Nutrition.
CONCEPT OF MICRONUTRIENTS
THE PARADIGM SHIFT
Anti-inflammatory Antioxidant and Therapeutic aspects of
good balanced Nutrition
THERAPEUTIC ROLE
200
0
NUTRITION
SUPPORT
NUTRITION
THERAPY

6. 31 December 2019 Cluster of pneumonia of unknown etiology detected in Wuhan City,Hubei Province,China
7 January 2020 The Chinese authorities identified a novel type of coronavirus
12 January 2020 China shared the genetic sequence of the novel coronavirus
13 January 2020 Thailand reported the first confirmed case of the novel coronavirus outside China.
20 January 2020 The USA reported its first confirmed case
22 and 23 January WHO convened an Emergency Committee under International Health Regulations
24 January 2020 The first report of a case in Europe was reported by France
30 January 2020 The WHO Director-General declared the 2019 nCoV a PHE –IC
11 February 2020 The virus, and the disease it causes, were officially named
27 February 2020 WHO updated the case definitions for COVID-19
11 March 2020 The WHO Director-General declared the COVID-19 outbreak a pandemic

7. January 27, 2020
A 20 yr. old female presented to the Emergency Department in General
Hospital, Thrissur, Kerala, with a one-day history of dry cough and sore
throat. There was no history of fever, rhinitis or shortness of breath. She
disclosed that she had returned to Kerala from Wuhan city, China, on
January 23, 2020 owing to COVID-19 outbreak situation there
March 18,2020
An 18-year-old man, who recently returned from England, tested positive for
the novel coronavirus (covid-19) on Tuesday, making it the first confirmed
case in West Bengal.

12.  Novel Corona Virus SARS CoV-2 was thought to cause SARS and Atypical
Viral Pneumonia. But COVID-19 a multimodal and multi-systemic disease,
with a varied range of signs and symptoms, which may range to present as
Pneumonia, ARDS, Sepsis, Shock (Hypotension), Acute Gastroenteritis,
Renal Failure and Thrombotic events involving varied organ systems.
 Around 5% Patients affected with COVID are requiring Intensive
Care/ICU Care and are requiring long episodes of treatment. The average
hospital stay can range from weeks to months.

13. Respiratory
Infection
• Associated with loss of appetite
• Dysgeusia and dyssomnia
• Macro and micronutrient deficiencies are
associated with a worser outcome.
• Vitamin A, D C supplementation have
shown better results
Multimodal &
Multisystemic disease
• 5-10% requiring ICU Admission
• Prolonged Hospital Stays are necessary
• No specific good acting drug yet
• Cytokine Storm

14. Cellular homeostasis regulates
Free Radicals and Tissue Injury
Factors, by Cellular mechanisms.
HEALTH
DISEASE
Metabolic
Homeostasis
Metabolic and
Inflammatory
Derangement
Free Radicals and Tissue Injury Factor
generation are overt and not regulated, by
Antioxidant mechanism within cells,
resulting in tissue injury, inflammation.
Which in-turn involve more cytokine and cell
mediated tissue injury and dysfunction.
Good Nutrition

15. BENEFITS
0
4
0
3
0
2
0
1
IMPROVES OVERALL
CLINICAL OUTCOME AND
ROAD TO RECOVERY
SIGNIFICANTLY IMPROVES
MORTALITY AND MORBIDITY
REDUCES CHANCES OF
COMPLICATIONS
NUTRITION IS A HUMAN
RIGHT ISSUE. YOU HAVE TO
FEED A PATIENT ADMITTED
REDUCES OVERALL COST
BURDEN OF THE PATIENT

18. Acute respiratory complications that are reported to require
prolonged ICU stays are a major cause of morbidity and mortality
in COVID-19 patients, and older adults and poly-morbid
individuals have worst outcomes and higher mortality
•Zhu N. Zhang D. Wang W. Li X. Yang B. Song J. et al.
A novel coronavirus from patients with pneumonia in China, 2019.
N Engl J Med. 2020; 382: 727-733
•Chen N. Zhou M. Dong X. Qu J. Gong F. Han Y. et al.
Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a
descriptive study.
Lancet. 2020; 395: 507-513
•Huang C. Wang Y. Li X. Ren L. Zhao J. Hu Y. et al.
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
Lancet. 2020; 395: 497-500
•Bouadma L. Lescure F.X. Lucet J.C. Yazdanpanah Y. Timsit J.F.
Severe SARS-CoV-2 infections: practical considerations and management strategy for intensivists.
Intensive Care Med. 2020 Feb 26;

