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-Read our article on Ebola recently published by Sodexo.
Ebola and nutrition support: shedding light on its role in managing Ebola infection
Written by: Raffaele DiMatteo, RD
It’s not uncommon for a dietitian to walk into a patient’s room and be immediately told, "I don't need to be on a diet." But the work of the dietitian is more complex than just counting calories or helping patients lose weight. The treatment of Ebola (EBV) patients provides a good example of how nutrition support is not just about calories and weight loss, but about the science of food and how it is used to help either prevent disease, manage a chronic illness or aid in the treatment of an active condition such as EBV.
EBV is a hemorrhagic condition; the virus leads to excessive fluid loss and in some cases, uncontrolled bleeding, as a result of the virus’ ability to prevent cells that line the blood vessels from adhering to one another. In one documented case, a patient experienced an excess of 8 liters of liquid stool in a 24 hour period (Kreuels 2014). The primary goal in managing these patients is restoring and maintaining volume and electrolyte balance (West 2014) as well as restoring lost essential nutrients and protein. In addition, patients must be closely monitored for coinfection, acute kidney injury and respiratory failure (West 2014). A loss in appetite (approximately 65% of all cases), sore throat (20%) and difficulty swallowing (30-35%) is common in EBV patients (WHO 2014), adding to the difficulty in managing a patient’s care.
Since patients are experiencing altered GI function related to loss of mucosal integrity, it is important to ensure that patients do not consume anything that will exacerbate further fluid losses. Providing the patient with Oral Rehydration Solution (ORS) is ideal, but if not available, Lactaid milk can be used. Lactaid is lactose free (better tolerated with decreased mucosal integrity), isotonic (having same concentration of solutes as blood), and provides much needed electrolytes (potassium, sodium, magnesium, calcium), as well as other essential nutrients such as protein. In addition to encouraging patients to drink Lactaid, patients should be given a protein supplement to help replace protein loss from excess diarrhea, vomiting and proteinuria (losses from urine) and to meet the increased physiological demands for protein. Nutrient dense foods such as fortified oatmeal are also recommended, as it is high in protein and easy for patients to chew
and swallow. A multivitamin, with minerals such as zinc, copper and iron is also recommended, to replace lost nutrients and provide the body with nutrients needed for healing and protein synthesis, energy metabolism, and so on. In addition to the multivitamin, a 1000mg dose of vitamin C can be provided to EBV patients, since vitamin C is involved in collagen formation, is an anti-oxidant and can enhance immune function. To further control symptoms such as diarrhea, patients should be placed on a low fiber diet. Although Glutamine (amino acid) becomes conditionally essential in times of critical illness and is also one of the main energy sources for white blood cells and cells that line the GI tract, it is controversial for use in Ebola cases due to the increased risk of capillary leakage; EBV patients are at greater risk of respiratory failure and renal failure. Studies have suggested that patients with multiorgan failure have an increased risk of mortality when given glutamine (Heyland 2013). However, in one severe case, Glutamine was given as part of a parenteral nutrition regiment (0.3 g/kg) (Kreuels 2014) since this patient could not tolerate formula or food through the GI tract as a result of paralytic ileus. Given its controversy, glutamine will not be included in the treatment of EBV at Bellevue Hospital.
Bellevue is well equipped to handle future cases of Ebola should they arise. This all requires a strong interdisciplinary team- supporting one another and encouraging the patient to adhere to all recommendations being made. With early detection, aggressive fluid and electrolyte management, and strong nutrition support, EBV can be successfully treated.
Kreuels B, et al. A Case of Severe Ebola Virus Infection Complicated by Gram-Negative Septicemia. New England Journal of Medicine. 2014;Dec 18;371(25):2394-2401.
West TE, et al. Clinical Presentation and Management of Severe Ebola Virus Disease. Ann Am Thorac Soc. 2014 Nov;11(9):1341-50.
WHO/UNICEF/WFP. Interim guideline:Nutrition care of children and adults with Ebola virus disease in treatment centres. Geneva: World Health Organization ;2014.
Heyland D, et al. A Randomized Trial of Glutamine and Antioxidants in Critically Ill patients. N Engl J Med.2013 Apr 18;368(16):1489-97.Type your paragraph here.