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Small Animal Final Year > Nutrition for critically ill patients > Flashcards

Nutrition for critically ill patients Flashcards

1
Q

Discuss nutrition in the critically ill patient?

A
  • Can often be overlooked in the emergency and critically ill patient
  • Addressed appropriately can have a massive impact on morbidity and mortality
  • Why is it so important? Need to provide fuel as sickness is a metaboliclydemanding process and GI tract needs to maintain motility.
  • Enteral versus parenteral? Enteral is always best.
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2
Q

What is the goal of enteral nutrition?

A

Provide adequate caloric and nutrient intake via GIT to prevent adverse consequences of malnutrition

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3
Q

Often hospitalised patients have decreased voluntary intake due to:

A
  • Nausea, pain and anxiety
  • MAY be endocrine changes result in catabolic state –this has recently be questioned
    • Catecholamines, CS’s, IL-1, TNF-α
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4
Q

Decreased intake leading to Protein catabolism leading to severe effects on?

A
  • Tissue synthesis
  • Immunocompetence
  • Maintenance of GI integrity
  • Drug metabolism

Malnutrition in humans has been associated with:

  • Increased complication rates
  • Duration of hospitalisation
  • Cost
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5
Q

How should you do a nutritional assessment?

A

Need to think about each patient as an individual

  • Low, medium or high risk

Information about all aspects of patients’ previous diet, appetite and objective measure of amount of food consumed

High risk

  • Patients that have not consumed resting energy requirements (RER) for 3-5days
  • Weight loss of 10% adults (5% neonates)

On Physical Exam

  • Be aware obese patients can have low muscle (lean body) mass
    • Critical illness leads to dramatic loss in lean muscle mass
      • High risk for protein calorie malnutrition
  • Don’t miss straightforward abnormalities that will preclude eating
    • Jaw fracture
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6
Q

Underlying disease processes will affect various aspects of the nutritional plan –Route of delivery –Nutrient composition of the diet e.g?

A

HE (hepatic encephalopathy)

  • Protein intolerant
  • Meet calorie needs
  • Limit increasing nitrogenous wastes
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7
Q

Discuss when you will need an aggressive nutritional plan?

A

Aggressive nutritional plan –protein and calories

  • PLE (protein loosing enteropathies)
  • PLN (nephropathy)
  • Chylothorax
  • Burns
  • Draining wounds
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8
Q

How do you monitor aggressive nutrtional plans?

A

High risk patients Aggressive nutritional plans

  • Closer monitoring
  • Positive response are they maintaining weight
  • Complications
  • Need for re-evaluation and nutritional plan re- assessment
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9
Q

What do both enteral and parental routes require?

A

Either route requires a haemodynamically stable patient (especially enteral) with minimal acid-base and electrolyte derangements. If you have hypovolemic animal 1 st place blood is removed from is splanchnic circulation food in a haemodynamically unstable patient will get ileus, D+ and bacterial overgrowth.

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10
Q

What does giving via enteral and parenteral routes depend on?

A

Patient

  • GI function
  • Ability to protect their own airway (no point feeding if they are going to inhale their own food)

Non-patient

  • Cost
  • Predicted length of hospitalisation
  • Technical expertise
  • Level of patient monitoring
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11
Q

Discuss enteral feeding?

A

Preferable

  • Physiological sound
  • Less costly

Physiological benefits

  • Prevent intestinal villous atrophy
  • Maintains intestinal mucosal integrity
  • Decreases risk of bacterial translocation
  • Preserves GI immunological function

Contra-indications to enteral therapy

  • Uncontrolled vomiting
  • GI obstruction
  • Ileus (anything sick or hypovolemic likely to have this)
  • Malabsorption
  • Maldigestion
  • Inability to protect the airway
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12
Q

Discuss enteral feeding further?