19.  Food intake is very reduced by several factors: anorexia secondary to
infection, dyspnea, dyssomnia, dysgeusia, stress, confinement, and
organizational problems limiting attendance at meals. Most COVID-19
patients admitted to the ICU are at high risk of malnutrition.
 Infection, hypermetabolism, hyper-immune (cytokine storm) and physical
immobilization expose to rapid muscle wasting. The worsening of
malnutrition should therefore be prevented by an appropriate nutritional
strategy, including adequate protein-energy delivery and stimulation of
physical activity

20.  Many chronic diseases such as diabetes and cardiovascular diseases and
their clustering in poly-morbid individuals as well as older age per se, are
also very commonly associated with high risk and prevalence of
malnutrition and worse outcomes. And these are the groups which are mist
severely affected in COVID-19.
 In addition, inflammation and sepsis development may further and
primarily contribute to enhance all the above alterations in the presence of
SARS-CoV2 infections.

21.  Most importantly, appropriate nutritional assessment and treatment are
well-documented to effectively reduce complications and improve relevant
clinical outcomes under various conditions including ICU stays,
hospitalization, several chronic diseases and in older adults.

23. ESPEN
For all Individuals at Risk or
Infected with SARS CoV-2
For all Critically Ill COVID-19
Patients (Patients in ICU)
Non-Intubated patients
Intubated Patients
Post Intubation Patients
ICU Acquired Weakness

24. For all Individuals
At Risk or Infected with
SARS CoV-2

25. STATEMENT- 1
 Patients at risk for poor outcomes and higher mortality following
infection with SARS-COV-2, namely older adults and poly-
morbid individuals, should be checked for malnutrition
through screening and assessment.
 The check should initially comprise the MUST criteria∗ or, for
hospitalized patients, the NRS-2002 criteria.

26. STATEMENT- 2
 Subjects with malnutrition should try to optimize their nutritional
status, ideally by diet counseling from an experienced
professionals (registered dieticians, experienced nutritional
scientists, clinical nutritionists and specialized physicians).
 Obesity increases one's risk of being hospitalized with, and dying
from an influenza virus infection and that obesity inhibits both
virus-specific CD8+ T cell responses and antibody responses to
the seasonal influenza vaccine

27.  This is particularly important for the WHO European Region as
in many European countries obesity and overweight affects 30-
70% of the population
 Regarding Influenza and SARS independent variables, Male
sex, Malnutrition Severity Score, Serum Albumin
and Pneumonia are associated with survival 30 days from
the onset of influenza.

28.  Energy needs can be assessed using Indirect Calorimetry
if safely available with ensured sterility of the measurement
system, or as alternatives by prediction equations or weight-
formulae such as:
1. 27 kcal per kg body weight and day; total energy expenditure for poly-
morbid patients aged >65 years
2. 30 kcal per kg body weight and day; total energy expenditure for
underweight, poly-morbid patients
3. 30 kcal per kg body weight and day; guiding value for energy intake
older persons, this value should be individually adjusted with regard

29.  Protein needs are usually estimated using formulae such as:
1. 1 g protein per kg body weight and day in older persons; the amount
be individually adjusted with regard to nutritional status, physical
level, disease status and tolerance.
2. ≥1 g protein per kg body weight and day in poly-morbid medical
inpatients in order to prevent body weight loss, reduce the risk of
complications and hospital readmission and improve functional
1.3 g protein equivalents/day to be delivered progressively
 Fat and Carbohydrates: adapted to energy needs, fat-to-
carbohydrate energy ratio 30:70 (no respiratory deficiency) to
(ventilated patients) percent.

