Robert Gracia Small Animal Clinical Nutrition

AVC ID# 106395 August 2, 2012

Case 1: Bosco Robinett

Assess the animal – Bosco, a 3-year old, intact male English Springer spaniel, was recently struck by a motor vehicle. He had been a healthy dog prior to the accident. Bosco suffered a fractured right femur that was successfully repaired by one of the associate veterinarians in your practice. Post-operative recovery was uneventful except for bacterial infection of the suture line. A second minor surgical procedure was necessary to drain a small subcutaneous abscess and place a drain. Bosco is receiving parenteral antibiotics based on culture and sensitivity test results from a specimen obtained from the infected surgical site. There is no evidence of osteomyelitis.

Your current physical examination is unremarkable except for the infected surgical site and mild fever. Bosco currently weighs 53 pounds with an ideal BCS (3/5). Bosco is alert but is confined to a kennel in your hospital. He is allowed to go into a small run for a few minutes several times each day to eliminate. You anticipate that he will be hospitalized for at least another week or until the infection is completely under control.

Assess the food and feeding method – Prior to the accident, Bosco was fed a grocery brand dry dog food (Atta Boy). Table food and rawhide chews were offered frequently. In the hospital, Bosco has not been offered much food because of the multiple surgical procedures. His appetite today appeared questionable and you are not sure if he is eating enough food to meet his daily energy requirements. You note in the medical record that his appetite has been poor when he was boarded in your facility in the past.

Atta Boy Dog Food Ingredients: Cooked yellow corn, meat and bone meal, cooked wheat, wheat bran, corn gluten meal, animal fat (preserved with mixed tocopherols), brewer’s rice, digest of poultry by-product meal, poultry by-product meal, canola oil, fish meal, tomato meal, minerals and vitamins. Guaranteed analysis: Crude protein = not less than 23%; crude fat = not less than 9%; crude fiber = not more than 4%; moisture = not more than 10%; calcium = not less than 1% 320 kcal ME/cup Nutrition statement: Animal feeding test substantiate that Atta Boy Dog Food provides complete and balanced nutrition for all life stages.

Guiding Questions 1. What are the key nutritional factors to consider in this post-surgical patient with secondary bacterial infection? 2. Calculate Bosco’s current, estimated energy needs (i.e. illness energy requirement). Please show all work. How are you going to get these calories into Bosco (i.e. how will you get him to consume all of the calories)? 3. Based on the current information, what food, food dosage, and feeding method would you recommend for Bosco? How does this food compare to the key nutritional factors you listed in number 1? What would you do if he refuses to eat? 4. What parameters will you monitor to determine is you are feeding plan is adequate, insufficient, or excessive? How frequently will you monitor these in this patient and for how long? What are your long-term nutrition-related plans (next 2-3 months) for Bosco (i.e. plans for when he goes home)? Please be specific and thorough.

Case 1: Bosco Robinett

1. What are the key nutritional factors to consider in this post-surgical patient with secondary bacterial infection? The key nutritional factors would be High digestible proteins, High digestible fats, low to moderate digestible carbohydrates, low fiber, increased potassium, highly palatable, prebiotics, probiotics, very soft consistency for feeding ease through tube if necessary.

2. Calculate Bosco’s current, estimated energy needs (i.e. illness energy requirement). Please show all work. How are you going to get these calories into Bosco (i.e. how will you get him to consume all of the calories)? 53 lbs /2.2 lbs/kg= 24.1 kg , 1.0 x RER = 1.0 x [70(24.1 kg).75]=761 kcal per day initially increasing the multiplying factor depending on if weight loss has occurred, and/or health improvement continues. I would first begin by measuring the proper caloric amount of food necessary for the entire day and break that amount up over 4 - 6 feedings. I would measure the total amount of food fed for each meal before and after to first see if Bosco is consuming the correct amount. If not interested in eating I would try to entice him into eating by heating the food,hand feeding, or trying to provide an appetite stimulant such as diazepam, etc. If that does not work then I would place a feeding tube in Bosco, such as a E tube or G tube to ensure the correct amount of calories is being consumed.

3. Based on the current information, what food, food dosage, and feeding method would you recommend for Bosco? How does this food compare to the key nutritional factors you listed in number 1? What would you do if he refuses to eat? I would try to feed Bosco a recovery formula such as Hill’s Science Diet A/D. I would feed 4 ¼ cans per day, which is equal to 763 kcal ,I would adjust amount accordingly if weight loss has occurred, and as Bosco is becoming healthier. I would break up the feedings into 6 feedings. The first 5 feedings would be ¾ of a can and the 6th feeding would be ½ of a can. The latter is based on little to no weight loss as well as no history of anorexia causing any GI compromise. If there has been anorexia then I would adhere to the following schedule: 1/3 of the daily caloric intake for day 1, 2/3 of the daily caloric intake for day 2, and the full daily caloric intake for day 3 and beyond. This food contains the key nutritional factors as I listed above, except that it does not provide probiotics and prebiotics to help replenish the normal gut flora in the patient that is currently on antibiotics. If Bosco refuses to eat then I would most likely place a feeding tube such as an E or G tube until Bosco is consistently eating on his own for some time.

