Dan Chan

1/10/12

CAL: Feeding the Sick Patient

Malnutrition is defined as any disorder that results in inadequate or imbalanced nutrition associated with either nutritional deficiencies or excess. In most circumstances it refers to severe under nutrition. However, obesity is a form of malnutrition as there is an imbalance of energy and energy expenditure resulting in excess fat accumulation The metabolic responses to illness or severe injury are complex and place critically ill animals at high risk for malnutrition and its deleterious effects. These effects are likely to negatively impact overall survival, loss of muscle mass, decrease in protein synthesis, compromised immune function and decreased wound healing One of the major facets of the metabolic alterations associated with critical illness involves whole body protein metabolism in which protein turnover rates may become markedly elevates (usually referred to as catabolism). Whereas healthy animal primarily lose fat when deprived of sufficient calories (simple starvation), sick or traumatised patients catabolise lean muscle mass when they are not provided with sufficient calories (stressed starvation). Muscle catabolism that occurs during stress provides the liver with glucogenic precursors and other amino acids for glucose and acute phase protein production Due to the metabolic alterations associated with critical illness and in part due to an inability or reluctance of many critically ill dogs and cats to take in sufficient calories, this patient population is at increased risk for rapid development of malnutrition. Given the serious sequelae of malnutrition, preservation or reversal of deteriorating nutritional status via nutritional support when dealing with a sick patient Not every patient will benefit from nutritional support, however, no patient benefits from nutritional neglect Not every patient will come in with obvious signs of malnutrition Complete anorexia in obese patients is just as important

Case 1
5yr old, mixed breed Poor appetite for 5 days previous Vomiting for a few times per day BCS - 4/9, lost quite a bit of weight Sent home with antiemetic which decreased vomiting but dog still had no appetite Discovered it had very thickened segment of small intestine Plan is to go to surgery to remove abnormal segment Risk of malnutrition is higher as dog is already showing signs of malnutrition The thickened bowel is likely indicative of an infiltrative disease (which is often not determined until histopathology) which if responsive to therapy will take some time to resolve. Therefore appetite is unlikely to be immediately resolved Better plan is to think how to give good nutritional support to the dog in the face of poor food intake following surgery Had the intervention been definitely curative for example the removal of a chronic foreign body that was only partially obstructing the bowel, the risk for developing malnutrition would have been lower

Dan Chan

1/10/12

Case 2
8 month cross breed dog Loss of appetite Diarrhoea this morning, abdominal discomfort Owners found vomit in the house but did not witness or hear the event, they also have no other pets Shows some signs of dehydration BCS - 5/9, dog is quiet and alert With further questioning, the owners revealed the dog was scavenging in rubbish the previous night Abdominal radiographs taken, no obstruction seen just fluid distension Low risk of developing malnutrition dietary indiscretion whereby a dog consumes a variety of things usually leads to a short term, self-resolving bout of GI upset Dogs often respond to a day of starvation as long as treated for dehydration Fluid therapy usually sufficient enough Food is offered once dog has stopped vomiting offered gradually Use food which is easily digestible with low fat so boiled rice and chicken or mince

Case 3
14 yr old cat 4 week weight loss despite good appetite (more than usual) Some vomiting after eating which the client attributed to eating too fast Doesnt know if it is has diarrhoea because the cat is free to go outside Cat has lost 0.9kg since last check 6 months ago now weighs 4.2kg with a BCS of 4/9 Coat quality has also decreased Otherwise the cat is bright, alert, even anxious and vocal Has tachycardia with gallop rhythm Thyroid nodule is easily palpable Some muscle loss is noted over its back Hyperthyroidism is the most likely diagnosis This is not likely to produce malnutrition if treated correctly

Vomiting and nausea are common to many conditions and is a leading cause of poor food intake usually treated with antiemetic medications Hypersalivating is a classic sign of nausea If animals are inappetant, an enteral feeding tube can be used o When this is not possible eg the gut is intolerant of food or animal continues to vomit, parenteral nutrition is the only possible intervention

Dan Chan

1/10/12

Orogastric feeding tube (gastric gavage)

Not used very often as most conscious animals will not tolerate this method of feeding Tube passed through mouth to stomach Used in neonates which arent suckling can happen with complicated delivery, premature births, post anaesthesia for caesareans

Naso-oesophageal tube
Most common tube used in practice, however may not be the most efficient Easily placed with local anaesthetic within the nasal cavity Lubricated small feeding tube (3.5-5 Fr sized) is placed within the most medial and ventral nasal meatus and fed down to the caudal oesophagus After placement, a radiograph should be taken to confirm proper location Only allows liquid diets which are limited in choice and fairly expensive

Oesophagostomy tube
One of the most efficient tubes Tubes are well tolerated and allow more significant amounts of food to be fed because they are at least 14Fr in diameter Easy to place, only brief anaesthesia needed but it is general anaesthetic

Percutaneous Endoscopic-Guided Gastrostomy (PEG) tube

Does require specialist equipment and specialist skills using an endoscope Requires full anaesthesia Appropriate to use when oral cavity and oesophagus has to be bypassed Good for long term use and are quite large (20 Fr)

Complications with feeding tubes

Vomiting patients GIT is not able to cope with the amount of feeding Mechanical problems tube obstruction with food can be common but this can be avoided by choosing the right size of tube and properly preparing food (liquidising tinned food with sufficient water) Infection of the incision or leakage of contents in abdominal cavity possible with PEG and gastrostomy tubes which leads to septic peritonitis

If they do not tolerate tube feeding, parenteral nutrition is used Parenteral nutrition is amino acids, glucose and lipids directly into the bloodstream via IV It is expensive, requires specialist equipment and facilities to make There is a risk of complications hyperglycaemia, hyperlipidaemia and infection For these reasons, it is carried out at referral centres usually