COVID-19: The good, the bad and the ugly

Zudin Puthucheary  (London, UK)

 

THE UGLY:  CRIT-CON Pandemic Levels and their ethical risks

0 – Normal

1 – Preparatory

• Drawbridge ethics: withholding certain services in hospital / community to protect ourselves
• Moral panic: change in behaviour due to belief that we are at later stages of CRIT-CON than in reality

2 – Sustained surge (current state in the UK and many parts of Europe)

• Magic number ethics : using untested / unvalidated scoring systems, thereby relinquishing responsibility of decision making
• Moral blindness: taking on new concepts without rigour of evidence base
• Paternalism: making decisions believing they are the right ones, without discussing with colleagues / patients

3 – Super surge

• Moral confusion: making random decisions

4 – Code Red

• Moral paralysis: nobody makes decisions
• Hobbesian ethics: those who have loudest voices have most confidence in their views and therefore become dominant

 

Ethical risks in Nutritional care during COVID-19

• First, do no harm – Remember best practice, consider actions with regards to CRIT-CON levels
• Be aware of deviation from best practice

Example 1. Are HMB / probiotics / Vit C / Vit D justified just because of the pandemic?  – no evidence for these in normal critical care, let alone COVID-19

Example 2. Running out of feeding pumps – what to do, especially in pts proned for long duration

Systematic review: Administration of enteral nutrition in prone position  

• sparse, limited quality data on Enteral feeding in prone pts
• contradictory results re gastric residual volumes

Largest study of Enteral Nutrition in prone pts for ARDS

• only 47 pts
• apparently safe, BUT pts were not in prone position for long duration as seen in COVID-19 pts

==>> BDA provided guidance in response to these issues

• Avoid bolus feeding in prone position (no evid of safety)
• Consider gravity feeding if no pumps available

 

Effect of intermittent / continuous feeding on muscle wasting (Phase 2 clinical trial)

• intermittent feeding safe, tolerable and feasible in supine pts (no prone pts)
• but did not ameliorate acute skeletal muscle wasting

==>> BDA provided guidance on the basis of this trial

• bolus feed ONLY if no pump available, NOT FOR prone / GI tract abnormalities / via jejunal tube
• while safe, it is NOT standard of care

 

LESSONS:

1. Do not get caught up in moral confusion – maintain best practice
2. Refer to guidelines and updates, especially in evolving situation
3. Leave unproven interventions to RCTs

 

THE BAD: Persistent critical illness

UK Length of stay (LOS) in ICU survivors – mean 4.7 days  (stable for past 5 years)

Internationally, LOS in COVID-19 survivors  – median 12 days (5-28d) = more than twice usual LOS

Day 9/10 –> transition to Persistent critical illness

• antecedent characteristics e.g. age / pre-existing conditions more likely to kill than the illness itself (probably related to duration mech ventilation / muscle wasting)
• only 16% pts stay longer than 9/10 days
• COVID-19 pts (median LOS 12 days) are therefore all at risk of Persistent critical illness

• Rapid recovery –> Basic ADLs at 1-year
• Persistent critical illness –> no ADLs, not mobilising at 1-year

Muscle protein synthesis essential for rehabilitation from muscle wasting

Metabolic abnormalities likely limit energy and protein utilisation during persistent critical illness

Increased LOS / severity of illness = more severe muscle wasting

Muscle protein synthesis on Day 1 of critical illness is the same as Fasted controls (despite feeding) and has a variable recovery period

Muscle protein synthesis takes up to 30days to normalise 

Muscle protein synthesis is highly energy dependent

Critical illness (hypoxia + inflammation) reduces ATP generation from glucose and fatty acids

 

THE GOOD: Teamwork for rehabilitation

Mortality from COVID-19 is falling – more pts will survive

They WILL need nutrition, protein and energy for late phase of rehab

UK initiative to assess pts for post-ICU syndrome, initiate early rehabilitation, establish a framework to be used for both COVID and non-COVID pts

 

* Each coloured dot represents a specialist therapy

• size of dots reflects extent of requirement for that therapy
• lines indicate correlation; thickness of lines indicates strength of correlation

==>> In critical illness, there is an almost equal need for all classes of specialist therapy, with interlinkage between them and no single therapy more crucial than the others

 

Exercise ALONE is catabolic

Exercise must be combined with adequate protein intake

• one size does not fit all
• Older pts need more protein for muscle synthesis (70 yr old needs 3x as much as 20yr old)

Older pts need more exercise, and have a narrower window for muscle synthesis post-exercise  –>> Quantity and Timing of feeding are both important

Before COVID-19: prevalence of  laryngeal pain (76%) and dysphagia (49%) in crit illness

COVID-19 likely to result in a ‘pandemic’ of SALT issues including dysphagia, preventing pts from successful oral feeding

* A ‘cheat sheet’ for ICU doctors, nurses and dieticians

Occupational Therapist: not available in all centres; roles expanding in COVID-19 – assessment / guidance on meal preparation, positioning, adaptive cutlery etc… Ask an Occupational Therapist to see how they can help!

Anxiety, depression and PTSD extremely common – 50% critically ill pts will have combination of these

• ICD-10 criteria for anxiety: difficulty swallowing, nausea, abdo distress
• ICD-10 criteria for depression: loss of interest / pleasure, alteration in appetite
• Will impact on eating and nutrition

Deprivation = major reason for poor quality nutrition + protein intake – pts from deprived background unlikely to have good nutrition / good recovery

 

LESSONS:

1. COVID-19 pts likely to have metabolic derangements of persistent critical illness
2. Rehabilitation is a team game
3. Be aware of deprivation as a significant barrier to rehab + recovery –> it will undo all the good work by healthcare team