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Companion animal Critical Care Nutrition
V. Biourge DVM PhD Dipl ACVN&ECVCNHealth and Nutritional Sciences Director
R&D, Royal Canin SAS, Aimargues, France
P Mandigers
Thanks to D. Elliott and Y. Queau
Malnutrition
Introduction• Human hospitals
– US: 30-50% of patients are malnourished and 73 are never assessed for nutrition status.
– Europe: 80 % of surgeons believe that nutrition is an important part of the management of surgical patients, yet only 20% do a nutritional assessment.
– ASPEN CNW 2012: « Patients are fed too late, do not get enough calories, the sicker the patient the lower the intake of calories. Nutrition gets no respect »
• Veterinary hospitals– 73 % of hospitalized dogs achieved a positive
energy balance (Remillard et al 2001).– Only 7 % of dogs and cats that could benefit
from dietary management, actually do !Research & Development
Confidential information - Mars Inc
Malnutrition
Research & Development Confidential information - Mars Inc
The WSAVA 5th Vital Assessment Group (V5)
1. Temperature2. Pulse3. Respiration4. Pain assessment5. Nutritional assessment
Malnutrition
Research & Development Confidential information - Mars Inc
Acute weightloss > 10%
No intake for >3 d
Conditions associated with malnutition
Neurotoxin
Post-op PDA
Facial Trauma
Prostatic abscess
Esophageal dysfunction
Clinical consequences of malnutrition
• Malnutrition Impaired immune function Increased susceptibility to infection Delayed wound healing Decreased strength and vigor Altered gastrointestinal mucosal barrier
Bacterial translocation
• Decreases muscle mass and strength• Predictor of morbidity and mortality in
humans
J of Online Hepatology, 2011
Anorexia
• Common manifestation of disease– Particularly the GIT, pancreas,
liver
• Manifestation of pain• Side-effect of medications• Central alterations in
appetite, hunger or satiety• Unbalanced body fluids,
electrolytes, pH
Providing Nutritional Support
• If the animal is willing to eat feed it.• If the gut works, use it!• Assisted feeding
– Warm, wet, odiferous, palatable foods– Positive reinforcement
• Pharmacological stimulants – Benzodiazepines– Serotonin antagonists– Megestrol acetates – Androgens
Impossible to provide enough calories
Routes of Administration
Nasoesophageal tubes
Esophagostomy tubes
Gastrostomy tubes
Jejunostomy tubesTPN & PPN
Nasoesophageal tubes
• Shorter term support – <7 days to several weeks– Elizabethan collar
• Local anesthesia (Lidocaine)• Small diameter tubes
– Liquid diets only– Clog easily– 5-8 F cats and small dogs– 8 F medium to large dogs– PVC vs red rubber vs Polyurethane
Esophagostomy and gastrotomy tubes
• Medium - long term support• Well tolerated, easy (eso) to
moderately easy (gastro) to place• Larger diameter
– Cats and small dogs 12-20 Fr– Medium to large dogs 24 Fr– Slurries
• Requires general anesthesia• Indications
– Any nutritional support – Mandibular, maxillary, nasal, and
nasopharyngeal disease– Inability to prehend or masticate
Jejunostomy tubes
• Medium term support• Liquid “purified” diet• Continuous infusion• Indications
– Unable to tolerate gastric feeding
– Normal distal intestinal and colon function
• Surgical placement– Needle catheter jejunostomy– Small bowel pexied to wall
• Percutaneous endoscopic jejunostomy
Placement complications
• Splenic laceration• Gastric hemorrhage• Pneumoperitonium• Peritonitis• Tube displacement• Tube extraction• Epiphora
Armstrong et al JVIM 1990;4:202-6Mason et al JAVMA 2000; 216:1096-1099DeBowes et al JAVMA 1993;202:1963-5Bright et al AJVR 1988;49:629-33
