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Companion animal Critical Care Nutrition V. Biourge DVM PhD Dipl ACVN&ECVCN Health and Nutritional Sciences Director R&D, Royal Canin SAS, Aimargues, France.

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Presentation on theme: "Companion animal Critical Care Nutrition V. Biourge DVM PhD Dipl ACVN&ECVCN Health and Nutritional Sciences Director R&D, Royal Canin SAS, Aimargues, France."— Presentation transcript:

1 Companion animal Critical Care Nutrition V. Biourge DVM PhD Dipl ACVN&ECVCN Health and Nutritional Sciences Director R&D, Royal Canin SAS, Aimargues, France P Mandigers Thanks to D. Elliott and Y. Queau

2 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 Confidential information - Mars Inc

3 Malnutrition Research & Development Confidential information - Mars Inc The WSAVA 5 th Vital Assessment Group (V5) 1. Temperature 2. Pulse 3. Respiration 4. Pain assessment 5. Nutritional assessment

4 Malnutrition Research & Development Confidential information - Mars Inc Acute weightloss > 10% No intake for >3 d

5 Conditions associated with malnutition Neurotoxin Post-op PDA Facial Trauma Prostatic abscess Esophageal dysfunction

6 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

7 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

8 Candidates for Nutritional Support Patients which… –Have a poor body condition score –5-10% weight loss –Reduced oral intake for > 3 days

9 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

10 Routes of Administration Nasoesophageal tubes Esophagostomy tubes Gastrostomy tubes Jejunostomy tubes TPN & PPN

11 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

12 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

13 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

14 Placement complications Splenic laceration Gastric hemorrhage Pneumoperitonium Peritonitis Tube displacement Tube extraction Epiphora Armstrong et al JVIM 1990;4:202-6 Mason et al JAVMA 2000; 216:1096-1099 DeBowes et al JAVMA 1993;202:1963-5 Bright et al AJVR 1988;49:629-33

15 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

16 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

17 Nutritional management Pathophysiology Diet Energy Protein ARG, GLU, BCAA Fat EFA: n-3/n-6 Fiber Minerals, Vitamins Nutritional plan Metabolic complications Aversion

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

19 Pathophysiology Modern nutrition in Health & diseases 2006

20 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/kg 0,75 Canine & Feline convalescence diets

21 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

22 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 Tx3 Lt5 Anti-inflammatory Resolvins Protectins Dogs 7% Cats 0%

23 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

24 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

25 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

26 Nutritional management Complications Tube clogging Vomiting/diarrhea – Metoclopramide 2.2 mg/kg 15 min before meal – Maropitant citrate Aspiration/pneumonia Metabolic abnormalities Hypokalemia Hyperglycemia Hypophosphatemia

27 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

28 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

29 If you want to know more … Obrigado …

30 Questions? % fat ?

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