30. STATEMENT- 3
 Subjects with malnutrition should ensure sufficient supplementation
with vitamins and minerals.
 Subjects with malnutrition should ensure supplementation with Vitamin A, Vitamin D
and other micronutrients. As part of the general nutritional approach for viral infections
prevention is supplementation and / or adequate provision of vitamins to potentially reduce
disease negative impact.
 In general, low levels or intakes of micronutrients such as Vitamins A, E, B6 and B12, Zn
and Se have been associated with adverse clinical outcomes during viral infections2, 5.
 This notion has been confirmed in a recent review from Lei Zhang and Yunhui Liu who
proposed that besides vitamins A and D also B vitamins, vitamin C, omega-3
polyunsaturated fatty acids, as well as selenium, zinc and iron should be
the assessment of micronutrients in COVID-19 patients.
 ESPEN experts thus suggest to ensure the provision of daily allowances for vitamins and trace
elements to malnourished patients at risk for or with COVID-19, aimed at maximizing general
anti-infection nutritional defense

31. STATEMENT- 4
 Patients in quarantine should continue regular physical activity
while taking precautions.
Quarantine can lead to an increased risk for and potential worsening of chronic
health conditions, weight gain, loss of skeletal muscle mass and strength and
possibly also loss of immune competence.
There is a strong rationale for continuing physical activity at home to stay
healthy and maintain immune system function in the current precarious
environment2, 6.
Every day > 30 min or every second day > 1h exercise is recommended to
maintain fitness, mental health, muscle mass and thus energy expenditure and
body composition

32. STATEMENT- 5
 Oral nutritional supplements (ONS) should be used whenever possible to
meet patient's needs, when dietary counseling and food fortification are
sufficient to increase dietary intake and reach nutritional goals.
 ONS shall provide at least 400 kcal/day including 30 g or more of
protein/day and shall be continued for at least one month.
Efficacy and expected benefit of ONS shall be assessed once a month.

33. STATEMENT- 6
 In poly-morbid medical inpatients and in older persons with
reasonable prognosis, whose nutritional requirements cannot
be met orally, enteral nutrition (EN) should be administered.
Parenteral nutrition (PN) should be considered when EN is not
indicated or unable to reach targets.
 EN may be superior to PN, because of a lower risk of infectious and non-
infectious complications.
 There are no limitations to the use of enteral or parenteral nutrition based on
patient age or diagnosis, in the presence of expectable benefit to improve
nutritional status.

34. Critically Ill
Non-Intubated Patients

35. STATEMENT- 7
 In COVID-19 non-intubated ICU patients not reaching the
energy target with an oral diet, oral nutritional supplements
(ONS) should be considered first and then enteral nutrition
treatment.
 If there are limitations for the enteral route it could be advised to
prescribe partial peripheral parenteral nutrition in the
population not reaching energy-protein target by oral or enteral
nutrition.

36. Critically Ill
Intubated Patients

37. STATEMENT- 8
 In COVID-19 intubated and ventilated ICU patients enteral
nutrition (EN) should be started through a nasogastric
post-pyloric feeding should be performed in patients with gastric
intolerance after prokinetic treatment or in patients at high-risk for
aspiration;
 The prone position per se does not represent a limitation or
contraindication for EN.
ASPEN ESPEN Contradiction!!

38.  Energy requirements:
Patient energy expenditure (EE) should be determined by using
indirect calorimetry when available.
VO2 (oxygen consumption) from pulmonary arterial catheter or
VCO2 (carbon dioxide production) derived from the ventilator will
give a better evaluation on EE than predictive equations.

39.  Energy administration:
Hypocaloric nutrition, not exceeding 70 % of EE should be
administered in the early phase of acute illness with increments
up to 80 –100 % after day 3.
If predictive equations are used to estimate the energy need,
hypocaloric nutrition < 70 % estimated needs should be preferred
over isocaloric nutrition for the first week of ICU stay.

40.  Protein requirements:
During critical illness, 1.3 g / kg protein equivalents per day can
delivered progressively.
Obese patients: in the absence of body composition
measurements 1.3 g / kg “adjusted body weight” protein
per day is recommended.
Adjusted body weight is calculated as IBW+ (ABW– ABW) * 0.336

41. STATEMENT- 9
 In ICU patients who do not tolerate full dose enteral nutrition (EN)
during the first week in the ICU, initiating parenteral nutrition (PN)
should be weighed on a case-by-case basis.
PN should not be started until all strategies to maximize EN
tolerance have been attempted.
 Limitations and precautions: Progression to full nutrition coverage should be
performed cautiously in patients requiring mechanical ventilation and
stabilization.

