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

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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 !
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Malnutrition
The WSAVA 5th Vital Assessment Group (V5)
Temperature
Pulse
Respiration
Pain assessment
Nutritional assessment
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Malnutrition
Acute weightloss > 10%
No intake for >3 d
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5. Conditions associated with malnutition
Esophageal
dysfunction
Facial Trauma
Neurotoxin
Post-op PDA
Prostatic abscess

6. Clinical consequences of 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 Manifestation of pain
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
Gastrostomy tubes
Nasoesophageal tubes
TPN & PPN
Jejunostomy tubes
Esophagostomy tubes

11. Nasoesophageal tubes Shorter term support Local anesthesia (Lidocaine)
<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 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:
DeBowes et al JAVMA 1993;202:1963-5
Bright et al AJVR 1988;49:629-33

15. Stoma Complications Complications Management 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 Treatment 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. Canine & Feline convalescence diets
Energy
Dogs & cats
Protein: % ME
Fat: 35-70% ME
Carbohydrates: % ME
Complete and balanced, highly digestible, easy to pass through a tube
RER = 70 Kcal/kg0,75

21. Protein High levels (30-50%ME) Glutamine Branched chain aas (BCAA)
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) N-3 Fatty acids
Low volume
Palatibility
N-3 Fatty acids
EPA-DHA.
Anti-inflammatory benefits
Resolvins, protectins
Γ-linolenic acid
Borage oil
Anti-inflammatory
Dogs 7%
Cats 0%
PGE3
Tx3
Lt5
Anti-inflammatory
Resolvins Protectins

23. Others Dietary fibers Nucleic acids Minerals Vitamins
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 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 …
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30. Questions?
% fat ?