nutrition for the sick patient Flashcards
How do we detect malnutrition?
- MEDICAL & DIET HISTORY:
– Physiological status: reproduction, age, activity
– Persistent GI signs: nausea, vomiting, diarrhea
– Disease history: Concurrent diseases may:
> Worsen without nutrition support
> Inhibit food intake for long time
– Diet history: homemade, limited ingredient, therapeutic, etc. - PHYSICAL EXAM:
– Significant weight loss
– Evidence of muscle wasting
– Depletion of subcutaneous fat
– Poor hair coat, discolouration - Lab work
wiehgt loss or BCS indicative of malnutrition
Weight loss > 10% in 1 wk
BCS < 3/9
MCS < mild muscle loss
Who should receive nutritional support?
- Patients already with malnutrition
- Patients at risk of malnutrition
- Inappetant
> Not eating for 48 h
> Food intake < RER for > 3 d - Concurrent disease
- GI dysfunction
food deprivation - what is used for endogenous fuel
- Glycogen
- Fat tissue
- Muscle protein
> Fuel to meet metabolic needs
> Maintain blood glucose
cachexia:
- mechanism
- appetite
- effect of feeding
- metabolism
- thyroid
- body energy stores
- mechanism: chronic illness
- appetite: decreased
- effect of feeding: does not change appetite, may maintain body weight but lean losses continue
- metabolism: no change to increased
- thyroid: no change to increased
- body energy stores: use fat or muscle for energy, but seems to be a preference for muscle breakdown
cachexia is driven by
catecholamines, glucocorticoids, glucagon, inflammatory mediators
complications of protein malnutrition
- Ileus & Bacterial translocation > Sepsis
- Immunity ↓ - infection risk ↑
- Tissue synthesis & repair ↓
- Drug metabolism > risk for activity and overdose
> Hepatic biotransformation ↓
> Binding & transport ↓
> Renal blood flow ↓ - Elimination↓
- Not always appropriate to feed a therapeutic diet in hospital because
learned food aversion
Every day without adequate nutrition impacts recovery how?
3-5 days extra for recovery
when should we make sure a sick patient is eating?
ASAP
GOAL - Within 24-48 h of hospitalization
- Hemodynamically stable
what to feed the hospitalized patient?
KNFs
PROTEIN
* Protein requirement ↑ (2-3 x > healthy)
Dog ~3g/kg BW0.75
FAT
- efficient energy source
CARBOHYDRATE
* Less efficient as energy source
* Adverse effects: DIARRHEA, HYPERGLYCEMIA
why do hospitalized animals need more protein? cautions?
- Protein breakdown ↑
- protein synthesis ↑
- GOAL
- Protein synthesis ↑
- Spare endogenous muscle protein
- Essential AA and amino groups acute phase proteins / immune response
- caution if:
- liver or renal dz
> if less than RER high protein can be ok
caution feeding more fat to hospitalized patient if
Pancreatitis
Hyperlipidemia
Diarrhea
Vomiting
> If less than RER, Moderate/high fat diet can be OK!
purpose of fat in hospital diet
- Much more efficient (> 2x calories/volume)
- Calorically dense > smaller volume
- Shift glucose to fat metabolism
> Metabolic complications ↓
> CO2 production ↓
adverse effects of carbohydrate in hostpital diet
Malabsorption > DIARRHEA
- Dehydration
- Acid/base & mineral balance
- Contamination of wounds
- Colonic fermentation ↓
- Butyrate production ↓
()
Altered glucose control > HYPERGLYCEMIA
- Osmotic shifts: Refeeding syndrome
- Glucosuria
- Altered immune function
- Predispose to infection
- Oxidative stress / damage
- Respiratory work ↑ (CO2)
how much protein, fat, carbs do we want in a recovery diet
PROTEIN:
Dog ~3g/kg BW0.75
Cat ~5g/kg BW0.75
Dog 5 – 12 g/100 kcal
Cat 7.5 – 12 g/100 kcal
FAT
2g/kg BW0.75
5 – 7.5 g/100 kcal
CARBOHYDRATE
2 – 4 g/100 kcal
can we feed cat food to dog, or dog food to cat for recovery?
