SA Clinical Nutrition 1 Flashcards
What is the resting energy requirement (RER).
Calculation formula?
Energy used in thermoneutral conditions at rest e.g. in hospital.
70(BW in kg)^0.75 (for any weight).
30(BW in kg) + 70
(for animals 2-30kg).
RER very similar to basal metabolic rate (BMR).
Calculating food intake (RER).
Calculate RER for patient (kcals ME/day).
Calculate food intake weight/day.
- divide evenly between meals.
- How many calories do protein and carbohydrates provide?
- How many calories does fat provide?
- 3.5 kcal per gram.
- 8.5 kcal per gram.
- What is maintenance energy requirement?
- RER multiplied by what for entire dog?
- RER multiplied by what for neutered dogs?
- RER multiplied by what for entire cats?
- RER multiplied by what for neutered cats.
- Energy used i thermoneutral conditions by a moderately active animal including energy required to obtain and use the food. e.g. at home.
- 1.8.
- 1.6.
- 1.4.
- 1.2.
* these just starting point. variation of +/- 50% may be required in an individual.
* must actively assess BCS and weight post-neutering.
Life-stage factors for pets in home environment and effect on MER…
1. Pregnancy.
2. Lactation.
3. Working.
4. Growth.
- 3 x RER (last trimester) in dogs.
2 x RER (by parturition; gradual increase throughout pregnancy).
Discourage calcium supplementation during pregnancy as prevents normal metabolic adaptations and can lead to an increased risk of preeclampsia. - 4-8 x RER or free choice in dogs.
2-6 x RER or free choice in cats. (peak ~6w post-partum).
- Can feed a puppy/kitten diet as has a greater energy provision. - 2-8 x RER in dogs.
- <4m = 3 x RER.
50-80% of expected adult weight kg = 2.5 x RER.
>80% expected adult weight kg = 1.8-2 x RER.
2.5 x RER in cats.
- Causes of obesity in dogs.
- Why are owners frequently unaware their pet is overweight?
- What should form part of every CE?
- Overfeeding.
Inadequate exercise.
May be secondary to disease e.g. osteoarthritis.
Always consider whether health reason for apparent weight gain. - Owners frequently unaware as obesity so common that they see overweight pets as ‘normal’.
- Weighing the patient.
Feeding for weight loss.
Not appropriate for growth, pregnancy, lactation.
Dogs 1-2 x RER for current weight.
Cats 0.8-1 x RER for current weight.
Regularly re-weigh i.e. q2-4w.
- aim 1-2% loss per week in dogs.
- nearer 0.5-1% loss per week in cats.
– risk of hepatic lipidosis.
If loss slower than desirable, decrease caloric intake by 5-10%.
Calorie restriction and lifestyle modification.
Ideally 90% daily ration should be complete diet and 10% should be complimentary foods.
May help to use a weight management food that helps provide enough nutrients with restricted calories.
Feed veg as treats.
Increased exercise - walks and play.
Feeding games.
Timed feeding.
How does the owner feel?
Precontemplation - O not aware of obesity or need to change.
Contemplation - O aware of obesity but ambivalent to change.
Preparation - O committed to change and seeking advice.
Action - O making overt changes with some successes.
Maintenance - Sustained changes, o continuing to monitor.
Owner engagement and compliance.
Nurse clinics.
Involve whole family:
- check compliance.
- cats; alternative food source from hunting or neighbour?
Use images:
- BCS charts / photos.
- Photo diary / monitoring.
Set targets.
Pre-book regular review appointments.
Play/exercise reward.
NB. drug therapy for weight loss NOT advised.
Oral feeding of the patient.
Most physiologically normal.
Offer food early on.
Record food intake - hospital charts.
Monitor BC / weight.
- effect of fluid balance.
Nutritional support needed if:
- >10% BW loss (outwith fluid balance)
- >3d hyporexia less than 80% RER.
- underlying disease that increases calorie requirement (head trauma, sepsis, severe burns, large wound that are exudating – associated with protein loss).
Encouraging oral intake.
Address:
- underlying disease.
- fluid deficits, electrolyte imbalances.
- nausea, pain, stress.
Highly palatable, highly digestible.
Flat bowls, no bowls.
NEVER syringe feed as creates aversions and risks inhalation pneumonia.
Many anorexic cats are B12 +/- potassium deficient.
- may exacerbate anorexia.
- so correct these beforehand.
Feeding for illness.
IER~RER.
Illness factors rarely applicable.
Most hospitalised patients require their RER.
- hypermetabolic states may be an exception.
– e.g. sepsis, burns, head trauma.
- overfeeding is detrimental too.
Monitor BC / weight.
- if losses continue, consider 25% increase in offered food.
- reassess every few days.
How to feed?
