Exam 1 - Nutrition & Feeding Tubes in Small Animals

Question 1

what are some indications of doing a nutritional assessment of small animal patients?

Answer 1

all patients with inadequate voluntary food intake

patients with gi signs

patients with weight loss

all hospitalized/critically ill patients

high index of suspicion

Question 2

if your patient has a normal BCS/muscle mass & a preserved appetite, does your patient need assisted feeding?

Answer 2

no assistance required

Question 3

if your patient has a low BCS and/or muscle mass & a preserved appetite, does your patient need assisted feeding?

Answer 3

evaluate the sufficiency of voluntary intake (RER calculation)

Question 4

if your patient has a low BCS and/or muscle mass & an absent appetite, does your patient need assisted feeding?

Answer 4

requires assisted feeding

Question 5

how is RER calculated for animals 2-30kgs? what is the other equation that can be used?

Answer 5

RER = (30 x current body weight in kg) + 70

RER = 70 x (current body weight in kg)^0.75

Question 6

why are illness factors not recommended anymore when calculating RER?

Answer 6

avoided to prevent overfeeding

Question 7

how is the increase in energy-needs associated with disease processes counterbalanced?

Answer 7

the decreased physical activity experienced by hospitalized/ill patients is the counterbalance

Question 8

what are some examples of routes of enteral nutrition support?

Answer 8

nasogastric/nasoesophageal tubes

esophagostomy tubes

gastrostomy/jejunostomy tubes & forced feeding (not recommended)

Question 9

why is enteral nutritional support so important for critical patients?

Answer 9

the gut receives the majority of its nutrients via the enteral route - not hematogenous

need to feed your patient’s enterocytes

Question 10

what questions should be asked when deciding if enteral nutritional support is indicated?

Answer 10

1. is the gi tract functional
2. does the patient have an intact gag reflex

if both answers are yes - proceed with enteral nutrition which is always preferred over parenteral

Question 11

if you need enteral nutritional support longer than 5-7 days, what route are you considering?

Answer 11

esophagostomy tube

Question 12

if you need enteral nutritional support, but your patient can’t tolerate general anesthesia & a surgical procedure, what route should you consider?

Answer 12

NE/NG tube

Question 13

what are the benefits of using an NG/NE tube?

Answer 13

cheap, non-invasive procedure, no need in anesthesia, & easy procedure

Question 14

what are the limitations of using an NG/NE tube?

Answer 14

can’t be used at home, only can do a liquid diet, can’t use in animals with nasopharyngeal disease, & only is for temporary use

Question 15

what are the benefits of using an esophagostomy tube?

Answer 15

can be used by the owner, cost-effective, can be used for several months, well tolerated, & blenderized food can be given

Question 16

what are the limitations of using an esophagostomy tube?

Answer 16

requires general anesthesia, requires surgical incision, can’t be used in animals with esophageal disease or pyloric obstruction

Question 17

what is the proper placement of an NG tube? NE tube?

Answer 17

NG - in the stomach

NE - distal tip of the feeding tube should be placed between the carina and diaphragm for an NE tube

Question 18

how do you confirm the placement of your NG/NE tube?

Answer 18

rads -

NG - in the stomach

NE - distal tip of the feeding tube should be placed between the carina and diaphragm for an NE tube

once placed, aspirate the tube with a syringe, looking for stomach contents or gas from stomach, or confirmation of negative pressure

Question 19

T/F: a patient should be hemodynamically stable prior to initiating assisted feeding

Answer 19

true

Question 20

how much food do you give when starting assisted feeding?

Answer 20

on day 1, start with 1/3 of RER split across 4-6 meals

day 2, feed 2/3 of RER

day 3, feed full RER

Question 21

what should you monitor your patient for when using assisted feeding?

Answer 21

monitor for vomiting, regurgitation, gastric distension, & ileus

Question 22

if your patient has pancreatitis, what type of diet should you give?

Answer 22

low fat

Question 23

if your patient has hepatic encephalopathy, what type of diet should be given?

Answer 23

protein-restricted diet only if signs are present

Question 24

if your patient has acute gastroenteritis, what type of diet should be given?

Answer 24

highly digestible diet

Question 25

how do you treat dysmotility & ileus encountered during enteral nutrition?

Answer 25

temporarily discontinue or slow down nutrition if not tolerated, but remember that the best pro-kinetic agent is food in the stomach

prevent gastric overdistension - empty the stomach through the NG tube

antiemetics - maropitant, ondansetron, & metoclopramide
prokinetics - cisapride, metoclopramide, & erythromycin

Question 26

what animals are at risk of developing refeeding syndrome?

Answer 26

animals that are severely malnourished or have experienced prolonged starvation

due to intracellular depletion of electrolytes

Question 27

what is the pathogenesis of refeeding syndrome?

Answer 27

too much food given to a severely malnourished patient

increased insulin production - leads to insulin-driven glucose, PO4-, K+, & Mg2+ uptake

leads to severe hypophosphatemia, hypomagnesemia, & hypokalemia

hemolytic anemia, cardiac failure, neurological dysfunction, & respiratory failure causing death

Question 28

what are the general guidelines for preventing refeeding syndrome?

Answer 28

identify at risk patients

correct fluid & electrolyte imbalances first

administer nutrition gradually & increase incrementally

frequently monitor electrolytes every 4-8 hours (especially during the 1st 48 hours - K, Mg, PO4, Ca, glucose, PCV,TS)

supplement electrolytes & thiamine as needed

discontinue or slow down nutrition should complications arise

Question 29

what common complication is seen in NG tubes in cats?

Answer 29

removal of the feeding tube secondary to sneezing, coughing, or vomiting despite continuous use of e-collars

Question 30

what size NG tube is indicated for dogs & cats?

Answer 30

dogs - 6-8 french

cats - 3.5-5

Question 31

what are common complications seen with NG tubes? how are these avoided?

Answer 31

epistaxis, rhinitis, & tracheal intubation with secondary pneumonia

place an e collar on the patient

Question 32

what is the most common complication seen with esophagostomy tubes?

Answer 32

skin infection at the site of placement

Question 33

what size tube is commonly used for esophagostomy placement?

Answer 33

12-14 french

Question 34

what is the proper placement of an esophagostomy tube? how is this confirmed?

Answer 34

extends to the 7th or 8th intercostal space - distal esophagus but not past the LES

rads are used to confirm correct placement of the tube in the mid to distal esophagus

the tip of the tube should not pass beyond the lower esophageal sphincter as this can cause irritation and predispose the patient to gastric reflux

Question 35

what are the clinical manifestations seen with abnormalities caused by refeeding syndrome?

Answer 35

peripheral edema, hemolytic anemia, cardiac failure, neurological dysfunction, & respiratory failure

Question 36

why does refeeding syndrome occur?

Answer 36

total body reserves of sodium, potassium, phosphorous, and magnesium are depleted in starvation while serum levels are maintained

natriuresis during anorexia can lead to volume depletion

typically, the body uses protein and fat for energy during starvation - during re-feeding, the body isn’t equipped for the carbohydrates that are present in the diet, tube feeding mixture, or parenteral nutrition that we commonly use

when malnutrition is reversed, there is a significant shift back to the use of carbohydrates, rather than fat reserves, resulting in a significant insulin release

this increases the uptake of glucose, potassium, phosphorous and magnesium - naturiesis stops and edema can develop

Increases in HR, BP and cardiac output can lead to volume overload and pulmonary edema, even in animals with no previous history of heart disease