Nutrition of the emergency and critical care patient Flashcards
Why is nutrition so important in critical patients?
- Being sick is a metabolically active process
- GIT becomes leaky and leads to bacterial translocation if not functioning properly
Which patients are classed as high risk following a nutritional assessment?
- Patients that have not consumed RER for 3-5days
- E.g. chronic renal failure
- Weight loss of 10% adults (5% neonates) over similar time period
What nutritional considerations are there for a patient with hepatic encephalopathy?
- Become protein intolerant
- Meet calorie needs with low protein/appetising diet (the two things do not go together well necessarily)
Which is the preferred method of administering nutrition to critical patients?
Enteral feeding (as far rostrally as possible)
Note: either route (parenteral or enteral) requires a haemodynamically stable patient (especially enteral) with minimal acid-base and electrolyte derangements
Physiological benefits of enteral feeding?
- 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
- Malabsorption
- Maldigestion
- Inability to protect the airway
Which anti-emetic drugs can be used to prevent nausea?
Combination of maropitant and metoclopramide combinations can work very well for dogs and cats
Options for enteral feeding tubes?
- Naso-oesophageal
- Naso-gastric
- Oesophagostomy
- Gastrostomy
- Jejunostomy
How should naso-oesophageal or nasogastric tubes be used?
- LA or light sedation
- Limited to liquids
- Short term
- 7-14dd
- Irritating
Contraindications for naso-oesophageal or nasogastric tubes?
- Facial trauma
- Respiratory disease
- Excess sneezing or vomiting
Complications of naso-oesophageal or nasogastric tubes?
- Epistaxis
- Rhinitis
- Sinusitis
- Dacryocystitis
- Inadvertent placement and dislodgement
- Oesophageal irritation
- Reflux
- Blocked tube
- Aspiration pneumonia
Where are oesophagostomy tubes placed?
- Proximal oesophagus at mid-cervical level
- Tip in distal oesophagus
Benefits of oesophagostomy tubes?
- Well tolerated
- Can leave them in for weeks to months
- Wider selection of diets
- Blenderised canned diets
- Suitable for those with facial and oral disease
Risks and complications of oesophagostomy tubes?
- Risks
- Placed into airway or mediastinum
- Damage to vessels and nerves in Ce
- Complications
- Cellulitis and infection at site
- Dislodgement – patient, vomiting, regurgitation
- Oesophageal irritation and reflux
- Blocked tube
How is a gastrotomy tube placed?
- Surgery
- Laparotomy
- Endoscopy
- Can visualise placement
- Reduced iatrogenic risk to other viscera
- Blind technique
How quickly can gastrotomy tubes be used?
- Cannot be used for 24 hours
- Return of gastric motility
- Fibrin seal
- Leave in until stomach adhered to body wall
- 10-14dd or longer
Benefits of gastrotomy tubes?
- Well tolerated
- Bolus feeding
- Long-term home feeding
- Wider selection of diets
Disadvantages of gastrotomy tubes?
- Before using them have to leave them 24 hours so you get some fibrin development
- Closer monitoring
- More costly
Risks of gastrotomy tubes?
- Cellulitis and infection at stoma site
- Pyloric outflow obstruction if inappropriately placed
Indications for jejunostomy tube?
- Ideal for patients that can’t tolerate gastric feeding:
- Gastroparesis
- Uncontrolled vomiting
- Pancreatitis
- Cannot protect airway
Period of use for jejunostomy tube?
- Short period of use
- Days to weeks
- 24-48hrs until can use
Placement of jejunostomy tube?
- Laparotomy
- Visualise tube, pexy bowel to body wall
- Technically difficult to place
- Transpyloric placement
- Nasojejunal, gastrojejunal
- Less invasive
- A LOT of skill
Disadvantages of jejunostomy tube?
- Small tubes -Limits diet
- More diligent monitoring
- Mostly non-suitable for management at home
Complications of jejunostomy tube?
- A lot more than others
- Peristomal cellulitis or infection
- Peritonitis secondary to leakage
- Retrograde migration of tube
- Intestinal obstruction – tube migration
- Clogging of tube
Generally, how much should you feed with a critical patient?
- Rest energy requirements (RER=70BW(kg)0.75)
- Use for lean not obese body mass
- Re-assess nutritional needs q12-24hrs
Some conditions require more than RER, which conditions are these?
- Sepsis
- Head trauma
- Burns
If patients have prolonged anorexia, GI compromise or metabolic derangements how should they be managed nutritionally?
- Caloric goal should be gradually increased over 3-5 days
- If they have not been eating loads you do not want to overload them
- Start at 30-50% RER goal
Which conditions may require a lower fat diet?
- Pancreatitis
- Hyperlipidaemia
- GI disease
Complications of enteral feeding?
- Usually minor
- The main thing is going to be GI intolerance
- Can include
- Aspiration and pneumonia
- Tube dislodgement
- Metabolic abnormalities
Non-patient complications of enteral feeding?
- Obstructed tubes
- Tube migration
Routes of parenteral nutrition?
IV or IO
Indications for parenteral nutrition?
- For use when the enteral route is not feasible
- Nausea and vomiting
- Or other GI disease
- Cannot protect the airway
- Can be life sustaining
Technical requirements for parenteral nutrition?
- Aseptic vascular access
- 24 hour nursing care
- Point-of-care glucose monitoring (glucometers – most practices have these)
- Formulation of PPN or TPN
- Partial parenteral nutrition
- Total parenteral nutrition
- Vascular access
- Measure blood glucose and regulate as required with insulin infusions
- Catheters should be long-stay, dressed and re-dressed BID and examined frequently
- Best delivered as a CRI
Difference between partial parenteral nutrition and total parenteral nutrition?
- PPN has glucose and protein
- TPN has both plus lipid
What other measures should be monitored when parenteral nutrition is being administered?
- Electrolytes
- BUN
- Albumin
Predisposing conditions to hyperglycaemia?
DM, Hyperadrenocorticism
Predisposing conditions to lipaemia?
Pancreatitis, Idiopathic hyperlipidaemia, DM, Hyperadrenocorticism
Predisposing conditions to azotaemia?
Renal failure
Predisposing conditions to hyperammonaemia?
Hepatic failure, PSS
Predisposing conditions to re-feeding syndrome?
Prolonged starvation or catabolic disease, DM
Characteristics of re-feeding syndrome?
hypokalaemia, hypophosphataemia and hypomagnesaemia
What % of calorie requirements should be protein in dogs and cats?
- Dogs: 15-25% calories
- Cats: 25-35% calories
Why is parenteral feeding a good option for equine neonates with sepsis?
GI tract unable to cope with feeding and enteral feeding would lead to fatal C. difficile enterocolitis (normally fatal)
How long should the parenteral nutrition formulation be used for and what does it do?
- Maximum use 1-2 weeks
- Don’t provide complete nutrition
- Not trying to give them all the calories they need, just enough to prevent them to go into malnutrition
- Provide energy, protein and water-soluble vitamins
In which patients should parenteral nutritional formulation be used with care?
- Care in patients with CHF, oliguria
- Volume overload
What are the practicalities of parenteral nutrition?
- 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 if outdoors (Causes things to denature and become toxic)
- 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
Complications of parenteral feeding?
- Catheter issues
- PN admixture
- Microbial contamination
- Precipitation
- Drug-nutrient interactions
- Metabolic
- Re-feeding syndrome
- Electrolyte abnormalities
- Supplementation of fluids
