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Enteral CriticalCare Nutrition
MM•
MARKMORRIS
NSTITUTEI
The need to feed
The enteral route
Diets/diet
management
Enteral Critical Care Nutrition
The Need To Feed
Histortic perspectives
Clinical/metabolic perspectives
Patient selection
Historic Perspectives
1793 John Hunter
— Eel skin nasoenteral tube
1990’s $ billion industry
Clinical/Metabolic Perspectives
Equation for nutritional support:
FoodDeficit
Disease/InjuryHypermetabolism
AcceleratedStarvation
+ =
Clinical/Metabolic Perspectives
Endocrine CytokinesCortisol
Catecholamines
Insulin: glucagon
Thyroxine
Growth hormone
TNF
Prostaglan
dinsIncreasedmetabolic
rate
Clinical/Metabolic Perspectives
Metabolic Rate During Clinical Conditions
Maintenanceenergyrequirement
Restingenergyrequirement
0 10 20 30 40 50 60 Days
160
100
Sepsis
Majorburn
Trauma,cancer
TotalpartialFood deprivation:
RestingMetabolism
(%)
Clinical/Metabolic Perspectives
Equation for nutritional support:
Fooddeficit
Disease/injuryhypermetabolism
Acceleratedstarvation
+ =
Acceleratedstarvation
Compromisedhost defenses
Compromisedwound healing
+ =
Clinical/Metabolic Perspectives
1 liter = 170 kcal
Provides 1/5 patient’s energy requirement
No protein or micronutrients
Vegetable
Oil
5%Dextrose
I.V.
Patient Selection
History & exam
Laboratory tests
Predictive Indicators
Patient Selection
Weight loss of > 10% Poor food intake for > 3
days Increased nutrient
demands(Trauma, surgery, infection)
Increased nutrient losses(Vomiting, diarrhea, wounds)
Laboratory parameters(Albumin, creatine kinase)
Patient Selection
Patient selection = common sense
When in doubt: feed
Feed early
The Enteral Route
Advantages of enteral nutrition (EN)
Appetite stimulation Forced feeding Tube feeding
Advantages of Enteral Nutrition (EN)
The golden rule of critical care nutrition:
When the gut works, use it.
EN feeds intestine as well as patient— Decreased bacterial
translocation
— Glutamine - enterocyte nutrient
— Enhanced enteric immunity
Advantages of Enteral Nutrition (EN)
Highly palatable, balanced
diets
Assure optimal olfaction
Warm food to body
temperature
Appetite Stimulation
Appetite Stimulation
Foodpreference(%)
80
60
40
20
Food temperature (ºC)Sohail, Nutr Abst Rev, 1983
10 20 30 40 50
Effect of Food Temp on Preference in Cats
Foodpreference(%)
80
60
40
20
Food temperature (ºC)Sohail, Nutr Abst Rev, 1983
10 20 30 40 50
Appetite Stimulation
Highly palatable, balanced diets
Assure optimal olfaction Warm food to body
temperature Avoid K, Zn, & B vitamin
def. Drugs
Appetite Stimulation
Diazepam1 - 2 mg PO cat0.1 - 0.2 mg/kg PO dog0.05 - 0.1 mg/kg IV
Oxazepam (Serax )0.3 - 0.4 mg/kg PO dog2.5 mg (1/4 tab) PO cat
Fluazepam (Dalmane )0.1 - 0.5 mg/kg PO dog0.1 - 0.2 mg/kg PO cat
®
®
Tube Feeding
Orogastric Nasoesophageal Pharyngostomy Esophagostomy Gastrostomy Enterostomy
Indwelling
Diets/Diet Management
Nutrient requirements
Diet selection
Feeding protocols
Cost analysis
Water
Energy
Protein
Minerals & vitamins
Nutrient Requirements
Nutrient Requirements
Resting energy requirement (RER)
— 1000 kcal/m2
— 70 (Wt kg 0.75)
— 30 (Wt kg) + 70** > 2 kg and < 45 kg
Dogs&
Cats
Nutrient Requirements
Maintenance energy requirement (MER)
— MER dogs = 1.6 RER
— MER cats = 1.2 RER
Clinical/Metabolic Perspectives
Metabolic Rate During Clinical Conditions
Maintenanceenergyrequirement
Restingenergyrequirement
0 10 20 30 40 50 60 Days
160
100
Sepsis
Majorburn
Trauma,cancer
TotalpartialFood deprivation:
RestingMetabolism
(%)
Energy Requirements
IER = 1.0 - 1.25
Energyrequirement(IER)
Infection
Illness (cancer)
Injury (surgery,
trauma)
Nutrient Requirements
Protein quantity— At least maintenance
amounts4g protein/100 kcal16% of energy as protein
6g protein/100 kcal24% of energy as protein
Dogs
Cats
Nutrient Requirements
Protein quality— Digestibility/availability— Amino acid profile
EAA’s (extra arginine, branched chains)Glutamine (conditionally essential)Taurine (cat)
Nutrient Requirements
Minerals and vitamins— Maintenance/growth levels— Micronutrient def. common
Nutrient Requirements
Concept:
When a diet is properly formulated, the nutrients are balanced to the energy density of the diet
Nutrient Requirements
Thus, when such a diet is fed to meet a patient’s energy requirements, the requirements for the non-energy nutrients are automatically met
Patient’s Diet Daily
Daily energy Energy Diet
Requirement Density Dosage
Clinical/Metabolic Perspectives
÷ =
Nutrient Requirements
Example 10 kg dog with septic bile peritonitis
RER = 30 Wt kg+ 70 = 30(10) + 70 = 370 kcal
IER = 1.25 RER = 1.25(370) = 463 kcal/day
Patient’s Diet Daily
Daily energy Energy Diet
Requirement Density Dosage
(463 kcal/day) (675 kcal/can) (2/3 can/day)
÷ =
Nutrient Requirements
Canned pet food = 675 kcal/can
Patient’s Diet Daily
Daily energy Energy Diet
Requirement Density Dosage
(463 kcal) (1 kcal/ml) (463 ml/day)
÷ =
Nutrient Requirements
Liquid diet = 1 kcal/ml
Diet Selection
Defined formula diets— Meal replacement
(polymeric, intact protein)— Elemental (monomeric)
Diet Selection
Blenderized diets - follow recipe— 15 oz. Can (recuperative
type) cat food
— 1½ cup water— Blend - high speed 1 minute— Strain through kitchen
strainer— > 8 Fr
Diet Selection
Diameter of tube
Location of tube
Functional status of GI tract
Feeding Protocols
Bolus - maximal amount/feeding30-45 ml/kg
Bolus - minimal feeding frequency3-5/day
Gradual transition1/3 day 1, 2/3 day 2, full feeding day 3
Cost Analysis
Canine/Feline a/d 2.77
Clinicare Canine 10.62
Levity 5.12
Peptamen 13.82
Daily cost ($)Diet 10 kg septic dog
Feeding Protocols
Vomiting, Overly-aggressive administration,cramping, excessive diet osmolality,diarrhea improper diet composition,
GI alterations
Airway Regurgitation,aspiration not checking for proper
tube placement
Plugged Inadequate tube maintenancetube
Diet- & feeding-related complications:
Due to
Due to
Due to
Summary
Critically ill animals are in a hypermetabolic state
When it comes to nutritional support, the sooner the better
When the gut works, use it Use RER rather than MER for
calculation of energy needs in the critically ill patient
Summary
Veterinary products are more suitable than human preparations for use in critically ill patients