Nutrition for Hospitalized Patients/ assisted feeding.

Question 1

Why is nutrition important in regards to hospitalized patients?

Answer 1

Prognosis of frail, muscle wasted patients is poor

Question 2

What state are patients in when they have critical disease and what is the cause? In this state what is used for energy and what is at a negative energy balance?

Answer 2

• Critical disease -> cytokines (TNFα etc)  catabolic state
• Preferential use of amino acid oxidation for energy
• Negative nitrogen and energy balance

Question 3

What are some causes that induce catabolic cytokines? What is the result?

Answer 3

Causes:
- Actions of cytokines catabolic hormones
- Severe injury, trauma, sepsis, burns, cancer, critical illness.
- Decreased calorie and nutrient intake
Results:
- Malnutrition
- Negative nitrogen balance and muscle catabolism.
- Decreased healing, depressed immune function, increased intestinal permeability, increased morbidity and mortality.
- Alterations in carbohydrate, lipid, and protein metabolism.

Question 4

What percent of dogs meet 95% of the resting energy requirements while hospitalized

Answer 4

under 30%
- 0.95XRER met only 27% of the time

Question 5

What conditions may increase energy/ protein requirements?

Answer 5

Seizures
Burns
Sepsis

Question 6

Why is malnutrition such a common issue in hospitalized patients?

Answer 6

1. Poorly written orders (22%)
2. NPO per doctor (34%)
3. Patient not eating (44%)

Question 7

What is the discharge rate for an animal with voluntary food intake? Low BCS? Ideal body weight/ overweight? What is associated with more severe disease?

Answer 7

93% of animals with voluntary food intake were discharged
73% low BCS 84.7% for those at an ideal BCS or overweight
[However- low BCS may also be associated with a more severe disease]

Question 8

What can be said about older dogs prognosis that have a higher initial bcs and vomiting at admission? What about dogs that consumed RER and had higher initial BCS at admission?

Answer 8

Older patients, higher initial BCS and vomiting at admission were associated with a decrease of BCS status during hospitalization

Dogs that consumed their energy requirements, and had a higher initial BCS had lower odds of dying

Question 9

What are the important parts of creating a nutritional support plan?

Answer 9

Meeting the energy needs- meeting RER is typically our goal
Achieving and maintaining ideal bodyweight/ BCS/ muscling Meeting nutrient requirements
Addressing electrolyte shifts
Addressing specific metabolic problems (HE, CKD, pancreatitis etc)

Question 10

What should you be looking for when completing a nutritional assessment?

Answer 10

1. Screening- is there a nutrition related risk factor?
   ◦ A. disease with nutrition related management
   ◦ B. prolonged dysrexia
   ◦ C. patient unable to consume food/ unlikely to be able to feed
   ◦ D. poor body condition
   ◦ E. poor muscling
2. Extended nutritional assessment

Question 11

When would we intervene in regards to nutrition?

Answer 11

Depends on several factors:
◦ Length of dysrexia:
◦ 1-2 days: monitor food intake ◦ 3-4 days: support is likely required if recovery is not imminent ◦ 5 days: intervention required
◦ Evidence of malnourishment ◦ Puppies/kittens

Question 12

When is it ideal to fast a patient? What is the new recommendations in regards to pancreatitis and severe enteritis?

Answer 12

• NPO may be necessary in cases where uncontrolled vomiting is present or high risk of aspiration
• BUT Early enteral feeding is beneficial even in conditions where ‘NPO’ was traditionally recommended
• pancreatitis (Qin et al. 2002)
• severe enteritis (Mohr et al. 2003)

Question 13

What does the resting energy requirements helping the body achieve? Is it better to feed more to patients ?

Answer 13

Accounts for energy needed for homeostasis in a thermoneutral environment Energy needed for basic metabolic processes: protein turnover, ATP requiring pumps, etc.
Not necessarily helpful to feed more

Question 14

What are the risks of overfeeding?

Answer 14

Risks of overfeeding:
◦ Hyperglycemia- negative prognostic indicator
◦ Increased CO2 production

Question 15

How much should we feed patients with prolonged dysrexia?

Answer 15

Starting feeding with 25% of RER in patients with prolonged dysrexia may help decrease the risk for metabolic complications

Question 16

What is important when feeding any patient?

Answer 16

Monitoring ( Monitor patient response)

Question 17

What is considered low level nutritional intervention?

Answer 17

Low level intervention:
◦ Offer food for voluntary intake
◦ Switch foods as possible (dry/wet/flavor)
◦ Offer food in a quiet environment/away from cage/change
bowl/food temperature/mix with palatants ◦ Address health factors that could contribute to dysrexia
◦ Dehydration
◦ Pain
◦ Reduced mentation

Question 18

What are the appetite stimulant medications?

Answer 18

• Mirtazapine (antidepressent)
• Capromorelin
• Ciproheptidine
• (Valium)
- midazolam
• (Propofol)

Question 19

What is the potential drawbacks to assisted/ force feeding?

