Nutrition: Critical Care and Management of Obesity Flashcards
What is nutritional support?
What is parenteral and enteral nutritional support?
Method to support metabolic status of hospitalised patients
Parenteral- bypassing the GI with elemental diet- IV
Come in bag, segments broken- into central vein
Enteral- methods that utilise the GI tract
Easier, fewer complications, more economical, physiological
What is the importance of nutrition (enteral)?
What are the general rules of intervention?
Malnutrition- can happen to a sick animal in a couple of days
affects 1/2, cannot compensate
Malnutrition develops in early illness
facial trauma, megaoesophagus, polyneuropathy, post-surgery
General rules
Recent weight loss >10%
Partial/complete anorexia >3d
Disease-causing excess catabolism
Treat patients with obesity the same
What are the ways of enteral nutrition?
Encourage feeding
Force-feeding
Drugs
Tube feeding
How can normal feeding be encouraged?
Why is force-feeding unlikely to be helpful?
- Privacy
- Comfortable environment
- Favourite foods
- Fresh feed- warming
- Do not ‘overface’
- Record closely how much
Force-feeding- often a reason why an animal not eating
What drugs can be used to encourage feeding?
Diazepam- cats
Mitrazapine
cats- best stimulant, well-tolerated, only short term
Cyproheptadine- H1 antagonist
What are the different techniques for tube feeding above the oesophagus?
What are the indications/contraindications for each?
Naso-oesophageal tubes
Short to medium term
Small diameter- limits type of food
Contraindications- vomiting, no gag reflex, disease of nose/pharynx
Simplest, cheapest
Pharyngostomy tubes- not used much- damage BVs
Oesophagostomy tubes-
Through skin into the distal oesophagus
Medium- long term (number of months)
Well tolerated, GA required
Indications- oral cavity/nasal/pharyngeal disease
Contraindications- disease of oesophagus and below
What tube feeding techniques are used below the oesophagus?
Gastrostomy/PEG tubes
Long term support- minimum of 7 days- up to year
well tolerated, GA required
Indications- all but gastric, intestinal and pancreatic, Oesophageal disease- megaoes
Enterostomy/Jejunostomy tubes
GA required
Indications- good for pancreatitis
Contraindications- diffuse intestinal disease
Need constant rate for infusion
When giving enteral food, what diets should be given?
Highly digestable
Cooked meat or fish
Critical care diet- prescription
What should be considered before choice of tube feeding?
- Duration of treatment
- Illness
- Condition and temprament
- Equipment and experience
- Cost
- As proximal as possible
Describe how a naso-oesophageal tube is placed, maintained and removed?
Equipment- tube, tape, topical local, collar of shame, suture material, local anaesthetic
- Instill topical local anaesthetic solution- 10 min
- Length- either nose to 9/10th rib of 3/4 of the nose to caudal rib
- Hold tube in ventromedial direction- to ventral meatus- other hand on cats head
- Dogs- first push nose dorsally- need to move cartilage
- Then flex head ventrally- if in the oesophagus- patient will swallow
- Attach empty syringe- pull back on plunger- negative pressure in the oesophagus, trachea has air
- Attach tube with water- in trachea will cough
- Create 3 folds of tape- butterfly wings used for securing
- Run the tube between the eyes- interferes with whiskers
- Secure the tube, some superglue
- Collar of shame on
Describe how to place oesophagostomy tubes
Places in the right or left lateral nack- left side better
Use a pair of carmalt forceps- curved tip
Mouth gags protect hands but may get in way
- Equipment- forceps, simple suture kit, tube, scalpel, suture material
- Measure carmalt- insert into oesophagus and push out laterally to find location and incision- avoid jugular
- One the carmalt through the muscle- incise the skin and force tip of clamp through
- Most of the tube pulled out of the animals mouth
- Tube is then reversed and pushed as far down into the oesophagus as possible
- Remove excess- pull and should ‘flip’ to show its directing into oesophagus then push down
- X-ray to check positioning
- Tube is secured to the skin with a fingertrap pattern
- Cover with bandage
Describe how to do a peg tub placement?
- Right lateral recumbancy- tube on left, fundus on left, pylorus on right
- Aseptically prepare- push finger caudal to last rib, look for on endoscope
- Hypodermic needle inserted at point and thread some wire
- Wire grabbed by the endoscope and pulled out
- Tube attached to wire and pulled back through to correct place
- Mushroom tip
- Not used for 24 hours
How is the resting energy requirements calculated in dogs and cats?
How should tubed animals be fed at first?
What is tube ettiquette?
Dogs RER = 30 x BW +70
Cats RER = 40 x BW
Getting started-
nothing for 24 hours- gastrostomy tube, enterostomy tube
Start slowly- 1/3 on day 1, then 2/3 then 3/3 on day 3
Tube etiquette-
- Small frequent meals- 4-6 per day
- Always aspirate first
- Warm the food
- Administer over several minutes
- Flush tube with warm water- pass meal before into SI
What quantity of food is needed?
How long should the duration of tube feeding last?
What nutrients be given?
- Energy requirement/caloric density of food
- Caloric density
- 3.5 x % protein + 8.5 x % fat + 3.5 x % carbs
Duration of tube feeding-
until voluntary uptake >85% BER
perhaps longer
Nutrients-
Fluid and electrolytes, energy requirements, protein with or without specific amino acids, micronutrients, easy to use critical care liquid diets
What are the complications of feeding a hospitalised patient?
Mechanical blockage
Metabolic- GI upset, Hypophosphataemia
Tube dislodgment- peritonitis
Stoma infection
Tube removal by patient
What is obesity?
‘excess body fat’
A disease in which excess body fat has accumulated such that health may be adversely affected
What are the health consequences of obesity?
What is the pathogenesis of obesity?
Functional impairment
Comorbidities- diabetes mellitus, orthopaedic disease, resp disease, neoplasia, pancreatitis, hepatic lipidosis
Shorter lifespan
Poorer quality of life
Pathogenesis- energy intake along with disease, drugs, factors, environment, owner factors, affects metabolic rate, increases activity, thermoregulation and therefore energy expenditure
What BCS is obesity?
What is ideal?
What is the most effective way of weight reduction?
BCS scoring either 5 or 9
3 or 5 ideal
Weight reduction- controlling food intake is more effective then increasing expenditure
How is energy intake calculated for dogs?
Dog- estimate ideal weight
Ideal weight = SBW / correction factor
Calculate MER at ideal weight
MER= 95kcal per kg ^0.75 /day
Feed 60-80% of MER at ideal weight
Entire male -80%
Neutered male or entire female- 70%
Neutered female- 60% MER
How is energy intake calculated for cats?
BW/ Correlation factor = Ideal BW
40kcal per IBWkg
What are the benefits of therapeutic diet?
Decreased energy content
Nutrients in balance for weight loss
Diet changed to reduce intake- increasing water content in the diet, expanding food with air, changing shape, increasing protein and fibre
Accuracy- weight
Consider how fed- puzzle feeders
What other things can be done to assist weight loss?
Excercise- preserve lean tissue, positive reward, some calories
Describe how to return to maintenance after weight loss
Gradually increase food intake 5-10% every 2 weeks
Reweigh at regular intervals