No problem feeding cat food to dog – short term
- NOT vice versa!!!
can we feed human products to animals for hospital recovery? why
Human products, not complete & balanced for dogs/cats
Not high enough in protein & fat, too much carbohydrates
can we feed GI diets to animals for recvoery? why?
Usually not high enough in protein & fat, too much carbohydrates
can we feed baby food or home cooked stuff for recovery?
- Not complete & balanced
- other risks eg. toxic ingrediets, risk of contaminatin
ENERGY REQUIREMENT – In hospital
RER = 70 kcal x BW0.75
- Unless underweight
- Increase gradually
- Multiple small meals / day
why is enteral feeding the best?
- Less expensive
- More physiological
- Stimulate systemic & GI immune systems
- Maintain gut mucosal barrier
- Risk for bacterial translocation ↓
- Metabolic complications ↓
()
> ORAL FEEDING
> TUBE FEEDING
Encourage eating how?
- Palatability ↑
> Wet food (dog)
> Fat ↑ & protein ↑
> Sweet (dog) / salt - Freshness, aroma
> Warm the food > body temp.
> Leave food in cage for MAX 15 min - Texture (cat)
> Diet history!!
> Try dry food as well - Variety – cafeteria-style
> Record each item
> Watch for food aversion - Multiple small meals!!
- Environment – Minimize stressors
- Gentle coaching – Verbally encouraging / hand feeding
- Food on lips, paws, in mouth – gently!!
- Owner – NOT if basing live/death “on eat or not eat”
are appetite stimulants reccomended? why?
IN GENERAL: NOT recommended
- Unpredictable / unreliable / intermittent
- Short-term effect
- Delaying true nutritional support
how fast does mirtazapine work?
- Should see a response in 1-2 hours
Capromorelin - what is it how does it work? danger maybe?
- Ghrelin receptor agonist
- Appetite stimulant
- Safety and efficacy not known after 4 consecutive days
force feeding - is it useful? risks?
- Imagine this in human medicine ?!?!
- It is an inappropriate form of nutritional support
- Its use should be DISCOURAGED
- RISKS/CONCERNS:
- Poorly accepted
- Food aversion
- Oral and/or pharyngeal trauma
- Food aspiration
how long would we place nasoesophageal or nasogastric tube, vs esophagotomy, gastrotomy, jejunostomy tube?
nasoesophageal or nasogastric tube
- Typically <5 days
esophagotomy, gastrotomy
- Long term (weeks to months)
jejunostomy
- while hospitalized only
OROGASTRIC TUBE FEEDING - how it works? concerns? when acceptable?
- Tube passed down the mouth into the stomach
- Placed at each feeding
() - RISKS/CONCERNS:
- Poorly accepted
- Food aversion
- Food aspiration
()
Acceptable in 2 circumstances : - Birds
- Neonatal puppies & kittens
Complications of enteral feeding
- Gastrointestinal
~ volume intolerance
Distension
Nausea & vomiting
Diarrhea - Metabolic
Refeeding syndrome
Hyperglycemia
Hyperlipemia
Azotemia - Mechanical
Tube occlusion
Tube displacement
Sinusitis - Infectious
Aspiration pneumonia
Parenteral nutrition issues? indications?
- Nutrition delivered intravenously
- More Expensive!
- Needs more technical expertise!
- More complications!
> Catheter placement & management
> Metabolic complications > Probably because of overfeeding
() - Indications:
- Abnormal gut function
- Inability to gain enteral access (ie. coagulopathy)
- Inability to consume adequate amounts of energy
Refeeding Syndrome
- what is it?
Metabolic derangements
- ↓ Potassium / ↓ Magnesium / ↓ Phosphorus
* Neuromuscular dysfunction
* Cardiac dysfunction
* RBC & WBC dysfunction
- Altered glucose metabolism; hyperglycemia
how to prevent refeeding synrome
- Not exceed RER
- GRADUAL introduction of food
- Correct electrolyte abnormalities PRIOR to feeding
- Monitor electrolytes: K, P, Mg
fundamentals for hospital nutrition
- Each patient deserves a feeding plan
- Diet history on every patient
- Write food orders like drug orders
- If the gut works use it
- Proceed only as the patient tolerance allows
- Avoid food aversions
