enteral critical care nutrition mm m ark m orrisnstitute i

Enteral CriticalCare Nutrition

MM•

MARKMORRIS

NSTITUTEI

The need to feed

The enteral route

Diets/diet

management

Enteral Critical Care Nutrition

The Need To Feed

Histortic perspectives

Clinical/metabolic perspectives

Patient selection

Historic Perspectives

1793 John Hunter

— Eel skin nasoenteral tube

1990’s $ billion industry

Clinical/Metabolic Perspectives

Equation for nutritional support:

FoodDeficit

Disease/InjuryHypermetabolism

AcceleratedStarvation

+ =

Clinical/Metabolic Perspectives

Endocrine CytokinesCortisol

Catecholamines

Insulin: glucagon

Thyroxine

Growth hormone

TNF

Prostaglan

dinsIncreasedmetabolic

rate

Clinical/Metabolic Perspectives

Metabolic Rate During Clinical Conditions

Maintenanceenergyrequirement

Restingenergyrequirement

0 10 20 30 40 50 60 Days

160

100

Sepsis

Majorburn

Trauma,cancer

TotalpartialFood deprivation:

RestingMetabolism

(%)

Clinical/Metabolic Perspectives

Equation for nutritional support:

Fooddeficit

Disease/injuryhypermetabolism

Acceleratedstarvation

+ =

Acceleratedstarvation

Compromisedhost defenses

Compromisedwound healing

+ =

Clinical/Metabolic Perspectives

1 liter = 170 kcal

Provides 1/5 patient’s energy requirement

No protein or micronutrients

Vegetable

Oil

5%Dextrose

I.V.

Patient Selection

History & exam

Laboratory tests

Predictive Indicators

Patient Selection

Weight loss of > 10% Poor food intake for > 3

days Increased nutrient

demands(Trauma, surgery, infection)

Increased nutrient losses(Vomiting, diarrhea, wounds)

Laboratory parameters(Albumin, creatine kinase)

Patient Selection

Patient selection = common sense

When in doubt: feed

Feed early

The Enteral Route

Advantages of enteral nutrition (EN)

Appetite stimulation Forced feeding Tube feeding

Advantages of Enteral Nutrition (EN)

The golden rule of critical care nutrition:

When the gut works, use it.

EN feeds intestine as well as patient— Decreased bacterial

translocation

— Glutamine - enterocyte nutrient

— Enhanced enteric immunity

Advantages of Enteral Nutrition (EN)

Highly palatable, balanced

diets

Assure optimal olfaction

Warm food to body

temperature

Appetite Stimulation

Appetite Stimulation

Foodpreference(%)

80

60

40

20

Food temperature (ºC)Sohail, Nutr Abst Rev, 1983

10 20 30 40 50

Effect of Food Temp on Preference in Cats

Foodpreference(%)

80

60

40

20

Food temperature (ºC)Sohail, Nutr Abst Rev, 1983

10 20 30 40 50

Appetite Stimulation

Highly palatable, balanced diets

Assure optimal olfaction Warm food to body

temperature Avoid K, Zn, & B vitamin

def. Drugs

Appetite Stimulation

Diazepam1 - 2 mg PO cat0.1 - 0.2 mg/kg PO dog0.05 - 0.1 mg/kg IV

Oxazepam (Serax )0.3 - 0.4 mg/kg PO dog2.5 mg (1/4 tab) PO cat

Fluazepam (Dalmane )0.1 - 0.5 mg/kg PO dog0.1 - 0.2 mg/kg PO cat

®

®

Tube Feeding

Orogastric Nasoesophageal Pharyngostomy Esophagostomy Gastrostomy Enterostomy

Indwelling

Diets/Diet Management

Nutrient requirements

Diet selection

Feeding protocols

Cost analysis

Water

Energy

Protein

Minerals & vitamins

Nutrient Requirements

Nutrient Requirements

Resting energy requirement (RER)

— 1000 kcal/m2

— 70 (Wt kg 0.75)

— 30 (Wt kg) + 70** > 2 kg and < 45 kg

Dogs&

Cats

Nutrient Requirements

Maintenance energy requirement (MER)

— MER dogs = 1.6 RER

— MER cats = 1.2 RER

Clinical/Metabolic Perspectives

Metabolic Rate During Clinical Conditions

Maintenanceenergyrequirement

Restingenergyrequirement

0 10 20 30 40 50 60 Days

160

100

Sepsis

Majorburn

Trauma,cancer

TotalpartialFood deprivation:

RestingMetabolism

(%)

Energy Requirements

IER = 1.0 - 1.25

Energyrequirement(IER)

Infection

Illness (cancer)

Injury (surgery,

trauma)

Nutrient Requirements

Protein quantity— At least maintenance

amounts4g protein/100 kcal16% of energy as protein

6g protein/100 kcal24% of energy as protein

Dogs

Cats

Nutrient Requirements

Protein quality— Digestibility/availability— Amino acid profile

EAA’s (extra arginine, branched chains)Glutamine (conditionally essential)Taurine (cat)

Nutrient Requirements

Minerals and vitamins— Maintenance/growth levels— Micronutrient def. common

Nutrient Requirements

Concept:

When a diet is properly formulated, the nutrients are balanced to the energy density of the diet

Nutrient Requirements

Thus, when such a diet is fed to meet a patient’s energy requirements, the requirements for the non-energy nutrients are automatically met

Patient’s Diet Daily

Daily energy Energy Diet

Requirement Density Dosage

Clinical/Metabolic Perspectives

÷ =

Nutrient Requirements

Example 10 kg dog with septic bile peritonitis

RER = 30 Wt kg+ 70 = 30(10) + 70 = 370 kcal

IER = 1.25 RER = 1.25(370) = 463 kcal/day

Patient’s Diet Daily

Daily energy Energy Diet

Requirement Density Dosage

(463 kcal/day) (675 kcal/can) (2/3 can/day)

÷ =

Nutrient Requirements

Canned pet food = 675 kcal/can

Patient’s Diet Daily

Daily energy Energy Diet

Requirement Density Dosage

(463 kcal) (1 kcal/ml) (463 ml/day)

÷ =

Nutrient Requirements

Liquid diet = 1 kcal/ml

Diet Selection

Defined formula diets— Meal replacement

(polymeric, intact protein)— Elemental (monomeric)

Diet Selection

Blenderized diets - follow recipe— 15 oz. Can (recuperative

type) cat food

— 1½ cup water— Blend - high speed 1 minute— Strain through kitchen

strainer— > 8 Fr

Diet Selection

Diameter of tube

Location of tube

Functional status of GI tract

Feeding Protocols

Bolus - maximal amount/feeding30-45 ml/kg

Bolus - minimal feeding frequency3-5/day

Gradual transition1/3 day 1, 2/3 day 2, full feeding day 3

Cost Analysis

Canine/Feline a/d 2.77

Clinicare Canine 10.62

Levity 5.12

Peptamen 13.82

Daily cost ($)Diet 10 kg septic dog

Feeding Protocols

Vomiting, Overly-aggressive administration,cramping, excessive diet osmolality,diarrhea improper diet composition,

GI alterations

Airway Regurgitation,aspiration not checking for proper

tube placement

Plugged Inadequate tube maintenancetube

Diet- & feeding-related complications:

Due to

Due to

Due to

Summary

Critically ill animals are in a hypermetabolic state

When it comes to nutritional support, the sooner the better

When the gut works, use it Use RER rather than MER for

calculation of energy needs in the critically ill patient

Summary

Veterinary products are more suitable than human preparations for use in critically ill patients