4. What parameters will you monitor to determine is you are feeding plan is adequate, insufficient, or excessive? How frequently will you monitor these in this patient and for how long? What are your long-term nutrition-related plans (next 2-3 months) for Bosco (i.e. plans for when he goes home)? Please be specific and thorough. I would monitor weight every day using the same scale and at the same time to determine weight gain or loss and preserve consistency. I would also monitor daily defecations to ensure the diet is being tolerated and there are no signs of diarrhea. I would also perform a body condition score on Bosco every 2 to 3 days to see if I notice any significant deviations from the ideal. I would also run blood glucose at least twice daily to ensure

that Bosco’s glucose levels do not drop below normal levels between feeding intervals. I would monitor all these levels until Bosco is consistently eating on his own or has left the hospital. If Bosco is at home and still being fed by tube I would have to adjust what monitoring I could do according to the owner and availability. Once Bosco is eating consistently I would remove the tube if it was necessary and start to transition him over to his new diet. I would recommend trying to gradually decrease the amount of table food and rawhides that Bosco was receiving in the past because they are a source of increased calories

and not necessarily of any significant nutritional benefit. If in the past Bosco was at an ideal body condition score, and was healthy while being fed Atta Boy Dog food, then I see no need to change that food. I would feed him the recommended caloric amount for an intact male 53 lbs /2.2 lbs/kg= 24.1 kg , 1.8 x RER = 1.8 x [70(24.1 kg).75]=1,371 kcal per day. This is equivalent to 4 ¼ to 4 ½ cups of Atta Boy dog food per day. I would break the meal up into two separate feedings of 2 ¼ cups each. I would like to see Bosco back in two weeks to check his weight and perform a body condition score. I would adjust diet accordingly depending on my findings. Once the infection has subsided and Bosco is off antibiotics I would like to start him on a course of prebiotics/probiotics (fortiflor, bene bac) to help restore normal gut flora. Recheck radiographs to ensure proper fracture healing. I would also recommend that if Bosco is not going to be a stud, the owners may consider castration at a later time, since this may help prevent roaming and decrease the risk of another motor vehicle encounter. (The latter is dependent on if the accident occurred off the property etc.) If the owners do elect to have Bosco castrated then the amount of food being fed must be recalculated for a dog that is no longer intact and also depends on his current activity level.

Case 2. Heidi Willis

Assess the Patient Heidi, a 7-year old, spayed female, Doberman pinscher, is presented to your clinic for her annual heartworm test. She currently weighs 60 pounds. Heidi is an outdoor dog who is kept in a fenced back yard or chain link kennel with insulated doghouse. She lives with her caregiver, Ms. Willis, and 2 elderly cats. She is current on all of her vaccinations. Your physical examination reveals a lean and alert Doberman with a BCS of 2/5. The medical record indicates that she weighed 69 pounds and had a BCS of 3/5 two years earlier.

Blood drawn for the heartworm test reveals a yellow tinge to the plasma. Being concerned, you draw more blood and submit it for a CBC and serum biochemistry profile. The dog’s urinary bladder is barely palpable but you manage to obtain 5 cc of urine via cystocentesis for a UA. On a second and more careful look, you notice that her mucous membranes appear icteric. The only abnormality noted on the CBC results is a comment about occasional target cells being seen on the microscopic examination of the blood smear. Abnormalities on the serum biochemical profile include albumin = 1.9 g/dl (normal 2.5-3.8 g/dl); BUN = 8 mg/dl (normal 9-27 mg/dl); ALT = 301 IU (normal 21-67 IU); SAP = 362 IU (normal 14-72 IU); and total bilirubin = 2.5 mg/dl (normal < 0.3 mg/dl). The urinalysis reveals a 3+ bilirubinuria with a specific gravity of 1.030 and a urine pH of 7.0. Additional workup: survey abdominal radiography (small liver) and liver biopsy (hepatic degeneration and necrosis with a mixed inflammatory response). Additional liver tissue is submitted for hepatic copper levels, which reveals 1,450 g of copper/g

of tissue (normal hepatic copper levels are < 200 g of copper/g of tissue). You suspect chronic active hepatitis.

Assess the Food and Feeding Method Heidi has been free choice fed dry, High-Pro dog food. However, Ms. Willis indicated that Heidi’s appetite was a bit “off” because she was not refilling Heidi’s food bowl as often.

High-Pro Dog Food Ingredient list: Cooked yellow corn, meat and bone meal, cooked wheat, wheat bran, corn gluten meal, animal fat (preserved with mixed tocopherols), brewer’s rice, digest of poultry

byproduct meal, poultry by-product meal, canola oil, fishmeal, tomato meal, minerals and vitamins. Guaranteed analysis: 27% protein; 10% fat; 4% fiber; 12% moisture Nutrition statement: Hi-Pro is formulated to provide complete and balanced nutrition for maintenance.

