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