42. Contraindications:
EN should be delayed in the presence of uncontrolled shock and
unmet hemodynamic and tissue perfusion goals; in case of
uncontrolled life-threatening hypoxemia, hypercapnia or acidosis.
Precautions during the early stabilization period:
Low dose EN can be started as soon as shock is controlled with
fluids and vasopressors OR inotropes, while remaining vigilant for
signs of bowel ischemia; in patients with stable hypoxemia, and
compensated or permissive hypercapnia and acidosis.

43. General comments:
In stabilized patients even in prone position, EN can be started ideally after
measurement of IC with a target of 30 % of measured energy expenditure.
Increase energy administration progressively.
In Emergency times:
 Predictive equation recommending 20 kcal / kg / d can be used,
 energy increased to 50 – 70 % of the predicted energy at d2 to 80 – 100
at d4.
 The protein target of 1.3 g / kg / day should also be reached by day 3 –

44.  Gastric tube is preferred but in case of large gastric residual volume
(above 500 mL), duodenal tube should be inserted quickly.
Enteral omega-3 fatty acids may improve oxygenation but strong evidence
is missing.
 If intolerance to EN is present, PN should be considered.
 Blood glucose: maintained at target levels between 6-8 mmol / l.
Monitoring of blood triglycerides and electrolytes including phosphate,
potassium and magnesium

45. Critically Ill
Post-Intubation Patients

46. STATEMENT- 10
 In ICU patients with dysphagia, texture-adapted food can be
considered after extubation. If swallowing is proven unsafe, EN
should be administered.
 In cases with a very high aspiration risk, Post-pyloric EN or, if
possible, temporary PN during swallowing training with removed
Naso-enteral tube can be performed
The post-extubation swallowing disorder could be prolonged for up to 21 days
mainly in the elderly and after prolonged intubation, which makes this
complication particularly relevant for COVID-19 patients.

47. ICU Acquired Weakness

48.  The long-term prognosis of patients surviving intensive care is
affected by physical, cognition and mental impairment that
occur following ICU stay.
 Loss of muscle mass: Cachexia/Sarcopenia
 Although definitive guidance cannot be made on additional
specific treatments potentially due to lack of high-quality studies,
recent evidence seems to indicate potential positive impact of
physical activity with supplemental calorie, protein, amino acids
or their metabolites

50. “We refer the reader to the full guidelines for specific
recommendations in various specific conditions that
could be encountered in association with COVID-19.”

55. Recommendation-1
 Dietitians may contact patients by telephone to obtain
information for the assessment.
However, this has been challenging at times, especially
when patients are not able to participate in a telephone
interview.
Alternatively, clinicians are calling family members to
gather background information when the patient is unable
to be on the call.
Nutrition

56. Recommendation-2
Timing of Nutrition
Delivery
 Initiating Early EN within 24-36 hours of admission to the
ICU or 12 hours of Intubation and placement of mechanical
ventilation should be the Goal.
 The Majority of patients with sepsis or circulatory shock
have been shown to tolerate Early EN at Trophic Rate.
 Provision of early EN in ICU patients has shown improved
mortality and reduced infections when compared with
delayed EN or withholding EN

57.  Parenteral Nutrition may be delayed upto 5-7 days, in patients
with low risk of progression to malnutrition.
 Patient must be reassessed for improvement of condition
every3-4 days for shifting to EN/ check the level of under-
nutrition risk.