Stoma Complications
• Complications– Pain – Tissue swelling – Discharge – Erythema – Abscess formation – Ulceration
• Management– Warm antiseptic soaks– Daily cleaning– Antimicrobial ointment– Avoid patient licking– Consider post- placement antibiotics
Tube clogging
• Minimized by – Adequate liquefaction– Strain food – Flush with water after use
• Treatment– Small syringe (2 mL)– Simultaneous massage,
flushing and aspiration– Instill carbonated drinks,
meat tenderizer, pancreatic enzymes
Nutritional management
• Pathophysiology• Diet
Energy Protein
• ARG, GLU, BCAA Fat
• EFA: n-3/n-6 Fiber Minerals, Vitamins
• Nutritional plan• Metabolic complications• Aversion
Pathophysiology
Royal Canin Encyclopedia, 2004Modern nutrition in Health & diseases 2006
Pathophysiology
Modern nutrition in Health & diseases 2006
Diet
• Energy– Dogs & cats
• Protein: 30-50 % ME• Fat: 35-70% ME• Carbohydrates: 20-30 % ME
– Complete and balanced, highly digestible, easy to pass through a tube
• RER = 70 Kcal/kg0,75
Canine & Feline convalescence
diets
Protein
• High levels (30-50%ME)– Energy substrate– To sustain wound recovery– To minimize negative nitrogen balance
• Glutamine– Main energy substrate for the gut.– Nucleotide synthesis
• Branched chain aas (BCAA)– Leucine, isoleucine, valine– To sustain muscle mass
• Arginine– Urea cycle– Immune function, wound healing– Precursor of NO– To avoid when excessive inflammation
Fat
• Efficient source of energy (30-70%ME)– Low volume– Palatibility
• N-3 Fatty acids– EPA-DHA.– Anti-inflammatory benefits– Resolvins, protectins
• Γ-linolenic acid– Borage oil– Anti-inflammatory PGE3
Tx3Lt5Anti-inflammatory
Resolvins Protectins
Dogs 7%Cats 0%
Others
• Dietary fibers – 15-25 g/1000 kcal– Soluble Vs Insoluble– Transit – colonic health
• Nucleic acids– DNA, RNA precursors– Immunity, dividing cells
• Minerals– Ca, P, K, Na, Cl– Fe, Cu, Zn, Mn
• Vitamins– Antioxidants: Vit E, Vit C, Lutein, Taurine– Vitamin B12– Vitamin K
Cellulose Psyllium
Nutritional management
• Calculate resting energy requirements – RER = 70(BW Kg)0.75
• Daily volume to feed = RER/energy density– Initially provide ¼ to ½ daily
energy– Increase over several days
• Weigh daily and adjust intake as needed in order to maintain or gain weight
Nutritional Management
• Warm food to room temperature• Give drugs prior to food
– Except phosphate binders which must be mixed with food
• Administer food over 10-15 minutes– Salivation and discomfort suggests
nausea• Slow the rate of feeding and/or
reduce the volume
• Flush tube with warm water following use
Nutritional management
Complications• Tube clogging• Vomiting/diarrhea
– Metoclopramide 2.2 mg/kg 15 min before meal
– Maropitant citrate
• Aspiration/pneumonia• Metabolic abnormalities
HypokalemiaHyperglycemiaHypophosphatemia
Nutritional management
Food aversion
Diet&
GI upset
Food aversion
Do not expose to all the diets before tube-feeding Do not give food to eat for the first 10 d Appetite stimulants not found useful
Conclusions
• Malnutrition is common in hospitalized patients 5 Vs
• Most critical patients are catabolic• Enteral nutrition is preferred• Nutritional support will facilitate
recovery ↑protein ↑fat ↓carbohydrates GLN, EPA/DHA, Nucleotic acid AntiOx complex
• Begin within 24 hours or immediately following stabilization
• Monitor regularly to optimize patient needs
If you want to know more …
Obrigado …
www.ivis.org
Questions?
% fat ?
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