Nutritional Support. Critical Care Nutrition: A Key to Good Outcomes

Transcription

1 Critical Care Nutrition: A Key to Good Outcomes Lisa M. Freeman, DVM, PhD, DACVN Nutritional Support Why is it important? Who needs it? When should it be initiated? How should it be given? How much should be fed? What monitoring is needed? Joey 10 yr old CM Domestic Shorthair Previously healthy Indoor/outdoor Body weight=13.2 pounds Body condition score=6/9 Normal muscle condition Unknown trauma Stabilized, radiographs Mandibular symphyseal fracture + maxillary frx Plan: Wire mandible today and place feeding tube

2 Intake < Requirement Mobilization of amino acids Decr. protein turnover Preferential fat utilization Conservation of LBM No adaptive response Continued loss of LBM (Simple Starvation) (Stressed Starvation) It s BAD to Lose Lean Body Mass! No storage for protein Inefficient energy source All protein is functional Decreased strength Decreased immune function Decreased wound healing Increased morbidity and mortality

3 Nutritional assessment Quick screening Any red flags? Is diet optimized? Extended evaluation Benefits of nutritional assessment Diagnosis Initial treatment Ongoing care Nutritional assessment (Medical history/physical exam) 1. Body weight 2. Body condition score 3. Muscle condition score 4. Diet history

4 Body weight 7/7/14

5 Red flags on the physical exam Unintentional weight loss Body condition score <4 or >5 Muscle loss (any) Diet history Diet history for ill/injured animals Why? Clues toward health problems Encourage patient to eat while hospitalized (short-term) Optimal nutrition (long-term)

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7 Nutritional deficiencies/excesses Hypocalcemia (seizures, fractures) Hypercalcemia (vitamin D toxicity) Anemia (various deficiencies) Thiamine deficiency Diet history Cat food (brand, product, flavor, amount, frequency) Treats and table foods Dental products Rawhides Dietary supplements Foods used to administer medications nutrition-toolkit

8 Red flags on the diet history Unconventional diets (raw, veggie) Unfamiliar (small) companies Pet foods designed for intermittent/supplemental use Dietary supplements Snacks, treats, table foods Large percentage Inappropriate nutrients (eg, protein, Na) Medication administration Nutritional assessment: Nutritional plan Evaluate: Medical/dietary history Physical exam findings Diagnostic tests Assign low, moderate or high risk for malnutrition Patient selection: High risk Debilitated patients Weight loss Anorexia Muscle loss Poor haircoat Abnormal lab values Be aggressive!

9 Patient selection: Moderate risk Non-debilitated patients At risk for malnutrition: High protein loss NPO for >3-5 days Pancreatitis Head injury Sepsis Extensive intestinal resection Address nutrition early! Patient selection: Low risk Non-debilitated patients Not at immediate risk Continue to reassess! Joey 10 yr old CM Domestic Shorthair Previously healthy Indoor/outdoor Body weight=13.2 pounds Body condition score=6/9 Normal muscle condition Unknown trauma Stabilized, radiographs Mandibular symphyseal fracture + maxillary frx Plan: Wire mandible today and place feeding tube

10 When to Feed General rules: If any signs of malnutrition are present (after patient is stabilized) Per os feeding Advantages Physiologically best Cost effective Requirements GI tract must be fx Ensure adequate intake»write specific feeding orders»record food consumption

11 Appetite stimulation Treat nausea Diazepam (Valium) Oxazepam (Serax) Cyproheptadine (Periactin) Mirtazapine (Remeron) Per os feeding Coax feeding Minimize stress Familiar foods Altering food temperature Owner present Quantify intake Force (syringe) feeding Can cause Stress Food aversions Appropriate diet

12 How much to feed? Start at RER Maintenance energy requirement (MER) Illness energy requirement (IER) Resting energy requirement (RER)

13 Resting energy requirement RER = 70 (BW kg ).75 Or, for 3-25 kg, can use: RER = 30 (BW kg ) + 70 I hate math options Post an RER chart Joey 6 kg Body condition score=6/9 Resting energy requirement: 70x(6 kg) x(6 kg)+70

14 Joey 6 kg Body condition score=6/9 Resting energy requirement: 70x(6 kg) x(6 kg)+70 Joey 6 kg Body condition score=6/9 Resting energy requirement: 70x(BW) 0.75 = 268 kcals/day 30x(BW)+70 = 250 kcals/day Where to feed: Enteral nutrition Advantages (vs. parenteral) Safer/more physiologic Less expensive Feeds the GI tract as well as the patient Improves GI structure/function