If gut works, use it and use as much of it as possible.
Voluntary oral feeding.
Feeding tubes.
- naso-oesophageal, oesophagostomy, gastrostomy tube, jejunostomy tube.
Micro-enteral nutrition.
- still offer water, electrolytes and add in amino acid glutamine.
– energy source for enterocytes in gut who take it up direct from the gut.
Parenterial nutrition.
IV amino acid, lipid solution and usually dextrose.
- referral level, complications.
- Naso-oesophageal feeding time frame.
- When would N-O feeding be unsuitable?
- Advantages of N-O feeding?
- Disadvantages of N-O feeding?
- Suitable for short term (<7d) nutritional assistance.
- Unsuitable if:
- regurgitating/vomiting.
- nasal, oral, pharyngeal, oesophageal disease.
- (laryngeal incompetence). - Simple to place - can be conscious patient.
Reasonably well-tolerated - most patients happy to eat orally at the same time.
Easy removal - no healing required. - Can only feed liquid diet as narrow bore tube, esp. cats.
- risk of blocking.
- time consuming to feed.
Cannot be managed at home
- problematic if dislodges.
Aspiration risk.
Irritating and can inhibit eating.
- Oesophagostomy tube time frame?
- Advantages of O tube feeding?
- Disadvantages of O tube feeding?
- Indications for O tube feeding?
- 5-7+ days; may last months.
- Larger bore - usually 8-16Fr.
– enables thicker consistency / greater variety foods to be fed.
– can administer oral meds through it.
Well-tolerated - patients may eat orally with tube in place.
May be managed at home. - GA required for placement.
- a surgical procedure.
Stoma site can become infected.
Can dislodge it v+/regurgitation.
Aspiration risk.
Can block.
Time consuming feeds. - Diseases restricting N-O tube use e.g. facial trauma, nasal disease etc.)
Any disease where medium term hyporexia anticipated.
- Gastrostomy tube time frame?
- Advantages of gastrostomy feeding?
- Disadvantages of gastrotomy tube?
- Indications for gastrostomy feeding.
- Contraindications of gastrostomy feeding?
- What does PEG stand for?
- Longer term (can be months) +/- at-home use.
- Larger bore - enable thicker consistency / blended food feeding.
Can be in situ for months and be managed by the owner. - GA required.
Has to be in situ for 7d before removal, not good for short term support.
Cannot use it for first 24hrs. - Where bypass of proximal GIT needed - particularly oesophageal disease.
- Vomiting.
Severe gastric disease/surgery or local peritonitis. - Percutaneous endoscopic gastrotomy tube.
- Tube feeding complications.
- Metabolic complications.
- Stoma infections.
Tube dislodgement/migration.
- x ray to check placement.
Tube obstruction.
- important to flush before and after feeding. - ‘Re-feeding syndrome’.
- insulin release following prolonged fasting/anorexia.
– leads to hypophosphatemia which leads to haemolysis.
– get hypokalaemia.
- reason to gradually titrate food up.
– 1/3 RER day 1.
– 2/3 RER day 2.
– full RER day 3.
General tube care guidelines.
Keep tube sealed to prevent air entry.
Tube hygiene:
- always wear gloves when handling.
- wipe port before use.
- check and clean stoma twice daily.
- check sutures/tube position twice daily.
- swab stoma if any concerns.
- dress with iodoflex/similar and primapore.
Record all tube intervention on hospital records.
Tube feeding principles.
Complete, appropriate, liquid diet, at room temperature.
If hyporexic prior to hospitalisation:
- feed 1/4-1/3 requirement on day 1.
- gradually increase to 100% over 3-4d.
Infuse slowly (20-30mins/meal).
Continuous infusion possible with some tubes.
Flush well with water (5-10ml) before/after use.
Blockages - try carbonated water.
Feed until voluntary oral intake of >85% requirement.
Tube removal.
Remove any sutures/glue.
Keep end of tube capped to prevent aspiration.
NO, O: apply gentle, continuous traction until withdrawn.
G: depends on patient size/tip end.
- larger patients, cut tube, leave mushroom tip in stomach to pass naturally.
- smaller patients, endoscopically remove mushroom tip from stomach.
NO: clean nose with warm water.
O, G: clean stoma site and apply a primapore.
N-O placement process.
Apply LA e.g. proxymetacaine minim.
- 2-3 drops in each nostril – in case one fails and need to try other.
- leave to work for at least a minute.
- can apply to eyes too to improve comfort.
Measure tube from nares to 7th-9th rib.
- mark end of tube with tape to know when to know when to stop inserting.
Lubricate tube.
Insert tube ventromedially, aiming toward the opposite ear.
- easier to pass if hold patient’s head up.
- see patient swallowing as passes.
Secure tube with tape to head.
BC.
