Nutritional support in critical patients

Question 1

When should you provide nutritional support

Answer 1

-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

Question 2

What medications can you give anorexic patients

Answer 2

-Maropitant: anti-emetic
-Ondansetron: anti-emetic med used in chemotherapy patients
-Metoclopramide: anti-nausea

Question 3

How do you ideally want to feed the anorexic patient

Answer 3

-Ideally in the most proximal and physiological way possible
-Enteral nutrition preferred, maintains integrity of GIT, decreased bacterial translocation

Question 4

What are ways you can provide enteral nutrition

Answer 4

-Nasophageal tube
-Nasogastric tube
-Oesophagostomy tube
-Gastrostomy tube
-Percutaneous gastrostomy tube
-Transpyloric duodenal/jejunal tube/jejunostomy tube

Question 5

What are the 4 questions you should ask to decide on enteral nutrition

Answer 5

-What method of feed?
-What is the caloric requirement for the patient?
-Which diet do they need?
-What should the feeding plan look like?

Question 6

Is voluntarily oral feeding a good option

Answer 6

-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

Question 7

Do you need to sedate/anesthetize the patient to place an NO/NG tube

Answer 7

-No, so this is a good option if patient is super sick

Question 8

How do you place an NO/NG tube

Answer 8

-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

Question 9

What are some complications of NG/NO tubes

Answer 9

-epistaxis, dislodgment, placed in airway accidentally
-check for negative pressure before each feeding

Question 10

Do you need to anesthetize to place an esophagostomy tube

Answer 10

-Yes, cannot use tube until patient is awake from GA

Question 11

How to place esophagostomy tube

Answer 11

Look at lecture lol I dont feel Iike typing that out

Question 12

When should you not place an esophagostomy tube

Answer 12

-Esophageal disorders (megaesophagus, stricture)
-Regurgitation
-Intractable vomiting
-Lack of gag reflex

Question 13

What should you use if an esophagostomy tube gets clogged

Answer 13

Coca-cola

Question 14

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

Answer 14

-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

Question 15

How do you place a peg tube

Answer 15

Look at the lecture teehee

Question 16

What are the contraindications and complications of Peg tubes

Answer 16

-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

Question 17

When would you use a transpyloric duodenal/jejunal tube

Answer 17

-For very critical animals with very proximal disease to allow for post-pyloric feeding

Question 18

What is the equation for calculating resting energy requirement

Answer 18

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

Question 19

What factors could make an animals RER increase

Answer 19

More calories could be needed if growing, pregnant, lactating, severe disease (can multiple RER by factors of 1.2, 1.5, or even 2)

Question 20

How do we refeed an anorexic patient

Answer 20

-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

Question 21

When do we use parenteral nutrition and what types of parenteral nutrition are there

Answer 21

-We use it only when enteral nutrition is not possible
-Types of parenteral nutrition are Total Parenteral Nutrition (TPN) and Partial Parenteral Nutrition (PPN)

Question 22

What is the difference in catheter placement for TPN vs PPN

Answer 22

TPN must be given through a central vein IV catheter, while PPN can be given through a peripheral or central vein

Question 23

What are complications of TPN

Answer 23

-Sepsis, thrombophlebitis, metabolic derangements, liver disease, bone disease

Question 24

What is the hallmark of refeeding syndrome

Answer 24

-Hypophosphatemia

Question 25

Describe what happens intra/extracellularly with refeeding syndrome

Answer 25

-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

Question 26

What clinical signs do we see with hypophoshatemia, hypomagnesemia, hypokalemia, and thiamine deficiency

Answer 26

-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

Question 27

How to avoid refeeding syndrome

Answer 27

-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