Companion animal Critical Care Nutrition

V. Biourge DVM PhD Dipl ACVN&ECVCNHealth and Nutritional Sciences Director

R&D, Royal Canin SAS, Aimargues, France

P Mandigers

Thanks to D. Elliott and Y. Queau

Malnutrition

Introduction• Human hospitals

– US: 30-50% of patients are malnourished and 73 are never assessed for nutrition status.

– Europe: 80 % of surgeons believe that nutrition is an important part of the management of surgical patients, yet only 20% do a nutritional assessment.

– ASPEN CNW 2012: « Patients are fed too late, do not get enough calories, the sicker the patient the lower the intake of calories. Nutrition gets no respect »

• Veterinary hospitals– 73 % of hospitalized dogs achieved a positive

energy balance (Remillard et al 2001).– Only 7 % of dogs and cats that could benefit

from dietary management, actually do !Research & Development

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Malnutrition

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The WSAVA 5th Vital Assessment Group (V5)

1. Temperature2. Pulse3. Respiration4. Pain assessment5. Nutritional assessment

Malnutrition

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Acute weightloss > 10%

No intake for >3 d

Conditions associated with malnutition

Neurotoxin

Post-op PDA

Facial Trauma

Prostatic abscess

Esophageal dysfunction

Clinical consequences of malnutrition

• Malnutrition Impaired immune function Increased susceptibility to infection Delayed wound healing Decreased strength and vigor Altered gastrointestinal mucosal barrier

Bacterial translocation

• Decreases muscle mass and strength• Predictor of morbidity and mortality in

humans

J of Online Hepatology, 2011

Anorexia

• Common manifestation of disease– Particularly the GIT, pancreas,

liver

• Manifestation of pain• Side-effect of medications• Central alterations in

appetite, hunger or satiety• Unbalanced body fluids,

electrolytes, pH

Providing Nutritional Support

• If the animal is willing to eat feed it.• If the gut works, use it!• Assisted feeding

– Warm, wet, odiferous, palatable foods– Positive reinforcement

• Pharmacological stimulants – Benzodiazepines– Serotonin antagonists– Megestrol acetates – Androgens

Impossible to provide enough calories

Routes of Administration

Nasoesophageal tubes

Esophagostomy tubes

Gastrostomy tubes

Jejunostomy tubesTPN & PPN

Nasoesophageal tubes

• Shorter term support – <7 days to several weeks– Elizabethan collar

• Local anesthesia (Lidocaine)• Small diameter tubes

– Liquid diets only– Clog easily– 5-8 F cats and small dogs– 8 F medium to large dogs– PVC vs red rubber vs Polyurethane

Esophagostomy and gastrotomy tubes

• Medium - long term support• Well tolerated, easy (eso) to

moderately easy (gastro) to place• Larger diameter

– Cats and small dogs 12-20 Fr– Medium to large dogs 24 Fr– Slurries

• Requires general anesthesia• Indications

– Any nutritional support – Mandibular, maxillary, nasal, and

nasopharyngeal disease– Inability to prehend or masticate

Jejunostomy tubes

• Medium term support• Liquid “purified” diet• Continuous infusion• Indications

– Unable to tolerate gastric feeding

– Normal distal intestinal and colon function

• Surgical placement– Needle catheter jejunostomy– Small bowel pexied to wall

• Percutaneous endoscopic jejunostomy

Placement complications

• Splenic laceration• Gastric hemorrhage• Pneumoperitonium• Peritonitis• Tube displacement• Tube extraction• Epiphora

Armstrong et al JVIM 1990;4:202-6Mason et al JAVMA 2000; 216:1096-1099DeBowes et al JAVMA 1993;202:1963-5Bright et al AJVR 1988;49:629-33

Stoma Complications

• Complications– Pain – Tissue swelling – Discharge – Erythema – Abscess formation – Ulceration

• Management– Warm antiseptic soaks– Daily cleaning– Antimicrobial ointment– Avoid patient licking– Consider post- placement antibiotics

Tube clogging

• Minimized by – Adequate liquefaction– Strain food – Flush with water after use

• Treatment– Small syringe (2 mL)– Simultaneous massage,

flushing and aspiration– Instill carbonated drinks,

meat tenderizer, pancreatic enzymes

Nutritional management

• Pathophysiology• Diet

Energy Protein

• ARG, GLU, BCAA Fat

• EFA: n-3/n-6 Fiber Minerals, Vitamins

• Nutritional plan• Metabolic complications• Aversion

Pathophysiology

Royal Canin Encyclopedia, 2004Modern nutrition in Health & diseases 2006

Pathophysiology

Modern nutrition in Health & diseases 2006

Diet

• Energy– Dogs & cats

• Protein: 30-50 % ME• Fat: 35-70% ME• Carbohydrates: 20-30 % ME

– Complete and balanced, highly digestible, easy to pass through a tube

• RER = 70 Kcal/kg0,75

Canine & Feline convalescence

diets

Protein

• High levels (30-50%ME)– Energy substrate– To sustain wound recovery– To minimize negative nitrogen balance

• Glutamine– Main energy substrate for the gut.– Nucleotide synthesis

• Branched chain aas (BCAA)– Leucine, isoleucine, valine– To sustain muscle mass

• Arginine– Urea cycle– Immune function, wound healing– Precursor of NO– To avoid when excessive inflammation

Fat

• Efficient source of energy (30-70%ME)– Low volume– Palatibility

• N-3 Fatty acids– EPA-DHA.– Anti-inflammatory benefits– Resolvins, protectins

• Γ-linolenic acid– Borage oil– Anti-inflammatory PGE3

Tx3Lt5Anti-inflammatory

Resolvins Protectins

Dogs 7%Cats 0%

Others

• Dietary fibers – 15-25 g/1000 kcal– Soluble Vs Insoluble– Transit – colonic health

• Nucleic acids– DNA, RNA precursors– Immunity, dividing cells

• Minerals– Ca, P, K, Na, Cl– Fe, Cu, Zn, Mn

• Vitamins– Antioxidants: Vit E, Vit C, Lutein, Taurine– Vitamin B12– Vitamin K

Cellulose Psyllium

Nutritional management

• Calculate resting energy requirements – RER = 70(BW Kg)0.75

• Daily volume to feed = RER/energy density– Initially provide ¼ to ½ daily

energy– Increase over several days

• Weigh daily and adjust intake as needed in order to maintain or gain weight

Nutritional Management

• Warm food to room temperature• Give drugs prior to food

– Except phosphate binders which must be mixed with food

• Administer food over 10-15 minutes– Salivation and discomfort suggests

nausea• Slow the rate of feeding and/or

reduce the volume

• Flush tube with warm water following use

Nutritional management

Complications• Tube clogging• Vomiting/diarrhea

– Metoclopramide 2.2 mg/kg 15 min before meal

– Maropitant citrate

• Aspiration/pneumonia• Metabolic abnormalities

HypokalemiaHyperglycemiaHypophosphatemia

Nutritional management

Food aversion

Diet&

GI upset

Food aversion

Do not expose to all the diets before tube-feeding Do not give food to eat for the first 10 d Appetite stimulants not found useful

Conclusions

• Malnutrition is common in hospitalized patients 5 Vs

• Most critical patients are catabolic• Enteral nutrition is preferred• Nutritional support will facilitate

recovery ↑protein ↑fat ↓carbohydrates GLN, EPA/DHA, Nucleotic acid AntiOx complex

• Begin within 24 hours or immediately following stabilization

• Monitor regularly to optimize patient needs

If you want to know more …

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Questions?

% fat ?