58.  Administering EN has been shown to be safe in most ICU
patients on a stable low‐dose vasopressor

59.  Acutely ill patients may have a nasogastric (NG) tube placed for
gastric decompression; this same tube may later be used for
enteral feeding when gastric decompression may no longer be
needed. Replacing the NG suction tube with a Naso-enteric
feeding tube increases staff risk of contamination

60.  Enteral Nutrition should be preferred
 Infusion formula into the stomach via 10-12 Fr Nasogastric
Tube should be the 1st priority.
 A prokinetic agent may be used to augment gastric
in case if any.
 Post pyloric feeding is recommended when these strategies
fail to increase gastric tolerance, and or with high risk of
aspiration
Recommendation-3 Route, Tube Placement and
Method of Nutrition

61.  Tube placement must be ensured with Abdominal
skiagrams. Confirmatory abdominal X-Rays should be
clustered along with chest X-Ray timing.
 In many cases larger bore NGT (Naso Gastric Tube) or OGT
(Oro Gastric Tube) may be placed at the time of intubation.
 HCW must wear full PPE along with N-95/PAPR during
insertion of NGT/OGT
Recommendatio Route, Tube Placement and
Method of Nutrition Delivery

62. Recommendation-3 Route, Tube Placement and
Method of Nutrition
 Continuous rather than bolus EN is strongly recommended
for COVID-19 patients, this is supported by both the
ESPEN and SCCM/ASPEN guidelines.
 Critically ill patients with COVID-19 disease have been
reported to be older with multiple comorbidities. Such
patients are at higher risk of Refeeding syndrome.

63.  Regular Abdominal exam must be clustered with other
clinical exams to reduce time of exposure.
 Post pyloric feeding tubes tend to be of smaller calibre and
therefore are more likely to become clogged with decreased
flushing than a larger bore OGT/NGT, which may occur with
clustering of care and goal to limit patient contact.
 Lastly placement of PPFT may take longer to place than
tubes, increasing exposure time to health care provider.
Recommendation-3 Route, Tube Placement and
Method of Nutrition

64. Recommendation-3
Route, Tube Placement and
Method of Nutrition
Delivery
Route
Enteral Parenteral
High NUTRIC Score/
NRS Score
Shock with
multiple/escalating
vasopressor
requirement
Concern for
Intolerance even with
corrective measures.
Bowel Ischemia/
Evidence of GI
Bleeding
Abdominal pain,
Nausea Severe
Diarrhoea,
Pneumatosis
Intestinalis, Acute
Intestinal Obstruction
Increased Naso-Gastric Outputs in previous 6-12 hours with start of EN

65. Recommendation-4 Nutrition Dose,
to goal and Adjustments
 During acute phase feeding should be initiated with low dose
enteral nutrition, either hypocaloric or trophic.
 Advancing to full dose enteral nutrition must be done slowly
over the 1st week of critical illness to meet 15-20kcal/ABW/day
(which should meet ~70-80% of the REE and a protein goal of
1.2-2gm/kg ABW/day.
 Calorie demands must be ideally done with Indirect
Calorimetry.

66. Recommendation-4 Nutrition Dose,
to goal and Adjustments
 Patients with COVID-19 disease may deteriorate quickly. EN
Should be withheld in patient requiring vasopressor support at
high or escalating dosages, on multiple vasopressor agents or
with rising lactate levels.
 EN may be restarted after the patient is stable on a single
vasopressor dose with sustained MAP of ≥65 mm-hg and slowly
advanced to a goal of 80-100% of estimated needs by the end of

67. Recommendation-4 Nutrition Dose,
to goal and Adjustments
 If parenteral nutrition is necessary, conservative dextrose
content and volume should be used in the early phase of the
critical illness, slowly advancing to meet the same energy goals
as outlined above.

68. Recommendation-5 Formula
 A standard high protein (≥20% Protein)polymeric, iso-
osmotic enteral formulae should be used in the early acute
phase of critical illness. As the patients status improves and
vasopressor requirements abate, addition of fibres should be
considered.
 If there is significant GI dysfunction a fiber-free formulae
may be better tolerated. As soon as GI function improves, a
fibre containing formula or supplement should be attempted

69. Recommendation-5 Formula
 Animal models and a few small human trials suggest that
fish-oil containing formulations may be benefit in immune
modulation and helping to clear viral infections. The fish oil
metabolites seem to be the active participant.
 Currently with only animal data and a few human trials,
inadequate specific human trials are available, to make this
a formal recommendation.

