Nutritional support in critical patients Flashcards
When should you provide nutritional support
-If you have to ask if you should be providing nutritional support, the answer is yes
-If anorexic for >3 days
-If hyporexic for >7 days
-If hgihhhly invasive/painful procedure or specific to GIT
What medications can you give anorexic patients
-Maropitant: anti-emetic
-Ondansetron: anti-emetic med used in chemotherapy patients
-Metoclopramide: anti-nausea
How do you ideally want to feed the anorexic patient
-Ideally in the most proximal and physiological way possible
-Enteral nutrition preferred, maintains integrity of GIT, decreased bacterial translocation
What are ways you can provide enteral nutrition
-Nasophageal tube
-Nasogastric tube
-Oesophagostomy tube
-Gastrostomy tube
-Percutaneous gastrostomy tube
-Transpyloric duodenal/jejunal tube/jejunostomy tube
What are the 4 questions you should ask to decide on enteral nutrition
-What method of feed?
-What is the caloric requirement for the patient?
-Which diet do they need?
-What should the feeding plan look like?
Is voluntarily oral feeding a good option
-May work for very small number of dogs but almost never in cats. It’s easy to overestimate how much they’re actually eating
-Syringe feeding is almost never appropriate: stressful, rarely enough calories, aspiration pneumonia
Do you need to sedate/anesthetize the patient to place an NO/NG tube
-No, so this is a good option if patient is super sick
How do you place an NO/NG tube
-Local anesthetic down intended nasal passage
-measure tube to length (9th rib for NO, 13th for NG)
-Lubricate, place ventromedially into nares, allow animal to swallow tube and advance to position
-Suture in place using finger trap to side of nose and finger trap up the tube
-Check position with radiograph
What are some complications of NG/NO tubes
-epistaxis, dislodgment, placed in airway accidentally
-check for negative pressure before each feeding
Do you need to anesthetize to place an esophagostomy tube
-Yes, cannot use tube until patient is awake from GA
How to place esophagostomy tube
Look at lecture lol I dont feel Iike typing that out
When should you not place an esophagostomy tube
-Esophageal disorders (megaesophagus, stricture)
-Regurgitation
-Intractable vomiting
-Lack of gag reflex
What should you use if an esophagostomy tube gets clogged
Coca-cola
Do you need GA to place a gastrostomy tube, how long must they be in place before removal, and how long after placement until it can be used
-Yes, needs GA
-Has to be in place for 2 weeks before removing can be considered because adhesions need to form between gastric lining and abdominal wall so contents dont leak into abdominal cavity
-Have to wait 24 hours before using to allow a good seal to the body wall
How do you place a peg tube
Look at the lecture teehee
What are the contraindications and complications of Peg tubes
-Contraindications: primary gastric disease, severe vomiting
-Complications: abdominal injury during placement (spleen), infection/cellulitis around abdominal wound/tube exit, pressure necrosis at the point of fixing the tube to the abdominal wall, peritonitis (rare complication), inadvertent removal (bandaging, sting vest and ecollar
When would you use a transpyloric duodenal/jejunal tube
-For very critical animals with very proximal disease to allow for post-pyloric feeding
What is the equation for calculating resting energy requirement
RER= 70(BW in kg)^.75 kcal/day (suitable for dogs and cats)
Can also use 30(BW in kg) + 70 kcal/day (for 2-30 kg), but typically we use the first one
What factors could make an animals RER increase
More calories could be needed if growing, pregnant, lactating, severe disease (can multiple RER by factors of 1.2, 1.5, or even 2)
How do we refeed an anorexic patient
-Start at 1/3rd of the RER on day 1
-2/3rd of RER on day 2
-100% RER on day 3
Generally feed 4-5 times per day and feed over 10-15 minutes to mimic natural ingestion
When do we use parenteral nutrition and what types of parenteral nutrition are there
-We use it only when enteral nutrition is not possible
-Types of parenteral nutrition are Total Parenteral Nutrition (TPN) and Partial Parenteral Nutrition (PPN)
What is the difference in catheter placement for TPN vs PPN
TPN must be given through a central vein IV catheter, while PPN can be given through a peripheral or central vein
What are complications of TPN
-Sepsis, thrombophlebitis, metabolic derangements, liver disease, bone disease
What is the hallmark of refeeding syndrome
-Hypophosphatemia
Describe what happens intra/extracellularly with refeeding syndrome
-During prolonged fasting, energy source becomes fat and protein stores in the body. Basal metabolic rate decreases and fatty acid utilization generates ketone bodies.
-Intracellular minerals are severely depleted to maintain extracellular levels
-Upon refeeding, glucose increases releasing insulin. This drives potassium, magnesium, and phosphorus into cells-dangerously low
-Insulin stimulates glycogen, fat, and protein synthesis- require phosphate (ATP), magnesium,, and thiamine (protein synth) which depletes these more
What clinical signs do we see with hypophoshatemia, hypomagnesemia, hypokalemia, and thiamine deficiency
-Hypophosphatemia: skeletal muscle weakness, cardiac dysfunction, respiratory failure, seizures, and hemolysis
-Hypomagnesemia: cardiac and neuromuscular consequences
-Hypokalemia: arrhythmias and cardiac arrest
-Thiamine deficiency: neurological consequences- ataxia, vestibular dysfunction, and visual disturbances
How to avoid refeeding syndrome
-Look for at risk patients: Poor BCS, lost 15% BW in previous 3 months, reduced food intake for 10 or more days, low potassium magnesium, or phosphate prior to refeeding
-If identified, slow rate of feeding and supply electrolytes, monitor electrolytes daily