A

Voluntary oral intake

  • No special equipment or techniques
  • Owner can participate in patient care
  • Need specific feeding orders with records of what is consumed
    • WEIGH what is eaten and what it didn’t.
    • If cannot meet goal needs re-assessment of patient, diet, environment
  • If not totally appropriate
    • Change diet (more palatable, warmed)
  • Change environment (quieter, owner feeding patient)

Syringe feeding –SID or BID to meet needs

  • Frequently this is stressful and time consuming
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13
Q

If feeding enterally and animal has nausea what should you do?

A

Nausea

  • Discontinue oral feeding
  • Food aversion

Provide anti-emetics

  • Different route of administration
  • Maropitiantand +metacloprimide= cat and dog works well
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14
Q

Discuss enteral feeding tubes?

A

Well tolerated

Easy to administer required, calculated amount of food

Cat owners surveyed were happy to manage their pets at home with oesogostomy and gastrotomytubes

5 Options

  • Naso-oesophageal
  • Naso-gastric
  • Oesophagostomy
  • Gastrostomy
  • Jejunostomy
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15
Q

Look at this decision tree for enteral nutrition routes?

A
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16
Q

Discuss naso-oesophageal or nasogastric tubes?

A
  • 3.5-8Fr silicone/ PU feeding tubes
  • NO preferred to NG
    • Reduced risk of reflux
  • NG tubes
  • Allow for gastric decompression and assessment of residual volume
  • Radiography to check placement
  • LA or light sedation
  • Limited to liquids to use as quite thin
  • Short term
    • 7-14dd
    • Irritating
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17
Q

What are the contraindications and complications for naso-gastric and naso-oesophageal tubes?

A

Contra-indications

  • Facial trauma
  • Respiratory disease
    • Exacerbate signs
  • Excess sneezing or vomiting
    • Dislodges tube
    • Requires detailed replacement

Complications

  • Epistaxis
  • Rhinitis
  • Sinusitis
  • Dacryocystitis
  • Inadvertent placement and dislodgement
  • Oesophageal irritation
  • Reflux
  • Blocked tube
  • Aspiration pneumonia
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18
Q

Discuss oesophagostomy tubes?

A
  • Larger feeding tubes
    • 2-14Fr -cats –22Fr –larger dogs
  • Proximal oesophagus at mid- cervical level
    • Tip in distal oesophagus
  • Well tolerated
  • Can leave in from weeks to months
    • Hospital and outpatient
  • Wider selection of diets
    • Blenderised canned diets
  • Suitable for those with facial and oral disease
  • GA and technical skill
    • Simple and well described
    • Radiographs to check position
    • Use straight away
    • Easily removed
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19
Q

What are risk and complications associated with oesophagostomy tube?

A

Risks

  • Placed into airway or mediastinum
  • Damage to vessels and nerves in Cervical region

Complications

  • Cellulitis and infection at site
  • Dislodgement
  • patient, vomiting, regurgitation
  • Oesophageal irritation and reflux
  • Blocked tube
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20
Q

Discuss a gastrotomy tube?

A
  • Larger mushroom-shaped tubes
    • 16-22Fr
  • GA –Technical skill
  • Percutaneously into stomach
    • Surgery
      • Laparotomy
      • Can visualise placement
      • Pexystomach
    • Endoscopy
      • Can visualise placement
      • Reduced iatrogenic risk to other viscera
    • Blind technique
  • Well tolerated
  • Bolus feeding
  • Long-term home feeding
  • Closer monitoring
  • More costly
  • Wider selection of diets
  • Must tolerate feeding without vomiting
  • Cannot be used for 24 hours until there is:
    • Return of gastric motility
    • Fibrin seal
  • Leave in until stomach adhered to body wall so have a seal for when you pull them out
    • 10-14dd or longer
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21
Q

What are the risks of gastrotomy tubes?

A

Risks

  • Cellulitis and infection at stoma site
  • Pyloric outflow obstruction if inappropriately placed
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22
Q

Discuss a jejunostomy tube?

A

5-8Fr small bore feeding tube

Proximal duodenum

Ideal for patients that can’t tolerate gastric feeding

  • Gastroparesis
  • Uncontrolled vomiting
  • Pancreatitis
  • Cannot protect airway

Short period of use

  • Days to weeks

24-48hrs until can use

Laparotomy

  • Visualise tube
  • Pexybowel to body wall

Transpyloric placement

  • Nasojejunal
  • Gastrojejunal
  • Less invasive
  • Reduced risk of bowel leakage
  • A LOT of skill
23
Q

Discuss the limits and complications of jejunostomy tube?