70. Recommendation-5 Formula
 If PN is required in the 1st week of ICU stay during the
acute inflammatory phase of COVID-19, limiting steps
should be taken for use of pure SOYBEAN LIPID
EMULSIONS as outlined in published guidelines.
Alternative mixed lipid emulsions can b used.
 Propofol may be avoided as a subset of patients who are
receiving propofol as a medication are developing severe

71. Recommendation-6
Monitoring
Tolerance
 Enteral feeding intolerance (EFI) is common during early
and late acute phases of critical illness. Early experience
with COVID-19 patients suggests that gastro-intestinal
symptoms (which might manifest as EFI) are associated
with greater severity of illness.
 GRV monitoring is not reliable for detecting delayed gastric
emptying and risk of aspiration, has been shown to be a
deterrant to the delivery of EN, and should not be utilized

72. Recommendation-6
Monitoring
Tolerance
 Patients should be monitored by daily physical and
abdominal examinations and confirm the passage of stool
and gas.
 As with any ICU patient, recording of the percent of calories
and protein delivered should be recorded for both EN and
PN

73. Recommendation-7 Nutrition for the Patient
Undergoing Prone
 Several retrospective and small retrospective trials have
shown EN during prone position is not associated with
increased risk of gastro-intestinal or pulmonary
complications, thus we recommend the patient requiring
prone positioning receive early EN.
 Most patients tolerate EN delivered into the stomach
(Gastric EN) while in prone position.

74. Recommendation-7 Nutrition for the Patient
Undergoing Prone
 On occasion some patients suffer from reflux/vomiting or
high gastric output. In these patients post-pyloric tube
placement of feeding tube may be indicated.
 When EN is introduced in prone positioning, we recommend
of keeping HOB (Reverse Trendelenburg) to at-least 10-25°
to decrease the risk of aspiration of gastric contents, facial edema and
intra abdominal hypertension.

75. Recommendation-8
Nutrition therapy
during ECMO
 One of the major barriers to EN during ECMO is the
perception that ECMO patients are at risk of delayed
Gastric emptying and bowel ischemia. But this is not
universally true.
 Thus we recommend starting early low dose (trophic) EN in
those on ECMO with close monitoring for EFI and slow
advancement to goal over the 1st week of critical illness.

76. Recommendation-8
Nutrition therapy
during ECMO
 In patients where PN is utilized, there was a concern
because the initial ECMO filters allowed lipid infiltration
into the oxygenator. However newer ECMO circuits have
negated the lipid infiltration issue.

79. ESPEN
For all Individuals at Risk or
Infected with SARS CoV-2
Check for malnutrition
Optimisation of
Nutritional Status
Supplementation with
vitamins and minerals
Regular Physical
Activity
Nutritional Support
Oral
Enteral
Par-enteral
For all Critically Ill COVID-19
Patients (Patients in ICU)
Non-Intubated patients
Intubated Patients
Post Intubation Patients
ICU Acquired Weakness

81. 1. COVID-19 patients should be considered for malnutrition.
2. Nutritional evaluation based on the Global Leadership Initiative on
Malnutrition (GLIM) should be adapted to the COVID-19 epidemic.
3. Indirect calorimetry should be proposed only for patients staying for more
than 10 days in the ICU or those on full parenteral nutrition (PN) to avoid
overfeeding.
4. Refeeding syndrome (RS) and complications related to propofol use must be
prevented.
5. Enteral nutrition (EN) should be preferred over PN and started within 48 h
of admission.

82. 6. Gastric EN is generally possible, including in the prone position, and
should be preferably performed using a pump with flow regulator.
7. PN is indicated if EN is impossible, contraindicated, or insufficient and
should be prescribed using a case-by-case decision making.
8.The use of EN enriched with omega-3 fatty acids should be preferred in
case of ARDS. Fish oil-enriched intravenous fat emulsions should be
prescribed if PN is required.
9. After extubating, the nutritional support is promoting patient’s recovery
and rehabilitation and should be continued until the patient resumes
sufficient oral intake.
10.Physical activity should be promoted to preserve muscle mass and