Guiding Questions 1. Given this information, what is your initial treatment plan? Please be concise and thorough. 2. What are the key nutritional factors (KNF) and their appropriate levels to consider for this patient? 3. What food, food dosage and feeding method would your recommend for Heidi (show all work)? How does the food compare with the key nutritional factors (i.e. compare each factor) you listed in question 2? When and how will you introduce your chosen food? 4. What are your long-term plans for Heidi? What parameters will you monitor to determine if your treatment is adequate, insufficient, or excessive? How frequently will you monitor these in this patient and for how long?

Case 2: Heidi Willis

1. Given this information, what is your initial treatment plan? Please be concise and thorough. If any signs of dehydration I would begin with fluid therapy to replace loses and to correct any electrolyte imbalances. I would start Heidi on a course of prednisolone (glucocorticoids) and antibiotics (depending on culture or can use ampicillin, metronidazole, etc.) for 1 – 2 months. Also start on hepatoprotectants (ursodiol), and possibly supplement with Vitamin C and Zinc to decrease copper levels. B vitamins and digestive enzyme supplementation can also be given. Provide support for any other clinical signs that develop such as vomiting, ascites, etc. Provide a new diet with high quality restricted protein and certain minerals. Recheck in 2 weeks to determine weight gain, and diet tolerance. Recheck blood levels while on steroids. Follow up radiographs and/or ultrasound to determine ascites or progression of cirrhosis. Additional liver biopsy as needed due to long term glucocorticoid treatment.

2. What are the key nutritional factors (KNF) and their appropriate levels to consider for this patient? The key nutritional factors for this patient are high quality and highly digestible moderate amounts of protein, normal amount of highly digestible fat, normal amount of highly digestible carbohydrates, higher levels of fermentable fiber, normal to slightly higher levels of taurine, iron, zinc, potassium, L-Carnitine, and vitamins, decreased levels of sodium chloride, and copper.

3. What food, food dosage and feeding method would you recommend for Heidi (show all work)? How does the food compare with the key nutritional factors (i.e. compare each factor) you listed in question 2? When and how will you introduce your chosen food? I would feed Heidi Hill’s Science Diet L/D Canine Hepatic Health. I would feed Heidi for weight gain to bring her back to an ideal body

condition score, but starting out at a lower multiplier since she might have been anorexic. If there has been anorexia then I would adhere to the following schedule: 1/3 of the daily caloric intake for day 1, 2/3 of the daily caloric intake for day 2, and the full daily caloric intake for day 3 and beyond. 69 lbs /2.2 lbs/kg= 31.4 kg , 1.2 x RER = 1.2 x [70(31.4 kg).75]= 1,113 kcal per day. I would feed 2 ¾ cups to 3 cups per day, 1 ½ cups twice daily equal to 1,197 kcal per day. The key nutritional factors match up well concerning protein, carbohydrates, fat, fiber, L- Carnitine, copper, iron, zinc, potassium, and sodium, I could not find information about the various types of vitamins, and taurine and there levels included in the diet. I would introduce the food to Heidi at home rather than the clinic so that she would not be adverse to it. I would slowly switch her over to the new food over a week long period as follows: day 1=

90% old, 10% new; day 2= 75% old, 25% new; day 3= 60% old, 40% new; day 4= 50% old, 50% new; day 5= 40% old, 60% new; day 6= 25% old, 75% new; day 7= 10% old, 90% new; day 8= 100% new diet.

4. What are your long-term plans for Heidi? What parameters will you monitor to determine if your treatment is adequate, insufficient, or excessive? How frequently will you monitor these in this patient and for how long? I would start Heidi on a course of prednisolone (glucocorticoids) and antibiotics (depending on culture or can use ampicillin, metronidazole, etc.) for 1 – 2 months. Also start on hepatoprotectants (ursodiol), and possibly supplement with Vitamin C, E and Zinc to decrease copper levels. B vitamins and digestive enzyme supplementation can also be given. Provide support for any other clinical signs that develop such as vomiting, ascites, etc. Recheck in 2 weeks to determine weight gain, and diet tolerance. Reweigh and assess diet, recheck again every 2 weeks until weight level is appropriate then adjust caloric intake for maintenance. Recheck blood levels (Albumin, AST, ALP, total Bilirubin, BUN, CBC, WBC, copper, sodium, potassium, etc.) while on steroids for long term. Follow up radiographs and/or ultrasound in a couple of months to determine ascites or progression of cirrhosis. Additional liver biopsy as needed due to long term glucocorticoid treatment. I would monitor weight, BCS, blood levels, and radiographs. Once Heidi is at a good weight she can be monitored for weight stability every 4 to 6 months, and blood levels at least twice yearly, and radiographs/ultrasound at least yearly.