A
  • Small tubes
    • Limits diet
  • CRI rather than boluses
    • Cramping
    • Vomiting
  • More diligent monitoring
  • Mostly non-suitable for management at home

Complications

  • Peristomal cellulitis or infection
  • Peritonitis secondary to leakage
  • Retrograde migration of tube
  • Intestinal obstruction
  • tube migration
  • Clogging of tube
24
Q

How much to feed your patients?

A

Start point

  • Rest energy requirements
  • Amount of energy in calories need to maintain homeostasis in a thermo neutral environment

RER=70BW 0.75

  • Use for lean not obese body mass
  • ‘Illness factors’ no longer used (some things we know may need to increase RER)
  • Re-assess nutritional needs q12- 24hrs
  • Need to maintain bodyweight (excluding changes in hydration status) and lean body mass
  • Overfeeding –GI –Metabolic complications
25
Q

Some conditions require more than RER what are they?

A
  • Sepsis
  • Head trauma
  • Burns
26
Q

If patients have had prolonged anorexia how should you feed?

A
  • If patients have
    • Prolonged anorexia
    • GI compromise
    • Metabolic derangements
    • Caloric goal should be gradually increased over 3(5) days
  • Start at 30-50% RER goal
  • If not been eating loads don’t want to suddenly over feed them
27
Q

How should you select the appropriate diet?

A
  • Work out daily requirements and split into multiple, small meals
  • Highly digestible
    • Good quality
  • Poor appetite
    • Calorie dense
    • Smaller volume meets goal
  • Protein requirement
    • 5g/100Kcal (20% total energy as protein) dogs
    • >6g/100Kcal (>30% total energy as protein) –cats
  • Hepatic encephalopathy
    • Minimum protein requirement
      • 14% dogs; 30% cats
      • High degree branched chain
    • Still need appropriate calories
      • Carbohydrates
  • High degree of protein loss
    • More protein than recommended
  • Other modifications
    • Low sodium for CHF
    • Lower fat
      • Pancreatitis
      • Hyperlipidaemia
      • GI disease
  • Size of tube
  • Cost
  • Knowledge
28
Q

What is the starting point diet for most cases?

A

Hills a/d diet

29
Q

How should nutrition be monitored?

A

Monitoring

  • At least 12-24 hours
  • If did not meet dietary goals
    • Patient issues (nausea/ unpalatable diet)
    • Non-patient
      • Improper orders
      • Not followed
      • Food withheld for procedures
  • Repeated
    • Weight
    • Physical Exam
    • Hydration status
    • Metabolic lab work
      • Blood glucose
      • TS
      • Triglycerides/cholesterol
      • BUN
      • Electrolytes
30
Q

Discuss enteral complications?

A

Complications

Enteral

  • Usually minor
  • Can include
    • Aspiration and pneumonia
    • Tube dislodgement
    • Metabolic abnormalities
  • GI intolerance
    • Vomiting
    • Diarrhoea
    • Ileus
    • Will severely limit this route
    • Check haven’t missed anything
    • Check medications no contributing
    • Anti-emetics/prokinetics
31
Q

Discuss refeeding syndrome?

A

Refeeding syndromes

  • Are life-threatening
  • Anything that has had prolonged anorexia or in certain metabolic states
    • Can include obese dogs and cats that have not eaten for over 24hrs
  • Results in rapid shift of electrolytes from vascular to intravascular space. Results in profoundly low:
    • Hypokalaemia
    • Hypophosphataemia
    • Hypomagnesaemia
  • Days of resuming feeding
  • Re-feed very very slowly
32
Q

Discuss non-patient complications?

A
  • Obstructed tubes
    • Prevent by flushing with warm water before and after use
    • Care re volumes
    • Don’t use for medications
    • Unclogging tubes
      • Pancreatic enzyme, sodium bicarbonate, water
  • Tube migration
33
Q

Discuss enteral nutrition again?