Answer 19

Assisted/forced feeding
◦ Aspiration
◦ Food aversion
◦ Trauma
Works well in rabbits and rodents

Question 20

Why do we prefer enteral feeding?

Answer 20

Feeding the enterocytes
◦ The enterocytes depend on food in the lumen of
the gut for nutrition
◦ Glutamine is used as fuel for gut enterocytes and lymphocytes
◦ Glutamine is also used for purine synthesis
Healthy enterocytes are vital to maintain gut barrier and prevent villus atrophy

Question 21

When should you consider a feeding tube? How do you select the right kind of tube?

Answer 21

When to consider a feeding tube?
◦ Failure to meet RER
◦ Patient unwilling to consume appropriate diet
◦ Need to provide many oral medications How to select the right type of tube?
◦ Type of food to be provided
◦ Length of time tube will need to be maintained
◦ Need for anesthesia
◦ Need for incision
◦ Desire to bypass the airways, mouth, esophagus, stomach, duodenum

Question 22

What are the kinds of feeding tubes and how are they placed?

Answer 22

Feeding tubes types include:

1. Nasoenterel: small lumen, temporary, no anesthesia or incision required
2. Esophagostomy tube: larger lumen, can be long-term, requires anesthesia and incision
3. Gastrostomy tube: Larger lumen, long-term, requires anesthesia and incision
4. Jejunostomy tube: long-term, requires anesthesia, diet- liquid and highly digestible

Question 23

Where does each tube terminate/ bypass?

Answer 23

Tube selection and where the tube terminates may also be impacted by what we want to bypass

• Naso-enteric or nasogastric tube: does not bypass the airways or most of the GI
• Esophageal feeding tube- bypass the mouth, upper airways
• Gastric tube- bypass the esophagus
• J tube- bypass the esophagus, stomach, pancreas, duodenum

Question 24

How can you confirm tube placement in patients?

Answer 24

Can be difficult! Direct visualization:
◦ Endoscopically placed
◦ Surgically placed
◦ Fluoroscopically placed Radiographs
◦ May provide limited information if tube ends in the esophagus Injection of water/ air through the tube may help (coughing/ borborygmus)

Question 25

What is preferred when feeding through different feeding tubes?

Answer 25

CRI preferred for J tube
CRI preferred where GI motility may be abnormal
Bolus or CRI both ok for NE, NG, e-tube, G-tube
No difference in residual and regurgitation rate

Question 26

What are potential diets that can be used for hospitalized patients?

Answer 26

Commercial veterinary diets: canned or liquid
Commercial human diets: liquid (may not be balanced for dogs and cats!)
Home-prepared die

Question 27

What factors should be considered when selecting a diet?

Answer 27

Select the right diet for the specific patient! Macronutrient composition
Electrolytes
Caloric density
Tube clogging
Ease of feeding

Question 28

What are the different complications associated with feeding tubes?

Answer 28

Erythema
Cellulitis
Early removal
Tube clogging/coiling/migration
Infection of stoma
Vomiting, coughing, sneezing
Diarrhea

Question 29

How frequent are complications with feeding tubes?

Answer 29

Overall complications are common (up to 77%), but most of them are minor

Question 30

Which is most safe and effective in unclogging a feeding tube?

Answer 30

Water

Question 31

How to unclog a feeding tube?

Answer 31

In vitro study-
Water is at least as effective as soda, cranberry juice
Water + ¼ tsp pancreatic enzyme and 325 sodium bicarbonate most effective (Parker and Freeman 2013)

Question 32

When should a patient be offered parenteral nutrition?

Answer 32

A good option for patients that cannot tolerate enteral feeding
◦ Severe pancreatitis
◦ Not stable for anesthesia
◦ GI obstruction/ dysfunction
◦ Temporary support

Question 33

What are the types of parenteral nutrition?

Answer 33

• CPN= Central parenteral nutrition (i.e jugular)
• PPN= Peripheral parenteral nutrition (i.e cephalic)

Question 34

What are the benefits of CPN feeding? Where is the catheter placed in the animal?

Answer 34

• Requires central vein access (through jugular or femoral veins)
• Allows feeding a higher osmolarity solution (up to 1400 mOsm/L)
• Allows for a highly concentrated solution, lower volume, or for a low- fat solution if desired

Question 35

What is their a higher risk for with PPN? What factors must we be conservative with and mindful of?

Answer 35

Higher risk for phlebitis
◦ Max mOsm/L is 700
Must be mindful of :
◦ pH
◦ Flow rate

Question 36

What must you do with PPN to meet energy requirements?

Answer 36

Must use higher fat solutions, which can cause issues with hyperlipidemia, or other issues with lipid metabolism. Studies also show risk for immune dysfunction in higher fat diets.

Question 37

How do you compound Parenteral nutrition?

Answer 37

Aseptic/sterile procedure (lipid solution has highest risk for contamination) Order of mixing-
◦ 1. AA
◦ 2. Lipid
◦ 3. Dextrose
Important to maintain pH (dextrose has low pH) Temperature Light affects stability of B vitamins (not really of AA)

Question 38

How should we administer Parenteral nutrition?

