Critical care nutrition

what is nutritional support?

method to support metabolic status of hospitalised patients

what are the differences between enteral and parenteral nutrition?

• enteral - methods utilising the GI tract

• parenteral - feeding via IV

• enteral nutrition is easier, has lower complications, more economical and more physiological —> preferred

Why is malnutrition significant in hospitalised patients?

• healthy animals can reduce nutrient utilisation to compensate

• sick animals cannot compensate —> nutritional deficiencies are magnified

when do we need to intervene and provide enteral nutrition?

• recent weight loss > 10%

• partial / complete anorexia for > 3days

• diseases causing excess catabolism

how should we provide enteral nutrition in obese patients?

treat patient the same

what are the types of enteral nutrition?

• encourage feeding

• force feeding

• drugs

• tube feeding

what is essential for encourage feeding?

• privacy and comfortable environment

• favourite foods in small amounts

• feed fresh and try warming

• do not ‘overface’

• record closely how much they have eaten

what diets should we feed during nutritional support?

• highly digestible diet

• cooked meat or fish

• critical acre diet

what drugs are appetite stimulants?

• diazepam

• mirtazapine

• cyproheptadine

• capromorelin

what appetite stimulant would we usually use in dogs?

• capromorelin (ghrelin agonist - liquid form)

• = central appetite stimulant

• only licensed in USA - import

• 3 mg/kg once daily

what appetite stimulant would we usually use in cats?

• can use capromorelin but mirtazapine more common

• well tolerated

• only partial / short term anorexia

• ¼ tablet every 3 days

what are the types of feeding tubes?

• naso-oesophageal tubes

• (pharyngostomy tubes)

• oesophagostomy tubes

• gastrostomy / PEG tubes

• enterostomy tubes

how would we use naso-oesophageal tubes?

• short to medium term

• small diameter tubes

what are contraindications for naso-oesophageal tubes?

• disease of head, nose, pharynx and below

• if they have no gag reflex

how would we use oesophagostomy tubes?

• medium to long term support

• well tolerated

• GA required

what are indications for oesophagostomy tubes?

oral cavity, nasal or pharyngeal disease

what are contraindications for oesophagostomy tubes?

diseases of oesophagus and below

how would we use gastrostomy tubes?

• long term support - minimum 7 days

• well tolerated

• GA required

what are contraindications for gastrostomy tubes?

gastric, intestinal or pancreatic disease

how would we use enterostomy tubes?

• GA required

• no gastric reservoir

• need constant rate infusion

what are indications for enterostomy tubes?

good for pancreatitis

what are contraindications for enterostomy tubes?

diffuse intestinal disease

how do we decide what tube method we would use?

• duration of treatment

• illness

• conditions and temperament

• equipment and expertise

• cost

• use as proximal as possible

what equipment is needed for naso-oesophageal tubes? (recording)

how do we prep for placing naso-oesophageal tubes?

topical local anaesthetic solution in the nose

how do we place naso-oesophageal tubes? (recording)

how can we tell if we are in the oesophagus or the trachea in conscious patients when placing naso-oesophageal tubes?

• oesophagus has no air in it - pull back on empty syringe to ensure negative pressure

• use syringe with water in it - push some water into tube, if in the trachea, the patient will cough

how do we secure naso-oesophageal tubes in place? (recording)

what equipment would we use for placing oesophagostomy tubes?

• long pair of carmalt forceps

• may need mouth gags to protect hands - but may get in the way of placement

• basic suture kit - material, scalpel, etc.

• couple of sizes of tubes ready

what are pros and cons of bung on the end of tubes?

• pros - shows up really well on radiographs - to check position

• cons - can increase blockages, so better to cut off for long term placement

how are oesophagostomy tubes placed?

• placed in the right or left lateral neck - left side better

• patient in lateral recumbency

• insert carmalt and push out laterally - so you can see the curved tip position through the skin

• ensure you are well above the jugular vein

• incsie the skin with scalpel to exposure the tip of the carmalt forceps

• grab tip of tube with the foreceps and pull the tube through oesophagus, and out the mouth

• reposition the foreceps on the tip of the tube, to redirect the tube down the oesophagus

how can we ensure the tube is in the oesophagus properly with oesophagostomy tubes?

• as you are redirecting the tube down the oesophagus, gently pull the excess tubing back out the incision site - will see the tube flip directions

• take radiograph to check position

• can use endoscopy to check position - but not usually done

how do we secure the tube in place for oesophagostomy tubes?

• using finger trap pattern

  

• bandage in place

  

what equipment is needed for PEG tube placement? (recording)

how do we place PEG tube? (recording)

what energy requirement do we use for hospitalised patients?

resting energy requirement (RER) - reassess regularly

• build up to this gradually - 1/3 on day 1, 2/3 on day 2, 3/3 on day 3

what is the aim for nutritional support in underweight patients?

stabilisation - don’t need to make them put on weight

if using a gastrostomy tube or enterostomy tube, when do we start feeding?

after the first 24 hours - for first 24 hours just allow them to adjust to the tube

how should we give food in tube feeding?

• small, frequent meals (4-6 per day)

• always aspirate first

• warm the food

• administer over several minutes

• flush tube with warm water

what are the possible complications of tube feeding?

• mechanical blockage

• metabolic issues - GI upset, hypophosphataemia

• tube dislodgement

• stoma infection

• tube removal by patient