A
  • Start early –should be on your to-do list to address as soon as an animal’s initial resuscitation plan has been completed
  • Consider route of administration
  • Do the calculations
  • Choose appropriate products
  • Keep re-visiting and monitoring success
  • Don’t under-estimate the value of anti-emetics and pro-motility drugs
  • Know when to quit (or never to start) and move onto parenteral nutrition
34
Q

Look at this case:

150Kg donkey that became anorexic after castration (no analgesia provided)

Initially would pick at grass and bits of hay, but then stopped eating

Owners tried schmorgerbordof goodies

Blood work –Triglyceride concentration 20mmol/l; normal -<1.5mmol/L

So what shall we do?

A

Start as far forward as possible enteral route isn’t working, so move on to nasogastric tube so calculate what he needs RER and administer that, can use a complete fibre diet/horse and pony nuts mixed into gruel but these block tube other option is ready break and complan(food replacement stuff). We don’t want to give more than 1.5 litres per meal (1 litre per 100kg is stomach size). Reason he is anorexic is because he is hyperlipaemic so get some food into him to remove triglycerides from blood and get him appetent again.

35
Q

Discuss parenteral nutrition?

A

IV or IO routes for patients and neonates

For use when the enteral route is not feasible either got:

  • GI disease
  • Nausea and vomiting
  • Cannot protect the airway

Can be life sustaining so don’t put off starting it if haven’t sorted underlying disease process

Don’t put off starting if required –The enteral route may not be any more appropriate tomorrow than it is today

36
Q

Discuss parenteral nutrition further?

A

Used more frequently in horses than small animals

Used in Equine neonates with sepsis

  • GI tract unable to cope with feeding and enteral feeding would lead to fatal C. difficile enterocolitis

Equine post-operative colics. Anything that has:

  • Ileus and nasogastric reflux
  • Should start sooner to prevent catabolism
  • Poor for restoration of GI function
  • Poor for wound healing
37
Q

What are the technical requirements for parenteral nutrition. We need:

A
  • Aseptic vascular access
  • 24 hour nursing care
  • Point-of-care glucose monitoring
  • Formulation of Partial or total parental nutrition PPN(glucose+protein) or TPN (glucose+protein+lipids) –
  • Vascular access
    • Dedicated venous catheter or through port in multi-lumen catheter
      • SHOULD NOT BE USED FOR ANYTHING ELSE
    • Solutions are hyper-osmolar
      • Should be administered through a central line
      • Reduces the risk of thrombophlebitis
      • Can dilute and then administer peripherally but can be limited by tolerance of fluid volumes
    • Catheters should be long-stay, dressed and re-dressed BID and examined frequently
    • Should be given as a CRI.
38
Q

Discuss other technical requirements for parental nutrition?

A
  • Best delivered as a CRI
  • Measure blood glucose and regulate as required with insulin infusions
  • Not by turning down the PN
  • Other measures required regularly
    • Electrolytes
    • BUN
    • Albumin
    • In-house
39
Q

Discuss parenteral nutrition formulation?

A
  • Maximum use 1-2 weeks
  • Don’t provide complete nutrition
  • Provide energy, protein and water-soluble vitamins
    • Occasionally need electrolytes and trace elements
  • Mix in the correct order and under aseptic conditions to prevent microbial contamination
  • Care in patients with CHF, oliguria
    • Volume overload
  • Aiming to give enough calories so they don’t go into malnutrition state.
  • Need to manage catheter in aseptic way as glucose is great for growing bugs.
40
Q

Look at these metabolic complications?

A
41
Q

Discuss calculation of requirements for energy and protein?

A

Energy

  • Aim for RER or less (less better than more when dealing with parental nutrition)
  • Excessive calories can lead to complications
  • Fatty infiltration of the liver
  • Hypercapnia

Protein

4-6g/100KCal –dogs

  • 15-25% calories

6g/100KCal –cats

  • 25-35% calories

Amino acid solutions

  • 3-15% -hyper-osmolar
  • 6-8.5% often used
  • Less concentrated already supplemented with electrolytes
  • 4KCal/g protein
42
Q

Discuss calculations of carbohydrates and fats requirements?

