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Enteral Critical Care Nutrition MM M ARK M ORRISNSTITUTE I.

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Presentation on theme: "Enteral Critical Care Nutrition MM M ARK M ORRISNSTITUTE I."— Presentation transcript:

1 Enteral Critical Care Nutrition MM M ARK M ORRISNSTITUTE I

2 The need to feed The enteral route Diets/diet management Enteral Critical Care Nutrition

3 The Need To Feed Histortic perspectives Clinical/metabolic perspectives Patient selection

4 Historic Perspectives 1793 John Hunter Eel skin nasoenteral tube 1990s $ billion industry

5 Clinical/Metabolic Perspectives Equation for nutritional support: Food Deficit Disease/Injury Hypermetabolism Accelerated Starvation +=

6 Clinical/Metabolic Perspectives Endocrine Cytokines Cortisol Catecholamines Insulin: glucagon Thyroxine Growth hormone TNF Prostaglandi ns Increased metabolic rate

7 Clinical/Metabolic Perspectives Metabolic Rate During Clinical Conditions Maintenance energy requirement Resting energy requirement Days Sepsis Major burn Trauma, cancer Total partial Food deprivation: Resting Metabolism (%)

8 Clinical/Metabolic Perspectives Equation for nutritional support: Food deficit Disease/injury hypermetabolism Accelerated starvation += Accelerated starvation Compromised host defenses Compromised wound healing +=

9 Clinical/Metabolic Perspectives 1 liter = 170 kcal Provides 1/5 patients energy requirement No protein or micronutrients 5% Dextrose I.V.

10 Patient Selection History & exam Laboratory tests Predictive Indicators

11 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)

12 Patient Selection Patient selection = common sense When in doubt: feed Feed early

13 The Enteral Route Advantages of enteral nutrition (EN) Appetite stimulation Forced feeding Tube feeding

14 Advantages of Enteral Nutrition (EN) The golden rule of critical care nutrition: When the gut works, use it.

15 EN feeds intestine as well as patient Decreased bacterial translocation Glutamine - enterocyte nutrient Enhanced enteric immunity Advantages of Enteral Nutrition (EN)

16 Highly palatable, balanced diets Assure optimal olfaction Warm food to body temperature Appetite Stimulation

17 Food preferenc e (%) Food temperature ( º C) Sohail, Nutr Abst Rev, Effect of Food Temp on Preference in Cats Food preferenc e (%) Food temperature ( º C) Sohail, Nutr Abst Rev,

18 Appetite Stimulation Highly palatable, balanced diets Assure optimal olfaction Warm food to body temperature Avoid K, Zn, & B vitamin def. Drugs

19 Appetite Stimulation Diazepam mg PO cat mg/kg PO dog mg/kg IV Oxazepam (Serax ) mg/kg PO dog 2.5 mg (1/4 tab) PO cat Fluazepam (Dalmane ) mg/kg PO dog mg/kg PO cat ® ®

20 Tube Feeding Orogastric Nasoesophageal Pharyngostomy Esophagostomy Gastrostomy Enterostomy Indwelling

21 Diets/Diet Management Nutrient requirements Diet selection Feeding protocols Cost analysis

22 Water Energy Protein Minerals & vitamins Nutrient Requirements

23 Resting energy requirement (RER) 1000 kcal/m 2 70 (Wt kg 0.75 ) 30 (Wt kg ) + 70* * > 2 kg and < 45 kg Dogs & Cats

24 Nutrient Requirements Maintenance energy requirement (MER) MER dogs = 1.6 RER MER cats = 1.2 RER

25 Clinical/Metabolic Perspectives Metabolic Rate During Clinical Conditions Maintenance energy requirement Resting energy requirement Days Sepsis Major burn Trauma, cancer Total partial Food deprivation: Resting Metabolism (%)

26 Energy Requirements IER = Energy requirement (IER) Infection Illness (cancer) Injury (surgery, trauma)

27 Nutrient Requirements Protein quantity At least maintenance amounts 4g protein/100 kcal 16% of energy as protein 6g protein/100 kcal 24% of energy as protein Dogs Cats

28 Nutrient Requirements Protein quality Digestibility/availability Amino acid profile EAAs (extra arginine, branched chains) Glutamine (conditionally essential) Taurine (cat)

29 Nutrient Requirements Minerals and vitamins Maintenance/growth levels Micronutrient def. common

30 Nutrient Requirements Concept: When a diet is properly formulated, the nutrients are balanced to the energy density of the diet

31 Nutrient Requirements Thus, when such a diet is fed to meet a patients energy requirements, the requirements for the non-energy nutrients are automatically met

32 PatientsDietDaily Daily energyEnergyDiet RequirementDensityDosage Clinical/Metabolic Perspectives ÷ =

33 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

34 PatientsDietDaily Daily energyEnergyDiet RequirementDensityDosage (463 kcal/day)(675 kcal/can)(2/3 can/day) ÷ = Nutrient Requirements Canned pet food = 675 kcal/can

35 PatientsDietDaily Daily energyEnergyDiet RequirementDensityDosage (463 kcal)(1 kcal/ml)(463 ml/day) ÷ = Nutrient Requirements Liquid diet = 1 kcal/ml

36 Diet Selection Defined formula diets Meal replacement (polymeric, intact protein) Elemental (monomeric)

37 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

38 Diet Selection Diameter of tube Location of tube Functional status of GI tract

39 Feeding Protocols Bolus - maximal amount/feeding ml/kg Bolus - minimal feeding frequency 3-5/day Gradual transition 1/3 day 1, 2/3 day 2, full feeding day 3

40 Cost Analysis Canine/Feline a/d2.77 Clinicare Canine10.62 Levity5.12 Peptamen13.82 Daily cost ($) Diet10 kg septic dog

41 Feeding Protocols Vomiting,Overly-aggressive administration, cramping,excessive diet osmolality, diarrheaimproper diet composition, GI alterations AirwayRegurgitation, aspirationnot checking for proper tube placement PluggedInadequate tube maintenance tube Diet- & feeding-related complications: Due to

42 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

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


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