Nutricia is taking all necessary precautions and measures to ensure product safety by applying high product safety standards and quality controls throughout the value chain, from the sourcing of our raw material and packaging to the delivery of our products. The risk of infections arising from contact with food ingredients or packaging coming from affected areas, sourced from commercial suppliers, is considered negligible as stated by expert organizations (like the World Health Organization, European Food Safety Authority and the European Center for Disease Control).
Coronaviruses are generally thought to be spread from person-to-person through respiratory droplets. Currently there is no evidence to suggest transmission of COVID-19 associated with food or medical nutrition products. Before preparing/consuming/ delivering tube feeding products it is important to always wash hands with soap and water for 30 seconds for general food safety.
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Before preparing and delivering tube feeding products, practice respiratory hygiene, wash hands thoroughly with soap and water for at least 30 seconds. At all times, carefully follow the recommendations that you have been given for safe and proper handling of feeding tubes and devices according to the product instruction manual.
On a regular basis thoroughly clean all surfaces of the pump with warm soapy water, a multipurpose disinfectant cleaner or a soft cloth. Always follow the instructions according to the product manual.
COVID-19 viruses are generally thought to be spread from person-to-person through respiratory droplets. Currently there is no evidence to suggest transmission of COVID-19 associated with food or medical nutrition products.
It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.
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Based on most up to date publicly available information, gastric feeding is not contraindicated in these patients. Nasogastric (NG) feeding can in principle be continued during prone positioning if there are no concerns regarding gastrointestinal intolerance (GI) (e.g. high gastric residual volumes (GRVs), vomiting).
Critical care specialist group (CCSG) makes the following recommendations:
For more information see also the following websites:
Publication: Administration of enteral nutrition to adult patients in the prone position
As per publicly available information, about 20% of COVID-19 patients have gastrointestinal (GI) symptoms (such as abdominal pain and diarrhea) due to direct viral infection of the intestinal mucosa or antiviral and anti-infective drugs. The balance of the bacterial microbiome in the gut seems to be disturbed. Some COVID-19 patients seem to experience GI tolerance issues due to the high level of sedative drugs used, which can have an impact on the smooth muscle of the GI tract causing gastric stasis.
Since the tolerance issues are mainly related to a delayed gastric emptying, the recommendation is to start standard high protein feeds from 1.3kcal-1.5kcal/ml if fluid restricted.
There are publications suggesting that a special 4 proteins (whey, casein, soy and pea) blend called P4 provides better tolerance/ faster gastric volume emptying as compared to casein-based products. Casein dominant enteral nutrition coagulates in the stomach due to its precipitation by gastric acid. The P4 blend has been shown to be non-coagulating.
The British Dietetic Association (BDA) Critical Care Group has specified that 2.0kcal/ml feeds may not be well tolerated, however this could be due to the high concentration/ being casein based. They can be useful for severe fluid restricted patients with renal failure where dialysis is delayed or may not be available. However in persistent cases of ongoing gastrointestinal intolerance (GI) complications, nasojejunal (NJ) feeding is more recommended. If this is not available, hydrolysed feeds could be an alternative if this does not work it is possible parenteral nutrition (PN) will be implemented.
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Medical societies such as [ESPEN, BDA] recommend giving enteral nutrition (EN) within 24–48 hours of admission. Early EN should comprise a standard high-protein formula. The provision of nutrition must be weighed against the risk of generating a positive fluid balance, which has been shown to have an important detrimental impact on clinical outcome in acute respiratory distress syndrome (ARDS).
For more information see also the following websites:
Publication: ESPEN guideline on clinical nutrition in the intensive care unit
Publication: ESPEN Guidelines on Enteral Nutrition: Intensive care
General guidance for severely ill COVID-19 patients is to receive enteral feeding as early as possible. If there are limitations for the enteral route it could be considered to prescribe peripheral parenteral nutrition. 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.
Critical care specialist group (CCSG): ‘Patients with COVID-19 may require significant levels of sedation and neuromuscular blockade which may increase the incidence of GI intolerance. There is guidance for monitoring GI tolerance and suggestions for feed use. Only once these are explore including placement of NJ tubes, then use of PN is indicated. It may therefore increase in sites where post-pyloric feeding is not available.’
