[Inflammation, malnutrition, and SARS-CoV-2 infection: a disastrous combination]

Abstract

SARS-CoV-2 infection is associated with a high risk of malnutrition, mainly due to increased nutritional requirements and the presence of a severe and universal inflammatory state. Associated symptoms contribute to hyporexia, which perpetuates the negative nutritional balance. Furthermore, dysphagia, especially post-intubation, worsens, and makes intake unsafe. This risk is greater in elderly and multimorbid patients. Inflammation to varying degrees is the common link between COVID-19 and the onset of malnutrition, and it is more correct to refer to disease-related malnutrition (DRM). DRM worsens the poor prognosis of SARS-CoV-2 infection, especially in the most severe cases. Therefore, it is necessary to identify and treat people at risk early, avoiding overexposure and direct contact with the patient. We cannot forget the role that a healthy diet plays in both prevention and recovery after discharge.

Keywords: Citoquine storm; Disease related malnutrition; Inflamation; SARS-CoV-2.

Figure 1

Relationship between SARS-CoV-2 infection, inflammation, and onset of malnutrition. The infection of a patient, who may have previous chronic diseases, gives rise to a “cytokine storm” which, due to various mechanisms, triggers the onset of malnutrition.

Figure 2

Recommendations for the nutritional approach to hospitalized COVID-19 patients. Exposure must be safe, minimizing the risk of contagion. Therefore, we must be practical, take a proper medical history, and use disposable materials. The five fundamental points are: 1. Nutritional screening, for which the MNA-SF test (due to its simplicity and because patient contact is not necessary. Another test that is validated but not recommended because it entails close contact with the patient for calculating the BMI is the NRS-2002) and a calf diameter (cutoff point of 31 cm) will be used. If possible, the nutritional screening will be performed in the first 48 hours following admission. 2. Nutritional evaluation: medical history and a determination of malnutrition with an MNA-SF test score of less than 12 points. 3. Calculation of needs according to the patient’s habitual weight and ideal weight in the case of obesity. 4. Nutritional support: oral intake will be prioritized, optimizing it when possible. If intake is not adequate, it will be supplemented with two oral nutrition supplements that are high in calorie and protein density, especially if there is sarcopenia or if the patient is elderly with multimorbidity. If reaching daily needs is severely endangered, total enteral nutrition will be used, avoiding tubes so long as it is possible. Continuity of care will be taken closely into account after discharge from the hospital. Oral intake will be reinforced by maintaining supplementation until the patient reaches 70% of his or her needs. 5. Take into account the most common clinical conditions of hospitalized patients, which may affect their nutritional state and the approach to it. Abbreviations: Ca2⁺: elemental calcium; PPE: personal protective equipment; CH: carbohydrates; HMB: β-hydroxy β-methylbutyrate; K: potassium; MNA-SF: Mini Nutritional Assessment-Short Form; Na: sodium; EN: enteral nutrition; P: phosphorus; PCR: Polymerase chain reaction; NGT: nasogastric tube; Sat: saturated; Vit D: vitamin D.

Figure 3

Recommendations for the approach to dysphagia in hospitalized and post-ICU COVID-19 patients. In the approach to dysphagia, it is necessary to distinguish between diagnosis and treatment. The diagnosis will be made based on the clinical record and on the EAT-10 screening tool. The screening will be carried out at first contact with the patient, although given that direct contact is not recommended in these cases, using the MECV-V test in select patients can be considered. Treatment will be individualized and safe in order to avoid the generation of aerosols and to promote patient autonomy. Proper oral hygiene must not be forgotten. We recommend prioritizing an oral diet adapted in composition and texture. In the event supplements are needed, they will be provided through specific supplements with adapted textures. If intake is not sufficient, the use of feeding tubes can be proposed, with a postpyloric approach in these cases. Parenteral nutrition will be reserved for severe cases or those in which it is impossible to use a gastric tube. Abbreviations: EAT-10: Eating Assessment Tool; MECV: Volume-Viscosity Clinical Exploration Method; NP: parenteral nutrition; O₂: oxygen; ONS: oral nutritional supplementation; NGT: nasogastric tube; ICU: intensive care unit.

Figure 4

Recommendations for the approach to sarcopenia in hospitalized and post-ICU COVID-19 patients. The diagnosis of sarcopenia will be based on the medical record. First, the common symptoms: fatigue and prolonged repose due to asthenia, hypoxia, or sedation which, along with systemic inflammatory symptoms, hypercatabolism, and significant weight loss, entail physical deconditioning. In order to diagnose sarcopenia—and following the maxim of avoiding contact with the patient and/or use of non-disposable material as much as possible—the MNA-SF score and calf diameter (cutoff point of 31 cm, which correlates well with lean mass and muscle strength) will be prioritized, as indicated in Fig. 1. Bioimpedance is not available in the majority of internal medicine departments. If it is available, it can be used, given that it is a simple technique that uses a portable, easy-to-clean device. Avoid techniques that entail a high risk of transmission, such as a DEXA scan, for example. Treatment is based on two pillars: oral diet and early mobilization of the patient. First, the oral diet has to be adapted and have a high content of high biological value protein and energy density. If nutritional supplements are needed, those enriched with high biological value protein, HMB, and leucine will be prioritized, as they regulate protein turnover. Second, early mobilization of the patient: it will be active or passive, if incapacity is severe, and adapted to each patient’s functional condition. Abbreviations: HMB: β-hydroxy β-methylbutyrate; MNA-SF: Mini Nutritional Assessment-Short Form; Prot: protein; ICU: intensive care unit; Vit. D: vitamin D.