- Oral feeding is preferred over EN, if possible
- The goal of oral diets and supplements should be a high-calorie and high-protein diet 
- The preferred method of EN is nasogastric tube feeding
- If nasogastric tube feeding fails, nasointestinal feeding is preferred, but due to convenience, PN is often used instead, despite additional potential complications


Nutrition Delivery and Access

- For the critically ill patients, EN is advised to be initiated early 
- Low‐dose EN is favoured over the full dose in the first week of critical illness
- During critical illness, the protein goal is set at 1.2–2.0 g/kg ABW/d
- Continuous feeding is recommended over bolus feeding to reduce the incidence of diarrhea, optimize blood glucose levels, and diminish patient-healthcare worker interaction


Timing of Nutrition Delivery


Critically ill patients may require mechanical ventilation, and therefore may require prone positioning. The relatively flat body position, increase in abdominal pressure, and the use of sedative and paralytic agents in high doses on these patients may result in gastric intolerance, making healthcare providers hesitant to feed patients orally. Early EN has been recommended for COVID-19 patients in the prone position.

Nutrition in the Prone Position


GI intolerance, including unexplained abdominal pain, nausea, vomiting, diarrhea, or significant abdominal distention, is common during the early and late acute phases of critical illness.

Countermeasures that can be taken if there is GI intolerance:
- Prokinetics to enhance motility
- If there is delayed gastric emptying, enteral formula should not be concentrated
- Feeding volume or rate can be reduced and formulas with the proper nutrients can also be considered if there is abdominal distension or diarrhea
- If GI intolerance persists, postpyloric feeding can be considered


The Challenge of GI Intolerance

- Nutrition Delivery and Access
- Timing of Nutrition Delivery
- Nutrition in the Prone Position
- The Challenge of GI Intolerance

Smith College

- Understanding the GI Tract, COVID‐19, and Related Nutrition Issues
- Innovating Nutrition Practices in the COVID‐19 Pandemic

Results of Gastrointestinal Manifestations of COVID‐19: Impact on Nutrition Practices

Aguila, E., Cua, I., Fontanilla, J., Yabut, V., & Causing, M. (2020). Gastrointestinal Manifestations of COVID-19: Impact on Nutrition Practices. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 35(5), 800–805. https://doi.org/10.1002/ncp.10554

Gastrointestinal Manifestations of COVID‐19: Impact on Nutrition Practices

- ACE2 is expressed abundantly in the gastrointestinal tract, especially the ileum and colon
- When SARS-CoV-2 binds to ACE2 receptors, it is believed that it disrupts the microbiome of the intestinal tract
- There are GI symptoms of COVID-19 (e.g. anorexia, nausea, vomiting, diarrhea, and abdominal pain) that may impact the ability for a patient to eat. If oral intake is not possible, enteral nutrition is preferred (studies have shown that this method decreases length of hospital stay, costs, mortality rate, and septic complications)
- Simulating the digestive system is important because a lack of nutrients in the intestines can result in lymphoid tissue and decline of the immune system, as well as increased bacterial translocation. Therefore parenteral nutrition is not recommended
- A few journals indicate that EN is extremely beneficial for patients Crohn's disease and Inflammatory Bowel Disease
- Probiotics are being used in addition to primary treatments to mitigate the damage done to the gut microbiota done by antibacterial and antiviral treatments


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