For more information see also the following websites:
Publication: ESPEN guideline on clinical nutrition in the intensive care unit
Publication: ESPEN guideline on clinical nutrition in the intensive care unit
Publication: ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection
What type of enteral nutrition is recommended for critically ill COVID-19 patients? Standard high protein enteral feeds with 1.2 -1.5kcal/ml are suggested. In the case of GI tolerance issues avoidance of 2kcal/ml may be indicated. There are 2.0kcal/ml products containing a P4 protein blend (consisting of whey, casein, soy and pea protein) available] where evidence shows good gastric emptying in critically ill patients.
For COVID-19 patients with renal failure either the feeds as above can be used or in case of disturbances feeds with low electrolyte concentrated feeds prescribed.
In the event there are not enough dialysis machines a 2.0kcal enteral feed with low electrolytes may be indicated. Many COVID-19 patients with pre-esisting diabetes could benefit from feeds supporting glycaemic control.
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The Flocare Infinity™ pump should be cleaned according to its product manual. On a regular basis thoroughly clean all surfaces of the pump (including the sensors and rotor) with warm soapy water, a 5% bleach solution in water, a multipurpose disinfectant cleaner or a soft cloth. Many alcohol- and bleach-based products have been contra-indicated for cleaning use with Infinity II due to the long-term corrosive and/or housing cracking effects. However, a 5% bleach solution and 70% IPA for short term contact are approved for cleaning and disinfecting the Infinity pumps.
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If the pump has been stored for any period of time, it should be plugged into the mains to recharge the battery before commencing enteral feeding. The battery will be completely charged after approximately 6 hours.
It is in general safe to use older pumps when they have undergone a service-check. All pumps must be serviced either by one of Nutricia’s external service partners or by the hospital using the Flocare Service Suitcase every 2 years as recommended and indicated on the pump. Only authorized personnel is allowed to perform the service check on Flocare pumps.
It is not necessary to service the pump in-between 2 patients if the pump is still within next service check date. However, normal pump cleaning and disinfection should be done in-between patients to avoid cross- via the pump and to ensure the patients receive a pump in pristine condition.
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Acceptable cleaning agents are:
- Warm soapy water (standard dish soap)
- Bleach/ chlorine solution (5% chlorine or equivalent and 95% water) - Metrex CavaCide® (ammonium chloride)
- MetriCide®28 Glutaraldehyde - 70% Isopropyl Alcohol*
- Antisept N® or equivalent (povidone iodine)
- Approximately 1:1000 anti-bacterial detergent to water mixture
- Mikrobac (Bode) Forte and Tissues
- Dismozon Plus (Bode)
* CAUTION Only use 70% Isopropyl Alcohol or alcohol based disinfectants on the purple colored over-mold surface for short term contact only. Avoid any contact with other, transparent, parts of the pump. Refer to the service manual for approved cleaners for other surfaces.
Document reference: MTF2020027 v02.1
The administration sets (giving sets for the pump feeding, gravity feeding sets) should be changed at least every 24 hours (as indicated on the label). It can be sooner if deemed appropriate (e.g. reduction in risk of microbiological contamination).
Using the administration sets for more than 24 hours is generally not recommended because as it might result in:
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Please refer to all Instructions for use.
Always follow the instruction on the product label. In general, respect the maximum 24 hours hanging time of the ready to feed tube nutrition.
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Please refer to all Instructions for use.
Flush the nasal tubes regularly, at least every 8 hours and before and after every delivery of feed and medication.
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Please refer to all Instructions for use.
In many circumstances, patients requiring Non Invasive Ventilation (NIV) do not meet their energy and protein targets via oral intake alone. Healthcare professionals weigh the decision for nasogastric (NG) feeding in patients requiring Non Invasive Ventilation with the likelihood of the patient requiring intubation.
Critical Care Dietitians Specialist Group (CCSG recommends) the following:
For more information see also the following website:
Critical Care Dietitians Specialist Group (CCSG recommends) the following:
For more information see also the following website:
It is not possible to use Flocare InfinityTM feeding sets for gravity feed. Flocare InfinityTM pump feeding sets are fitted with an anti-free flow concept for optimal safety.
For more information see also the following website:
Please refer to all Instructions for use.
The product information for this area of specialization is intended for healthcare professionals or (carers of) diagnosed patients only, as these products are for use under healthcare professional supervision.
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