85. DOCTOR PRESCRIPTION TO
TEAM BASED APPROACH
NUTRITIONIST
NURSES
TECNICIAN
DOCTORS

86. Must be done as
early as patient gets
admitted. Screening
identifies deficit/ need
for special diet and
standardization/ type
of diet.
Calculate also the
amount of Diet.
MONITOR &
RE-PLAN
REASSESS
& FINE-TUNE
PLAN &
START
SCREEN &
CALCULATE
3
4
2
1
Start feeding within
36 hours of
admission. Its
guideline of Early
enteral Nutrition.
SET OBTAINABLE
GOALS
Monitoring must be in
a continuous process
in ICU and daily in
wards.
Any major dietary
changes must be
documented.
CHECK IF GOALS
REACHED
After starting feeding
patient must be
reassessed clinically
every 8 hourly and
metabolic parameters
must be considered
every day.

89. MAINTAIN A NUTRITION CARD AND ASSESSMENT
SHEET
 Daily for ICU patients and every 72hours for gen ward
 Involve all staffs, ascertain specific jobs
 Enteral tube placement must be checked with skiagram
This should be preferably done along with Chest-X Rays
In case of intubation a Ryle’s tube/ Naso-gastric tube must be inserted in the
same setting.
 Mention obtainable goals

90. Vitamin-C Supplementation
Vitamin D Supplementation
Glutathione and Acetyl Cysteine Supplementation
Vitamin D Supplementation has documented benefits in Viral
Influenza and Influenza like respiratory illness.
Vitamin deficiency has shown higher morbidity and mortality in
respiratory illnesses.

92.  Daily Monitoring of Electrolytes
 Sodium
 Potassium
 Magnesium
 Phosphate
 Chloride
 Bicarbonate
 Continuous Glucose Monitoring
 Hydration Status Monitoring

94. Diagnosis
and
Management
01
03
02 Recovery and
Release/
Rehabilitation
Continuous
Monitoring
of Patient
Nutrition in ICU is a different ball
game. It is in continuum with
A good nutritional support will
enhance the vitality of the patient
and augment cure rate
Any deviation will contribute into
deterioration of patient condition
and will add to morbidity and
mortality

106. REFERENCES
1. Zhu N. Zhang D. Wang W. Li X. Yang B. Song J. et al.
A novel coronavirus from patients with pneumonia in China, 2019.
N Engl J Med. 2020; 382: 727-733
2. Chen N. Zhou M. Dong X. Qu J. Gong F. Han Y. et al.
Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive
Lancet. 2020; 395: 507-513
3. Huang C. Wang Y. Li X. Ren L. Zhao J. Hu Y. et al.
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
Lancet. 2020; 395: 497-500
4. Bouadma L. Lescure F.X. Lucet J.C. Yazdanpanah Y. Timsit J.F.
Severe SARS-CoV-2 infections: practical considerations and management strategy for intensivists.
Intensive Care Med. 2020 Feb 26;
5. Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.
Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort
Lancet. 2020 Mar 11
6. Singer P. Blaser A.R. Berger M.M. Alhazzani W. Calder P.C. Casaer M.P. et al.
ESPEN guideline on clinical nutrition in the intensive care unit.
Clin Nutr. 2019; 38: 48-79
7. Gomes F. Schuetz P. Bounoure L. Austin P. Ballesteros-Pomar M. Cederholm T. et al.
ESPEN guideline on nutritional support for polymorbid internal medicine patients.
Clin Nutr. 2018; 37: 336-353

108.  MUST Criteria
 NRS 2002
 NUTRIC Scoring
 MNA (Mini Nutritional Assessment)
 Subjective Global Assessment criteria
 GLIM (Global Leadership Initiative on Malnutrition) criteria
 ASPEN Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient
 ESPEN Expert statements and practical guidance for nutritional management of
individuals with SARS-CoV-2 infection.
 Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance

109. Weir equation used to calculate energy expenditure:
Energy expenditure = (3.9VO2 + 1.1VCO2) – 2.17 (urinary nitrogen)
Abbreviated Weir Equation = used to calculate REE: REE = [(3.94 VO2)+(1.11 VCO2)]x 1440

111. CALORIE
MICRO NUTRIENTS
ELECTROLYTES
HYDRATION
DISEASES