Answer 38

Dedicated line/lumen
- Aseptic placement Catheter- maintain clean area, cover/bandage
-Do not disconnect line if possible (walk dogs with line connected)
- Cover if B vitamins added
Replace bag every 24-48 hours

Question 39

What must you monitor with Parenteral nutrition?

Answer 39

Magnesium, potassium and phosphorous: Within 24 hr of initiating PN, then EOD
BUN & albumin: Within 24 hr of initiating PN, then EOD Thiamin injection; if lack of B-vitamins in solution/ concern of Refeeding Syndrome
Thoracic radiographs: If signs of respiratory disease develop during administration
Triglycerides: If hypertriglyceridemia or lipemia is present
Blood culture: If evidence of sepsis
Blood glucose every 4 hours If hyperglycemia is present (>300 mg/dL) consider reducing rate, add insulin, or reduce dextrose in solution.

Question 40

How do you discontinue parenteral nutrition in patients? What is the concern with stopping cold turkey?

Answer 40

Discontinuing PN
Usually discontinue in parallel to patient consuming food or fed through tube Wean gradually Abrupt d/c is may lead to serious complications!
◦ While PN is provided, insulin is increased
◦ Abrupt stop = glucose is not provided= insulin still high = hypoglycemia

Question 41

What are complications with parenteral nutrition?

Answer 41

Metabolic complications are relatively common
◦ Hyperglycemia
◦ Hyperlipidemia
◦ Hyperammonemia
◦ Electrolyte shifts Mechanical complications Septic complications- 0-8%

Question 42

What is refeeding syndrome? When does it occur? What can be seen occurring metabolically and why?

Answer 42

• Animals with prolonged anorexia (longer than 4 days) are at risk of refeeding syndrome
• For example, a young healthy dog with foreign body GI obstruction that resolves
• Can be severe enough to be life threatening
• During prolonged fasting, hormonal and metabolic changes are aimed at preventing protein and muscle breakdown
• Muscle and other tissues decrease their use of ketone bodies and use fatty acids as the main energy source
• This results in an increase in blood levels of ketone bodies, stimulating the brain to switch from glucose to ketone bodies as its main energy source
• The liver decreases its rate of gluconeogenesis, thus preserving muscle protein
• During the period of prolonged starvation, several intracellular minerals become severely depleted
• However serum concentrations of these minerals (including phosphate) may remain normal
• This is because these minerals are mainly in the intracellular compartment, which contracts during starvation
• In addition, there is a reduction in renal excretion

Question 43

What occurs between glucose, electrolytes, and other important vitamins during refeeding syndrome?

Answer 43

• Rapid increase in glucose -> insulin increase - Na-K pump is coupled to sodium glucose transporter -> high insulin->hypokalemia
• Phosphorous is shifted intracellularly for ATP
• Magnesium is shifted intracellularly as it is a cofactor for enzymes that participate in glycolysis
  ◦ Hypomagnesemia may cause GI, muscle and cardiac
  abnormalities
  ◦ Magnesium is important to prevent passive potassium membrane leakage
• Thiamin is important for CHO metabolism

Question 44

How can you prevent refeeding syndrome?

Answer 44

Prevention:
◦ Identify patients at risk
◦ Supplement with a B complex (thiamin)
◦ Introduce food gradually
◦ Start with 25% RER while monitoring electrolytes ◦ Increase by 25% each day

Question 45

How can you treat refeeding syndrome?

Answer 45

Treatment:

1. Slow feeding rate
2. Correct electrolyte abnormalities
3. Thiamin supplementation

Question 46

What happens if you do not feeding orally? What are the potential complications?

Answer 46

Intestinal mucosal hypoplasia or atrophy may occur
This may lead to several complications:
- GI dysbiosis
- Bacterial translocation
- Decreased digestive function

Question 47

What is the best method for nutritional support for a dog with megaesophagus?

Answer 47

 Have the owners feed the puppy in a Baily’s chair ????

Question 48

What should you feed through a G tube?

Answer 48

1. Complete and balanced diet for growth
2. Highly digestible
3. Calorically dense (lower volume)
4. Short GI transit time
5. Low fiber
6. low fat
7. Affordable
8. Easy to prepare
   Ideal is not canine recovery diet. Its a homemade diet which is in the image

Question 49

What are some causes of mega esophagus?

Answer 49

• Myesthenia Gravis, idopathic, vascular abnormalities, ect.

Question 50

What would be the best option for a patient with prolonged anorexia and diagnosed idiopathic megaesophagus?

Answer 50

Best would be to place a gastrostomy tube and provide a liquid diet . This is so we can prevent chance of regurgitation as well as to control the speed of feeding and bypass the esophagus entirely. Make sure diet is highly digestible, short transit time, (low fiber, low fat), caloriclly dense (lower volume), and complete and balanced diet (for growth in this case).