15 Feeding tubes Indications Won t eat Can t eat GI tract is functional Simple GI surgery is not a reason to avoid enteral Which of the following have you used? Nasoesophageal Esophagostomy Gastrostomy Jejunostomy Parenteral nutrition Nasoesophageal/ Nasogastric tubes Short-term use No anesthesia or sedation required Require a liquid diet NG tubes allow gastric decompression

16 Esophagostomy tubes Can use a large tube Requires anesthesia Can be used long-term Easy to place Curved (Carmalt) forceps Placement devices Indications for E-tubes Functional GI tract Avoid with esophageal disease (use G-tube) Caution with vomiting (red rubber) Long-term feeding (>1 week) Consider NE tube for short-term

17 watch?v=yn8fqrxcwoo &list=plcliglrenrkth0w GySwbJc7q2YkagGrAq&i ndex=1 E-Tube: Type Red rubber fr $2 Polyurethane (Mila) 14 fr $44 Silicone (Surgivet) 14 fr $54 Plus E-tube placement fee = $68 Gastrostomy tubes Can use a large tube Requires anesthesia Can be used long-term Bypasses esophagus Requires surgery or endoscopy Risk of early removal (<10-14 days)

18 Jejunostomy tubes Most surgically placed Restricted to in-hospital use Require liquid diet Require continuous rate infusion Enteral tube selection How much of GI tract is functional? How long do you expect the patient to need enteral support? Is surgery indicated? Think about tube choice pre-op! Available facilites/equipment?

19 Enteral tube size Use the largest tube possible More choices in diet selection Cat Dog NE tube fr 5-8 fr E tube 14 fr fr G tube 18 fr fr What to feed? Patient factors Nutrient requirements Energy Protein Nutrient intolerances Palatability Enteral feeding tube

20 Critical care diets Diet Kcal per can Water added (ml per can) Kcal per ml (slurry) Protein (g/100 kcal) Fat (g/100 kcal) Sodium (g/100 kcal) Iams Veterinary Formula TM Maximum-Calorie Plus TM Hill s Prescription Diet a/d Canine/Feline Critical Care Royal Canin Veterinary Diet Recovery RS TM Feeding orders A. Feed anything tasty B. Feed 1/2 can Purina EN q 6 hrs C. Feed either Purina EN, Royal Canin Lowfat, Iams Low Residue, or Hill's i/d D. Feed 1 meatball Purina EN q 8 hrs Write specific feeding orders Resting energy requirement: 268 kcals/day Iams Maximum Calorie»1 can + 25 ml water = 1.8 kcals/ml 149 ml of mixture/day Day 1 (50%) or 75 ml»19 ml q 6 hr Day 2 (100%) or 150 ml»38 ml q 6 hr 50 ml q 8 hr

21 Diets Enteral nutrition Esophagostomy/gastrostomy tubes» Critical care diet 1. Iams Maximum Calorie 2. Hill s a/d 3. Royal Canin Recovery» Blenderized therapeutic diet Nasoesophageal/jejunostomy tubes» Liquid diet 1. Veterinary products (CliniCare, CliniCare RF) 2. Human products (only with supplementation) Stomach volumes Normal dog/cat: ml/kg Ill/injured animals: ml/kg Start at 5-10 ml/kg/feeding Assess tolerance If volume is an issue, modify Caloric density of diet Feeding frequency (or CRI) Potential complications Mechanical Clogged tubes Malpositioning Pulmonary aspiration Esophageal erosion Inadvertent removal Pressure necrosis (G tubes) Metabolic Hyperglycemia Refeeding syndrome ( PO 4, K, Mg) Volume overload Congestive heart failure - adjust IV fluids Gastrointestinal Vomiting Diarrhea

22 Daily monitoring Review prior day s feeding plan Was caloric goal met? Body weight Electrolytes GI issues Metabolic complications Tube site Discontinuing enteral nutrition Only when eating! Indications Parenteral nutrition Inadequate calorie intake (>3-5 days of anorexia) When enteral nutrition is contraindicated» GI dysfunction Vomiting/regurgitation Severe diarrhea/malabsorption» Pancreatitis» Inability to guard airway

23 Key Points Optimal nutrition = critical for success Anticipate the need for nutritional support Remember stressed starvation Enteral is the preferred feeding route RER is the typical starting caloric goal Set goals and write specific feeding orders Good protocols decrease risk for complications Monitor, reassess, and adjust plan