Out of ICU and into recovery is only the beginning

Ensuring the nutritional care of COVID-19 patients, from hospital to home

We have to take responsibility for our patients’ outcomes not just in the ICU, but also what happens to them after ICU… because if our patients go home, but can’t walk down the street with the people they love or hold their grandchildren again, then are we creating survivors or are we creating victims?”

Professor Paul Wischmeyer, ESPEN 2018

As a healthcare professional, you will be aware of the continuing advances in medicine and technology that, together with the skill and dedication of ICU (Intensive Care Unit) staff, are allowing greater numbers of patients to survive critical illness. Especially during the Coronavirus pandemic, discharge of a patient from ICU is a success for the team treating them and will come as a great relief to the patient as well as their family and friends.

However, many of those patients will have undergone significant physical and psychological changes during their stay that may negatively impact their health and wellbeing for weeks, or even months, following discharge.1 This is a particular concern for COVID-19 patients who are spending, on average, a much longer time in ICU than those with other health issues (2 weeks vs 2-3 days, respectively).2,3

Professor Elisabeth De Waele on patients leaving ICU and role of nutrition. Would you like to learn more?

60-80% patients leave ICU with physical and functional issues4

The increased number of patients surviving ICU has been accompanied by a rise in reported physical and functional disability, poor quality of life and even a greater risk of mortality in the first 12 months after discharge.5-9 A key cause of this is muscle wasting, one of the most common complications of critical illness. It can have a major impact on a patient’s ability to recover from illness as well as on their long-term quality of life.11 In fact, the physical impacts associated with muscle loss can last for up to a year after discharge from ICU.5

Rapid and significant muscle loss affects up to half of ICU patients [10] and is caused by several factors including inflammation, immobility and malnutrition [11]. Some patients can lose up to 1kg lean body mass for each day spent in ICU [11]. 

Find out more on the physical impact of an extended ICU stay

Restoring the strength lost during critical illness is a process that can be difficult without an adequate supply of the right balance of nutrients,12 particularly protein, the building blocks of muscle.13,14 However, there are both physical and psychological issues directly linked to their time in the ICU that can make it difficult for patients to get the nutrition they need.1

For example, some patients will have difficulty swallowing after intubation, a common procedure for patients with serious respiratory diseases such as COVID-19. They may also experience loss of appetite, early satiety and changes in taste and smell that may make eating a normal meal difficult or unpleasant. Patients who are short of breath, in pain or whose sleep is disturbed are also likely to reduce the amount they eat. Social isolation, unfamiliar surroundings and different routines and structures whilst still in the hospital can further compound the situation.1


After ICU, an opportunity to rebuild body strength

Together, these factors mean that many patients aren’t getting the nutrition they need at the time they need it most. In fact, one study showed that post ICU patients often receive just 33-55% of their daily requirement of energy and only 23-35% of their requirement of protein.15 Poor oral intake during hospitalization can increase the prevalence and worsen the degree of ICU-related malnutrition, which has been associated with increased complications, mortality and length of hospital stay.16 When these patients are finally allowed to go home, they often do so in a weakened state, unable to undergo the rehabilitation programmes recommended for them and without the strength to perform basic activities of daily living, such as personal hygiene, preparing and eating food, or taking a walk outside.17

Where an active nutritional care plan has been put into place, including both enteral and oral nutritional supplementation, intake rises to above 90% of the requirement for both energy and protein.12

It is therefore critical that patients, particularly those who have had COVID-19 and are moving from an extended period of intensive care on to the hospital ward - and then finally home - receive ongoing nutritional support, tailored to their individual needs, to give them the best chance possible for a full recovery.14 Indeed, research shows high protein nutritional intake during hospitalization is associated with decreased mortality following hospital discharge.13

The timing, dose and duration of nutritional therapy should be approached in the same way we approach their other medications”

Professor Elisabeth De Waele, ESPEN 2018 

Clinical guidance for COVID-19 patients post ICU

Whilst there is evidence to support the benefits of ongoing nutritional support of patients in the ICU setting,13 clinical guidance for the post-ICU period, in particular after discharge from hospital, remains unclear and more work is needed.

That’s why Nutricia is supporting new, independent research that will help raise awareness of the importance of nutritional care after hospital discharge, enable the development of evidence-based clinical guidance and practical care pathways so that healthcare professionals can improve patient recovery and quality of life following their stay in ICU for COVID-19, and during the rehabilitation period after hospital discharge.

Nutricia supports new research initiatives to aid COVID-19 patient recovery after hospital discharge. Read more in our press release.

Information on this page is not intended to be a substitute for professional medical advice. Always seek the advice of a healthcare professional if you have any questions or concerns.

  1. Merriweather J, et al. Nutritional rehabilitation after ICU - does it happen: a qualitative interview and observational study. J Clin Nurs. 2014;23(5-6)654-62. https://doi.org/10.1111/jocn.12241
  2. Stam HK, et al. COVID-19 and post intensive care syndrome: a call for action. J Rehabil Med. 2020;52(4).
  3. Choon-Huat G, Hoenig H. How should the rehabilitation community prepare for 2019-nCoV?. Archives of Physical Medicine and Rehabilitation 2020, in press.
  4. Latronico N, et al. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysi. Lancet Neurol. 2011;10:931-41
  5. Herridge MS, et al. One-Year Outcomes in Survivor of the Acute Respiratory Distress Syndrome. NEJM. 2003;348(8);683-93.
  6. Puthucheary ZA. An update on muscle wasting in ICU. Signa Vitae. 2017;13-30-1.
  7. Cheung AM, et al. Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2006;174(5):538–44.
  8. Iwashyna TJ, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304(16):1787–94.
  9. Wischmeyer PE. Are we creating survivors…or victims in critical care? Delivering targeted nutrition to improve outcomes. Curr Opin Crit Care. 2016;22(4):297-84
  10. Herridge MS, et al. Functional disability 5 years after acute respiratory distress syndrome. NEJM. 2011; 364(14):1293-304
  11. Puthucheary ZA, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310:1591-600.
  12. Ridley EJ, et al. What Happens to Nutrition Intake in the Post Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults. JPEN. 2019;45(1);88-95
  13. Weijs PJM, et al. Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study. J Clin Med. 2019;8(1):E43.
  14. Zanten van ARH, et al. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. Crit Care. 2019; 23:368.
  15. Peterson SJ, et al. Adequacy of oral intake in critically ill patients 1 week after extubation. J Am Diet Assoc. 2010;110(3):427-33.
  16. Desai SV, et al. Long-term complications of critical care. Crit. Care Med. 2011;39(2):371–9
  17. Hopkins RO, et al. Instrumental activities of daily living after critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(8):1332-4.


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