Enteral Critical

1
Enteral Critical Care Nutrition
2
Enteral Critical Care Nutrition

• The need to feed
• The enteral route
• Diets/diet management

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 Prostaglandins
Increased metabolic rate
7
Clinical/Metabolic Perspectives

• Metabolic Rate During Clinical Conditions

Major burn
Maintenance energy requirement
160
Sepsis
Trauma, cancer
Resting energy requirement
100
Total partial
Food deprivation

• Days

0 10 20 30 40 50 60
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 gt 10
• Poor food intake for gt 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
Advantages of Enteral Nutrition (EN)

• EN feeds intestine as well as patient
• Decreased bacterial translocation
• Glutamine - enterocyte nutrient
• Enhanced enteric immunity

16
Appetite Stimulation

• Highly palatable, balanced diets
• Assure optimal olfaction
• Warm food to body temperature

17
Appetite Stimulation

• Effect of Food Temp on Preference in Cats

80 60 40 20
80 60 40 20

• Foodpreference()

• Foodpreference()

10 20 30 40 50

• Food temperature (ºC)Sohail, Nutr Abst Rev, 1983

10 20 30 40 50

• Food temperature (ºC)Sohail, Nutr Abst Rev, 1983

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Appetite Stimulation

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

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Appetite Stimulation

• Diazepam 1 - 2 mg PO cat 0.1 - 0.2 mg/kg PO
  dog 0.05 - 0.1 mg/kg IV
• Oxazepam (Serax ) 0.3 - 0.4 mg/kg PO dog 2.5
  mg (1/4 tab) PO cat
• Fluazepam (Dalmane ) 0.1 - 0.5 mg/kg PO
  dog 0.1 - 0.2 mg/kg PO cat

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Tube Feeding

• Orogastric
• Nasoesophageal
• Pharyngostomy
• Esophagostomy
• Gastrostomy
• Enterostomy

Indwelling
21
Diets/Diet Management

• Nutrient requirements
• Diet selection
• Feeding protocols
• Cost analysis

22
Nutrient Requirements

• Water
• Energy
• Protein
• Minerals vitamins

23
Nutrient Requirements

• Resting energy requirement (RER)
• 1000 kcal/m2
• 70 (Wt kg 0.75)
• 30 (Wt kg) 70

Dogs Cats
gt 2 kg and lt 45 kg
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

Major burn
Maintenance energy requirement
160
Sepsis
Trauma, cancer
Resting energy requirement
100
Total partial
Food deprivation

• Days

0 10 20 30 40 50 60
26
Energy Requirements
Infection Illness (cancer) Injury (surgery,
trauma)
Energy requirement (IER)

• IER 1.0 - 1.25

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Nutrient Requirements

• Protein quantity
• At least maintenance amounts

4g protein/100 kcal16 of energy as protein
Dogs
6g protein/100 kcal24 of energy as protein
Cats
28
Nutrient Requirements

• Protein quality
• Digestibility/availability
• Amino acid profile

EAAs (extra arginine, branched chains) Glutamine
(conditionally essential) Taurine (cat)
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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
Clinical/Metabolic Perspectives
Patients Diet Daily Daily energy Energy Diet Requ
irement Density Dosage


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
Nutrient Requirements

• Canned pet food 675 kcal/can

Patients Diet Daily Daily energy Energy Diet Requ
irement Density Dosage (463 kcal/day) (675
kcal/can) (2/3 can/day)


35
Nutrient Requirements

• Liquid diet 1 kcal/ml

Patients Diet Daily Daily energy Energy Diet Requ
irement Density Dosage (463 kcal) (1
kcal/ml) (463 ml/day)


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
• gt 8 Fr

38
Diet Selection

• Diameter of tube
• Location of tube
• Functional status of GI tract

39
Feeding Protocols

• Bolus - maximal amount/feeding30-45 ml/kg
• Bolus - minimal feeding frequency3-5/day
• Gradual transition1/3 day 1, 2/3 day 2, full
  feeding day 3

40
Cost Analysis
Daily cost () Diet 10 kg septic dog
Canine/Feline a/d 2.77 Clinicare
Canine 10.62 Levity 5.12 Peptamen 13.82
41
Feeding Protocols

• Diet- feeding-related complications

Vomiting, Overly-aggressive administration, cramp
ing, excessive diet osmolality, diarrhea improper
diet composition, GI alterations Airway Regurgit
ation, aspiration not checking for proper tube
placement Plugged Inadequate tube
maintenance tube
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