A

Carbohydrates

  • Can simply add carbohydrates to the protein
    • Dextrose solutions
      • 50% (1.7KCal/ml; 2500MOsm/L)
      • Max 10-20% in peripheral veins
  • Higher risk of hyperglycaemia
    • Cats

Adding lipids

  • 10% to 30% solutions (1.1-3.0 KCal/ml)
  • 20% solution most frequently used
  • Soybean/ safflower oils
  • Advantage of being iso-osmolar
  • More concentrated form of calories
  • 60-70% lipid
  • 30-40% dextrose
43
Q

Look at this table of micro-nutrients to supplement when using parental nutrition?

A
44
Q

Discuss the practicalities of parenteral nutrition?

A
  • Start with 25-50% RER over first 12-24 hours and then increase by 25% every 8 hours up to 100% maximum
  • Use a clean giving set every day
  • Fluid pump
  • Always wear gloves when handling port
  • Don’t make more than is required for 24 hours
  • Protect the bag from sunlight –Black tape –Dark bag
  • Stop parenteral nutrition gradually
    • Pre-treat with glutamine (1-2g/kg)
    • Start enteral food gradually and build-up
    • Gradually decrease PN by 25% every 6 to 8hrs
45
Q

What happens when we with-hold food?

A
  • Leads to GI changes
    • Villi stunting
    • Decreased absorptive capacity
  • Human medicine
    • Provide glutamine prior to re- feeding to ‘feed’ enterocytes
    • Q cheap - nutritional human supplement
  • Predisposes to mild gastric ulceration
  • Controversial re prophylaxis and treatment
    • Gastric acid has a purpose
      • Diarrhoea in septic foals/human patients
    • Glandular ulcers are more likely due to hypoperfusionthan acid
46
Q

How do we manage changes in GI flora?

A
  • Do nothing
    • Commonly adopted
  • Care re use of pre and pro-biotics
    • Often no EBM to support their use
    • May contain inappropriate or even pathogenic organisms
    • Many unlikely to survive gastric acid
  • Transfaunation
    • Pre-treat with acid suppressants
    • ‘Poo’ soup
    • Becoming more popular in human ECC
47
Q

What does parenteral nutrition look like?

A
48
Q

what is this?

A

Vitamin solution

49
Q

What is this?

A

Trace mineral solution

50
Q

Look at this cases calculation?

A
51
Q

Look at this case calculation for trace elements?

A
52
Q

How should parenteral nutrition be monitored?

A
  • Check the catheter q8 hours for signs of swelling –infection and phlebitis
  • Frequent (q2-4 hrsthen q8-12hrs once stable) glucose concentration measurements
  • Daily or BID
    • Glucose
    • Sodium
    • Potassium
  • Insulin administration if you need to reduce the glucose
    • 0.1U/Kg regular insulin IV or as CRI
  • Check blood for lipaemia
  • Serum phosphorus and magnesium evaluated after the first day
  • Ammonia concentrations - hepatic insufficiency and encephalopathy
53
Q

Discuss complications of parenteral nutrition?

A
  • Catheter issues
  • PN admixture
    • Microbial contamination
    • Precipitation
    • Drug-nutrient interactions
      • Proper compounding
      • Dedicated line
      • Check bag for lipid peroxidation
        • ?in-line filter
  • Metabolic
    • Minimised with conservative estimations of need
    • Re-feeding syndrome
    • Electrolyte abnormalities
      • Supplementation of fluids
54
Q

Summarise parenteral nutrition?

A
  • Enteral is best, but not always possible
  • Wean on and off
  • Don’t be afraid of using this product
  • Be able to cope with metabolic instabilities in first 24 hours
    • Insulin is your friend –especially as an infusion
  • Gradually wean off as enteral nutrition is tolerated
  • Be patient!

Small Animal Final Year (317 decks)

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